Implementation of the 'Healthy Moms, Healthy Kids' Program in Head Start: An Application of the RE-AIM QuEST Framework Centering Equity
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| Title: | Implementation of the 'Healthy Moms, Healthy Kids' Program in Head Start: An Application of the RE-AIM QuEST Framework Centering Equity |
|---|---|
| Language: | English |
| Authors: | Abigail Palmer Molina (ORCID |
| Source: | Administration and Policy in Mental Health and Mental Health Services Research. 2024 51(1):69-84. |
| Availability: | Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ |
| Peer Reviewed: | Y |
| Page Count: | 16 |
| Publication Date: | 2024 |
| Document Type: | Journal Articles Reports - Research |
| Descriptors: | Program Implementation, Depression (Psychology), Health Services, Mental Health, Mothers, Health Behavior, Minority Groups, Program Effectiveness, Access to Health Care, Hispanic Americans, African Americans, Group Therapy, Barriers |
| DOI: | 10.1007/s10488-023-01312-8 |
| ISSN: | 0894-587X 1573-3289 |
| Abstract: | Background: Marginalized mothers are disproportionately impacted by depression and face barriers in accessing mental health treatment. Recent efforts have focused on building capacity to address maternal depression in Head Start; however, it is unclear if mental health inequities can be addressed by two-generation programs in Head Start settings. Therefore, this study examined the implementation outcomes and processes of a two-generation program called "Healthy Moms, Healthy Kids" (HMHK) that provided an evidence-based depression treatment to ethnic minority Head Start mothers. Method: Quantitative and qualitative data were collected and merged in a convergent mixed method design in accordance with the RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework. Qualitative data included interviews with 52 key stakeholders, including intervention participants and staff members, and 176 sets of meeting minutes from the implementation period. Quantitative data included intervention study data and administrative data. Results: It was difficult for HMHK to reach the target population, with only 16.8% of eligible mothers choosing to participate. However, mothers who participated experienced reductions in depressive symptoms and parenting stress and shared a variety of positive impacts in interviews. The program was also more successful in enrolling Latinx mothers who were Spanish-speaking or bilingual rather than English-speaking and Black/African American mothers, limiting its reach. Conclusion: Providing IPT therapy groups was effective in reducing maternal depressive symptoms and stress for those who enrolled, but additional work should focus on reducing barriers to participation, considering other delivery models to meet participants' needs, and identifying culturally relevant ways to meet the needs of Black mothers. |
| Abstractor: | As Provided |
| Entry Date: | 2024 |
| Accession Number: | EJ1434381 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwG96cI2gQCtbvZfKTgx62O1AAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDMBMlK-0P6fQThuR-wIBEICBmnXzGsiyN7g13-pRa64A6H116Qz0xfIY93rY1sWuM7vBatH_DJhQQmg7-Rg_y-PTOiJYuWESY0rEG7vQYYkytm2VjIE_94nyLQ-ePhZiYlipyun0-4AY5aCAT6mcAuayJeKqIeuurnL396aLZ3aNeuCWvWl8AIeg5_8FFaXB1dgh5nSqAXkz84_MpF4yi9DubTIxqjDcWNVMsVI= Text: Availability: 1 Value: <anid>AN0174817609;[1xdo]01jan.24;2024Jan18.05:04;v2.2.500</anid> <title id="AN0174817609-1">Implementation of the "Healthy Moms, Healthy Kids" Program in Head Start: An Application of the RE-AIM QuEST Framework Centering Equity </title> <p>Background: Marginalized mothers are disproportionately impacted by depression and face barriers in accessing mental health treatment. Recent efforts have focused on building capacity to address maternal depression in Head Start; however, it is unclear if mental health inequities can be addressed by two-generation programs in Head Start settings. Therefore, this study examined the implementation outcomes and processes of a two-generation program called "Healthy Moms, Healthy Kids" (HMHK) that provided an evidence-based depression treatment to ethnic minority Head Start mothers. Method: Quantitative and qualitative data were collected and merged in a convergent mixed method design in accordance with the RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework. Qualitative data included interviews with 52 key stakeholders, including intervention participants and staff members, and 176 sets of meeting minutes from the implementation period. Quantitative data included intervention study data and administrative data. Results: It was difficult for HMHK to reach the target population, with only 16.8% of eligible mothers choosing to participate. However, mothers who participated experienced reductions in depressive symptoms and parenting stress and shared a variety of positive impacts in interviews. The program was also more successful in enrolling Latinx mothers who were Spanish-speaking or bilingual rather than English-speaking and Black/African American mothers, limiting its reach. Conclusion: Providing IPT therapy groups was effective in reducing maternal depressive symptoms and stress for those who enrolled, but additional work should focus on reducing barriers to participation, considering other delivery models to meet participants' needs, and identifying culturally relevant ways to meet the needs of Black mothers.</p> <p>Keywords: Maternal Depression; Group Psychotherapy; Interpersonal Psychotherapy; Implementation Science; RE-AIM; racial/ethnic Minorities</p> <p>Copyright comment Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</p> <hd id="AN0174817609-2">Introduction</hd> <p>Depression is a significant public health concern impacting mothers during the early childhood years, with research consistently documenting negative impacts on child health and development (Goodman et al., [<reflink idref="bib32" id="ref1">32</reflink>]; Kingston &amp; Tough, [<reflink idref="bib35" id="ref2">35</reflink>]; Sutherland et al., [<reflink idref="bib58" id="ref3">58</reflink>]). Although most research focuses on maternal depression during the perinatal period, studies show that maternal mental health difficulties can persist into the early childhood years (van der Waerden et al., [<reflink idref="bib59" id="ref4">59</reflink>]; Woolhouse et al., [<reflink idref="bib61" id="ref5">61</reflink>]) and continue to be associated with developmental concerns for children as they grow (van der Waerden et al., [<reflink idref="bib60" id="ref6">60</reflink>]).</p> <p>Higher maternal depression rates have also been associated with factors like poverty and being from an ethnic minority background (Ertel et al., [<reflink idref="bib25" id="ref7">25</reflink>]; Oh et al., [<reflink idref="bib43" id="ref8">43</reflink>]; Rahman, [<reflink idref="bib52" id="ref9">52</reflink>]). For example, one study found that 52% of mothers endorsed clinical levels of depressive symptoms in Early Head Start, a program for families living under the federal poverty level (Early Head Start Research and Evaluation Project, [<reflink idref="bib23" id="ref10">23</reflink>]). This raises concerns about how to intervene to best support maternal and family well-being throughout the early childhood period for marginalized mothers and their young children.</p> <p>Although there are several evidence-based interventions for depression (Cuijpers et al., [<reflink idref="bib21" id="ref11">21</reflink>]), low-income and ethnic minority populations continue to face challenges in accessing and benefiting from mental health services in general. For example, in a nationally representative study conducted in the United States, all racial and ethnic minority groups were significantly less likely than non-Latino whites to receive access to any mental health treatment for depression (Alegría et al., [<reflink idref="bib3" id="ref12">3</reflink>]). Studies also show that low-income and ethnic minority mothers have difficulty accessing mental health services, particularly those that are high quality (Anderson et al., [<reflink idref="bib6" id="ref13">6</reflink>]; England &amp; Sim, [<reflink idref="bib24" id="ref14">24</reflink>]; Kallem et al., [<reflink idref="bib34" id="ref15">34</reflink>]; McDaniel &amp; Lowenstein, [<reflink idref="bib39" id="ref16">39</reflink>]). For example, a study of mothers of children from birth to age 6 found that more than a third of mothers who met criteria for major depression had neither used prescription medication nor received therapy for their depression in the past year (McDaniel &amp; Lowenstein, [<reflink idref="bib39" id="ref17">39</reflink>]). In addition, insured status played a large role in this disparity, since nearly half of mothers without health insurance did not receive treatment for major depression, compared to one-third of the mothers with insurance (McDaniel &amp; Lowenstein, [<reflink idref="bib39" id="ref18">39</reflink>]).</p> <p>Recently, innovative two-generation approaches have focused on supporting early childhood health and development by identifying depressed mothers and embedding mental health services for parents in public child-serving settings, including settings like early childhood education, home visiting, and pediatrics (Buka et al., [<reflink idref="bib14" id="ref19">14</reflink>]; Perry &amp; Conners-Burrow, [<reflink idref="bib49" id="ref20">49</reflink>]). For example, several efforts have focused on building capacity to address maternal depression in Head Start, including providing mental health services for mothers with subclinical symptoms and those meeting criteria for depression (Beardslee et al., [<reflink idref="bib9" id="ref21">9</reflink>]; Palmer Molina et al., [<reflink idref="bib46" id="ref22">46</reflink>], [<reflink idref="bib47" id="ref23">47</reflink>]; Silverstein et al., [<reflink idref="bib56" id="ref24">56</reflink>], [<reflink idref="bib57" id="ref25">57</reflink>]). However, questions remain about whether two-generation mental health programs are scalable in Head Start, as well as about the barriers and facilitators to successful implementation in community-based Head Start settings.</p> <p>Implementation research shows that simply disseminating efficacious interventions does not ensure successful implementation in under-resourced community settings (Damschroder et al., [<reflink idref="bib22" id="ref26">22</reflink>]). Instead, there are multiple factors related to consumer preferences, agency settings, and the larger funding and policy environments that impact the ultimate adoption of interventions (Aarons et al., [<reflink idref="bib1" id="ref27">1</reflink>]; Damschroder et al., [<reflink idref="bib22" id="ref28">22</reflink>]; Greenhalgh et al., [<reflink idref="bib33" id="ref29">33</reflink>]). Within mental health services, Alegría et al. ([<reflink idref="bib4" id="ref30">4</reflink>]) found that obstacles to service use for ethnic and racial minority populations included difficulty navigating service systems, transportation barriers, time demands, billing restrictions, and a lack of linguistic and cultural competence. Studies have shown that additional factors impeding mental health service utilization among low-income mothers include stigma, lack of trust in formal systems, and poor fit with clients' cultural beliefs (Anderson et al., [<reflink idref="bib6" id="ref31">6</reflink>]; Caplan &amp; Whittemore, [<reflink idref="bib15" id="ref32">15</reflink>]).