- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03267563
Minimum Intervention to Maintain a Postpartum Depression Prevention Program in Clinics Serving Low-income Women (ROSE)
Implementing to Sustain: Determining the Minimum Necessary Intervention to Maintain a Postpartum Depression Prevention Program (ROSE) in Clinics Providing Prenatal Services to Low-income Women
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
A recent expert consensus report concluded that, "Little is known about how well or under what conditions health innovations are sustained and their gains maintained once they are put into practice. Implementation science typically focuses on uptake by early adopters. The later-stage challenges of sustaining evidence-supported interventions receive too little attention." This report placed high priority on conducting return on investment (ROI) studies to determine how much is gained when effective programs are sustained, and cost-benefit trade-offs for effort required to sustain.1 Information is especially needed for preventive behavioral health interventions for adults in outpatient medical (e.g., primary care; OBGYN) settings.
Postpartum depression (PPD) is common and can have serious and lasting consequences for mother and child, including maternal increased risk for suicide, compromised functional status, and adverse infant developmental outcomes. Prevalence of PPD is ~13% in the 12 weeks after childbirth, with rates up to 50% among low-income women, who are especially vulnerable to the consequences of PPD. Outpatient clinics offering prenatal care are an opportune place to deliver PPD prevention services because most women will visit while pregnant. Recent guidelines suggest that prenatal clinics should screen for PPD after birth and refer once it is identified. Unfortunately, prenatal clinics do not routinely do anything to prevent PPD from occurring.
The ROSE Program (Reach Out, Stay Strong, Essentials for mothers of newborns) is a small-group intervention to prevent PPD that is delivered during pregnancy in outpatient prenatal settings. ROSE is the only PPD preventative intervention that (1) has been found to significantly reduce cases of PPD in multiple randomized trials, and (2) has been tested in community prenatal settings with racially and ethnically diverse low income pregnant women. ROSE consists of four 90-minute group sessions and a 50-minute individual booster session after delivery. Requests for ROSE training in Philadelphia and nationwide in Japan, and recent policy changes supporting payment for comprehensive perinatal services (including behavioral health care) to underserved populations all suggest a context ripe for embedding ROSE in prenatal clinics long-term. Given the need for ROI studies about sustainment efforts and that ROSE is well-positioned for implementation and sustainment research, we propose a Sequential Multiple Assignment Randomized (SMART) Trial of the effectiveness and cost-effectiveness of a stepwise approach to sustainment of ROSE in 90 outpatient clinics providing prenatal care to pregnant women on public assistance accross the US. Our conceptual framework comes from RE-AIM and a review on sustainment by Co-I Wiltsey-Stirman,3 with sustainment strategies based on the Replicating Effective Programs (REP) framework. All clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). Clinics will be assessed using surveys and qualitative interviews 9 times over 2.5 years after receiving EIAU. Clinics at risk for failure to sustain operationally (defined as no ROSE intervention in 3 months and none planned) and/or clinically (defined as low fidelity to ROSE core elements) will be randomized to receive additional sustainment support for up to 18 months after baseline. At the first time period at which a clinic is determined to be at risk (i.e., at 3, 6, 9, 12, or 15 months), that clinic will be randomized to receive either: (1) no additional implementation support (EIAU only), or (2) EIAU plus low-intensity (every 3 months) coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent monitoring periods, they will be randomized to (1) EIAU + LICF only, or (2) EIAU + LICF + high-intensity (monthly) coaching and feedback (HICF). Additional study follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. We will assess costs and benefits of sustainment strategies. Aims are to:
Compare effectiveness of each sustainment step for the following final and proximal OUTCOMES:
- Sustainment of core program elements at each time point, and total length of time in weeks that: (i) any ROSE services were provided, and (ii) were provided with adequate fidelity to core elements (primary).
- Health impact (e.g., PPD rates over time at each clinic) and reach (number of patients enrolled in and completing the ROSE program).
- Return on Investment (costs and cost-effectiveness of each sustainment step).
- Hypothesized mechanisms include sustainment of: (a) clinical and organizational capacity to deliver core elements, and (b) a sense of engagement/ownership by key clinic staff, Examine predictors and processes to determine which kinds of clinics need which level of support.
