University of Southern California Dissertations and Theses

Effectiveness and implementation of a maternal depression treatment in a Head Start setting: a mixed method study

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Effectiveness and implementation of a maternal depression treatment in a Head Start setting: a mixed method study

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Content Copyright 2022 Abigail Palmer Molina

EFFECTIVENESS AND IMPLEMENTATION OF A MATERNAL DEPRESSION
TREATMENT IN A HEAD START SETTING:
A MIXED METHOD STUDY
by
Abigail Palmer Molina, M.A., LCSW, IFECMHS, PMH-C

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

May 2022
ii
Dedication

This dissertation is dedicated to mothers of color from communities that have been
systematically oppressed for many years. Mothers who are juggling competing demands, facing
numerous challenges, and still showing up for their children each day, who show ingenuity and
strength as they navigate the path of motherhood. Their stories inspire me to continue to fight for
meaningful change for young children and families in this country.
To my mother and father, who instilled in me a love of learning and commitment to
service from a very early age, thank you for always supporting me in each new adventure and for
your prayers and pep talks throughout this journey. I love you more than words can say. To my
husband Rich who I absolutely adore, thank you for your love and unwavering support. Thank
you for being my “proud husband,” I would not have made it through this experience without
you. I am excited to see what is in store for us next!

iii
Acknowledgements

There are so many wonderful people to acknowledge for their support and guidance
throughout my doctoral journey:
First, my profound thanks go to Dr. Ferol Mennen. Thank you for being an anchor for me
in this program from the very beginning and for your passion and commitment to the social work
profession. You have always believed in me and have encouraged me in every new endeavor
over these past six years. I have learned so much from you, thank you for showing me how to
strive for excellence in social work research, teaching, and practice. I knew that we were kindred
spirits when we first met and shared so many similar thoughts about social work and the
importance supporting young children and families. I look forward to continuing these
conversations and am so thankful to call you my dear friend, mentor, and colleague. Thank you
for hanging in there with me to the very end of my time here at USC, and congratulations on
your well-deserved retirement!
To Dr. Dorian Traube, thank you for your support and guidance and for providing me
with endless opportunities to grow under your leadership. You are a wonderful mentor and role
model and I appreciate the time you have taken to guide me through each phase of the doctoral
program (and beyond!). Our work together has been exciting and fulfilling and has helped me to
think critically about how I want to contribute to our profession. I look forward to continuing our
collaborations for many years to come. To Dr. Larry Palinkas, thank you for graciously sharing
your time and immense knowledge every step of the way, and for helping me discover my great
love of qualitative and mixed methods approaches. You have been a true blessing. To Dr. Daniel
Hackman, thank you for your mentorship in becoming an independent researcher and for taking
the time to help me hone my methodological and writing skills, I have learned so much from
iv
you. I would also like to thank several other faculty members of the USC community: To Drs.
Michael Hurlburt, Julie Cederbaum, Darby Saxbe, Jacquelyn McCroskey, and Janet
Schneiderman, who have influenced my thinking and shared your time and wisdom with me over
the past six years. It has been an absolute joy to work with each of you.
I am also thankful to the USC Social Work Doctoral Program and National Institute of
Mental Health for supporting my dissertation work, and to the leadership at Children’s Institute,
Inc. for partnering with me in this project. Thank you also to Dr. Scott Stuart, I have enjoyed
learning about IPT and hope to continue to collaborate with you.
Thank you also to all of the wonderful student colleagues and friends in the doctoral
program, you bring an energy and excitement that inspires me. To the members of the PhD self-
study subgroup on social justice (Dr. Michael Hurlburt, Dr. Olivia Lee, Adriane Clomax,
Beatrice Martinez, Eunhye Anh, Ronna Banada, and Daniel Green) thank you for sharing your
perspectives as we seek to further promote social justice in the PhD program, these conversations
have been rewarding and exciting, and continue to inform my work. Thank you also to my
amazing cohort (Wichada La Motte-Kerr, Daniel Green, Kati McNamara, Mia Liu, Daniel Lee,
Chyna Hill, and Kexin Yu) for making the doctoral journey fun! Thank you also to Sapna
Mendon, Kate Sullivan, and Jessica Dodge for taking the time to talk with me and share your
experiences and advice. Thank you also to the staff at the USC Suzanne Dworak-Peck School of
Social Work. Special shout-out to Malinda Sampson, who was always kind and informative,
thank you for keeping our program running so well!
Lastly (but certainly not least) to all of my amazing friends and family who have
supported me during this process. Thank you for cheering me on and also helping me to
remember that there is a world full of life outside of this. I am thankful for each one of you.
v
TABLE OF CONTENTS

Dedication ....................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iii
List of Tables ................................................................................................................................ vii
List of Figures .............................................................................................................................. viii
Abbreviations ................................................................................................................................. ix
Abstract ............................................................................................................................................x
Chapter One: Introduction ...............................................................................................................1
Review of the Literature ............................................................................................................1
Study Context.............................................................................................................................4
Study Approach .........................................................................................................................6
Dissertation Structure.......................................................................................................................8
Study 1: Implementation of the “Healthy Moms, Healthy Kids” Program in Head Start:
An Application of the RE-AIM QuEST Framework .................................................................9
Study 2: Group Interpersonal Psychotherapy for Ethnic Minority Head Start Mothers with
Depressive Symptoms: A Mixed Method Study of Experiences and Mechanisms.................11
Chapter Two (Study 1): Implementation of the “Healthy Moms, Healthy Kids” Program in
Head Start: An Application of the RE-AIM QuEST Framework ..................................................13
Introduction ..............................................................................................................................13
Methods....................................................................................................................................15
Results ......................................................................................................................................26
Discussion ................................................................................................................................42
References ................................................................................................................................54
Chapter Three (Study 2): Group Interpersonal Psychotherapy for Ethnic Minority Head
Start Mothers with Depressive Symptoms: A Mixed Method Study of Experiences and
Mechanisms ...................................................................................................................................58
Introduction ..............................................................................................................................58
Methods....................................................................................................................................61
Results ......................................................................................................................................66
Discussion ................................................................................................................................78
vi
References ................................................................................................................................84
Tables and Figures ...................................................................................................................88
Chapter Four: Conclusions, Implications, and Future Directions..................................................93
Introduction ..............................................................................................................................93
Key Findings of Dissertation Studies ......................................................................................95
Study 1: Implementation of the “Healthy Moms, Healthy Kids” Program in Head
Start: An Application of the RE-AIM QuEST Framework ...............................................95
Study 2: Group Interpersonal Psychotherapy for Ethnic Minority Head Start
Mothers with Depressive Symptoms: A Mixed Method Study of Experiences
and Mechanisms.................................................................................................................98
Limitations .............................................................................................................................100
Implications and Recommendations ......................................................................................101
Conclusion .............................................................................................................................103
References ....................................................................................................................................105
Appendices ...................................................................................................................................114

vii
List of Tables

Table 2.1. Quantitative and Qualitative RE-AIM Components, Including Indictors
and Measures .................................................................................................................................21
Table 2.2. Characteristics of Mothers Who Participated in Universal Depression Screening
Compared to Non-Participants .......................................................................................................27
Table 2.3. Characteristics of Mothers Who Participated in IPT Therapy Groups Compared
to Non-Participants ........................................................................................................................29
Table 2.4. Association Between Screener Role and Screening Participation ................................36
Table 2.5 Association Between Screener Role and IPT-G Participation .......................................39
Table 2.6. Comparison of RE-AIM Implementation Outcomes Across HMHK
Components ...................................................................................................................................50
Table 3.1. Participant Characteristics ............................................................................................88
Table 3.2 Joint Display of Participants’ Presenting Concerns and Reasons for Participation
by Treatment Progress ...................................................................................................................90
Table 3.3 Joint Display of Participants’ Perceptions of Participating in IPT by Treatment
Progress ..........................................................................................................................................91
Table 3.4 Joint Display of Participants’ Reports of Treatment Impacts by Treatment
Progress ..........................................................................................................................................92

viii
List of Figures

Figure 1.1 Embedded Intervention Trial Mixed Method Design ....................................................8
Figure 1.2 Paper 1: Convergent Mixed Methods Design ..............................................................10
Figure 1.3 Paper 2: Explanatory Sequential Mixed Methods Design ............................................11
Figure 2.1 Variation in Positive Depression Screenings Among FSWs ........................................37
Figure 3.1. Explanatory Sequential Mixed Methods Design .........................................................89

ix
Abbreviations

CES-D Center for Epidemiology Studies Depression Scale
EBT Evidence-Based Treatment
FSW Family Service Worker
HMHK “Healthy Moms, Healthy Kids” program
IPT Interpersonal Psychotherapy
IPT-G Group Interpersonal Psychotherapy
RE-AIM Reach, Effectiveness, Adoption, Implementation, and Maintenance model

x
Abstract

Maternal depression disproportionally affects low-income, ethnic minority mothers of
young children, and can lead to poor child outcomes in a variety of domains, including parent-
child relationship quality, child behavior problems, and school readiness skills. Although
intervention researchers have developed several efficacious treatments for depression over the
past several decades, utilization of these treatments among low-income ethnic minority mothers
in community settings remains limited. Two-generation programs in Head Start offer a unique
opportunity to provide evidence-based mental health services for mothers that may have
difficulty accessing and utilizing treatment. This dissertation study utilizes a transformative
mixed methods approach to evaluate the implementation effectiveness of the “Healthy Moms,
Healthy Kids” (HMHK) program, which provided a gold standard evidence-based treatment for
depression (Group Interpersonal Psychotherapy) in Head Start. Paper 1 assesses HMHK
implementation outcomes and factors impacting implementation using the mixed methods RE-
AIM QuEST framework. Paper 2 explores mothers’ experiences in the HMHK intervention, and
uses a mixed methods approach to identify factors and mechanisms that impacted treatment
outcomes. Taken together, these findings will be used to develop recommendations for
researchers, practitioners, and policymakers regarding how to further adapt IPT-Group and other
mental health treatments for use in Head Start to best address the needs of low-income minority
mothers experiencing depression.