</p> <p>The field of implementation science has long been focused on promoting the reach of evidence-based interventions and programs so that more families and communities can benefit. However, in recent years there has been a call to integrate implementation science more clearly with efforts to address health equity, especially in terms of racial and ethnic equity (Baumann &amp; Cabassa, [<reflink idref="bib8" id="ref33">8</reflink>]; Chinman et al., [<reflink idref="bib16" id="ref34">16</reflink>]). Baumann and Cabassa ([<reflink idref="bib8" id="ref35">8</reflink>]) highlight the importance of using an equity lens in assessing implementation outcomes, particularly inequities in feasibility, penetration, acceptability, and uptake of evidence-based interventions.</p> <hd id="AN0174817609-3">The Current Study</hd> <p>The current study used the "Reach, Effectiveness, Adoption, Implementation, and Maintenance" (RE-AIM) Framework to assess the implementation outcomes of a two-generation maternal mental health intervention that was implemented in Head Start using an equity lens. RE-AIM was developed to evaluate implementation effectiveness across several important domains and enables researchers to evaluate the public health impact of an intervention, rather than just examining the effectiveness of the intervention itself (Glasgow et al., 1999). This framework also highlights important factors that help illuminate why an intervention succeeded or failed in making its desired impact. A systematic review of the RE-AIM framework reported that it has been used in over 71 empirical articles in multiple fields (Gaglio et al., [<reflink idref="bib28" id="ref36">28</reflink>]), and its usage continues to grow.</p> <p>The RE-AIM framework focuses on evaluating the following domains: (<reflink idref="bib1" id="ref37">1</reflink>) "Reach," which refers to the proportion and characteristics of persons who received care, (<reflink idref="bib2" id="ref38">2</reflink>) "Effectiveness," which refers to the positive and negative outcomes of a program, (<reflink idref="bib3" id="ref39">3</reflink>) "Adoption," which refers to the proportion and representativeness of settings that adopt a program, (<reflink idref="bib4" id="ref40">4</reflink>) "Implementation," which refers to how well the intervention was delivered as intended, and (<reflink idref="bib5" id="ref41">5</reflink>) "Maintenance," which refers to the extent to which a program is sustained in a given setting over time (Glasgow et al., 1999). More recently, the RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework was developed to leverage both quantitative and qualitative data in a structured, organized framework to more fully evaluate RE-AIM implementation outcomes (Forman et al., [<reflink idref="bib27" id="ref42">27</reflink>]). In this study, the RE-AIM QuEST framework was used to assess the five implementation outcomes using an equity lens to identify factors that influenced implementation of the intervention.</p> <hd id="AN0174817609-4">Methods</hd> <p></p> <hd id="AN0174817609-5">Study Design</hd> <p>For the purposes of examining the implementation effectiveness of the program, quantitative and qualitative data were drawn from various sources and merged in a convergent mixed method design (Creswell &amp; Plano Clark, [<reflink idref="bib19" id="ref43">19</reflink>]). Data collection, analysis, and integration were guided by the RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework (Forman et al., [<reflink idref="bib27" id="ref44">27</reflink>]). The RE-AIM QuEST framework seeks to assess implementation effectiveness by utilizing the quantitative data to report on the outcomes in each of the 5 domains (the "what") and the qualitative data to provide explanations for these outcomes (the "why"). However, the current study adds to the RE-AIM QuEST framework by utilizing both qualitative and quantitative data when available to evaluate each RE-AIM outcome (the "what") using methodological triangulation, in addition to utilizing qualitative data to explain "the why". In this way, quantitative and qualitative data are used to assess implementation outcomes more fully and investigate convergent and divergent findings.</p> <hd id="AN0174817609-6">Intervention and Setting</hd> <p>The "Healthy Moms, Healthy Kids" (HMHK) program (Mennen et al., [<reflink idref="bib40" id="ref45">40</reflink>]) consisted of two major components: (<reflink idref="bib1" id="ref46">1</reflink>) instituting a universal depression screening program for all Head Start mothers, and (<reflink idref="bib2" id="ref47">2</reflink>) providing an adapted group intervention for mothers with elevated depressive symptoms. This paper reports on the implementation outcomes for the group mental health intervention. Outcomes focused on the implementation of universal maternal depression screening are reported elsewhere (Palmer Molina et al., [<reflink idref="bib45" id="ref48">45</reflink>]).</p> <p>The HMHK program provided a gold standard maternal depression intervention to Head Start mothers in the hopes of improving both maternal and child well-being. As part of the Head Start intake process, staff screened mothers for depression using the 10-item Center for Epidemiology Studies Depression Scale Short Form (CES-D Short Form; Andresen et al., [<reflink idref="bib7" id="ref49">7</reflink>]). A cutoff score of 8 was used to indicate that the participant met criteria for mild depressive symptoms. Mothers at the targeted sites who scored above 8 on the CES-D were then referred by a Head Start Family Service Worker (FSW) to participate in the intervention, Interpersonal Psychotherapy-Group (IPT-G).</p> <p>IPT-G was originally developed by Reay (2006) for women experiencing depression during the perinatal period. In this study, an adapted version of IPT-G was tested with mothers of Head Start children, whose ages ranged from 3 to 5 years old. IPT-G is a brief treatment that focuses on addressing interpersonal conflict, grief and loss, and role transitions that can contribute to heightened psychological distress, and it has been found to be effective in community practice settings (Reay et al., [<reflink idref="bib53" id="ref50">53</reflink>]). For this study, IPT-G was extended from 8 to 12 weekly sessions, and food, transportation, and childcare were provided to address potential barriers to participation. Therapy groups were also held at Head Start sites to facilitate participation and trust. See Mennen et al., ([<reflink idref="bib40" id="ref51">40</reflink>]) for more details regarding the intervention.</p> <p>The HMHK program was implemented within a large social service agency in a major metropolitan area that provides a range of child and family services, including early childhood education programs (e.g., Head Start), home visiting programs, outpatient, intensive, and school-based Medicaid-funded mental health services, support programs for fathers, family preservation services, and community awareness campaigns. The agency's mental health services are publicly funded. Within the organization, Head Start programs and mental health services are managed as separate departments, and there have been changes over time in terms of whether the lead agency administrator oversees both programs. At the time this study was conducted, Head Start services and mental health services were overseen by different agency leaders.</p> <hd id="AN0174817609-7">Evaluation Participants</hd> <p>This study included a variety of key informants (<emph>n</emph> = 52), including intervention participants and staff members at different levels of the organization who were involved in implementation. Mothers who did not choose to participate in IPT-G were also invited to participate in interviews, but none consented. Staff members included HMHK therapists who ran groups and agency leadership involved in overseeing the study's implementation. All potential informants were contacted and recruited into this study due to its small scale and concerns about staff turnover. All mothers who participated in the intervention were invited to participate (<emph>n</emph> = 49), and the 26 who consented were interviewed. The PI interviewed 5 of the 12 front-line therapists who conducted IPT therapy groups; the other 7 therapists had left the agency. All supervisors and managers who were involved in the project's implementation were interviewed (<emph>n</emph> = 3). All participants provided informed consent in accordance with the University of Southern California Institutional Review Board and received a $40 gift card for their participation.</p> <hd id="AN0174817609-8">Data Collection</hd> <p></p> <hd id="AN0174817609-9">Quantitative Data Collection</hd> <p>Quantitative data included intervention study data and de-identified administrative data from the implementing agency's database of families served across its Head Start sites in South Los Angeles, as well as internal agency records documenting staff training and retention. All data was de-identified to protect the identities of Head Start families, intervention participants, and agency staff.</p> <p>First, quantitative impact data were gathered as part of the parent study. Both maternal and child outcomes were measured. Maternal outcomes included depressive symptoms (CES-D; Radloff, [<reflink idref="bib51" id="ref52">51</reflink>]), parenting stress (Parenting Stress Index-Short Form; Abidin, [<reflink idref="bib2" id="ref53">2</reflink>]), parent report of parenting attitudes (Parenting Behavior Inventory, Lovejoy et al., [<reflink idref="bib37" id="ref54">37</reflink>]), observed parenting behaviors (Keys to Interactive Parenting Scale; Comfort &amp; Gordon, [<reflink idref="bib17" id="ref55">17</reflink>]), etc. For more information about the maternal measures used, see Mennen et al. ([<reflink idref="bib40" id="ref56">40</reflink>]). Child outcomes included parent report of behavior problems (Eyberg Child Behavior Inventory, Eyberg &amp; Pincus, [<reflink idref="bib26" id="ref57">26</reflink>]), and observational measures of school readiness (Bracken School Readiness Assessment–3rd Edition, Bracken, [<reflink idref="bib11" id="ref58">11</reflink>]) and executive functioning (Dimensional Change Card Sort, Zelazo, [<reflink idref="bib64" id="ref59">64</reflink>]). For more information about the child measures used, see Palmer Molina et al. ([<reflink idref="bib44" id="ref60">44</reflink>]).</p> <p>Second, administrative data were gathered regarding the population of Head Start mothers served through the agency's primary contracts in South Los Angeles, including maternal age and race/ethnicity. Administrative data included the number and background of mental health staff that were trained in IPT-G and staff turnover among frontline staff. Third, quantitative data included the number of mothers who completed the therapy group versus those who dropped out.</p> <hd id="AN0174817609-10">Qualitative Data Collection – Interviews</hd> <p>The PI and research team conducted semi-structured individual interviews with mothers who participated in therapy groups as well as the staff involved in implementation. For intervention participants, an interview guide was developed based on existing studies that qualitatively assessed RE-AIM outcomes, consumer satisfaction, program feasibility, and outcomes for adaptations of IPT with other populations (Brandon et al., [<reflink idref="bib12" id="ref61">12</reflink>]; Bransford &amp; Choi, [<reflink idref="bib13" id="ref62">13</reflink>]). The complete interview guide is included in an appendix. Interviews with intervention participants lasted 45 min on average and were conducted in-person at the individual's home or another location.