- Explore which clinic characteristics (e.g., organizational and state policy contexts) and hypothesized mechanisms (Aim 4) are associated with best sustainment to determine tailoring variables for choosing/sequencing EIAU, LICF, HICF in the future.
- Document implementation/sustainment effort processes, their timing relative to desired outcomes, critical incidents to explore factors most related to sustainment after accounting for hypothesized mechanisms.
To our knowledge, this study will be the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. The study will also examine a set of strategies to promote sustainment of an effective PPD prevention intervention for low-income women, reducing negative consequences for mother and child. The proposal directly addresses the goal of PAR-16-238 to conduct longitudinal studies on "factors that contribute to the sustainability of evidence-based interventions," to test strategies to improve quality of care among underserved populations, examine mediators and moderators, and examine cost-effectiveness or other economic outcomes. Thus, the study will advance implementation science, knowledge of implementation science mechanisms, and clinical care for an at-risk population.
Study Type
Enrollment (Anticipated)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
Michigan
-
Flint, Michigan, United States, 48502
- Michigan State University
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Study enrollment and randomization takes place at the clinic level. Study participants will be clinical and operational staff representatives of participating clinics.
To be included in the study, clinics will:
- provide outpatient prenatal services
- estimate that at least 50% of their pregnant patients receive some kind of public assistance (such as federal or state assistance in the form of cash assistance such as Temporary Assistance for Needy Families [TANF], food stamps, subsidized housing, and/or health care such as Medicaid)
- have at least 10 new pregnant women per month on average (i.e., enough patient flow to run ROSE)
- agree to study procedures.
Exclusion Criteria:
- None
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Health Services Research
- Allocation: Randomized
- Interventional Model: Sequential Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Enhanced implementation as usual (EIAU)
All clinics will receive enhanced implementation as usual (EIAU) that is initial clinical and operational training + tools for sustainment.
This occurs once at the beginning of the trial.
|
Enhanced implementation as usual consists of initial training and problem-solving plus planning for sustainment,
|
Experimental: Low-intensity coaching and feedback
Clinics will receive enhanced implementation as usual (EIAU) plus low-intensity (every 3 months) implementation coaching and feedback (LICF).
LICF consists of quarterly clinical and operational coaching and feedback calls, as well as quarterly participation in an implementation collaborative board.
|
Enhanced implementation as usual consists of initial training and problem-solving plus planning for sustainment,
Enhanced implementation plus low intensity will have received initial training and problem-solving plus planning for sustainment and after that every 3 months will receive one clinical and one operational telephone "booster" meeting.
|
Experimental: High-intensity coaching and feedback
Clinics will receive enhanced implementation as usual (EIAU) plus high-intensity (every month) implementation coaching and feedback (HICF).
HICF consists of monthly clinical and operational coaching and feedback calls, monthly participation in an implementation collaborative board, and on call technical assistance.
|
Enhanced implementation as usual consists of initial training and problem-solving plus planning for sustainment,
Enhanced implementation plus low intensity will have received initial training and problem-solving plus planning for sustainment and after that every 3 months will receive one clinical and one operational telephone "booster" meeting.
Enhanced implementation plus high intensity will receive will receive everything that the clinics in LICF receive, but at a higher intensity.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Sustainment of core program elements
Time Frame: Measured at 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
The total length of time that ROSE services were provided with adequate (75% or more) fidelity to core elements.
The ROSE Session-by-Session Adherence Scale, a self-rated intervention fidelity scale completed by ROSE interventionists after each session.
The outcome for each time point (i.e., quarter) will be the mean % of core elements delivered that should have been delivered at each ROSE session (mean [# of core elements delivered/# core elements should have been delivered] at each session; zero if no sessions were completed).
|
Measured at 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Total length of time any ROSE services were offered
Time Frame: Measured at 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
The total length of time any ROSE services were provided will be tracked using a monthly calendar method
|
Measured at 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
Health impact: Postpartum depression (PPD) rates over time at each clinic
Time Frame: Quarterly over 30 months
|
Quarterly, we will ask each clinic to report the following overall numbers: (1) # of women who should have come for their 6-week postpartum appointment; (2) # who came; (3) # that were screened for PPD; (4) # who screened positive for PPD.