1
Chapter One: Introduction
Review of the Literature
Maternal depression is a significant public health concern, particularly for low-income
mothers of young children. For example, studies have found that 52% of low-income mothers of
young children experience depression (Early Head Start Research and Evaluation Project, 2006),
compared to estimates of 10-30% of mothers in the general US population (Ertel et al., 2011).
Mothers living in poverty face many challenges not experienced by other parents, including
economic pressure (Masarik & Conger, 2017), irregular work hours (Hsueh & Yoshikawa,
2007), housing instability (Bassuk et al., 1996), high rates of exposure to community and other
forms of violence (Ammerman et al., 2009; Clark et al., 2008), and increased risk of child
welfare involvement (Hines et al., 2004). Ethnic minority mothers face additional difficulties,
including greater levels of acculturation stress (Emmen et al., 2013) and racial and ethnic
discrimination (Nazroo, 2003). These compounded stressors put low-income, ethnic minority
mothers at greater risk for depression (Horwitz et al., 2007) which incurs significant societal and
economic costs, particularly for the wellbeing of their children (Jackson et al., 2000; Masarik &
Conger, 2017; Mistry et al., 2002).
Decades of research show that maternal depression negatively impacts parenting
behaviors (Callender et al., 2012; England & Sim, 2012; Lovejoy et al., 2000) and can lead to
impaired child functioning. In particular, young children of depressed mothers are at greater risk
for developing attachment insecurity (Martins & Gaffan, 2000), behavioral problems (Dietz et
al., 2009; Goodman et al., 2011), and poor school readiness skills (Pan et al., 2005; Quevedo et
al., 2012). Therefore, it is critical that public health systems provide evidence-based treatments
2
(EBTs) for low-income mothers suffering from depression and other mental health difficulties in
order to promote healthy child development.
Although several EBTs for depression have been developed, disparities in access to and
utilization of depression treatments among low-income, minority mothers of young children
remain a significant problem (Anderson et al., 2006; England & Sim, 2012; McDaniel &
Lowenstein, 2013). For example, numerous clinical trials have established that Cognitive-
Behavioral Therapy (CBT), Interpersonal Psychotherapy (IPT), and other psychosocial
treatments are effective in reducing maternal depression (Cuijpers et al., 2020; Dennis &
Hodnett, 2007).

However, many low-income mothers of young children do not access and utilize
existing EBTs (McDaniel & Lowenstein, 2013). 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
neither used prescription medication nor received therapy for their depression in the past year
(McDaniel & Lowenstein, 2013). 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 & Lowenstein,
2013).

Therefore, one challenge for the field of maternal and child health is to develop ways to
promote access to interventions for low-income and uninsured mothers experiencing depression.
In addition to the problem of access, research from implementation science shows that
simply disseminating efficacious interventions does not ensure successful implementation in
under-resourced community settings (Damschroder et al., 2009). 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., 2011; L.
Damschroder et al., 2009; Greenhalgh et al., 2004). Studies show that disparities in mental health
3
service utilization among low-income mothers may be due to stigma, lack of trust in formal
systems, and poor fit with clients’ cultural beliefs (Anderson et al., 2006; Caplan & Whittemore,
2013).
Several implementation science frameworks have been developed to evaluate
implementation effectiveness and identify important factors that predict an implementation’s
success or failure (Aarons et al., 2011; L. J. Damschroder et al., 2009; Glasgow et al., 1999;
Greenhalgh et al., 2004). First, the “Reach, Effectiveness, Adoption, Implementation, and
Maintenance” (RE-AIM) framework 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).

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., 2013). The framework is composed of five
components: 1.) “Reach,” which refers to the proportion and characteristics of persons who
received care, 2.) “Effectiveness,” which refers to the positive and negative outcomes of a
program, 3.) “Adoption,” which refers to the proportion and representativeness of settings that
adopt a program, 4.) “Implementation,” which refers to how well the intervention was delivered
as intended, and 5.) “Maintenance,” which refers to the extent to which a program is sustained
over time (Glasgow et al., 1999).

More recent efforts have also focused on utilizing
implementation theories and frameworks to promote health equity (Baumann & Cabassa, 2020;
Chinman et al., 2017).
Although implementation science has identified several important factors influencing the
implementation of public health programs, few studies have focused on implementing parent
support and treatment services in child-serving organizations, and none have focused on Head
Start. Broader research examining the low utilization of mental health services by poor, minority
4
mothers shows that disparities may be due in part to consumer-level factors like perceptions of
stigma, lack of trust in formal systems, and poor fit with clients’ cultural beliefs and values
(Anderson et al., 2006; Caplan & Whittemore, 2013). A second body of research has focused on
difficulties with implementing parent support services in the child mental health system,
particularly due to unsupportive organizational cultures (Olin et al., 2014). However, in general
very little research has focused on implementing parent support and treatment services in child-
serving organizations. Research would benefit from an examination of factors that impact the
effectiveness of implementing parental support and treatment services in child-serving
organizations, specifically within settings like Head Start. In addition, implementation science
frameworks should incorporate consumer needs and preferences, which will also impact
implementation success or failure. Furthermore, researchers and policymakers would benefit
from understanding which factors are most important when developing and implementing parent
support and treatment services, in order to maximize the reach and effectiveness of programs.
Study Context
Federal Head Start programs provide a unique opportunity to address maternal depression
due to their mission as a “two generation” program. Head Start was designed to support the
developmental needs of low-income children and concurrently provide social services to address
the needs of their parents. However, the reach and quality of dual-generation programs in Head
Start settings remain limited (Chase-Lansdale & Brooks-Gunn, 2014). In 2013 the
Administration for Children and Families funded four innovative programs to accelerate the
development of dual-generation EBTs for Head Start settings (Administration for Children and
Families, 2013). One of the programs, called “Healthy Moms, Healthy Kids” (HMHK), was
funded to explore the effectiveness of providing a group depression treatment for low-income,
5
predominantly ethnic minority mothers of children enrolled in Head Start (Administration for
Children and Families, 2013). The HMHK program implemented Interpersonal Psychotherapy-
Group, an empirically validated psychotherapy for depression, which has been tested with a
variety of populations and is effective in both individual therapy and group formats (Stuart &
Robertson, 2012). Results show that IPT-Group was effective in reducing depressive symptoms
and parenting stress among depressed mothers in the intervention group compared to mothers in
the control group (Mennen et al., 2021). However, recruitment and retention posed a significant
challenge in the study, as well as equipping Head Start staff to screen mothers for depression and
address parental mental health concerns (Sommer et al., 2019).
Therefore, further research is needed that examines how the unique characteristics of
Head Start, agency factors, and consumer needs and preferences may have impacted the
implementation of IPT-G in this setting. In addition, part of assessing implementation
effectiveness includes identifying the mechanisms that lead to positive outcomes (Forman et al.,
2017), and since the HMHK program was a pilot study and the intervention group was small
(n=49), using mixed methods will allow the PI to amplify the voices of participants and elucidate
effective mechanisms in the program. ACF is currently seeking information regarding factors
promoting the successful implementation of HMHK and other innovative two-generation
programs, which would enable Head Start centers to provide accessible, effective services across
the United States. Therefore, this study will provide important insights to researchers and
policymakers providing parent support and treatment services in community settings like Head
Start that serve low-income, ethnic minority families.

