ENJOY YOUR BABY. Pilot Course Evaluation Report Summary. supported with funding from

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1 ENJOY YOUR BABY Pilot Course Evaluation Report Summary supported with funding from

2 CONTENTS Why do we need an Enjoy Your Baby course? 3 About the course 4 About the pilot 5 Participant characteristics 6 Participant changes in well-being 7 Participants experience of the course 8 Participant testimonials 9 Facilitators 10 Summary 11 Recommendations About CMHA BC Founded in 1918, The Canadian Mental Health Association (CMHA) is a national charity that helps maintain and improve mental health for all Canadians. As the nation-wide leader and champion for mental health, CMHA helps people access the community resources they need to build resilience and support recovery from mental illness. To learn more about CMHA BC, visit Phone: or toll-free phone (BC only) info@cmha.bc.ca Facebook: CMHABCDIVISION

3 WHY DO WE NEED AN ENJOY YOUR BABY COURSE? The postpartum period is complicated. Contrary to idealized images, this is a time of moderate to high stress for many new mothers. On top of new routines and skills needed to take care of a baby, there may also be big changes to income, identity, social support, sleep, body image, physical health and intimate relationships. Anywhere between 9 and 31% of mothers will experience depression in the first year after childbirth. 1 Rates of anxiety problems in new mothers are roughly double what they are among women of a similar age who are not postpartum. 1 Postpartum public health classes for new moms routinely teach about oral care, child safety, baby nutrition and breastfeeding. These are important topics, but what about skills to cope with the stress of motherhood and all the negative emotions and effects that go with it? Why does this matter in the long run? Mental health problems in pregnancy and postpartum, according to Perinatal Services BC and BC Reproductive Mental Health, are particularly important because they occur at a critical time in the lives of the woman, her baby and her family. Failure to treat promptly may result in a prolonged, negative effect on the mother, the relationship between the mother and baby and on the child s psychological, social and educational development. The relationship between the woman and her partner may also be negatively affected. 1 If we care about child mental health and family mental health, we need to care about maternal mental health. When moms thrive, babies can too. We need to support new moms at a vulnerable transition time in their lives and give them to tools not only to be mentally healthier, but to enjoy their baby. 1 BC Reproductive Mental Health Program & Perinatal Services BC. (2014). Best Practice Guidelines for Mental Health Disorders in the Perinatal Period. Canadian Mental Health Association, BC Division 3

4 ABOUT THE COURSE Enjoy Your Baby is a brand new mental health promotion course aimed at new mothers, which has been developed by the Canadian Mental Health Association (CMHA) BC Division, with financial support from Shoppers Drug Mart Ride Don t Hide, which raised funds for women s mental health. The 5-session, 8-hour course provides support and training in key skills to maintain wellness and cope with symptoms of low mood, stress and anxiety in the year after the birth of a child, and prevent more serious problems such as postpartum depression. The course was co-created in 2014 by the author of the Enjoy Your Baby booklet, Dr. Chris Williams, UK psychiatrist and internationally renowned expert in cognitive-behavioral therapy (CBT); and Dr. Michelle Haring, a BC-based registered psychologist, and expert in both CBT and reproductive mental health. CMHA BC Division invested approximately $45,000 in developing and piloting the course. The Enjoy Your Baby course is based on principles of CBT and is similar in approach and skills to the Living Life to the Full mental health promotion course, which is already delivered by CMHA affiliates across BC and Canada. Drs. Williams and Haring designed five modules pulling content from the Enjoy Your Baby booklet and adding additional content to create a theme for each session, with opportunities for mothers to engage in activities and discussion. The 5 sessions, each running between 90 minutes to 2 hours including breaks, are meant to be delivered weekly with 2 weeks between the 4 th and 5 th sessions. The sessions are briefly described below. Session 1: Why do I feel like I do... And how to change things around Participants learn how their response to outside events can affect their thoughts, feelings, physical symptoms and behaviours and how to change them to have more control over their lives and feel better. Session 2: Making Positive Changes Participants learn how to regain balance in their lives by looking at behaviours that improve how they feel and ways to make positive changes. Session 3: Looking at Things Differently Participants learn how to identify unhelpful thoughts and ways to focus on helpful ones. They also learn how to deal with problems by using a problem-solving tool. Session 4: Building Closeness Participants look at ways to reduce isolation and nourish or improve their relationships with their baby, partner and other significant people in their lives. Dealing with anger and asking for help are also covered. Session 5: Planning for the Future Participants look back on some of the learnings in the previous sessions and plan for the future. 4 Enjoy Your Baby Pilot Course Evaluation Report Summary

