Enhanced Engagement: A Feasibility Study Infusing Mental Health Services Into Maternal and Child Health Home Visiting
Low-income and ethnic minority women experience barriers to accessible, affordable, and timely treatment of depression occurring during and around the time of pregnancy. Maternal and child health (MCH) home visiting programs may play an integral role in identifying and addressing symptoms of depression in this population. Designing relevant and responsive ways to deliver mental health services within vulnerable populations is a vital component of research for social change. Thus, we designed and tested a social work led intervention which may build capacity to deliver mental health services within a community program where other social services are being provided. In partnership with the staff of a MCH home visiting program, we developed and tested a brief, manualized psychotherapeutic intervention, Enhanced Engagement. This study examines the feasibility and outcomes of Enhanced Engagement compared with usual care home visiting; we hypothesized Enhanced Engagement would decrease depressive symptoms, increase social support, and have equivalent cost/service utilization comparisons with usual care.
The two-group quasi-experimental mixed-methods design compared the Enhanced Engagement intervention with the home visiting program’s usual team care (which included generalist social work support). We enrolled pregnant and postpartum women into the home visiting agency during two pre-defined, consecutive four month intervals of time as the basis for group assignment (usual care n=13; Enhanced Engagement n=12), with intensive staff training on the intervention provided between recruitment intervals. Participants were 96% African-American; 100% had income below the poverty level. Quantitative outcome measures included the PHQ-9 (depressive symptoms), and the SSQ-R (social support); analysis was conducted using paired-sample t-tests and repeated analysis of variance (RMANOVA). Qualitative content analysis examined perceived psychosocial benefit and spontaneous recall of specific intervention content. Administrative data (via chart abstraction) compared delivery cost per person, team involvement, and service utilization. Quantitative, qualitative, and administrative data were triangulated to consider the overall feasibility of the intervention.
Examining bivariate differences, significant reductions in depressive symptoms (t=-3.24, p=.0036) and improvement in perceived social and emotional support (t=3.35, p=.0027) were associated with the Enhanced Engagement intervention over usual care. RMANOVA models demonstrated a significant group x time effect for social support (p=.0211) and a trend decrease in depressive symptoms approaching statistical significance (p= .0600). Content analysis demonstrated consistent and specific recall of intervention techniques and content in the EE group vs. usual care. The EE group also had fewer failed visits (27% vs. 35%) and fewer staff hours spent in crisis intervention between visits (14 vs. 47) resulting in a lower overall service delivery cost per client for EE over usual care.
Conclusions and Implications:
The quantitative, qualitative, and cost-benefit outcomes from this study demonstrate the feasibility and benefit of Enhanced Engagement as an augmentation to home visiting programs, particularly in communities where mental health service utilization barriers preclude or delay treatment for this vulnerable population of low-income pregnant and postpartum women. Next steps in our research include replication of Enhanced Engagement with a fully powered sample in order to demonstrate sustained and statistically significant changes across multiple home visiting programs.