6
Study Approach
This dissertation is grounded in the transformative paradigm, which was developed by
Dr. Donna Mertens (Mertens, 2007, 2009, 2010, 2012). The transformative paradigm focuses on
the “lives and experiences of communities that are pushed to society’s margins, for example
women, racial and ethnic minorities, those who are poor, and more generally, people in
nondominant cultural groups” (Mertens, 2009, p. 48). This paradigm focuses on using inquiry to
promote social justice and action in the real world and focuses on power at every stage of the
research process (Mertens, 2007). This paradigm fit well with the focus of implementation
science, which is to translate effective interventions into the real world, and provided much
needed guidance around how to conduct the dissertation research from a social justice
perspective. The transformative paradigm has several basic tenets, including (1) axiology, or
assumptions about ethics, (2) ontology, or assumptions about reality, (3) epistemology, or
assumptions about the nature of knowledge, and (4) methodology, or assumptions about the
appropriate methods of systematic inquiry (Mertens, 2009).
In terms of axiology, the transformative paradigm considers issues of ethics and includes
the fundamental principles of the furtherance of human rights, social justice, and respect for
cultural norms (Mertens, 2010). The axiological assumption also charges that researchers have “a
moral responsibility to understand the communities in which they work in order to challenge
societal processes that allow the status quo to continue” (Mertens, 2009, p. 48). This dissertation
enacted the values of the axiological assumptions by elevating the experiences of marginalized,
low income mothers and paraprofessional staff and establishing a research team that was
reflective of the cultural backgrounds of the population (Mertens, 2010), including hiring Latina
research assistants who lived in the community. In terms of ontology, the transformative
7
paradigm rejects cultural relativism and instead recognizes that “there is one reality about which
there are multiple opinions” (Mertens, 2010, p. 470). According to Mertens, this understanding
leads us to ask, “Whose reality is privileged in this context?” (Mertens, 2010, p. 470). This
dissertation sought to embody this value by privileging the perspectives of those with less power,
including intervention participants and frontline staff, in addition to soliciting the views of actors
with more power.
In terms of epistemology, the transformative paradigm describes the nature of knowledge
and asserts that researchers should be in close collaboration with participants in the study to
ensure that they are gathering accurate knowledge. In particular, this tenet asserts that
researchers must be in collaboration with the people of the community, not necessarily the
leaders of the community. In this dissertation study, the PI sought to develop collaborative
relationships with community members by soliciting their opinions and feedback and providing
adequate time and space for community members to share their opinions. When this diverged
from hierarchical channels within the partner organization, for example, the PI attempted to
establish other means of interaction with study participants. In terms of methodology, the
transformative paradigm makes several assertions about the appropriate methods of systematic
inquiry. First and foremost, the paradigm sees the inclusion of qualitative methods as “critical” in
establishing that collaborative connection between the researcher and the community. Mixed
methods are also recommended, in which the qualitative dimension gathers community
perspectives and the quantitative dimension provides the opportunity to demonstrate outcomes
that have credibility in the larger research community (Mertens, 2007).

8
Dissertation Structure
The overall aim of the proposed dissertation research was to comprehensively evaluate
the implementation of an EBT for depression among ethnic minority mothers of Head Start
children, as well as identify effective mechanisms operating in both the screening process and
intervention to improve the program. The proposed dissertation study is part of a larger
embedded intervention trial mixed method design, in which qualitative data is used before and
after the focal RCT to inform the study and intervention design and promote further adaptation to
improve effectiveness (see Figure 1.1).

This mixed method multi-study examined the implementation of the “Healthy Moms,
Healthy Kids” program and sought to identify effective mechanisms in the depression screening
process and IPT-G intervention to further adapt the program for low-income, ethnic minority
Head Start mothers. The parent HMHK study was a collaboration with Children’s Institute, Inc.
(CII) to evaluate an adapted IPT-G model for Head Start mothers with depression in south Los
Angeles. In the first phase of the dissertation study, qualitative and quantitative data were
Figure 1.1 Embedded intervention trial mixed method design
9
collected and analyzed, and were then used in different ways for each of the dissertation papers.
The qualitative data, which included individual interviews with intervention participants and
agency staff, explored key stakeholders’ perspectives to (1) evaluate implementation
effectiveness (according to the RE-AIM framework), and (2) illuminate the lived experiences of
HMHK intervention participants to identify factors and mechanisms that help explain differences
in treatment outcomes. The quantitative data, which included administrative and intervention
data, was used to (1) complement qualitative data in order to comprehensively evaluate
implementation effectiveness (according to the RE-AIM framework), and (2) identify subgroups
of HMHK intervention participants in terms of treatment progress to analyze qualitative themes
regarding factors and mechanisms impacting treatment outcomes. This dissertation is composed
of the following 2 papers:
1.) Mixed methods paper assessing HMHK implementation outcomes and factors
impacting implementation (using RE-AIM QuEST model)
2.) Mixed methods paper examining mothers’ lived experiences of HMHK intervention,
and factors and mechanisms that impacted treatment outcomes
Paper 1: “Implementation of the Healthy Moms, Healthy Kids Program: An
Application of the RE-AIM QuEST Framework.” After the qualitative and quantitative data
analysis portions of the study have been completed, the two sources of data will be integrated
using a convergent mixed method design to evaluate implementation effectiveness based on the
RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework (see
Figure 1.2). For this paper, implementation outcomes will be assessed for both 1) universal
maternal depression screening, and 2) the provision of IPT therapy groups. RE-AIM QuEST was
developed specifically to integrate qualitative and quantitative data to evaluate the RE-AIM
10

criteria (Forman et al., 2017). To determine the “Reach” of the program according to the QuEST
framework, quantitative data about the proportion and representativeness of depression screening
and IPT group participants will be analyzed together with qualitative data about mothers’ reasons
for participating in both screening and the IPT-G intervention (Forman et al., 2017). The
“Effectiveness” portion of the QuEST framework will be evaluated using quantitative data of the
program’s impact on maternal and child functioning and qualitative data to examine mothers’
perceptions of programs impacts and beliefs about mechanisms that made it successful (Forman
et al., 2017).
The “Adoption” portion of the QuEST framework will be evaluated by integrating
quantitative data on the proportion of staff trained to conduct depression screening and provide
groups with qualitative data regarding factors influencing adoption (Forman et al., 2017). The
“Implementation” portion of the QuEST framework will be evaluated by combining quantitative
data about variation in maternal depression screening and IPT group participation, along with
qualitative data regarding barriers and facilitators to implementation (Forman et al., 2017).
Lastly, the “Maintenance” portion of the QuEST framework will be evaluated by integrating
quantitative data regarding the numbers of staff continue to screen for depression and run IPT
Figure 1.2 Paper 1: Convergent mixed methods design
11
groups with qualitative data from agency leadership about barriers to maintaining the program
and factors that would promote their ability to sustain the intervention (Forman et al., 2017).
Paper 2. “Group Interpersonal Psychotherapy for Ethnic Minority Head Start
Mothers with Depressive Symptoms: A Mixed Method Study of Experiences and
Mechanisms.” For this paper, an explanatory sequential mixed methods design was used in
which qualitative data from intervention participants was used to explain quantitative
intervention results, including identifying which participants demonstrated reductions in
depression after IPT-G, how their experiences differed from those whose depressive symptoms
did not decrease or from mothers who had low levels of symptoms, and what mechanisms
promoted change over treatment for this group (see Figure 1.3).

The first section of the paper will consist of a qualitative analysis, which will identify
participants’ experiences of participating in the HMHK intervention. Subsequently, the PI will
split the group of mothers (n=25) into groups based on their quantitative change in depression
scores over the course of the HMHK program and examined differences in qualitative themes
between these groups using the MAXQDA mixed methods software. Although IPT-G was
effective overall in reducing maternal depression, some of the participants showed great
Qualitative
analysis:
What were
mothers’
experiences in
HMHK and
perceptions of
program
impacts?

Mixed methods
study:
Which factors
and
mechanisms
help explain
differences in
treatment
outcomes?

Qualitative
data
collection:
(Subset of 26
mothers who
participated in
IPT-G)
Quantitative
Pre-Test
Results
(maternal
depression)
Quantitative
Post-Test
Results
(maternal
depression)
Figure 1.3 Paper 2: Explanatory sequential mixed methods design
12
improvements while others did not, and qualitative interviews were conducted with mothers who
had a range of experiences, allowing the PI to examine differences in the views among these
groups.

13
Chapter Two (Study 1)
Implementation of the “Healthy Moms, Healthy Kids” Program in Head Start:
An Application of the RE-AIM QuEST Framework
Introduction
Depression is a significant public health concern impacting mothers during the early
childhood years (England & Sim, 2012), with research consistently documenting negative
impacts on child health and development (England & Sim, 2012; Goodman et al., 2011;
Sutherland et al., 2021). Low-income mothers and mothers of ethnic minority backgrounds are
disproportionately impacted by maternal depression and often also face significant barriers in
accessing high-quality mental health treatment (Ertel et al., 2011; McDaniel & Lowenstein,
2013; Oh et al., 2018; Witt et al., 2011). Although most research focuses on maternal depression
during the perinatal period, studies show that maternal mental health difficulties can continue
into the early childhood years (van der Waerden et al., 2015; Woolhouse et al., 2015) and
continue to negatively impact child development (van der Waerden et al., 2015b), raising
concerns about how to intervene to best support maternal and family well-being during the later
early childhood period. In fact, one study found that 52% of mothers of children in Early Head
Start endorsed clinical levels of depressive symptoms (Early Head Start Research and Evaluation
Project, 2006).
Recently, two-generation approaches have focused on supporting early childhood health
and development by identifying depressed mothers and embedding mental health services for
parents in child-serving settings. For example, several efforts have focused on building capacity
to address maternal depression in Head Start (Beardslee et al., 2010; Mennen et al., 2021; Palmer
Molina et al., 2019, 2020; Silverstein et al., 2017, 2019). However, questions remain about
14
whether two-generation mental health programs are scalable, and the barriers and facilitators to
successful implementation in community-based Head Start settings.
The “Reach, Effectiveness, Adoption, Implementation, and Maintenance” (RE-AIM)
Framework was developed to evaluate implementation effectiveness across several important
domains (Glasgow et al., 1999). It 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). 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., 2013), and its usage continues to grow. The
RE-AIM framework focuses on evaluating the following domains: 1.) “Reach,” which refers to
the proportion and characteristics of persons who received care, 2.) “Effectiveness,” which refers
to the positive and negative outcomes of a program, 3.) “Adoption,” which refers to the
proportion and representativeness of settings that adopt a program, 4.) “Implementation,” which
refers to how well the intervention was delivered as intended, and 5.) “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., 2017). In this study, the RE-AIM QuEST framework will be used to assess the
five implementation outcomes of Reach, Effectiveness, Adoption, Implementation, and
Maintenance and identify factors that influenced implementation of a two-generation maternal
depression intervention in Head Start.