5 ABOUT THE PILOT Pilot courses were delivered over a 4 6 week period between 2014 and They were delivered by four CMHA branches (Vancouver-Fraser, North and West Vancouver, Victoria and Prince George) in seven locations: five in Greater Vancouver (Langley, Vancouver, and North Vancouver), one in Greater Victoria, and one in Prince George. A total of 60 new mothers participated in the course; 60% attended at least three of the five sessions. The course was offered at no cost to the participants for this pilot. All the settings had free child care available and most of the facilitators felt that it was an extremely or very important factor in recruiting and retaining participants. Group size varied between 5 and 16 participants. Courses were delivered in different settings and varying days of the week and times of day. The settings that were most appreciated were spacious for strollers, with good access to kitchens and the child care space. Course participants were recruited using a variety of different means. Participants were asked to complete pre-course and post-course questionnaires. Of the 60 mothers participating, 35 provided at least partial precourse questionnaires and 24 provided at least partial post-course questionnaires. The Enjoy Your Baby course was co-delivered by two facilitators. One group of co-facilitators was already certified in delivering the Living Life to the Full course, the model for the new course. The other co-facilitator group was made up of health care professionals experienced at working with new mothers (such as public health nurses). The co-facilitator model was chosen because of the importance of having different knowledge and skills sets to work with this population. Canadian Mental Health Association, BC Division 5

6 PARTICIPANT CHARACTERISTICS 100% of participants were mothers or expectant mothers 77% of participants were first-time mothers 32 was the median age of course participants 3 weeks to months old was the age range of babies 7 9 months old was the median age range of babies majority of participants in a relationship employed full-time prior to the birth of the baby had at least some college education 66% participants self-identified as... 6% 14% 11% Caucasian Asian Indigenous mixed heritage majority of participants had never previously experienced postpartum depression had never been treated for anxiety, worry or stress had not received CBT 50% of participants reported that they had never been treated for depression in the past 6 Enjoy Your Baby Pilot Course Evaluation Report Summary

7 PARTICIPANT CHANGES IN WELL-BEING Across both measures (for postpartum depression and overall mental well-being), a comparison of pre- and post-course scores showed a pattern of lower risk for depression and better mental well-being. participant depression scores participant overall well-being scores* depression not likely before course after course 33% 55% lower well-being after course 4% before course 29% depression possible to probable before course after course 46% 67% moderate to high well-being before course after course 71% 96% * A change of between 3 and 8 points on the measure from preintervention to post-intervention is considered to be meaningful. This pilot found a 6-point overall mean difference in well-being scores between pre-course and post-course. A similar pattern of findings emerged for a series of items asking participants to rate how much they were affected by low mood, stress and anxiety/worry in their daily lives, and self-rated coping skills and connectedness pre- to post-course. Canadian Mental Health Association, BC Division 7

8 PARTICIPANTS EXPERIENCE OF THE COURSE Course Delivery Method: In the post-questionnaire, respondents strongly agreed or agreed somewhat that they felt comfortable sharing their thoughts and feelings with the class (85%), felt connected to the other mothers in the course (78%), and felt that talking about things in the class environment made them feel less isolated (89%). In fact, 42% of participants reported that they would be very likely or quite likely to stay in contact with other mothers following the course. Course Materials: The response to the course materials was generally positive: 83% of participants strongly agreed or somewhat agreed that the course was fun and interactive; 67% liked the design/appearance of the book, slides and worksheets; and 76% felt that the content and examples were relevant to them. Course Logistics : Overall, participants reported that the logistical aspects of the course, such as class times, locations, session length, and mom- and babyfriendly classrooms were very good. overall rating of course usefulness 92% of participants agreed or strongly agreed that the course was useful to them Course Value : Although the Enjoy Your Baby course was offered free of charge for this pilot project, participants were asked how much they would be willing to pay for the course: 56% would pay up to $50 for the course, 11% would pay up to $100, and 6% would pay up to $150. The remainder (27%) indicated they would not pay for the course. Facilitator Skill and Performance: Approximately 95% of participants rated their facilitators as good or very good overall. One person rated their facilitators as fair overall. No facilitators were rated as poor or very poor on any dimension. Most Useful Skills Learned from the Course: Noticing and stopping the vicious cycle (67%), taking me time (67%), assertiveness skills (58%), anger management skills (54%), problem solving skills (50%). Most Useful Learning Experiences: Hearing about other class members experiences (67%), sharing one s own examples with the class (54%), and brainstorming and practicing skills with a partner using real-life examples (46%). 91% of participants would be quite likely or very likely to recommend the program to others 8 Enjoy Your Baby Pilot Course Evaluation Report Summary