</p> <p>The PI also developed semi-structured interview guides for staff interviews based on the domains listed in the RE-AIM QuEST framework to evaluate implementation effectiveness for the overall program and discuss barriers and facilitators to implementation. Four separate interview guides were created from this template to cater to specific staff roles. The complete interview guide is included in the Appendices. Each of the staff interviews was conducted at the appropriate organizational site and lasted 30–60 min, depending on the staff member's role.</p> <hd id="AN0174817609-11">Qualitative Data Collection – Meeting Minutes</hd> <p>The PI also aggregated meeting minutes that were recorded during 176 team meetings over the implementation period, beginning in November 2013 and ending in September 2018. Meeting minutes were recorded weekly or biweekly by a research assistant.</p> <hd id="AN0174817609-12">Measures</hd> <p>Table 1 illustrates how each of the RE-AIM outcomes was assessed, including the source of quantitative and/or qualitative data for each indicator. Measures of "Reach" typically include quantitative data reporting the number, proportion, and representativeness of eligible clients enrolled in an intervention (Holtrop et al., 2018). We also utilized qualitative data to provide complementary information about the number, proportion, and representativeness of clients, and also the factors that influenced "Reach," including the individual and family-level barriers and facilitators that impacted mothers' participation in IPT groups. Measures of "Effectiveness" typically include quantitative measures reporting intervention effects on targeted outcomes (Forman et al., [<reflink idref="bib27" id="ref63">27</reflink>]). We report overall intervention outcomes and outcomes broken down by race/ethnicity and examined attendance in group IPT sessions.</p> <p>We also utilized qualitative data to assess mothers' perceptions of the intervention's impact on maternal functioning and parenting and to understand factors that influenced "Effectiveness," including the conditions and mechanisms that led to effectiveness, factors that explain variation in outcomes, and further adaptations that are needed to improve effectiveness. The domain of "Adoption" typically assesses the proportion of sites and staff members that participate in an intervention, as well as elucidating reasons for adoption or lack of adoption (Holtrop et al., 2018).</p> <p>The domain of "Implementation" typically assesses the consistency of implementation across different sites and settings, fidelity to key elements of the intervention, and whether adaptations were made to the implementation strategy (Holtrop et al., 2018). To assess "Implementation" of IPT-G we focused on understanding variation in the ways mothers were recruited, enrolled, and retained in therapy groups. We also examined fidelity to the IPT-G model itself; however, in this study quantitative data was not available to assess fidelity. Instead, therapists reported on their adherence to the model in qualitative interviews.</p> <p>Lastly, the domain of "Maintenance" is typically assessed by the number and proportion of staff continuing to implement the intervention after the study period has ended (Holtrop et al., 2018). We assessed the number of IPT groups continuing after the study ended and utilized qualitative data to elucidate the barriers to maintaining the HMHK program.</p> <hd id="AN0174817609-13">Data Analysis</hd> <p></p> <hd id="AN0174817609-14">Quantitative Data Analysis</hd> <p>Quantitative data were gathered for each RE-AIM domain (see Table 1) and analyzed in SPSS 27.0. For "Reach," univariate statistics were calculated to describe rates of participation in IPT therapy groups. Subsequently, bivariate comparisons using t-tests and chi-square tests were conducted to compare IPT therapy group participants and non-participants. Post-hoc tests that accounted for multiple comparisons were used to assess significant pairwise differences. Lastly, univariate statistics were calculated to describe maternal age and race/ethnicity and compared to demographics for IPT group participants.</p> <p>For "Effectiveness," intervention effects were previously assessed using linear mixed-effect models and details regarding the analysis strategy are presented elsewhere (Mennen et al., [<reflink idref="bib40" id="ref64">40</reflink>]). Intervention effects were assessed for both maternal outcomes (depressive symptoms, parenting stress, social support, etc.) and child outcomes (school readiness, behavior problems, executive functioning). In addition, the average change in depressive symptoms pre- to post-intervention were also calculated to assess differences in outcomes based on race and ethnicity.</p> <p>For "Adoption," univariate statistics were calculated to assess the proportion of staff trained who then led IPT groups and the proportion of sites that provided IPT groups. For "Implementation," univariate statistics were calculated to describe attendance and group sustainment rates. Subsequently, bivariate comparisons using chi-square tests were conducted to compare IPT-G participation by staff role. Post-hoc tests that accounted for multiple comparisons were used to assess significant pairwise differences. For "Maintenance," the number of participants enrolling in IPT-G after study ended was calculated.</p> <hd id="AN0174817609-15">Qualitative Data Analysis - Interviews</hd> <p>Qualitative interviews with intervention participants and staff members were analyzed using Dedoose, Version 8.3.43. Qualitative data were analyzed in two phases: (<reflink idref="bib1" id="ref65">1</reflink>) inductive coding was conducted to identify key themes emerging from the data, and (<reflink idref="bib2" id="ref66">2</reflink>) deductive coding was conducted subsequently to align data with one of the five domains of the RE-AIM QuEST framework. This coding process was used to ensure that the depth of the qualitative data was captured, and so that data were clearly coded to relevant aspects of the five different implementation outcomes.</p> <p>For the inductive coding process, the PI used "Coding Consensus, Co-occurrence, and Comparison" methodology (Willms et al., 1990). Interviews with frontline staff who conducted depression screening (<emph>n</emph> = 18) and intervention participants (<emph>n</emph> = 26) were analyzed separately. First, the PI and other members of the research team independently coded an initial interview and engaged in open coding to record initial themes. Subsequently, the PI met with the other members of the research team to discuss potential codes, and then prepared a draft codebook outlining codes, definitions, and examples of each code. Third, the PI and members of the research team independently coded 2–3 interviews to calculate a percent agreement on coding as an index of reliability (Boyatzis, 1998). During this process, disagreements in assignment or description of codes were resolved through discussion between the members of the research team and the team collaboratively developed enhanced definitions of codes and added new codes when appropriate. This process continued until the percent agreement of first level codes reached 80%. Based on these codes, the research team then independently coded the remaining interviews, condensing the data into segments of text ranging from a phrase to several paragraphs. Each block of text was assigned codes based on a priori themes from the interview guide and emergent themes, which is called open coding (Corbin &amp; Strauss, 2008).</p> <p>The PI then reviewed the final coding and codes were assigned to describe connections between categories and between categories and subcategories using axial coding methodology (Corbin &amp; Strauss, 2008). (<reflink idref="bib6" id="ref67">6</reflink>) The PI then compared categories to condense them into broader themes (Glaser &amp; Strauss, 1967). For the interviews with therapists who conducted IPT groups (<emph>n</emph> = 5) and leadership involved in implementation (<emph>n</emph> = 3), the PI conducted the inductive analysis individually based on the same process and regularly consulted with a second member of the research team.</p> <p>Once the inductive phase of coding was completed, the PI conducted a second sweep of the data and coded data into the relevant RE-AIM domains. Data could be coded to more than one domain. First, the PI reviewed the final inductive coding tree structure and aligned codes and subcodes under the appropriate RE-AIM dimension(s). Second, the PI re-read all interview transcripts to identify any other information to be coded to any RE-AIM domains.</p> <hd id="AN0174817609-16">Qualitative Data Analysis – Meeting Minutes</hd> <p>Document review (Bowen, [<reflink idref="bib10" id="ref68">10</reflink>]) was used to analyze meeting minutes that tracked the implementation of the HMHK project. Document review was conducted using Dedoose Version 8.3.43 and the PI followed a two-step coding process informed by Wozniak et al. ([<reflink idref="bib62" id="ref69">62</reflink>]). First, the data was deductively coded using the RE-AIM framework; content could be coded to more than one domain. The PI then returned to the data and used an inductive approach informed as described earlier to capture ideas and themes emerging from the data within each of the five domains.[<reflink idref="bib1" id="ref70">1</reflink>]</p> <hd id="AN0174817609-17">Results</hd> <p></p> <hd id="AN0174817609-18">Reach</hd> <p></p> <hd id="AN0174817609-19">Did the Intervention Reach the Target Population?</hd> <p> <emph>Assessing Reach</emph>. Out of a total of 291 eligible mothers who had a positive depression screening at any time during the intervention trial, only 49 proceeded to enroll in an IPT therapy group (16.8% participation rate). Of the positive screens, 31 mothers refused to participate and 210 were unable to be scheduled for a group. In addition, 9 who eventually enrolled in the therapy intervention screened negatively at the first screening encounter and were re-screened at a later time.</p> <p>Analyses showed that IPT therapy group participants, compared to mothers who had a positive depression screening but did not participate in a group, differed significantly by maternal language (English, Spanish, or bilingual, <emph>X</emph><sups>2</sups> (<reflink idref="bib2" id="ref71">2</reflink>, N = 536) = 9.65, p &lt; 0.05), but not in terms of maternal or child age (see Table 2). Post-hoc analyses revealed that English-speaking mothers were significantly less likely to participate in IPT therapy groups compared to Spanish-speaking or bilingual mothers, which is also reflected in the groups that were conducted. Of the 10 therapy groups, 7 were conducted in Spanish.</p> <p>We also compared the intervention group demographics with the larger population of Head Start mothers served by the agency partner's primary contracts in South Los Angeles. Findings showed that the overall population of Head Start mothers in South Los Angeles were 79% Hispanic/Latino and 20% Black or African American, whereas only 10% of mothers enrolled in the study's intervention group were Black or African American, and 90% were Hispanic/Latino.