15
Methods
This paper reports on the implementation effectiveness of the “Healthy Moms, Healthy
Kids” (HMHK) program (Mennen et al., 2021), which consisted of two major components: 1)
instituting a universal depression screening program for all Head Start mothers, and 2) providing
an adapted group intervention for mothers with elevated depressive symptoms.
Depression Screening Overview
First, the HMHK program implemented universal maternal depression screening in Head
Start to identify mothers who would benefit from therapeutic intervention. Paraprofessional
Family Service Workers (FSWs) screened mothers for depression using the 10-item Center for
Epidemiology Studies Depression Scale Short Form (CES-D Short Form; Andresen et al., 1994).
A cutoff score of 8 was used to indicate that the participant met criteria for mild depressive
symptoms. Mothers at the targeted Head Start sites who scored above 8 on the CES-D were then
referred to participate in the study.
Intervention Overview
Second, the HMHK program provided a gold standard maternal depression intervention
to Head Start mothers in South Los Angeles in the hopes of improving both maternal and child
well-being. Interpersonal Psychotherapy-Group (IPT-G) was originally developed by Reay &
Stuart (2003) 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., 2006). For this study,
IPT-G was extended from 8 to 12 weekly sessions, and food, transportation, and childcare were
16
provided to address potential barriers to participation. Therapy groups were also held at Head
Start sites to facilitate participation and trust. See Mennen at al. (2021) for more details regarding
the intervention.
Evaluation Participants
This study included a variety of key informants (n=52), including intervention
participants and staff members at different levels of the organization who were involved in
implementation. Staff members included HMHK therapists who ran groups, frontline staff
involved in depression screening, and agency leadership involved in overseeing the study’s
implementation. In terms of sampling, all potential informants were contacted and recruited into
the implementation study due to the small scale of the study and concerns about staff turnover.
All mothers who participated in the intervention were invited to participate (n=49), and the 26
who consented were interviewed for the implementation study. In terms of frontline staff, the PI
interviewed 5 out of the 12 therapists that conducted IPT therapy groups and was unable to reach
the other 7 therapists who had left the agency. In terms of frontline staff involved in depression
screening, the PI interviewed all staff that remained employed at the agency, including 13 Family
Service Workers (FSWs) who conducted depression screening and 5 Family and Community
Partnership Specialists who supervised FSWs in conducting screening. Lastly, all supervisors
and managers who were involved in the project’s implementation were interviewed (n=3). All
participants provided informed consent in accordance with the University of Southern
California’s Institutional Review Board and received a $40 gift card for their participation.
Study Design
For the purposes of examining the implementation effectiveness of the HMHK program,
quantitative and qualitative data were drawn from various sources and merged in a convergent
17
mixed method design. Data collection, analysis, and integration were guided by the RE-AIM
Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework (Forman et al.,
2017). The RE-AIM QuEST framework seeks to leverage qualitative and quantitative data to
assess implementation effectiveness across the outcomes of Reach, Effectiveness, Adoption,
Implementation, and Maintenance 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.
Data Collection
Quantitative Data Collection
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 regarding depression screening rates, and staff
training and retention. All data was de-identified to protect the identities of Head Start families,
intervention participants, and agency staff. First, 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 rates of
depression screening and positive screenings across FSWs and other staff roles, the number and
background of mental health staff that were trained in IPT-G, and staff turnover among frontline
18
staff. Second, quantitative data was drawn from the parent intervention study including the
number of mothers who completed the therapy group versus those who dropped out.
Qualitative Data Collection – Interviews
The PI and research team conducted semi-structured individual interviews with both
mothers who participated in therapy groups and 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., 2012; Bransford & Choi,
2012). The complete interview guide is included in the Appendices. Interviews with intervention
participants lasted 45 minutes on average and were conducted in-person at the individual’s home
or another location. 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 minutes, depending on the staff
member’s role.
Qualitative Data Collection – Meeting Minutes
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.

19
Measures
Table 2.1 illustrates how each of the RE-AIM outcomes was assessed, including the
source of quantitative and/or qualitative data for each indictor. We considered two aspects of the
implementation for each RE-AIM outcome: 1) universal maternal depression screening and 2)
the provision of IPT groups, except for the domain of “Effectiveness.” 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 depression screening, and in
enrolling in IPT groups. Measures of “Effectiveness” typically include quantitative measures
reporting intervention effects on targeted outcomes (Forman et al., 2017). We considered
“Effectiveness” only for the provision of the IPT group intervention. We report overall
intervention outcomes and outcomes broken down by race/ethnicity and examined attendance in
group IPT sessions. 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). The domain of “Implementation” typically assesses 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
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assess “Implementation” we assessed variation in screening rates across Head Start sites and
staff members and examined whether screener role was associated with screening and IPT-G
participation. We then used qualitative data to document variation in implementation of
depression screening and identify the staff and agency-level factors that impacted the
implementation of universal depression screening, as well as the recruitment and retention of
mothers in therapy groups. To assess “Implementation” of IPT-G we focused on understanding
variation in how 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, in qualitative interviews therapists reported on their ability to
follow the model in qualitative interviews. 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 staff who continued to
conduct maternal depression screening in Head Start and the number of IPT groups continuing
after the study ended and utilized qualitative data to elucidate the barriers to maintaining the
HMHK program.

21
Table 2.1 Quantitative and qualitative RE-AIM components, including indictors and measures.

Indicator Measure
Reach Quantitative:
• How many and what proportion of
the target population participated in
depression screening?
• What proportion of the target
population screened positively?

• To what extent was participation in
depression screening associated
with client characteristics?

• How many and what proportion of
the target population participated in
the intervention?
• To what extent was intervention
participation associated with client
characteristics?
• To what extent did mothers who
enrolled in the intervention
represent the greater HS population
in this area?
Qualitative:
• What were the barriers and
facilitators to participant
enrollment/participation in
screening and in IPT-G?
• What explains variation in
“Reach”?

Quantitative Measures:
• Participation rate (screening)= #
participating/ # eligible

• Positive screening rate = # screened
positive/ # participating in screening
• Associations between screening
participation and maternal age,
maternal language, child age

• Participation rate (IPT therapy
groups) = # participants enrolled /
eligible mothers who had a positive
depression screening
• IPT group participant demographics,
compared to those with positive
screening who did not participate
• IPT group participant demographics,
compared to CII HS population
racial/ethnic background

Qualitative Measures:
• Interviews with IPT-G participants,
non-participants, staff at multiple
levels
• Meeting minutes

Effectiveness Quantitative:
• What were the effects of the IPT-G
intervention for participants,
compared to the control group?
• To what extent did Black and
Latina mothers experience different
outcomes?

Qualitative:
• What are participants’ perceptions
of the effects of IPT-G?
• What are the conditions and
mechanisms that led to
effectiveness?
• What explains variation in
outcomes?
• What adaptations are needed to
improve effectiveness?

Quantitative Measures:
• Maternal outcomes results reported
in Mennen et al., 2021
• Child outcome results
• Subgroup differences based on
race/ethnicity
• Group attendance

Qualitative Measures:
• Mothers’ views on intervention
impacts, mechanisms of
effectiveness, further adaptations
• Staff views on variation between
groups, further adaptations

Adoption Quantitative:
• What was the percentage and
representativeness of
providers/settings participating in
the program?
Quantitative Measures:
• #/proportion of staff trained who
conducted depression screening
• #/proportion of staff trained who led
IPT groups
22

Qualitative:
• What affected provider/setting
participation?

• #/proportion of sites that provided
groups
Qualitative Measures:
• Therapists’ views about IPT-G, EBTs
• Other factors impacting
provider/setting participation
(interviews with agency leadership)
• Meeting minutes

Implementation Quantitative:
• Were depression screening and the
IPT-G intervention implemented as
intended?
• How consistent was delivery across
sites/staff?
o Were there variations in
depression screening?

o Were there variations in
how IPT-G was delivered?

Qualitative:
• Were depression screening and IPT
groups implemented as intended?
To what extent was there variation
in delivery?
• What explains differences in
implementation across sites/staff?

• To what extent did therapists
demonstrate fidelity to the model?
Did they adapt or modify the
model?

Quantitative Measures:
• IPT-G fidelity not assessed
quantitatively

• Association between screening
participation and screener role
• Rates of screening/positive screening
across staff roles, among FSWs
• Association between IPT-G
participation and screener role
• # of cancelled groups

Qualitative Measures:
• HMHK meeting minutes, FSW,
supervisor, and therapist reports

• FSW, supervisor, and therapist
perspectives regarding
barriers/facilitators
• Interviews with therapists regarding
fidelity

Maintenance Quantitative:
• Was the intervention maintained
after the study period (depression
screening and IPT-G)?

