Below are excerpts from this grantee’s quarterly reports.
Final Report
Briefly restate the specific aims or objectives associated with this project
Year 1
Aim 1: To develop a social media group counseling intervention to prevent perinatal depressive symptoms in adolescents in the Seattle, WA, area.
Aim 2: To evaluate the intervention’s uptake, acceptability, and preliminary impact on mental wellness in a pilot with pregnant adolescents.
Aim 3: To characterize content and patterns of participant engagement with the intervention and identify associations between engagement, content, and mental wellness.
Year 2
Aim 1. Adapt the IMAGINE intervention in response to the COVID-19 epidemic
1a. Explore the impact of the COVID-19 epidemic on peripartum youth’s mental health
1b. Develop COVID-19-related content for inclusion in the IMAGINE pilot intervention
1c. Determine yield of respondent-driven sampling (RDS) for pilot participant recruitment
Aim 2. Develop training materials for peer facilitation of the IMAGINE intervention
Summary of findings
IMAGINE intervention design
In year 1, we completed formative interviews with 10 perinatal youth and 6 healthcare providers in Washington, Colorado, Michigan, Rhode Island and Texas. Findings of these interviews and design recommendations for IMAGINE are summarized in Figure 1 (Gewali et al. 2021).
Based on these findings, we designed the IMAGINE intervention to be delivered through the Slack messaging platform. We adapted the Mothers and Babies (MB) in-person course to text messages, graphics, pre-recorded facilitator videos and optional weekly video calls. The group was facilitated by a social worker and lasted 10-12 weeks. We incorporated COVID-19-related content into the MB curriculum and in reference materials.
IMAGINE pilot
We piloted the intervention among participants who were age 16-24, pregnant or ≤180 days postpartum, had daily access to a smartphone and could read and write in English. Participants who reported elevated depression symptoms (PHQ-9≥10) were excluded from the pilot and referred to individual care. Participant flow is outlined in Figure 2. From outreach by paid social media advertisements, healthcare provider partners and respondent-driven sampling, 68 individuals contacted the study. Most of these participants either did not complete screening or were ineligible. Key barriers were reaching the participant to complete eligibility screening and ineligibility due to elevated depression symptoms. Contrary to our expectations, respondent-driven sampling did not yield gains in recruitment. Ten participants enrolled in the study, in two groups. Nine completed 12-week follow-up.
Of the 9 participants who completed follow-up, all reported they would recommend IMAGINE to a friend. Participant engagement in the different aspects of the intervention is summarized in Figure 3. Participants sent a median of 7 messages and joined a median of 9% of video calls over the course of the intervention. At exit, they reported they used a median of 7 of 11 core MB skills at least half the time.
In qualitative exit interviews, participants shared that IMAGINE had helped normalize participants’ challenges and supported them to develop skills to manage their moods:
“[IMAGINE] helped me just understand that my emotions were normal… Before I felt like I was broken or I needed to be fixed or there’s something wrong with me. And now… there’s nothing wrong with me. [I’m] normal.”
“You get support from people your age and y’all got the same type of stuff going on, so it’s kind of like… you’re not alone.”
“Now I’m able to identify if I’m having a frustrating day. I use one of the strategies, and I’m able to calm myself down and actually realize what is going on… and help with my frustration.”
Next steps
At the end of the pilot, we developed a facilitation guide that can be used by peers or mental health professionals to deliver the intervention. Based on these materials and the preliminary data generated by the TAM award, we have applied for an NIH R34 to define a model of delivery of IMAGINE in the context of existing healthcare systems and perform a pilot randomized controlled trial of the intervention.
Year 2, Quarter 3
Briefly restate the specific aims or objectives associated with this project
Year 2
Aim 1. Adapt the IMAGINE intervention in response to the COVID-19 epidemic.
1a. Explore the impact of the COVID-19 epidemic on peripartum youth’s mental health
1b. Develop COVID-19-related content for inclusion in the IMAGINE pilot intervention
1c. Determine yield of respondent-driven sampling (RDS) for pilot participant recruitment
Aim 2. Develop training materials for peer facilitation of the IMAGINE intervention
Summarize what was accomplished with regard to these aims in the present quarter.