</p> <p> <emph>Factors Impacting Reach</emph>. Qualitative data provided more information about the target population and barriers and facilitators to participation in IPT groups. First, meeting minutes chronicled discussions around the target population, showing that the implementation team re-examined the clinical cut-off used on the depression screening measure, eventually deciding to reduce the cut-off from 10 to 8 to capture mothers who did not meet the cut-off for depressive symptoms but still experienced mild symptoms that could negatively impact child functioning.</p> <p>Qualitative interview data also revealed several barriers and facilitators to participation in therapy groups for mothers. For example, the most endorsed barriers included stigma, scheduling issues, too many competing needs including caring for children, location, and waiting for a new therapy group to start. One mother shared the reality of having several competing needs:I'd forget things easily with having to go to therapy and having to wait for someone to take me on certain occasions. Therefore, timing and sometimes running around to pick up the children from school. Being sick doesn't mean that obligations are out of the way. Your obligation is to feed your kids even if you're dying. [laughs] If you don't do it, who else will?Mothers and staff members also reflected on the facilitators that promoted participation and engagement in IPT therapy groups. The most highly endorsed facilitator was having a strong family connection to either the partner agency or Head Start, which was also named as a facilitator for participation in maternal depression screening. One mother explains:I had a feeling that I was experiencing those symptoms, but I think it was the first time I've suffered from depression, which was intense at the time. So, I didn't understand, and I didn't know what depression was... Teachers at school were also aware and they saw a change in me; that I wasn't the same. I'm very grateful to them that they worried not just for the children but also for the parents because if parents aren't doing well, neither are their kids.Additional facilitators included using non-stigmatizing language when advertising the group and having group therapists conduct both the depression screening and intake to the group. Several therapists noted that the mothers who ended up participating in their groups were mothers that they themselves had screened.</p> <hd id="AN0174817609-20">Effectiveness</hd> <p></p> <hd id="AN0174817609-21">Did the Intervention Accomplish its Goals?</hd> <p> <emph>Assessing Effectiveness.</emph> Quantitative treatment outcomes reported in greater detail elsewhere (Mennen et al., [<reflink idref="bib40" id="ref72">40</reflink>]) show that IPT-G was effective in reducing maternal depressive symptoms and parenting stress up to six months post-intervention. Specifically, participants in the treatment group showed a significant decrease in depressive symptoms (β time = − 4.59, <emph>p</emph> &lt; 0.05; <emph>p</emph> for time*group interaction &lt; 0.05) and parenting stress (β time = − 6.77, <emph>p</emph> &lt; 0.05; <emph>p</emph> for time*group interaction &lt; 0.05) over the study period compared to the control group. Comparison of pre- and post-treatment scores in the intervention group showed a clinically significant decrease in depressive symptoms, with CES-D scores declining on average from 20.3 at baseline to 14.4 at the 3-month follow-up, which is below the clinical cutoff for probable Major Depressive Disorder. African American participants experienced an average decline of 6 points on the CES-D, and Latinx/Hispanic participants experienced an average decline of 6.2 points.</p> <p>In terms of intervention impacts, qualitative findings mirrored quantitative findings with mothers reporting that they experienced lower levels of anxiety, stress, and depressive symptoms. Several mothers described feeling a sense of release after the therapy groups:At the end of every meeting that we had I felt that like a big release. Almost like if you would go to the park and jog or run or whatever, I would feel different already. Before you feel heavy, but once the session ends you feel lighter and lighter.</p> <p>Qualitative results also revealed other impacts of the intervention, including improving relationships with partners and other family members and increasing self-awareness and self-care. Several mothers also experienced changes that they identified as fundamental shifts in their character because of their participation:It's things that you don't know, and you walk, and they begin to tell you, step by step what helps, what you can do and we're learning at the same time. I could tell you that it 100% helped me. Yes, honestly when I got there [to the end], I was totally different from before. Totally different person.</p> <p>Although IPT-G reduced maternal depressive symptoms and stress and improved maternal functioning in a variety of areas, quantitative results showed that it did not significantly impact maternal parenting (either maternal self-report of parenting attitudes or observed parenting), children's behavioral problems, children's school readiness skills, or children's executive functioning (Palmer Molina et al., [<reflink idref="bib44" id="ref73">44</reflink>]). However, qualitative data gathered from mothers who participated in the intervention provided a more nuanced picture. For example, several participants shared that the intervention improved their parenting and relationships with their children:There is more trust with my daughters and me. At the time I felt frustrated, and I was very impatient and cranky. Now I've reduced my anger. Before, everything was annoying to me, and I raised my voice.</p> <p> <emph>Factors Impacting Effectiveness</emph>. Qualitative data was also analyzed to assess the conditions and mechanisms that led to the effectiveness of IPT-G, and mothers identified several key factors, including the transformative power of being in community and experiencing emotional safety, processing trauma, loss, and other difficult experiences, developing more effective communication strategies, and having accountability in terms of goal setting. For example, one participant shares what it was like to process a traumatic experience in the group:There was a part about forgiving the people who hurt us. It made me open-up that little box that's been shut down in my heart which I never wanted to open...I cried that day. As the therapist said, I had to open it in order to close it and be at peace with myself.</p> <p>All group participants reported satisfaction with the group modality, with only one participant sharing that she might have preferred individual treatment instead.</p> <p>Mothers and mental health therapists also reflected on further adaptations that could improve the effectiveness of IPT-G. For participants, the most highly endorsed recommendation was to provide more time, both in terms of the length (more sessions) and duration of each session. Mothers also recommended that the group be expanded to mothers of older children, to other Head Start sites and early childhood settings, to fathers, and also suggested incorporating partners in sessions. For example, one mother shared that "it would be important to also include the partners because then we can both learn the same thing." Several mothers also noted that they would have benefited from additional content around parenting and dealing with specific developmental issues. Mental health therapists recommended providing more support services overall, since mothers often needed on-going mental health support or more specialized support in addition to the group.</p> <hd id="AN0174817609-22">Adoption</hd> <p></p> <hd id="AN0174817609-23">To what Extent did those Targeted to Deliver the Intervention Participate?</hd> <p>Adoption of IPT therapy groups was assessed at both the staff level (proportion of staff who led groups) and site level (proportion of Head Start sites that hosted groups), and factors that impacted adoption at each level.</p> <p> <emph>Assessing Staff Adoption.</emph> In terms of mental health staff who led therapy groups, a total of 19 therapists from the mental health and Head Start divisions of the agency were trained in the IPT-G intervention model; 12 (63%) went on to run at least one group. Of these 12, only two were Head Start mental health therapists, and the remainder worked within the outpatient mental health division of the agency. All the therapists were women. In addition, nine of the 12 were bilingual in Spanish and identified as Latina. Among therapists that led groups, the number ranged from one to four groups, and the average was 1.7 groups per therapist.</p> <p> <emph>Factors Affecting Staff Adoption</emph>. Meeting minutes revealed that one of factors impacting staff adoption was Spanish language fluency – since most of interest was from Spanish-speaking Head Start mothers, bilingual mental health therapists were more likely to lead groups. Frontline staff and agency leadership reported two other major factors that negatively impacted staff participation in terms of leading IPT groups, including concerns about staff time/productivity issues and staff turnover. This was particularly salient because the expectation was that two therapists would co-lead each group.</p> <p>Originally, the research team planned that Head Start mental health specialists would lead the IPT groups; however, it became clear early on in implementation that they did not have the capacity. As one agency leader explained:I think the biggest [challenge] was really just kind of that demand on staff time when it wasn't allocated anywhere...It was just like, "Well, we'll just train all the early childhood education staff." And I was like, "Okay, but some of them have caseloads as high as 30 or 40 kids," because the difference with Head Start versus say a DMH-funded program is that we don't have caps on caseloads.</p> <p>Because of this difficulty, mental health therapists from the agency's publicly mental health-funded program were then trained to lead the IPT groups. However, other challenges emerged at this point since these therapists worked in a separate department of the agency and had specific direct service expectations as part of their role in that mental health-focused department. Stakeholders noted that unevenness in agency leadership and support for the program may have been at issue. It was also unclear to some stakeholders whether IPT groups were a reimbursable expense for the majority of the implementation period. Another factor that impacted staff adoption was the high rate of turnover of mental health therapists. Many therapists were trained, but some never led groups because they left the agency.</p> <p> <emph>Assessing Site Adoption.</emph> The study originally planned to provide IPT therapy groups at each of the 25 Head Start sites operated by the partner agency to promote access for parents. However, there were difficulties utilizing Head Start sites where classes were held so adoption by the planned sites was 0%. Instead, all IPT therapy groups were offered at one of two administrative Head Start sites operated by the agency. Neither of these two sites operated Head Start classes, and so all participants were required to travel to an additional location for the group.