Qualitative:
• What are the barriers to
maintaining the program?

Quantitative Measures:
• Number of enrollees in IPT-G after
study ended (1 group running), staff
doing depression screening

Qualitative Measures:
• Interviews with agency
leadership/frontline staff
• Meeting minutes

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Data Analysis
Quantitative Data Analysis
Quantitative data were gathered for each RE-AIM domain (see Table 2.1) and analyzed
in SPSS 27.0. For “Reach,” univariate statistics were calculated to describe depression screening
participant characteristics (maternal and child age, maternal language) and rates of participation
in depression screening and IPT therapy groups. Subsequently, bivariate comparisons using t-
tests and chi-square tests were conducted to compare depression screening participants and non-
participants, and 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. For “Effectiveness,” intervention effects were
previously assessed using linear mixed-effect models and details regarding the analysis strategy
are presented elsewhere (Mennen et al., 2021). Intervention effects were assessed for both
maternal outcomes (depression, 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. For “Adoption,” univariate statistics were calculated to
assess the proportion of staff trained who conducted maternal depression screening, 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 both rates of
depression screenings and positive screening outcomes across staff roles and among FSWs.
Subsequently, bivariate comparisons using chi-square tests were conducted to compare screening
participation, positive screenings, and IPT-G participation by staff role. Post-hoc tests that

24
accounted for multiple comparisons were used to assess significant pairwise differences. For
“Maintenance,” the number of staff conducting screening and participants enrolling in IPT-G
after study ended were calculated.
Qualitative Data Analysis - Interviews
Qualitative interviews with intervention participants and staff members were analyzed
using Dedoose, Version 8.3.43. Qualitative data were analyzed in two phases: 1) inductive
coding was conducted to identify key themes emerging from the data, and 2) deductive coding
was conducted subsequently to align data with one of the five domains of the RE-AIM QuEST
framework. The PI chose this coding process to ensure that the depth of the qualitative data was
captured, and also that data were clearly coded to relevant aspects of the five different
implementation outcomes.
For the inductive coding process, the PI used a methodology called “Coding Consensus,
Co-occurrence, and Comparison” (Willms et al., 1990). Interviews with frontline staff who
conducted depression screening (n=18) and intervention participants (n=26) were analyzed
separately using the following process. 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

25
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 &
Strauss, 2008). The PI then reviewed the final coding and codes were assigned to describe
connections between categories and between categories and subcategories, which is known as
axial coding (Corbin & Strauss, 2008). (6) The PI then compared categories to condense them
into broader themes (Glaser & Strauss, 1967). For the interviews with therapists who conducted
IPT groups (n=5) and leadership involved in implementation (n=3), the PI conducted the
inductive analysis individually based on the same process and consulted regularly with her
mentor.
Second, 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 of “Reach,”
“Effectiveness,” “Adoption,” “Implementation,” and “Maintenance.” RE-AIM domains had
subsections for depression screening and the IPT-G intervention, except for the “Effectiveness”
domain, which only evaluated effectiveness for the IPT-G intervention. 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.
Qualitative Data Analysis – Meeting Minutes
The PI utilized document review (Bowen, 2009) 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 (2015).

26
First, the PI deductively coded the data using the RE-AIM framework, coding content related to
the reach, effectiveness, adoption, implementation, and maintenance of the HMHK program, and
content could be coded to more than one domain. Once this phase of coding was completed, the
PI 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.
1

Results
2.1 Reach
2.1.1. Is the intervention reaching the target population?
2.1.1.1 Depression Screening.
Assessing Reach. The HMHK program screened approximately 85% of a total of 2,902
eligible Head Start mothers for depression, with 436 mothers (15%) refusing to participate
during the first screening attempt. Analyses showed that participants who consented to complete
depression screening, compared to those who refused, were younger (mean ± SD: 31.4 vs. 34.6
years, p <.001) and differed significantly by maternal language (English, Spanish, or bilingual,
X
2
(2, N= 2,796) = 19.18, p < .001), but did not differ in terms of the child’s age (see Table 2.2).
Post-hoc tests showed that English-speaking mothers were significantly more likely than
Spanish-speaking or bilingual mothers to refuse screening. Unfortunately, information about
mothers’ racial/ethnic backgrounds was not collected at the time of screening, although agency
leaders reported that most English-speaking mothers were Black/African American.

1
The qualitative analysis process for document review differed from the interview transcripts (e.g., moving from
deductive to inductive, rather than from inductive to deductive) because of the significant amount of extraneous
information included in the meeting minutes.

27

Of the 2466 mothers who participated in an initial depression screening attempt, 457 (18.5%)
screened above the cut-off score of 8 for mild depression on the CES-D Short Form. Quantitative
data showed that 565 mothers (19.4%) were re-screened for depression at a later time, and of this
total, 108 mothers (19.1%) then met criteria for mild depression. Therefore, in total 565 mothers
(22.9%) met criteria for mild depression.
Factors Impacting Reach. Qualitative data revealed several client/family barriers and
facilitators to maternal depression screening in the Head Start setting that contributed to variation
in “Reach.” These included family barriers like the mother’s lack of availability, stigma, privacy
concerns, lack of interest, and lack of trust. Privacy concerns was the most highly endorsed
barrier that emerged from the qualitative data, with several frontline staff members reporting that
mothers were concerned that the information they disclosed would be shared with child
protective services, immigration authorities, or even their spouses and other family members. For
example, one FSW noted:
“They just didn't want to report it to DCFS, you know, how they are feeling.
Some of them are single parents. They were like ‘Okay, I don't want my kids to
be taken away.’ There's a lot of misconceptions.”
Table 2.2 Characteristics of mothers who participated in universal depression screening compared to non-
participants

Screening participants
(n= 2,466)
Screening non-
participants
a
(n=436)

Characteristic M (SD) or N (%) M (SD) or N (%) Sig. (p)
b
Maternal age 31.4 (7.3) 34.6 (11.1) <.001
Child age 4.0 (1.3) 4.0 (1.3) .517
Maternal language <.001
English 852 (35.1)
174 (46.9)

Spanish 1006 (41.5) 126 (34.0)
Bilingual 567 (23.4) 71 (19.1)
a
This group includes those who declined depression screening and have data available.
b
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.

28
Many frontline staff also shared that stigma was a significant barrier to engaging families in
depression screening, particularly stigma around mental health in this specific community. One
FSW shared:
“Really it stems to when anyone hears the term ‘mental health,’ it's an immediate
wall that goes up, because there is a cultural stigma. And both populations that we
serve in our area, which is African American and Hispanic, and primarily first or
second-generation immigrants that are Hispanic. And hearing mental health, it's
like what do you mean? They already tie it to “Oh, I'm not crazy.”

In contrast, qualitative results showed that there were several facilitators to participation in
maternal depression screening, including positive parental attitude, strong family connection to
the partner agency and/or Head Start, and having a close and trusting relationship with the FSW
that conducted the depression screening. One mother explained:
“It’s very difficult sometimes to say, "Yes, I’m going through this," because you
want to be your best. But I do not know, maybe the girl there inspired me with
confidence...She said, "Don’t worry."...She also said, "If you’re going through
this, we can help you." That’s what made me say "Yes, I'm going through this
right now."

2.1.1.2 IPT-G Intervention.
Assessing Reach. Out of a total of 291 mothers who had a positive depression screening
at an eligible intervention site at any time during the intervention trial, only 49 then proceeded to
enroll in an IPT therapy group (16.8% participation rate). Out of this total of 291 mothers who
screened positive, 31 refused to participate, and 210 were unable to be scheduled for a group. In
addition, 9 mothers who eventually enrolled in the therapy intervention screened negatively at
the first screening encounter and were re-screened at a later time. 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

29
bilingual, X
2
(2, N= 536) = 9.65, p < .05), but not in terms of maternal or child age (see Table
2.3).

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 reinforced by the types of groups that were conducted. Of the 10 total therapy groups, 7
were conducted in Spanish.
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.
Factors Impacting Reach. Qualitative data provided more information about the target
population reached by the IPT-G intervention and barriers and facilitators to participation in IPT
therapy groups. First, meeting minutes chronicled discussions around the target population,
Table 2.3. Characteristics of mothers who participated in IPT therapy groups compared to non-participants

IPT group participants
(n= 49)
IPT group non-
participants
a
(n=489)

Characteristic M (SD) or N (%) M (SD) or N (%) Sig. (p)
b
Maternal age 33.4 (6.3) 32.0 (7.8) .217
Child age 3.8 (0.6) 3.9 (0.6) .264
Maternal language .008
English 10 (20.4) 211 (43.3)
Spanish 27 (55.1) 192 (39.4)
Bilingual 12 (24.5) 84 (17.2)
a
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.
b
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.

30
showing that the implementation team re-examined the clinical cut-off used on the depression
screening measure, eventually deciding to the reduce the cut-off to capture mothers who did not
meet the cut off for depressive symptoms, but who still experienced mild symptoms that could
negatively impact child functioning. 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.”