We will also collect this information for 4 quarters (12 months) prior to baseline.
We will use these numbers to calculate PPD rates for each time period.
Although though not every woman in the clinic will receive ROSE, we chose to track overall PPD rates at each clinic because: (1) the study examines larger-scale sustainment aimed at clinic-wide (and eventually population-wide) outcomes; and (2) the clinic-level outcomes are primary; not consenting individual patients makes the needed sample size (90 clinics) feasible.
|
Quarterly over 30 months
|
ROSE Intervention reach
Time Frame: Quarterly over 30 months
|
# patients receiving ROSE and # of patients who complete at least 3 of 5 sessions
|
Quarterly over 30 months
|
Cost-effectiveness
Time Frame: Measured at 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
We will analyze 4 cost-effectiveness (CE) outcome measures: (1) a primary clinical outcome, number of PPD cases averted, estimated as the change in PPD rate at the clinic (post-pre)*(clinic's caseload), (2) another clinical outcome, number of quality-adjusted life years (QALYs) saved, computed from the primary outcome using Morrell et al.'s model, (3) an implementation process outcome, number of clients served with fidelity, and (4) a sustainment outcome, months of additional service delivery.
The latter 2 measures have little measurement error.
|
Measured at 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Hypothesized mechanism: Sustainment of clinical and organizational capacity to deliver core elements
Time Frame: Measured at baseline, 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
Organizational Capacity subscale of the Program Assessment Sustainability Tool (PSAT).
Secondary measures of this construct include number of people trained who have time to deliver ROSE and clinic's ability to manage space, scheduling, and reimbursement for ROSE
|
Measured at baseline, 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
Hypothesized mechanism: Sustainment of a sense of engagement/ownership by key clinic staff.
Time Frame: Measured at baseline, 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
The sum of 4 PSAT subscales: Political Support, Partnerships, Communications, and Strategic Planning.
The Staff section of the NHS's Sustainability Model and Guide and investment in addressing PPD will be secondary measures
|
Measured at baseline, 3, 6, 9, 12, 15, 18, 24, and 30 months after baseline
|
Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: Jennifer E Johnson, Ph.D., Michigan State University
- Study Director: Raven Miller, M.A., Michigan State University
Publications and helpful links
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- MichiganSUROSE
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
After data have been collected and study results published, de-identified data will be made available to other qualified researchers upon request, on a CD or other electronic means compatible with our systems. The request will be evaluated by the PIs to ensure that it meets reasonable standards of scientific integrity.
We have use standard measures where possible in order to promote data sharing and integration into larger databases and to allow other researchers to analyze the data, including conducting meta-analyses. We will work on the data dictionary throughout the study. Data checking will occur regularly. We will submit primary results for publication by the end of the project period, and will have final de-identified datasets and data dictionaries available by CD within the required time frame.
IPD Sharing Time Frame
IPD Sharing Access Criteria
IPD Sharing Supporting Information Type
- Study Protocol
- Statistical Analysis Plan (SAP)
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
Clinical Trials on Depression, Postpartum
-
University of British ColumbiaCanadian Institutes of Health Research (CIHR); Women's Health Research Institute...CompletedPostpartum Depression | Perinatal Disorder | Postpartum Disorder | Perinatal Depression | Postpartum Anxiety | Postnatal DepressionCanada
-
University of CoimbraEnrolling by invitationPostPartum DepressionPortugal
-
University of MinnesotaNational Institute of Mental Health (NIMH)Completed
-
Sage TherapeuticsCompletedSevere Postpartum DepressionUnited States
-
Women's College HospitalCanadian Institutes of Health Research (CIHR); Michael Garron HospitalCompletedPostpartum Depression | Postpartum Anxiety | Postpartum Blues | Postpartum Mood DisorderCanada
-
Gazi UniversityCompletedPostpartum Depression | Postpartum AdaptationTurkey
-
British Columbia Children's HospitalActive, not recruiting
-
University of RochesterMae Stone Goode FoundationCompletedPostpartum Depression | Postpartum AnxietyUnited States
-
Hacettepe UniversityCompletedQuality of Life | Postpartum Depression | Nursing Caries | Nurse's Role | Postpartum Disorder | Postpartum AnxietyTurkey