</p> <p> <emph>Factors Affecting Site Adoption</emph>. Meeting minutes revealed that reported barriers to providing IPT groups at all Head Start sites included space issues, security concerns about holding groups after dark, and Head Start licensing requirements, particularly rules around whether other children like siblings could be present at the site. However, stakeholders had differing opinions about whether licensing and space issues truly represented barriers. Additionally, in some cases there were not enough mothers at each Head Start site to form a group, meaning that they would need to travel to another location to participate.</p> <hd id="AN0174817609-24">Implementation</hd> <p></p> <hd id="AN0174817609-25">To what Extent was the Intervention Consistently Implemented?</hd> <p> <emph>Assessing Implementation.</emph> We examined variation in recruitment for the IPT groups and found that rates of participation in IPT groups differed by which type of staff member conducted the mother's depression screening, <emph>X</emph><sups><emph>2</emph></sups> (<reflink idref="bib2" id="ref74">2</reflink>, _I_N_i_ = 531) = 12.42, <emph>p</emph> &lt; 0.01, see Table 3. Post-hoc analyses revealed that mothers screened by an FSW were significantly less likely to participate in an IPT group compared to those screened by university study staff; there were no differences for agency research staff. Although we were unable to include mental health therapists in this analysis, many therapists reported in qualitative interviews that most of the mothers they screened for depression ended up participating in an IPT group because they had already established a therapeutic relationship.</p> <p>When assessing fidelity to the IPT-G model, therapists shared that they felt the IPT-G training was clear and structured, with different goals for each weekly session. However, there was significant variation in IPT-G implementation in terms of attendance and having enough participants to continue the group for the full 12 sessions. There was significant attrition, with 38.8% of participants completing 1–4 sessions, 34.7% completing 5–8 sessions, and only 26.5% completing 9–12 sessions.</p> <p>Meeting minutes document attendance difficulties over the course of implementation, and common barriers that prevented mothers from attending included interfering work opportunities, medical reasons, family responsibilities, and loss of interest. There were also difficulties recruiting enough mothers to begin English-speaking groups, and overall, there were only 4 English-speaking groups (12 participants total), compared to 6 Spanish-speaking groups (37 participants total). Out of the total of 10 IPT groups, two were eventually cancelled because there were too few participants to continue (including one English-speaking group and one Spanish-speaking group). All of the participants who completed the entire group treatment (finishing between 9 and 12 sessions) identified as Latina.</p> <p> <emph>Factors Affecting Implementation</emph>. Staff members identified several factors influencing implementation of the IPT-G model. For example, they reported that there were difficulties at times with consistency of supervision and consultation for the IPT model, particularly due to delays with starting new groups. In addition, other factors influenced implementation of IPT-G including participant attrition, quality of co-therapist, therapist attitudes, and therapists' prior training in parenting and parent-child interaction, which they infused into the IPT-G model. For example, one therapist reflected on the impact of working with co-facilitators with different training backgrounds:Of the people that I did groups with, one was a very seasoned clinician, and one was a very green clinician...And I think the things that were most impactful were things like, "Do you like groups? Do you have experience running groups?" I think like for my less seasoned clinician, it took a few weeks for her to feel like she could add to the direction or change the direction that we were going in based on what she's hearing in the room instead of checking out to see what the person with more experience says.</p> <p>In addition, therapists noted that there were also several ways that the model was adapted to fit the cultural backgrounds of clients, which was discussed and negotiated with the IPT-G team. For example, one therapist explained:[The IPT trainer] would ask our opinion. He was very understanding and say, "How would that fit in the community that you guys are working with?" Because the community he works with is different than the community we were working with here. He knew that we knew more about the community than he did. He was very flexible and said, "Well, if that's appropriate and if you feel that's okay, then go ahead and change that."</p> <hd id="AN0174817609-26">Maintenance</hd> <p></p> <hd id="AN0174817609-27">To what Extent did the Intervention Become part of Routine Organizational Practices?</hd> <p>Interviews with agency leadership and mental health therapists revealed the IPT-G was only continuing in a limited capacity. One mental health therapist was continuing to provide IPT-G to mothers at the agency, but most clients were mothers whose children were receiving child mental health services rather than mothers of children who were enrolling in the agency's Head Start centers. Agency leaders explained that since the study they had formally adopted two-generation practices throughout all divisions, and noted that this would impact future programming around maternal depression, as one administrator explained:We also took the [local] early childhood center universal screening tool and we are using it agency-wide now in our other programs. So, it's one tool that looks at all child and caregiver needs, which drives that two-generation planning. So, I think that the mental health services provided at [Head Start] centers will go up, but it may not take the form of a group.</p> <p>Agency leadership reflected on the difficulties posed by conducting IPT therapy groups, and whether individual services may be more feasible to provide in the future. They also noted that any interventions implemented in the future must be approved for mental health billing.</p> <hd id="AN0174817609-28">Discussion</hd> <p>The aim of this study was to utilize a mixed method approach to understand the Reach, Effectiveness, Adoption, Implementation, and Maintenance of "Healthy Moms, Healthy Kids," a two-generation program that provided a gold-standard maternal depression intervention (IPT-G) to ethnic minority mothers in a Head Start setting. Rather than just exploring whether the intervention worked, this study sought to reveal the processes and outcomes of implementation. Overall, we found that performance was high for the RE-AIM domain of Effectiveness and low for the domains of Reach, Adoption, Implementation, and Maintenance.</p> <hd id="AN0174817609-29">Reach: Did the IPT-G Intervention Reach the Target Population?</hd> <p>It was difficult for IPT-G to reach the target population. The rate of participation in this study (16.8%) is lower than other studies that implemented maternal depression treatments in community-based settings like hospitals (Coo et al., [<reflink idref="bib18" id="ref75">18</reflink>]; Klier et al., [<reflink idref="bib36" id="ref76">36</reflink>]; Reay et al., [<reflink idref="bib53" id="ref77">53</reflink>]; Zlotnick et al., [<reflink idref="bib65" id="ref78">65</reflink>]). However, it is important to note that in this study all Head Start mothers were screened for depression, rather than selectively recruiting a pool of mothers through flyers and other methods like referrals from staff, as in the studies above. For example, mothers who respond to flyers regarding a depression intervention are demonstrating interest, making them more likely to join. And mothers identified and referred by staff to join an intervention would be more likely to exhibit depressive symptoms. In these studies, identifying a selective subsample could result in a smaller pool of eligible mothers, and therefore the participation rate may appear higher. Furthermore, many of the above studies used clinical interviews to diagnose depression compared to using a screening tool, which may have reduced the eligible pool of mothers in those studies. Additionally, it is difficult to directly compare the participation rate in this study to a comparable study of a depression prevention treatment in Head Start that used universal screening (Silverstein et al., [<reflink idref="bib56" id="ref79">56</reflink>]) due to differences in the randomization procedures of the two studies. In this study, the program was more successful in enrolling Latinx mothers who were Spanish-speaking or bilingual rather than English-speaking and Black/African American mothers. This may be due to the fact that the majority of therapists who led IPT groups identified as Latinx and were bilingual in Spanish. There is also some evidence that Latinx mothers are more likely than Black or African American mothers to engage in early childhood programs like home visiting (National Home Visiting Resource Center, [<reflink idref="bib42" id="ref80">42</reflink>]). There were a variety of barriers to reach, with the most significant ones being issues around stigma and mothers having too many competing needs to participate, echoing prior research findings (Alegría et al., [<reflink idref="bib4" id="ref81">4</reflink>]; Anderson et al., [<reflink idref="bib6" id="ref82">6</reflink>]; Caplan &amp; Whittemore, [<reflink idref="bib15" id="ref83">15</reflink>]). These findings illuminate important concerns about why evidence-based programs like IPT may not demonstrate their desired impact.</p> <p>Future efforts to scale maternal mental health services within Head Start should focus on addressing stigma before implementing services, particularly in historically marginalized, ethnic minority communities like South Los Angeles. Providers should also prioritize persistent outreach, in which potential clients are contacted several times to schedule services rather than defaulting to the traditional practice of dropping clients after missed appointments or lack of contact, since this strategy has been found to be helpful for ethnic minority clients (Alegría et al., [<reflink idref="bib4" id="ref84">4</reflink>]). In addition, it would be beneficial to consider alternative ways to support maternal mental health. In particular, providing the option of either group or individual services like IPT might be helpful. For example, in this study it is unknown whether mothers who did not participate in the group intervention would have participated in individual IPT, since none of these mothers agreed to participate in follow-up interviews. However, many effective interventions for maternal depression in early childhood programs have been provided in an individual format (Ammerman et al., [<reflink idref="bib5" id="ref85">5</reflink>]; Silverstein et al., [<reflink idref="bib56" id="ref86">56</reflink>]), highlighting this as an important option for mothers. New delivery models like telehealth (video, phone, or text delivery) may also be a useful way to reach a greater proportion of the target population by addressing common barriers to accessing care (Alegría et al., [<reflink idref="bib4" id="ref87">4</reflink>]; Price et al., [<reflink idref="bib50" id="ref88">50</reflink>]).