2.2 Effectiveness
2.2.1 Does the intervention accomplish its goals?
2.2.1.1 IPT-G Intervention.
Assessing Effectiveness. Quantitative intervention outcomes are reported in greater detail
elsewhere (Mennen et al., 2021) and show that IPT-G was effective in reducing maternal

31
depressive symptoms and parenting stress up the six months post-intervention. Specifically,
participants in the treatment group showed a significant decrease in depression scores (β time= -
4.59, p<0.05; p for time*group interaction <0.05) and parenting stress (β time= - 6.77, p<0.05; p
for time*group interaction <0.05) over the study period compared to the control group (Mennen
et al., 2021). 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 (Mennen et al., 2021). In terms of differences by
race/ethnicity, 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.
In terms of intervention impacts, qualitative findings echoed quantitative findings and
mothers reporting that they experienced lower levels of anxiety, stress, and depressive symptoms
due to their participation. 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.”

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.”

32
Although IPT-G reduced maternal depression 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
(Mennen et al., 2021; Mennen at al., in progress). 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.”

Factors Impacting Effectiveness. Qualitative data was also analyzed to assess the
conditions and mechanisms that led to the effectiveness of IPT-G for this population, and
mothers identified several key ingredients, 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.”

Mothers and mental health therapists also reflected on further adaptations that would be
needed to improve the effectiveness of IPT-G for this population. For participants, the most
highly endorsed recommendation was to provide more time, both in terms of the length of the
intervention (more sessions), and the duration of each session. Mothers also recommended that

33
the group be expanded to mothers of older children, to other Head Start sites and early childhood
settings, to fathers, and to also incorporate partners in sessions. 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.
2.3 Adoption
2.3.1 To what extent are those targeted to deliver the intervention participating?
2.3.1.1 Depression Screening.
Assessing Adoption. All Head Start Family Service Workers (FSWs) employed during the
years of the study adopted universal maternal depression screening (n= 38), meaning that the
adoption rate was 100%. Since screening was adopted by all FSWs, all Head Start sites
participated in screening, as each Head Start site was represented by at least one FSW. In
addition, other staff roles also adopted screening due to variation in timeliness of screening and
concern regarding low levels of endorsement of depressive symptoms (as we discuss in later
sections). These additional staff members included mental health therapists who led IPT groups
(n= 4), research staff from the agency partner (n= 4), and research staff from the university
partner (n= 4). Data about staff member race/ethnicity was not gathered during the study, but
agency leaders shared that the majority of FSWs were bilingual in Spanish, due to the needs of
the Head Start population.
Factors Affecting Adoption. Interviews with FSWs and FSW supervisors called Family
and Community Partnership Specialists (FCPSs) revealed that Head Start leadership at the
agency decided to require all FSWs to complete maternal depression screening as part of their

34
jobs, which promoted universal adoption. FCPSs explained that they would review depression
screening completion rates for FSWs during monthly team meetings and department meetings,
and follow-up weekly with FSWs as well through email to ensure that screenings were
completed.
2.3.1.2 IPT-G Intervention. 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.
Assessing Staff Adoption. 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, and 12 therapists (63%) went on to run at least one group. Of the 12
mental health therapists who led groups, only two were Head Start mental health therapists. 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.
Factors Affecting Staff Adoption. 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. Originally, the 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

35
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.”

Because of this difficulty, mental health therapists from the agency’s DMH-funded
program were then trained to lead the IPT groups. However, similar challenges emerged at this
point since DMH-funded therapists had productivity expectations as part of their job, and the IPT
groups were not considered a reimbursable expense for the majority of implementation period.
Productivity expectations were then reduced for therapists who led groups, but difficulties
remained. 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 ended up
leaving the agency.
Assessing Site Adoption. 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 0/25, or 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.
Factors Affecting Site Adoption. Meeting minutes revealed that 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.

36
2.4 Implementation
2.4.1 To what extent was the intervention consistently implemented?
2.4.1.1 Depression Screening.
Assessing Implementation. Although all FSWs adopted maternal depression screening,
significant variation was seen in terms of screening completion, with meeting minutes showing
that several Head Start sites routinely turned in screenings late. In addition, variation was seen in
outcomes based on who conducted the screening. For example, nearly 92% of depression
screenings were conducted by frontline Head Start staff called Family Service Workers (FSWs),
but other staff members also conducted screenings over time as the need arose (e.g., mental
health therapists, university study staff, agency research staff, etc.). Rates of participation in
depression screening differed significantly by staff member type, X
2
(2, N= 2,893) = 24.05, p <
.001, see Table 2.4, with post-hoc analyses showing that mothers were significantly more likely
to refuse screening when the screener was an FSW or agency research staff member, rather than
if the screener was university study staff member.

Table 2.4. Association between screener role and screening participation

Screening participants
(n= 2,466)
Screening non-
participants
a
(n=436)

Staff characteristic M (SD) or N (%) M (SD) or N (%) Sig. (p)
b
Screener role
c
<.001
Head Start FSW 2235 (91.0) 424 (97.2)
University study staff 145 (5.9) 2 (0.5)
Agency research staff 77 (3.1) 10 (2.3)
a
This group includes those who declined depression screening and have data available.
b
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.
c
Therapists were not included because they only conducted 7 depression screenings.

37
Furthermore, rates of initial positive depression screenings (i.e., mothers scoring above
the cut-off for depression) also differed based on staff role, X
2
(2, N= 2,457) = 77.92, p < .001.
For example, the percentage of mothers meeting criteria for mild depression during the first
screening attempt for FSWs was 16.2%, whereas rates for university study staff and agency
research staff were much higher at 44.1% and 29.9%, respectively. FSWs conducted 71

screenings each on average, ranging from 4 to 174 screenings. When looking exclusively at FSW
initial screening rates, there was wide variation, with positive depression screening rates ranging
from a 0% to 46.3% (see Figure 2.1). Qualitative interviews with FSWs also revealed significant
variation in screening delivery, or how the FSW reported that they introduced and discussed the
screener with the mother. This shows that staff-level factors may have influenced the
implementation of depression screening and ultimately the identification of at-risk mothers with
depression.
Note: For the purposes of this figure, FSWs were only included if they conducted more than 10 screenings.
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
43 29 24 48 27 22 32 50 26 47 19 34 17 42 46 15 30 14 52 40 3 20 2 38 12 7 33 37 11 21 31 45 41 9
Positive Depression Screening Rate
FSW ID
Figure 2.1 Variation in positive depression screenings among FSWs

38
Factors Impacting Implementation. Qualitative data revealed several barriers and
facilitators to universal maternal depression screening by FSWs in the Head Start setting. For
example, HMHK program barriers included things like administrative problems, timing of
screening, lack of a private setting, the use of control sites, and the use of specific screening
tools. One major concern was when to administer the screening. Over the course of the
implementation period, the team discussed this issue and ultimately recommended that FSWs
complete screening as part of the family’s enrollment in Head Start services to make sure the
FSW was able to meet with the mother. However, many FSWs and their supervisors reported
that they felt they had not yet established a strong connection with the mother at that point. One
FSW supervisor explained:
“The way that we went about it was difficult, because when they fill out
paperwork initially coming to the program it is at minimum 20 pages. So, to add
something else on, like “Oh! By the way, do you want to enroll in the program?
What are your needs and strengths and things, and by the way, are you
depressed?” At the beginning was the best place to ensure that we got the
families, but it was also least appropriate because we had not developed that
relationship with them.”

There were also several screening barriers related to FSWs, including workload, stigma,
limitations of the FSW role, negative attitudes towards screening, and a lack of sufficient training
or knowledge to adequately conduct depression screening. The most highly endorsed theme was
insufficient training and knowledge, as one FSW explains:
“Honestly, I don't think we were properly trained in it, especially with some of the
sensitive questions that are being asked and the follow-ups...Because I think one
of the questions was like, “do you live in constant fear or like something is going
to happen?” And sometimes parents, once they got familiar with us, they would
kind of break down and I don't think we were properly trained to deal with those
situations.”

In contrast, staff also identified several screening facilitators for FSWs, including having
an established relationship with the family, a positive attitude towards screening, prior mental

39
health training outside the HMHK program, the support of a supervisor, a sensitive engagement
style, and/or using screening strategies like utilizing de-stigmatizing language. Furthermore, staff
and agency leadership identified that another facilitator was the decision to utilize other staff
members like mental health therapists and research staff to help screen mothers for depression.
2.4.1.2 IPT-G Intervention.
Assessing Implementation. When assessing fidelity to the IPT-G model, therapists shared
that they felt the training in IPT-G was clear and structured, with different goals for each weekly
session. We also considered whether there was variation in how mothers were recruited in IPT
groups and found that rates of participation in IPT groups differed by which type of staff member
conducted the mother’s depression screening, X
2
(2, N= 531) =12.42, p < .01, see Table 2.5.
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, and 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.
Table 2.5. Association between screener role and IPT-G participation

IPT group participants
(n= 49)
IPT group non-
participants
a
(n=489)

Staff characteristic M (SD) or N (%) M (SD) or N (%) Sig. (p)
b
Screener role
c
.002
Head Start FSW 31 (67.4) 396 (81.6)
University study staff 14 (30.4) 59 (12.2)
Agency research staff 1 (2.2) 30 (6.2)
a
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.
b
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.
c
Therapists were not included because they conducted a very small number of depression screenings.

