Implementation of the "Healthy Moms, Healthy Kids" Program in Head Start: An Application of the RE-AIM Quest Framework Centering Equity

Background and Purpose: Depression is a significant public health concern impacting mothers during the early childhood years, with research consistently documenting negative impacts on child development. Low-income mothers and mothers from ethnic minority backgrounds are disproportionately impacted by maternal depression and often face significant barriers in accessing high-quality mental health treatment. Two-generation approaches have focused on supporting early childhood development by embedding parent mental health services in child-serving settings that are easy to access and do not require insurance coverage. For example, recent efforts have focused on building capacity to address maternal depression in Head Start (Mennen et al., 2021; Silverstein et al., 2017); however, questions remain about whether two-generation mental health programs can be scaled and effectively address inequities experienced by marginalized racial groups.

Methods: In this study, the RE-AIM Qualitative Evaluation for Systematic Translation (QuEST) framework (Forman, 2017) was used to assess the outcomes of Reach, Effectiveness, Adoption, Implementation, and Maintenance and identify factors that influenced implementation of a two-generation maternal depression intervention with Black and Latinx mothers in Head Start settings in south Los Angeles. Implementation was examined in two areas: 1) conducting universal depression screening, and 2) providing group Interpersonal Psychotherapy (IPT-G) for mothers with elevated depressive symptoms. Quantitative and qualitative data were collected and merged in a convergent mixed method design. Qualitative data included interviews with 52 key stakeholders, including intervention participants and staff members, and 176 meeting minutes from the implementation period. Quantitative data included intervention study data, de-identified administrative data from the implementing agency’s database of families served across its Head Start sites, and agency records regarding depression screening rates and staff training and retention.

Results: The HMHK program screened 85% of total eligible Head Start mothers for depression, and English-speaking mothers were more likely to refuse screening than either Spanish-speaking or bilingual mothers, revealing a major barrier to identifying all mothers who may need additional support. Barriers to screening included mother’s lack of availability, stigma, privacy concerns, lack of interest, and lack of trust. Although staff broadly adopted screening, there was significant variation in rates of positive screenings among staff (which ranged from 0% to 46%). Results also showed that it was difficult for IPT-G to reach the target population, with only 16.8% of mothers choosing to participate. The program was more successful in enrolling Latinx mothers who were Spanish-speaking or bilingual rather than English-speaking and Black/African American mothers, limiting the reach of the program.

Conclusions and Implications: Universal maternal depression screening has the potential to reach low-income, ethnic minority Head Start mothers with sufficient institutional support, but additional efforts should be made to build capacity for paraprofessional staff to conduct screening and to engage mothers from all racial and ethnic groups in screening. Second, providing IPT therapy groups was effective in reducing maternal depression 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.