</p> <hd id="AN0174817609-30">Effectiveness: Did the IPT-G Intervention Accomplish its Goals?</hd> <p>Results showed overwhelmingly that IPT-G was effective in accomplishing its main goals in this study, which were to reduce maternal depressive symptoms and stress. There was a high level of convergence between the quantitative and qualitative data showing the intervention's impact on maternal depressive symptoms and stress, and participants and therapists alike shared glowing reports about the intervention's impact. In addition, African American and Latinx/Hispanic participants experienced similar decreases in depressive symptoms as a result of IPT-G. In addition, the majority of IPT-G participants preferred the group modality, which differs from prior studies showing that clients tend to prefer individual therapy services (Goodman &amp; Santangelo, [<reflink idref="bib31" id="ref89">31</reflink>]; Shechtman &amp; Kiezel, [<reflink idref="bib55" id="ref90">55</reflink>]).</p> <p>However, there were mixed findings regarding whether the intervention accomplished some of its secondary goals, which were to impact maternal parenting, parent-child relationships, and child outcomes. These aims were more exploratory and based on the program's theory of change. Although quantitative results showed no impact on maternal self-report of parenting attitudes or observed interactions in the parent-child relationship, several mothers reported changes in their parenting and relationships with their children in interviews. Quantitative data also showed that there were no significant impacts on child outcomes (including parent report of behavior problems and observational measures of school readiness skills and executive functioning). Therefore, quantitative and qualitative data were inconsistent in this study, and the reasons for this are not clear. Additionally, the literature examining the impacts of maternal depression treatment on parenting and children's outcomes is mixed (Cuijpers et al., [<reflink idref="bib20" id="ref91">20</reflink>]; Galbally et al., [<reflink idref="bib29" id="ref92">29</reflink>]), suggesting that maternal depression treatment alone may not be sufficient to cause changes in children, that change is only seen for specific parenting and/or child outcomes (which are inconsistently measured across studies), or that impacts on children are more distal and difficult to measure, particularly in short-term intervention studies. All of these considerations point to the needed for further research about whether maternal depression interventions lead to impacts in parent-child relationships and child outcomes.</p> <p>There were several mechanisms identified by mothers that contributed to the effectiveness of IPT-G. First, mothers described key processes that contribute to success in any group therapy model, including experiencing emotional safety and group cohesion (Yalom &amp; Leszcz, [<reflink idref="bib63" id="ref93">63</reflink>]). In addition, participants identified that several specific components of IPT-G promoted change, including processing trauma, loss, and other difficult experiences, developing more effective communication strategies, and having accountability in terms of goal setting. Recommendations for future adaptations including providing more sessions and longer sessions, providing services to a broader range of caregivers, including some content on parenting, and providing on-going supports after the group ends.</p> <hd id="AN0174817609-31">Adoption: Did those Targeted to Deliver IPT-G Participate?</hd> <p>Adoption at the staff level and the Head Start site level both showed significant difficulties with adoption, with low levels of success. A relatively high number (63%) of staff therapists who were trained in IPT-G went on to lead at least one group. However, due to constraints related to therapists' time and Head Start needs, the program decided to use mental health therapists outside of Head Start division to lead the majority of IPT therapy groups, which was not the original intention. Adoption among Head Start mental health therapists was low, with only two HS therapists leading a group. Furthermore, turnover also impacted staff adoption, as several therapists left the agency before leading a group. Studies show that rates of staff turnover in publicly funded mental health services are quite high, ranging from 30 to 60% annually (Mor Barak et al., [<reflink idref="bib41" id="ref94">41</reflink>]). Factors that predict staff turnover in mental health services include organizational culture and climate (Glisson et al., [<reflink idref="bib30" id="ref95">30</reflink>]) and employee burnout (Paris &amp; Hoge, [<reflink idref="bib48" id="ref96">48</reflink>]).</p> <p>Overall, findings from this study point to the difficulty in implementing the HMHK model and similar two-generation programs that would co-locate adult mental health services in Head Start. Even though the partner agency had the capacity to provide both Head Start programming and mental health services, stakeholders noted difficulties related to consistent leadership and buy-in that presented challenges. There were also simply too few human resources to provide groups utilizing Head Start mental health therapists alone, meaning that other Head Start programs will need to build capacity internally or create similar partnerships with other organizations like mental health agencies to provide treatment.</p> <p>In terms of site adoption, none of the original sites chosen ultimately hosted any groups. Instead, groups were hosted at two administrative Head Start offices owned by the partner agency. Stakeholders reported that logistical barriers related to community safety, space issues, and Head Start licensing standards made it difficult to implement groups at Head Start sites, although there were differing opinions about space and licensing standards among stakeholders. There was also difficulty recruiting enough interested mothers at individual Head Start sites for a group therapy model. These results show the importance of considering how Head Start can promote sites' abilities to provide two-generation programming, since two-generation services should ideally be co-located at the school site. Overall, results in the domain of Adoption highlight the need for additional Head Start funding to fulfill the program's two-generation vision.</p> <hd id="AN0174817609-32">Implementation: Was IPT-G Implemented Consistently?</hd> <p>Implementation of IPT-G was measured by assessing fidelity to the intervention and understanding variation in how mothers were enrolled and retained in therapy groups.</p> <p>There was significant variation in enrollment of mothers to groups depending on who conducted the depression screening initially, with mental health therapists and university study staff showing more success. Studies show that the alliance between therapist and client is one of the most important factors in predicting treatment outcomes (Martin et al., [<reflink idref="bib38" id="ref97">38</reflink>]) and that weak therapeutic alliances are associated with dropout (Roos &amp; Werbart, [<reflink idref="bib54" id="ref98">54</reflink>]). It may be helpful to ensure that mental health therapists are able to create the first contact with Head Start mothers in future programs, since establishing an early therapeutic alliance might make engagement in the group more likely.</p> <p>Once mothers were enrolled in IPT groups, there was significant variation in the ability to sustain membership. Attendance was problematic overall, to the point that two groups were eventually cancelled completely. Although IPT-G was extended from 8 to 12 sessions for the purpose of this study, it may be more feasible for participants to complete a shorter number of sessions. Difficulty with retention may also point to the need for individual therapy services. Additionally, Spanish-speaking groups were much more successful than English-speaking groups.</p> <p>Therapists reported that they maintained high fidelity to the treatment model, but there was significant variation in the implementation of groups. Qualitative data showed that therapists were able to demonstrate fidelity to the IPT-G model because it provided a general overview but also offered significant flexibility in how each session was executed.</p> <hd id="AN0174817609-33">Maintenance: Did Providing IPT-G Become part of Routine Practice in this Setting?</hd> <p>At the time of this evaluation, the provision of IPT therapy groups was continuing in a very limited capacity, and agency leadership did not plan to continue providing the intervention at its Head Start sites. This shows that even though IPT-G was effective in reducing maternal depressive symptoms and stress, it was difficult to sustain in real-world practice in Head Start settings. Many of the deterrents to continuing IPT-G were related to implementation difficulties, particularly related to enrolling mothers in a group modality and identifying staff who could continue to provide the intervention.</p> <hd id="AN0174817609-34">Strengths and Limitations</hd> <p>There are several strengths to this study. First and foremost, this study utilized both quantitative and qualitative data to provide a more complete picture of the five RE-AIM implementation outcomes. As intended by the RE-AIM QuEST creators, this allowed us to assess both the "what" and "why" behind each implementation outcome. In addition, methodological triangulation was used to assess several RE-AIM outcomes using both sources of data, which allowed us to explore points of convergence and divergence (for example, in terms of the intervention's impact on parenting).</p> <p>In addition, this study utilized a rich depth of information including meeting minutes and interviews with different stakeholders (IPT group participants, staff that led therapy groups, and supervisors and other agency leaders) that facilitated triangulation. For example, the same barriers were frequently reported by both frontline staff and agency leadership and then also appeared in meeting minutes from the implementation period. The sample itself is a strength because it included input and feedback from a group of low-income, ethnic minority mothers, a population that has been systematically marginalized.</p> <p>There are also limitations that should be acknowledged. First, there were some data that were not available, including quantitative measures of therapist fidelity to the IPT-G model. In addition, the treatment study had a small sample size, and therefore we were unable to analyze whether participant characteristics (race/ethnicity, income, etc.) were related to IPT-G completion. Additionally, with a low rate of overall participation in the intervention (16.8%) and a completion of all IPT-G sessions (26.5%), there is a risk for both nonresponse bias and attrition bias. Similarly, although this study includes information from interviews with many participants and staff, we were unable to interview several individuals involved in the study. For example, although mothers who chose not to participate in IPT-G were invited to be interviewed, none consented. This would have helped us understand non-participation beyond the use of basic background information. Therefore, findings and conclusions may not represent the views of mothers that did not choose to participate in the program or in the implementation interview, as well as the views of staff members who had left the agency and could not be contacted.