40
We also found that 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. In terms
of group attendance, there was some attrition with 38.8% of participants completing 1-4 sessions,
34.7% completing 5-8 sessions, and only 26.5% completing 9-12 sessions. 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 in terms of recruiting
enough mothers to begin English-speaking groups, and overall, there were only 4 English-
speaking groups conducted (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 the participants who completed the group (finishing between 9 and 12
sessions) identified as Latina.
Factors Affecting Implementation. Staff members identified several factors influencing
implementation of the IPT-G model. For example, they reported that there were difficulties at
times in terms of 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, having a strong 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

41
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.”

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.”’

2.5 Maintenance
2.5.1 To what extent did the intervention become part of routine organizational practices?
2.5.1.1.1 Depression Screening.
In terms of universal maternal depression screening in Head Start, interviews with Head
Start Family Service Workers (FSWs), FSW supervisors, and Head Start leadership at the agency
revealed that universal depression screening utilizing the structured CES-D tool was no longer
continuing in any capacity. Barriers to continuing the universal screening included lack of buy-in
from Head Start staff and hesitation about requiring paraprofessional staff to implement a
standardized screening tool. Agency leaders explained that the agency was becoming more
interested in building capacity to identify and address mental health concerns without relying
only on screening tools:
“We have trained a bunch of folks in mental health first aid, and I think that's
probably the direction we're inclined to go...Maybe to have just a little less
reliance on, “Did you complete the tool?? We completed...a ton of tools but we
don't necessarily do a good job identifying depression. I think sometimes people
complete a tool and that they feel like their job is done.”

42
2.5.1.1.2 IPT-G Intervention.
In terms of IPT therapy groups, 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
how 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.”

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.
Discussion
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. To evaluate the program, we assessed RE-
AIM outcomes for both: 1) universal maternal depression screening and 2) the provision of IPT
therapy groups, since each of these components represent a separate ‘intervention’ that was

43
implemented. Below we consolidate and make meaning of the results for each of these
components, and then compare results across components.
Universal Maternal Depression Screening
In considering the implementation of universal maternal depression screening, we
assessed four out of the five RE-AIM domains (Reach, Adoption, Implementation and
Maintenance). Overall, we found that performance was higher for the RE-AIM domains of
Reach and Adoption and lower for the domains of Implementation and Maintenance.
Reach: Did universal maternal depression screening reach the target population?
Universal maternal depression screening was able to reach a large portion of the target
population. Overall, 85% of mothers consented to depression screening on the first screening
attempt, with 15% refusing. This is a high rate of completion considering the stigma and fear of
DCFS reprisal that many mothers reported to staff, and difficulties that frontline Head Start staff
faced in terms of accessing mothers. However, it shows that there was a portion of mothers who
were not reached through screening using the standardized depression tool. In particular,
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 be experiencing
clinical depressive symptoms. Furthermore, although information about race/ethnicity was not
collected at the time of screening, the agency shared that most of the English-speaking mothers
they served were predominantly Black/African American, raising the possibility that
Black/African American mothers were least likely to participate in screening. Since many of the
frontline workers (FSWs) who conducted screenings were reported to be Hispanic/Latinx
(speaking to who adopted the intervention), it may be that the lack of staff with similar cultural
and racial backgrounds contributed to a higher rate of non-participation among this group of

44
English-speaking mothers. Future efforts to promote the reach of maternal depression screening
in Head Start and other public child-serving settings should focus on understanding the unique
barriers facing mothers from different racial/ethnic and language groups and exploring the
importance of racial/ethnic match in screening.
Overall, a total of 22.9% of mothers met criteria for mild depression, which is lower than
rates reported in other Head Start studies (Early Head Start Research and Evaluation Project,
2006; Silverstein et al., 2018). For example, Silverstein et al. (2018) implemented a maternal
depression prevention program in Head Start for mothers with mild symptoms and reported a
positive screening rate of 35.4%. However, the criteria used for a positive screening was having
an elevated score on the Patient Health Questionnaire–2 or reporting a previous episode of
depression, which differs from the criteria used in this study. In addition, a study of Early Head
Start families reported that 33.3% of mothers of 3-year-old children met criteria for depression.
The lower rate of depression in this study may be due to differences in eligibility criteria, child
age, true levels of depression in the population, or other factors related to the staff and project, as
will discuss later in the “Implementation” section.
Several facilitators were identified that promoted reach in maternal depression screening.
For example, one key finding is that repeated screening was useful in identifying at-risk mothers
that may have been missed during the first attempt, or who may not have met criteria at that time.
Additionally, having a trusting relationship with the partner agency, the Head Start program, or
the specific frontline worker who conducted the screening were facilitators that promoted the
reach of depression screening.

45
Adoption: To what extent did those targeted to deliver depression screening participate?
The rate of adoption of universal maternal depression screening in the HMHK program
was high, reaching 100% of Head Start FSWs. The major factor that promoted high levels of
adoption was that agency leadership required that all FSWs complete screening as part of their
regular job duties, and they tasked FSW supervisors with monitoring compliance. However, over
time additional types of agency staff members and university study staff were also utilized to
conduct depression screening, since implementation by FSWs was variable and rates of
depression remained low when screening was conducted by FSWs (as we cover in the next
section). Therefore, although adoption of maternal depression screening by FSWs was universal,
it was clearly not effective as a standalone intervention in reaching mothers with high levels of
depressive symptoms who could benefit from IPT-G.
Implementation: Was universal maternal depression screening implemented consistently?
The greatest number of challenges was reported in the domain of implementation, with
consistency of implementation scoring in the very low range. Results showed that
implementation of maternal depression screening varied across almost every measure we
examined. For example, rates of screening participation differed by staff role (FSW, agency
research staff, or study staff), rates of positive screenings differed by staff role, and there was
significant variation in positive screenings just within FSWs themselves, with rates of mothers
meeting criteria for mild depression ranging from 0% to 46%. It appears that whether a mother
was identified as experiencing depression could be more related to staff-level factors than true
differences in need for the population of mothers screened. Qualitative data revealed a high
number of barriers to screening, with the majority related to logistical issues around conducting
the screening (e.g., needing a private space, finding time during the school day to talk with

46
mothers, and not having an established relationship with the mother at the time of screening). In
addition, there were several barriers related to the FSWs and FCPSs themselves, including their
attitudes toward screening and mental health issues more broadly, their prior training in mental
health, and their engagement style and flexibility when working with parents, with many FSWs
stating that they did not feel that screening should ever be part of their job. These findings
demonstrate the importance of considering the best ways to help paraprofessional Head Start
staff develop greater capacity around mental health broadly. Since FSWs are tasked with
assessing a variety of family needs, it would benefit Head Start to provide universal trainings
opportunities for FSWs to gain more knowledge and comfort in assessing for mental health
problems.
Maintenance: Did universal maternal depression screening become part of routine practice?
At the time of this study, maternal depression screening was not continuing in any
capacity at the agency’s Head Start centers. This shows that even though the strategy of universal
maternal depression screening was highly adopted during the study period and reached a large
proportion of eligible Head Start mothers, it was not effective in real-world practice. Many of the
deterrents to continuing screening were related to the difficulties related to implementation and
uncertainty around whether the partner agency would continue to provide therapy interventions
for Head Start mothers experiencing depression.
Provision of IPT Therapy Groups
In considering the implementation of the IPT therapy groups, we assessed all five of the
RE-AIM domains (Reach, Effectiveness, Adoption, Implementation, and Maintenance). 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.

47
Reach: Did the IPT-G intervention reach the target population?
Our results showed that it was difficult for IPT-G to reach the target population. First,
only a small percentage of eligible mothers (16.8%) ultimately participated in an IPT therapy
group. The program was more successful in enrolling Latino mothers who were Spanish-
speaking or bilingual rather than English-speaking and Black/African American mothers. 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. It is recommended that future efforts to
scale maternal mental health services within Head Start focus on addressing stigma directly
before implementing services, particularly in historically marginalized, ethnic minority
communities like south Los Angeles. In addition, it would be beneficial to consider alternative
ways to support maternal mental health outside of weekly, in-person therapy services. New
delivery models like mhealth may be a useful way to reach a greater proportion of the target
population by addressing common barriers to accessing care (Price et al., 2014).
Effectiveness: Did the IPT-G intervention accomplish its goals?
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 depression 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. However, there were mixed findings regarding whether the intervention accomplished
one of its secondary goals, which was to impact maternal parenting and parent-child
relationships. This aim was more exploratory and based on the program’s theory of change.