9 PARTICIPANT TESTIMONIALS The course is very authentic, it acknowledges real-life feelings and is very problem-solving oriented (it focuses on the positive). [The course] helps me mostly with not letting my buttons be pushed. I was very supported and was excited to come each week. Great to connect with other moms and have open conversation about mental health. I have gained tools and skills that I can use daily in many situations. Interacting with other mothers was extremely helpful. I have had opportunities to reflect on my triggers and stressors. I have been noticing when I m sad or angry and analyzing the thoughts and talking about it with my husband. I feel much better!!! Empower, provides tools, love having worksheets. [I am] better at managing anger and considering my partner s perspective. [The course provided] tools to check myself (mood/anxiety) and get out of the bad places I am in, or to prevent myself from getting there. The course gave me the information to notice and understand the vicious cycle, stopping negative thoughts, anger management and appreciating your time and and how it can have a positive impact in your life. It was nice to share the 12 rules of assertiveness with my husband. He struggles when I expect him to read my mind. It is on our fridge now as a reminder! Canadian Mental Health Association, BC Division 9

10 FACILITATORS Training: Facilitators felt the one-day training they received by course co-creator Dr. Michelle Haring was sufficient but would have liked a bit more time to practice with the materials as well as the opportunity to connect with each other as the courses were being delivered. Impression of most useful sessions: Facilitators were asked to rate each session based on what participants said or did during the course and for the impact they felt it had on the new moms. Overall, participants were engaged with the materials. The first two sessions were rated the most useful. Impression of most useful skills: Some of the impressions of facilitators echoes what participants said in their questionnaires (particularly usefulness of the vicious cycle); other skills were rated differently by facilitators and participants. What facilitators liked about the course All facilitators reported that what they most enjoyed about delivering the course was seeing the moms engage with the course materials and with each other. One facilitator found the course relevant, practical and useful to moms. Life changing for the better. The majority of facilitators enjoyed the experience and said they would do it again. Suggestions to improve course content Facilitators found the slides were heteronormative, representing women unrealistically and would have liked to see more diversity represented. As well, it was felt that the pink and blue colours were based on gender assumptions that don t reflect today s society. The majority of facilitators felt that there was not enough time to deliver the sessions in the allocated time. Many observed there were too many topics or slides and not enough time or opportunities for mothers to exchange, get to know each other and reflect on the content. They made several suggestions around length and pacing. Concerns over what are seen as parenting choices were also noted, for example, issues such as bed sharing. It was felt that making these statements might put more pressure on moms who did not share these perspectives and that it also detracted from the course content. 10 Enjoy Your Baby Pilot Course Evaluation Report Summary

11 SUMMARY Overall, the Enjoy Your Baby pilot course was well-received by new mothers. The mothers found the coping skills and group format helpful; 92% of participants rated the course as useful and 91% would recommend it to others. The majority of facilitators have said that they would deliver the course again while providing some helpful insights about changes to the course and its materials that could make them a better fit for the new mothers who participated in the program. Face-to-face was key The face-to-face nature of the Enjoy Your Baby course appeared to be a key aspect of its success. As expected, learning coping skills alongside other new mothers provided opportunities for participants to learn from one another, helped to normalize some of the common challenges encountered in the postpartum period, and promoted the development of social connections. Coping skills improved The course aimed to teach participants a wide variety of different CBT-based skills that could be used to enhance their resilience in the face of the many challenges of new motherhood. Across all skill area ratings from participants ability to cope with low mood and stress using specific CBT strategies, to their parenting ability, to their sense of connection to others more new mothers reported confidence in these areas after course completion. Following the course, more new mothers also reported feeling more willing and able to find me time, to get out of the house and to ask for what they need in terms of support. They also said they would be likely to continue to use these new skills in the future. While we cannot conclude with certainty that these differences were due to the course rather than other factors (e.g., passage of time, change in routine, social support alone), the pattern of results is very encouraging. Better mental health Completing the Enjoy Your Baby course also appeared to be related to improvements in certain mental health measures including a lower risk for depression and better mental well-being, after comparing pre- and postcourse scores on two validated screening scales. Quality of materials high; some revisions suggested The results of this evaluation suggest that the course content and materials were appropriate, with the majority of participants reporting that the content and examples were relevant, that the design of materials was appealing and that course itself was fun and interactive. Participants reported that their facilitators were knowledgeable and able to create a safe and supportive learning environment. Facilitators and participants did also suggest revisions to make the Enjoy Your Baby Course even better. (See next page) Canadian Mental Health Association, BC Division 11