</p> <hd id="AN0174817609-35">Implications</hd> <p>Overall, this study reveals factors operating behind the scenes that impacted whether the implementation of IPT-G was effective for Head Start mothers who were experiencing depressive symptoms. Results show that embedding mental health services at Head Start centers could be a promising approach and provides several implications for programs and policymakers. First, mothers screened by a Head Start Family Service Worker (FSW) were less likely to participate in an IPT group than those screened by study staff. This is concerning considering that FSWs are typically responsible for two-generation programming within Head Start and highlights the need to consider how best to train and support frontline Head Start staff to address family mental health concerns. Additionally, when possible it may be beneficial for mental health therapists to engage families directly, since they appeared to have more success overcoming in stigma and families' concerns. Second, most mothers enjoyed the group format and had very positive experiences, but others may have accepted therapy if it had been available individually. In the future, programs should consider offering both individual and group modalities, including a telehealth option to overcome barriers to access. Third, results for impacts on children were mixed. Future work should measure child outcomes for a longer amount of time and consider how to strengthen the program to include a child focus. Fourth, a major barrier to adoption was the inability to host IPT groups at individual Head Start sites. Future research should focus on overcoming logistical and funding barriers to offer groups at Head Start centers so that adult and child services are truly co-located, which is the stated aim of Head Start's two-generation approach. Lastly, the majority of therapists who provided IPT groups in this study were employed outside of the Head Start division of the agency. Future Head Start initiatives should identify suitable therapists to provide maternal mental health services, either funded by Head Start or Medicaid, particularly if Head Start programs do not have access to in-house mental health services as in this study.</p> <hd id="AN0174817609-36">Conclusion</hd> <p>This retrospective assessment evaluated the RE-AIM outcomes of Reach, Effectiveness, Adoption, Implementation, and Maintenance for the "Healthy Moms, Healthy Kids" program in terms of providing IPT therapy groups in a Head Start setting in south Los Angeles. Results show that providing IPT therapy groups was effective in reducing maternal depressive symptoms and stress among the small percentage of mothers who attended, but that additional research should focus on reducing barriers to participation, considering other delivery models to meet participants' needs, and ensuring that Head Start centers have sufficient site and staff resources to conduct IPT groups.</p> <p>Table 1 Quantitative and qualitative RE-AIM QuEST components, including indictors and measures</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" /&gt;&lt;th align="left"&gt;&lt;p&gt;Indicator&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Measure&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;&lt;underline&gt;R&lt;/underline&gt;&lt;/bold&gt;&lt;bold&gt;each&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; How many and what proportion of the target population participated in the intervention?&lt;/p&gt;&lt;p&gt;&amp;#8226; To what extent was intervention participation associated with client characteristics?&lt;/p&gt;&lt;p&gt;&amp;#8226; To what extent did mothers who enrolled in the intervention represent the greater HS population in this area?&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; What were the barriers and facilitators to participant enrollment/participation in IPT-G?&lt;/p&gt;&lt;p&gt;&amp;#8226; What explains variation in "Reach"?&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Participation rate (IPT therapy groups) = # participants enrolled / eligible mothers who had a positive depression screening&lt;/p&gt;&lt;p&gt;&amp;#8226; IPT group participant demographics, compared to those with positive screening who did not participate&lt;/p&gt;&lt;p&gt;&amp;#8226; IPT group participant demographics, compared to CII HS population racial/ethnic background&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Interviews with IPT-G participants, non-participants, staff at multiple levels&lt;/p&gt;&lt;p&gt;&amp;#8226; Meeting minutes&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;&lt;underline&gt;E&lt;/underline&gt;&lt;/bold&gt;&lt;bold&gt;ffectiveness&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; What were the effects of the IPT-G intervention for participants, compared to the control group?&lt;/p&gt;&lt;p&gt;&amp;#8226; To what extent did Black and Latina mothers experience different outcomes?&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; What are participants' perceptions of the effects of IPT-G?&lt;/p&gt;&lt;p&gt;&amp;#8226; What are the conditions and mechanisms that led to effectiveness?&lt;/p&gt;&lt;p&gt;&amp;#8226; What explains variation in outcomes?&lt;/p&gt;&lt;p&gt;&amp;#8226; What adaptations are needed to improve effectiveness?&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Maternal outcomes results reported in (Mennen et al., &lt;xref ref-type="bibr" rid="bibr40"&gt;2021&lt;/xref&gt;)&lt;/p&gt;&lt;p&gt;&amp;#8226; Child outcome results&lt;/p&gt;&lt;p&gt;&amp;#8226; Subgroup differences based on race/ethnicity&lt;/p&gt;&lt;p&gt;&amp;#8226; Group attendance&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Mothers' views on intervention impacts, mechanisms of effectiveness, further adaptations&lt;/p&gt;&lt;p&gt;&amp;#8226; Staff views on variation between groups, further adaptations&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;&lt;underline&gt;A&lt;/underline&gt;&lt;/bold&gt;&lt;bold&gt;doption&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; What was the percentage and representativeness of providers/settings participating in the program?&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; What affected provider/setting participation?&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; #/proportion of staff trained who led IPT groups&lt;/p&gt;&lt;p&gt;&amp;#8226; #/proportion of sites that provided groups&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Therapists' views about IPT-G, EBTs&lt;/p&gt;&lt;p&gt;&amp;#8226; Other factors impacting provider/setting participation (interviews with agency leadership)&lt;/p&gt;&lt;p&gt;&amp;#8226; Meeting minutes&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;&lt;underline&gt;I&lt;/underline&gt;&lt;/bold&gt;&lt;bold&gt;mplementation&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Was the IPT-G intervention implemented as intended?&lt;/p&gt;&lt;p&gt;&amp;#8226; How consistent was delivery across sites/staff?&lt;/p&gt;&lt;p&gt;o Were there variations in how IPT-G was delivered?&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Were IPT groups implemented as intended? To what extent was there variation in delivery?&lt;/p&gt;&lt;p&gt;&amp;#8226; What explains differences in implementation across sites/staff?&lt;/p&gt;&lt;p&gt;&amp;#8226; To what extent did therapists demonstrate fidelity to the model? Did they adapt or modify the model?&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; IPT-G fidelity not assessed quantitatively&lt;/p&gt;&lt;p&gt;&amp;#8226; Association between IPT-G participation and screener role&lt;/p&gt;&lt;p&gt;&amp;#8226; # of cancelled groups&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; HMHK meeting minutes, therapist and supervisor reports&lt;/p&gt;&lt;p&gt;&amp;#8226; Therapist and supervisor perspectives regarding barriers/facilitators&lt;/p&gt;&lt;p&gt;&amp;#8226; Interviews with therapists regarding fidelity&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;&lt;underline&gt;M&lt;/underline&gt;&lt;/bold&gt;&lt;bold&gt;aintenance&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Was the intervention maintained after the study period?&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; What are the barriers to maintaining the program?&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;underline&gt;Quantitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Number of enrollees in IPT-G after study ended&lt;/p&gt;&lt;p&gt;&lt;underline&gt;Qualitative Measures&lt;/underline&gt;:&lt;/p&gt;&lt;p&gt;&amp;#8226; Interviews with agency leadership/frontline staff&lt;/p&gt;&lt;p&gt;&amp;#8226; Meeting minutes&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Table 2 Characteristics of mothers who participated in IPT therapy groups compared to non-participants</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" /&gt;&lt;th align="left"&gt;&lt;p&gt;IPT group participants (n = 49)&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;IPT group non-participants&lt;sup&gt;&lt;italic&gt;a&lt;/italic&gt;&lt;/sup&gt; (n = 489)&lt;/p&gt;&lt;/th&gt;&lt;th align="left" /&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Characteristic&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;M (SD) or N (%)&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;M (SD) or N (%)&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;Sig. (p)&lt;/italic&gt;&lt;sup&gt;&lt;italic&gt;b&lt;/italic&gt;&lt;/sup&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Maternal age&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;33.4 (6.3)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;32.0 (7.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.217&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Child age&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3.8 (0.6)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3.9 (0.6)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.264&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Maternal language&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left"&gt;&lt;p&gt;0.008&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;English&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;10 (20.4)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;211 (43.3)&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Spanish&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;27 (55.1)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;192 (39.4)&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Bilingual&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;12 (24.5)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;84 (17.2)&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p> <sups> <emph>a</emph> </sups> This group includes those who had a positive depression screening at either type of HS site (intervention or control) but did not participate in an IPT group. <sups><emph>b</emph></sups> T-tests and chi-square tests were conducted to compare screening participants and non-participants. Post-hoc tests that accounted for multiple comparisons were used to assess significant pairwise differences.