In the last quarter, we completed our first IMAGINE group pilot. Seven youth participated in the group. Three have completed exit visits, including quantitative evaluation of mental health and intervention effect, as well as qualitative interviews exploring experiences of the intervention and recommendations for improvement. The remaining 4 exit visits are currently being scheduled. Participants requested that the Slack group continue after the study was over, so administrative privileges were granted to a member of the group who volunteered for the role. All members of the IMAGINE study team exited the group.
Analysis of data from this group is ongoing. All participants exhibited some level of engagement, in the form of messaging in the group channels, joining a weekly Zoom call, or responding to individual mood polls and reflection questions. One participant stopped engaging and uninstalled the application after 6 weeks. Early feedback suggests Group 1 participants found the intervention acceptable and useful, and several expressed that they wished it could last longer. Different participants reported finding different aspects of the platform most engaging. Some reported the optional weekly Zoom calls were a highlight and facilitated connection-building with peers. Others reported video calls were challenging to join and that opportunities to individually reflect and track their mood were most useful.
In addition to the 7 participants in Group 1, we enrolled 3 participants who remain enrolled in a second pilot group. Messaging in Group 2 began on February 2, 2021. To date, this group has been much less interactive than Group 1, which may be explained by the smaller group size (3 compared with 7).The intervention is scheduled to end in early May, 2021.
Year 2, Quarter 2
Summarize what was accomplished with regard to these aims in the present quarter.
In the last quarter, we proceeded with recruitment for the IMAGINE pilot. We have continued conducting outreach with healthcare facilities and community organizations in WA, PA and TX, as well as running paid posts on Instagram and Facebook. We have been contacted by 60 interested youth, primarily recruited through social media, with 2 recruited through RDS referral from an enrolled participants. We have screened 19 for eligibility. Ten were eligible and 7 have enrolled in the study. All 7 are in one IMAGINE group on Slack and messaging began December 7, 2020.We have submitted a manuscript presenting findings from formative interviews and how they informed the process of adapting the Mothers and Babies curriculum to develop the IMAGINE intervention.The article is currently under peer review; a pre-print can befound at https://preprints.jmir.org/preprint/26188.
Year 2, Quarter 1
Summarize what was accomplished with regard to these aims in the present quarter.
In the last quarter, we finalized the IMAGINE intervention, including adaptation of the Mothers and Babiescurriculum on which IMAGINE is based, as well as developing COVID-19 related content. Our intervention delivers the 6 Mothers and Babies modules through daily messages, interactive prompts, and reflection exercises designed to last 6-12 weeks. Adapting Mothers and Babies content involved shortening content and making it less wordy and more visual, in order to retain participants’ attention when using a remote platform and cater to their younger age.We are in the process of preparing a manuscript summarizing the adaptation process that led to development of IMAGINE.
We have created a separate channel in Slack, the intervention platform, for COVID-19 related messaging. COVID-19-related messages will be posted in a channel named “ask an expert” once per week or as requested by participants. These messages include simple messages summarizing current guidelines for prenatal care, delivery, and neonatal care to mitigate risks of COVID-19, and linking to online and social mediasources of information.
We began recruitment for the IMAGINE pilot in September 2020, and have been in contact with 10 potential participants.To date, one participant has been screened for eligibility to participate in the study.
Quarter 4
Briefly restate the specific aims or objectives associated with this project
Aim 1: To develop a social media group counseling intervention to prevent perinatal depressive symptoms in adolescents in the Seattle, WA, area.
Aim 2: To evaluate the intervention’s uptake, acceptability, and preliminary impact on mental wellness in a pilot with pregnant adolescents.
Aim 3: To characterize content and patterns of participant engagement with the intervention and identify associations between engagement, content, and mental wellness.
Briefly summarize (3-5 sentences) what was accomplished with regard to these aims in the present quarter.
In the last quarter, we analyzed data from the first round of formative interviews and began developing intervention content. Both youth and providers supported the idea of a phone-based facilitated peer group to support youth’s peripartum mental health. However, they highlighted that many aspects of youth’s lives impact their mental health, such as navigating benefits programs, getting answers to pregnancy- related medical concerns, relationship challenges – and they desire a safe, anonymous space for holistic support. This shaped our choice of delivery platform for the IMAGINE study: we are planning to use Slack, since it offers multiple channels for different topics and provides anonymity.