12 RECOMMENDATIONS 1. More time for partnerships and outreach Many CMHA branches gave feedback that initiatives such as this one require more time to establish partnerships, especially when they represent a new area of intervention. It was also hard to recruit participants since mothers who could benefit most from the course are often hardest to reach. More time would have helped CMHAs reach out to groups like midwives, doulas and family doctors who have the potential to reach more postpartum mothers. Provincially, we need to continue discussions with the Pacific Post Partum Support Society and BC Reproductive Mental Health and initiate conversations with groups like the Public Health Association of BC. 2. Understand how much social support alone influenced findings The findings make it very clear that mothers felt that the social support provided by the group was key. How much this social support aspect of the course influenced the findings versus the CBT psychoeducation content is, unfortunately, hard to evaluate. In future, it would be useful to have a control group such as a new-mother support group not presenting CBT content. 3. Follow-up with participants down the road Using an independent evaluator, it would be useful to follow the mothers after three or six months to assess mental well-being and see if the skills are still being used. 4. Confirm and make changes to course content The course format and materials need to be reviewed by a focus group of new mothers (or Enjoy Your Baby alumni) and the following areas explored in greater detail: Spread content out over more weeks, and two hours each time Remove content and reduce the number of (and reliance on) slides; allow for more discussion time Review content around issues identified in the pilot such as controversial parenting advice Review Modules 3 and 5 as they were the least wellreceived by participants Include more diversity (ethnicity, size, gender, type of families) in the course and the companion booklet and re-evaluate the visual identity (e.g., colours, illustration style) 5. Test out an alternate facilitation model The pilot did not identify whether the co-facilitator model was particularly useful or necessary. Given the relatively small group sizes, one model to test might be just one Living Life to the Full certified facilitator with personal experience of motherhood in the last ten years and training in the course approach and materials. We can also investigate the model for the course now used in the UK by Dr. Williams. 6. Develop a French version To truly roll this out nationally, we would need to test and develop a French version of the course after the English version is finalized. For more details about the course or pilot findings, please contact Marie Dussault: marie.dussault@cmha.bc.ca 12 Enjoy Your Baby Pilot Course Evaluation Report Summary

13 AN OUNCE OF PREVENTION... Happier, healthier moms help create a foundation for happier, healthier kids and families. HOW YOU CAN HELP: LEARN Learn more about Enjoy Your Baby and Living Life to the Full program and order the Enjoy Your Baby booklet at Learn about all the work we do in CMHA BC s monthly e-news, Mind Matters. Sign up for free at JOIN Are you an organization that is interested in running the revised course? We are open to hearing from CMHAs and other allies in maternal wellbeing as we move forward. us at living.life@cmha.bc.ca. DONATE By donating to CMHA BC, you allow us to invest in making a great course even greater. Help us to empower new moms with coping skills and social connections, nation-wide, in at least two languages. Donate at ACKNOWLEDGEMENTS We are grateful to the following people who were involved in development and implementation of the Enjoy Your Baby course: For seeding and championing this project from its inception: Bev Gutray, CEO, CMHA BC. For the co-development of the course: Dr. Chris Williams, author of the Enjoy your Baby booklet, UK psychiatrist and CBT expert, and Dr. Michelle Haring, BC-based Registered Psychologist, expert in CBT and reproductive mental health course Master Trainer and Evaluation Consultant. For coordinating and delivering courses at four CMHA branches: Leanne, Dolly, Madith, Judy, Lana, Gisèle, Alyssa, Shawna, Norah, Maureen, Mary-Lu, Judie, Jocelyn, and Holly. For providing initial feedback on the course materials with a new-mom lens: Alyssa, Sarah and Maria. For coordination: Marie Dussault, National Manager, Living Life to the Full, CMHA BC, supported by Sarah Hamid-Balma, Director, Mental Health Promotion. And last but not least, for all the donors and riders of Shopper s Drug Mart Ride Don t Ride for helping to fund this pilot course to support women and their families.

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