</p> <p>Table 3 Association between staff screener role and IPT-G participation</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" /&gt;&lt;th align="left"&gt;&lt;p&gt;IPT group participants (n = 49)&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;IPT group non-participants&lt;sup&gt;&lt;italic&gt;a&lt;/italic&gt;&lt;/sup&gt; (n = 489)&lt;/p&gt;&lt;/th&gt;&lt;th align="left" /&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Staff characteristic&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;M (SD) or N (%)&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;M (SD) or N (%)&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;Sig. (p)&lt;/italic&gt;&lt;sup&gt;&lt;italic&gt;b&lt;/italic&gt;&lt;/sup&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Screener role&lt;sup&gt;&lt;italic&gt;c&lt;/italic&gt;&lt;/sup&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left"&gt;&lt;p&gt;0.002&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Head Start FSW&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;31 (67.4)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;396 (81.6)&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;University study staff&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14 (30.4)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;59 (12.2)&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Agency research staff&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1 (2.2)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;30 (6.2)&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p> <sups> <emph>a</emph> </sups> This group includes those who had a positive depression screening at either type of HS site (intervention or control) but did not participate in an IPT group. <sups><emph>b</emph></sups> Chi-square tests were conducted to compare screening participants and non-participants. Post-hoc tests that accounted for multiple comparisons were used to assess significant pairwise differences. <sups><emph>c</emph></sups> Therapists were not included because they conducted a very small number of depression screenings.</p> <hd id="AN0174817609-37">Funding</hd> <p>This work was supported by National Institute of Mental Health grant F31MH119772 to Dr. Palmer Molina.</p> <hd id="AN0174817609-38">Declarations</hd> <p></p> <hd id="AN0174817609-39">Ethical Approval</hd> <p>This study was approved by the Institutional Review Board at the University of Southern California. 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Mennen</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib32" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib35" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib58" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib59" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib61" firstref="ref5"></nolink> <nolink nlid="nl6" bibid="bib60" firstref="ref6"></nolink> <nolink nlid="nl7" bibid="bib25" firstref="ref7"></nolink> <nolink nlid="nl8" bibid="bib43" firstref="ref8"></nolink> <nolink nlid="nl9" bibid="bib52" firstref="ref9"></nolink> <nolink nlid="nl10" bibid="bib23" firstref="ref10"></nolink> <nolink nlid="nl11" bibid="bib21" firstref="ref11"></nolink> <nolink nlid="nl12" bibid="bib24" firstref="ref14"></nolink> <nolink nlid="nl13" bibid="bib34" firstref="ref15"></nolink> <nolink nlid="nl14" bibid="bib39" firstref="ref16"></nolink> <nolink nlid="nl15" bibid="bib14" firstref="ref19"></nolink> <nolink nlid="nl16" bibid="bib49" firstref="ref20"></nolink> <nolink nlid="nl17" bibid="bib46" firstref="ref22"></nolink> <nolink nlid="nl18" bibid="bib47" firstref="ref23"></nolink> <nolink nlid="nl19" bibid="bib56" firstref="ref24"></nolink> <nolink nlid="nl20" bibid="bib57" firstref="ref25"></nolink> <nolink nlid="nl21" bibid="bib22" firstref="ref26"></nolink> <nolink nlid="nl22" bibid="bib33" firstref="ref29"></nolink> <nolink nlid="nl23" bibid="bib15" firstref="ref32"></nolink> <nolink nlid="nl24" bibid="bib16" firstref="ref34"></nolink> <nolink nlid="nl25" bibid="bib28" firstref="ref36"></nolink> <nolink nlid="nl26" bibid="bib27" firstref="ref42"></nolink> <nolink nlid="nl27" bibid="bib19" firstref="ref43"></nolink> <nolink nlid="nl28" bibid="bib40" firstref="ref45"></nolink> <nolink nlid="nl29" bibid="bib45" firstref="ref48"></nolink> <nolink nlid="nl30" bibid="bib53" firstref="ref50"></nolink> <nolink nlid="nl31" bibid="bib51" firstref="ref52"></nolink> <nolink nlid="nl32" bibid="bib37" firstref="ref54"></nolink> <nolink nlid="nl33" bibid="bib17" firstref="ref55"></nolink> <nolink nlid="nl34" bibid="bib26" firstref="ref57"></nolink> <nolink nlid="nl35" bibid="bib11" firstref="ref58"></nolink> <nolink nlid="nl36" bibid="bib64" firstref="ref59"></nolink> <nolink nlid="nl37" bibid="bib44" firstref="ref60"></nolink> <nolink nlid="nl38" bibid="bib12" firstref="ref61"></nolink> <nolink nlid="nl39" bibid="bib13" firstref="ref62"></nolink> <nolink nlid="nl40" bibid="bib10" firstref="ref68"></nolink> <nolink nlid="nl41" bibid="bib62" firstref="ref69"></nolink> <nolink nlid="nl42" bibid="bib18" firstref="ref75"></nolink> <nolink nlid="nl43" bibid="bib36" firstref="ref76"></nolink> <nolink nlid="nl44" bibid="bib65" firstref="ref78"></nolink> <nolink nlid="nl45" bibid="bib42" firstref="ref80"></nolink> <nolink nlid="nl46" bibid="bib50" firstref="ref88"></nolink> <nolink nlid="nl47" bibid="bib31" firstref="ref89"></nolink> <nolink nlid="nl48" bibid="bib55" firstref="ref90"></nolink> <nolink nlid="nl49" bibid="bib20" firstref="ref91"></nolink> <nolink nlid="nl50" bibid="bib29" firstref="ref92"></nolink> <nolink nlid="nl51" bibid="bib63" firstref="ref93"></nolink> <nolink nlid="nl52" bibid="bib41" firstref="ref94"></nolink> <nolink nlid="nl53" bibid="bib30" firstref="ref95"></nolink> <nolink nlid="nl54" bibid="bib48" firstref="ref96"></nolink> <nolink nlid="nl55" bibid="bib38" firstref="ref97"></nolink> <nolink nlid="nl56" bibid="bib54" firstref="ref98"></nolink> |
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| Items | – Name: Title Label: Title Group: Ti Data: Implementation of the 'Healthy Moms, Healthy Kids' Program in Head Start: An Application of the RE-AIM QuEST Framework Centering Equity – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Abigail+Palmer+Molina%22">Abigail Palmer Molina</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-1879-194X">0000-0003-1879-194X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Lawrence+Palinkas%22">Lawrence Palinkas</searchLink><br /><searchLink fieldCode="AR" term="%22Yuliana+Hernandez%22">Yuliana Hernandez</searchLink><br /><searchLink fieldCode="AR" term="%22Iliana+Garcia%22">Iliana Garcia</searchLink><br /><searchLink fieldCode="AR" term="%22Scott+Stuart%22">Scott Stuart</searchLink><br /><searchLink fieldCode="AR" term="%22Todd+Sosna%22">Todd Sosna</searchLink><br /><searchLink fieldCode="AR" term="%22Ferol+E%2E+Mennen%22">Ferol E. Mennen</searchLink> – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Administration+and+Policy+in+Mental+Health+and+Mental+Health+Services+Research%22"><i>Administration and Policy in Mental Health and Mental Health Services Research</i></searchLink>. 2024 51(1):69-84. – Name: Avail Label: Availability Group: Avail Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 16 – Name: DatePubCY Label: Publication Date Group: Date Data: 2024 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Program+Implementation%22">Program Implementation</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Mothers%22">Mothers</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Minority+Groups%22">Minority Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Access+to+Health+Care%22">Access to Health Care</searchLink><br /><searchLink fieldCode="DE" term="%22Hispanic+Americans%22">Hispanic Americans</searchLink><br /><searchLink fieldCode="DE" term="%22African+Americans%22">African Americans</searchLink><br /><searchLink fieldCode="DE" term="%22Group+Therapy%22">Group Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Barriers%22">Barriers</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1007/s10488-023-01312-8 – Name: ISSN Label: ISSN Group: ISSN Data: 0894-587X<br />1573-3289 – Name: Abstract Label: Abstract Group: Ab Data: Background: Marginalized mothers are disproportionately impacted by depression and face barriers in accessing mental health treatment. Recent efforts have focused on building capacity to address maternal depression in Head Start; however, it is unclear if mental health inequities can be addressed by two-generation programs in Head Start settings. Therefore, this study examined the implementation outcomes and processes of a two-generation program called "Healthy Moms, Healthy Kids" (HMHK) that provided an evidence-based depression treatment to ethnic minority Head Start mothers. Method: Quantitative and qualitative data were collected and merged in a convergent mixed method design in accordance with the RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework. Qualitative data included interviews with 52 key stakeholders, including intervention participants and staff members, and 176 sets of meeting minutes from the implementation period. Quantitative data included intervention study data and administrative data. Results: It was difficult for HMHK to reach the target population, with only 16.8% of eligible mothers choosing to participate. However, mothers who participated experienced reductions in depressive symptoms and parenting stress and shared a variety of positive impacts in interviews. The program was also more successful in enrolling Latinx mothers who were Spanish-speaking or bilingual rather than English-speaking and Black/African American mothers, limiting its reach. Conclusion: Providing IPT therapy groups was effective in reducing maternal depressive symptoms and stress for those who enrolled, but additional work should focus on reducing barriers to participation, considering other delivery models to meet participants' needs, and identifying culturally relevant ways to meet the needs of Black mothers. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2024 – Name: AN Label: Accession Number Group: ID Data: EJ1434381 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1007/s10488-023-01312-8 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 16 StartPage: 69 Subjects: – SubjectFull: Program Implementation Type: general – SubjectFull: Depression (Psychology) Type: general – SubjectFull: Health Services Type: general – SubjectFull: Mental Health Type: general – SubjectFull: Mothers Type: general – SubjectFull: Health Behavior Type: general – SubjectFull: Minority Groups Type: general – SubjectFull: Program Effectiveness Type: general – SubjectFull: Access to Health Care Type: general – SubjectFull: Hispanic Americans Type: general – SubjectFull: African Americans Type: general – SubjectFull: Group Therapy Type: general – SubjectFull: Barriers Type: general Titles: – TitleFull: Implementation of the 'Healthy Moms, Healthy Kids' Program in Head Start: An Application of the RE-AIM QuEST Framework Centering Equity Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Abigail Palmer Molina – PersonEntity: Name: NameFull: Lawrence Palinkas – PersonEntity: Name: NameFull: Yuliana Hernandez – PersonEntity: Name: NameFull: Iliana Garcia – PersonEntity: Name: NameFull: Scott Stuart – PersonEntity: Name: NameFull: Todd Sosna – PersonEntity: Name: NameFull: Ferol E. Mennen IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Type: published Y: 2024 Identifiers: – Type: issn-print Value: 0894-587X – Type: issn-electronic Value: 1573-3289 Numbering: – Type: volume Value: 51 – Type: issue Value: 1 Titles: – TitleFull: Administration and Policy in Mental Health and Mental Health Services Research Type: main |
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