In what way did your project provide opportunities for training or professional development?
The PI has been able to deepen her skills in intervention development and mental healthcare provision by working collaboratively with a psychiatrist and behavioral scientist. Additionally, the logistical challenges associated with conducting this study with a marginalized population at a time of severe healthcare system disruption provided opportunities for the team to develop new community relationships and approaches to recruitment.
Quarter 3
Tell us about key learnings you’ve uncovered over the course of your project, including advice you might give to investigators conducting similar work.
We are learning a lot about the challenges of reaching youth participants through clinical settings, especially our target population which is generally underserved, vulnerable, and has historical mistrust of the medical system. Of the approaches we have explored, we’ve found old-fashioned, in-person, community-based recruitment through trusted networks (public health nurses with long-term relationships with their clients, and youth peers) to be the most successful means of recruiting. We’re also re-learning the importance of bringing youth into our study team (a value we know the TAM community embraces) – and also how challenging it is to build the connections necessary to do that in the first place.
Quarter 2
Tell us about the anticipated or real-time impact of this project.
We anticipate that completion of these aims will generate insights about young mothers’ mental health support needs and preferences with respect to use of social media platforms. It will also generate a social media intervention based on the Mothers and Babies program that can be used by others in the community. Completing the pilot will provide preliminary data on the acceptability and impact of the intervention on young women’s mental health, which will allow us to pursue larger scale funding for evaluation of efficacy.
Tell us about problems encountered, changes to your approach, and reasons behind these changes.
Three of our partner clinics have been distributing flyers to recruit youth but we have not been contacted by any youth participants so far. We are in the process of discussing this with the clinics to identify and address potential barriers and additional venues. We are also exploring recruiting through Facebook and Instagram, and plan to seek advice from our community advisory board. We welcome suggestions from SMAHRT and the TAM community to recruit young mothers.
Quarter 1
Tell us what excites you about the funded project.
Everyone on the team cares deeply about maternal mental health disparities, but this project represents a new research direction and new collaborations for us. The PI’s previous work has involved development and evaluation of social media interventions for adolescents in Kenya, and we are thrilled to combine lessons learned from that work with the expertise of the other team members to create new partnerships and projects in a new area. We especially value the opportunity to collect detailed formative data from the young women we aim to serve to deepen our understanding and drive development of a responsive intervention.
Tell us more about your team!
Keshet Ronen, Clinical Assistant Professor, Department of Global Health, University of Washington: Keshet holds a PhD in cell and molecular biology but realized as a PhD student that her true passion lay in doing research that addresses global health disparities. Outside of work, Keshet enjoys spending time outside – hiking in the mountains of the Pacific Northwest, riding her bicycle around Seattle, and protecting her backyard chickens from hawk attacks.
Jennifer Unger, Assistant Professor, Departments of Global Health and Obstetrics and Gynecology, University of Washington: Jennifer is an obstetrician-gynecologist and clinical researcher focusing on the utilization of novel technologies and behavioral interventions to improve global maternal child health and family planning. Outside of work, Jennifer enjoys traveling, cooking, and spending time outdoors with her family.
Amritha Bhat, Assistant Professor, Department of Psychiatry and Behavioral Science, University of Washington: Amritha is a psychiatrist whose clinical practice and research focus on the mental health of pregnant and postpartum women. Outside of work, she enjoys bicycling and listening to music.
Yolanda Evans, Associate Professor, Department of Pediatrics, University of Washington and Seattle Children’s Hospital: Yolanda is an adolescent medicine physician who provides care to adolescents in the Seattle area for a variety of concerns including eating disorders, obesity, reproductive health and ADHD. Outside of work, Yolanda plays the cello, is a regular blood donor and is involved with her children’s schools.
Elise Healy, Research Assistant, Department of Global Health, University of Washington: Elise Healy is a second-year Master of Public Health student in the Department of Global Health at the University of Washington. Outside of work, Elise enjoys exploring art museums, cooking new recipes, spending time outdoors, and making block prints.