48
Although quantitative results showed no impact, several mothers reported changes in their
parenting and relationships with their children. Finally, quantitative data showed that there were
no significant impacts on child outcomes (including behavior problems, school readiness skills,
and executive functioning).
There were several mechanisms identified by mothers that contributed to the
effectiveness of IPT-G in this study. First, mothers identified key processes that contribute to
success in any group therapy model, including experiencing emotional safety and group cohesion
(Yalom & Leszcz, 2008). 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 time in terms of the
length of the intervention and duration of sessions, providing services to a broader range of
mothers, including some content on parenting, and providing on-going supports after the group
ends.
Adoption: Did those targeted to deliver IPT-G participate?
Adoption at the staff level and the Head Start site level both showed significant
difficulties with adoption, with low levels of success. In terms of staff adoption, a relatively high
number (63%) of 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 access mental health therapists outside of Head Start 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 therapist leading a group. Furthermore, turnover also
impacted staff adoption, as several therapists left the agency before leading a group. Overall,

49
these findings point to the difficulty in utilizing existing Head Start resources to scale the HMHK
model and similar two-generation programs that would co-locate adult mental health services in
Head Start. There were simply two few human resources available to provide groups utilizing
Head Start mental health therapists, and future programs should consider how to build capacity
internally in Head Start programs or create partnerships with other organizations like mental
health agencies.
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. Logistical barriers related to community safety, space issues, and Head Start licensing
standards made it impossible to implement groups at Head Start sites themselves. 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.
Implementation: Was IPT-G implemented consistently?
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. Although
therapist fidelity appeared to be high, there was significant variation in the implementation of
groups. Qualitative data showed that therapists reported high fidelity to the model, partly because
the IPT-G model provided a general overview but also offered significant flexibility in how each
session was executed. However, there was significant variation in enrollment of mothers to
groups depending on who conducted the depression screening initially, with university study
staff and mental health therapists showing more success. It may be helpful to ensure that mental
health therapists are able to create the first contact with the participant, since establishing rapport

50
makes engagement in the group more likely. Once mothers were enrolled in IPT groups, there
was again significant variation in terms of whether the groups were able to sustain membership.
Attendance was problematic overall, to the point that two groups were eventually cancelled
completely, and Spanish-speaking groups were much more successful than English-speaking
groups. 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.
Maintenance: Did providing IPT-G become part of routine practice in this setting?
At the time of this study, 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
depression and stress, it was difficult to sustain in real-world practice in the Head Start setting.
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.
Comparing Findings Across HMHK Components
When considering findings across both the implementation of universal maternal
depression screening and IPT therapy groups, we see that performance was higher for depression
Table 2.6. Comparison of RE-AIM implementation outcomes across HMHK
components.
RE-AIM domain Maternal Depression
Screening
Provision of IPT
Groups
Reach High Low
Effectiveness - High
Adoption High Low
Implementation Low Low
Maintenance Low Low

51
screening in two of the four RE-AIM domains (i.e., Reach and Adoption) and higher for IPT
therapy groups in only one of the five RE-AIM domains (i.e., Effectiveness), see Table 2.6.
Overall, these outcomes show that implementation was more successful for universal maternal
depression screening and that there were difficulties with the RE-AIM domains of
implementation and maintenance across both components. Implementation of universal maternal
depression screening may have been more successful overall because the new screening
expectations were universally implemented by agency leadership, who considered the screening
to be an additional job requirement for staff. For example, leaders in the agency partner’s Head
Start program developed clear expectations for their subordinates and were able to supervise and
monitor compliance directly. Although there was significant variation in implementation of
screening, the universal adoption of maternal depression screening promoted higher performance
on the RE-AIM domain of Reach as well.
In contrast, a key difficulty for implementing IPT therapy groups was finding appropriate
staff to lead groups (leading to low adoption), and agency leadership were unable to institute
clear expectations for staff from different departments of the partner agency. This agency setting
was also unique, since it was able to utilize therapists from its mental health division, whereas
most Head Start centers do not have this kind of in-house mental health support. Unfortunately,
the HMHK program experienced significant difficulties in implementation and maintenance
across both components. Although the Head Start division of the agency was able to promote
high adoption of screening and reached many mothers experiencing depressive symptoms, and
although the IPT-G intervention was effective in reducing depression and parenting stress for the
mothers who then enrolled, the agency did not plan to continue either component of the HMHK

52
program after the study ended, raising concerns about the potential public health impact of this
program and similar efforts to provide maternal mental health treatment within Head Start.
Strengths and Limitations
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). In addition, this study utilized a rich depth of
information including meeting minutes and interviews with different stakeholders (IPT group
participants, staff that conducted screening, 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. Lastly, the sample itself is a strength because
this study was able to gather input and feedback from a group of low-income, ethnic minority
mothers, a population that has been systematically marginalized.
There are also limitations to this study that should be acknowledged. First, there were
some data that were not available, including race/ethnicity information for the larger group of
mothers that were screened for depression, race/ethnicity data for staff who conducted screening,
and quantitative measures of therapist fidelity to the IPT-G model. In addition, the larger
intervention 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.

53
Furthermore, although this study includes information from interviews with many participants,
non-participants, and staff, we were unable to interview several individuals involved in the study.
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.
Conclusion
This retrospective assessment evaluated the RE-AIM outcomes of Reach, Effectiveness,
Adoption, Implementation, and Maintenance for the “Healthy Moms, Healthy Kids” program in
two main areas: 1) implementing universal maternal depression screening and 2) providing IPT
therapy groups in a Head Start setting in south Los Angeles. First, results show that universal
maternal depression screening has the potential to reach low-income, ethnic minority Head Start
mothers and can be adopted broadly by Head Start Family Services Workers (FSWs) with
sufficient institutional support. However, additional efforts should be made to build capacity for
paraprofessional FSWs to detect maternal depression so that implementation of screening would
be more consistent across staff members and sustainable in Head Start. Second, results found that
providing IPT therapy groups was very effective in reducing maternal depression and stress for
this vulnerable population, but that additional work 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.

54
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Chapter Three (Study 2)
Group Interpersonal Psychotherapy for Ethnic Minority Head Start Mothers with
Depressive Symptoms: A Mixed Method Study of Experiences and Mechanisms
Introduction
Maternal depression is a serious mental health condition that can negatively impact
maternal and child well-being throughout the perinatal period and into early childhood (England
& Sim, 2012; Goodman et al., 2011; Sutherland et al., 2021; van der Waerden et al., 2015;
Woolhouse et al., 2015). If left untreated, maternal depression can impede effective parenting
(Lovejoy et al., 2000) and lead to deficits in children’s social emotional and cognitive
development (Goodman et al., 2011; Grace et al., 2003; Masarik & Conger, 2017). Rates of
maternal depression in the United States differ based on a variety of environmental stressors,
with low-income mothers and mothers of ethnic and racial minority backgrounds frequently
experiencing higher rates (Ertel et al., 2011; Oh et al., 2018). Low-income and ethnic minority
mothers also experience greater difficulties accessing high-quality mental health treatment
(McDaniel & Lowenstein, 2013; Witt et al., 2011).
Several evidence-based treatments for depression have been developed, including
Interpersonal Psychotherapy (IPT), which is widely used and has a significant base of research
support (Cuijpers et al., 2011, 2020). However, few studies have focused on examining the
utility of gold standard depression treatments with low-income mothers from minority racial and
ethnic backgrounds, with studies showing that significant barriers remain in terms of engaging
and supporting this population of mothers in treatment (Abrams & Curran, 2009; Anderson et al.,
2006; Lazear et al., 2008; Levy & O’Hara, 2010). Additional research is needed to explore low-

59
income, ethnic minority mothers’ experiences of participating in IPT and mechanisms of change
operating in the intervention to promote psychological well-being for this population.
IPT is a brief, structured treatment program that was initially developed by Klerman and
colleagues in the early 1970s to treat depression (Ravitz et al., 2019). IPT seeks to promote
healthy interpersonal relationships and emotional processing by addressing interpersonal
conflicts, grief and loss, and role transitions that can contribute to heightened psychological
distress (Ravitz et al., 2019). IPT has been found to be an effective treatment for depression, both
alone and in combination with medication, and for other mental health problems as well
(Cuijpers et al., 2011, 2016). IPT has been tested with low-income mothers in the perinatal
period, and has been found to be effective in reducing depression (Grote et al., 2009; Toth et al.,
2013). Specifically, Toth (2013) found that individual IPT was effective in reducing depressive
symptoms among low-income Black and Latinx mothers of infants in a community setting, and
that treatment gains were maintained for eight months after the trial ended. Group IPT (IPT-G)
was developed by Reay and Stuart and has been found to be effective for perinatal mothers
(Deans et al., 2014; Stuart & Schultz, 2015).
There are four mechanisms of change that have been hypothesized to operate in IPT,
including: 1) enhancing social support, 2) decreasing interpersonal stress, 3) facilitating
emotional processing, and 4) improving interpersonal skills (Lipsitz & Markowitz, 2013).
However, little research has explicitly tested these potential mechanisms or explored
participants’ perceptions of the components promoting growth and change in IPT. One notable
exception is a recent study by Grote et al. (2021) which examined mothers perceptions of
receiving a brief individual IPT intervention during the perinatal period. The authors used a
deductive approach to examine whether IPT participants endorsed conceptually derived codes

60
based on the four IPT change mechanisms outlined by Lipsitz & Markowitz (2013). They found
support for three of the four hypothesized mechanisms, with mixed support for enhancing social
support (Grote et al., 2021). However, this study utilized a majority White sample, examined an
individual IPT modality, and was limited to deductively identifying IPT treatment mechanisms,
rather than broadly exploring factors influencing treatment outcomes in IPT. It is unclear
whether the group IPT modality has similar mechanisms of change as those proposed by Lipsitz
& Markowitz (2013) or whether there are additional factors that may mediate treatment progress.
Furthermore, it is important to also understand factors that may moderate treatment progress for
low-income, ethnic minority mothers.
The Current Study
The current study seeks to explore low-income, ethnic minority mothers’ experiences of
participating in IPT-G in a Head Start setting to broadly understand their presenting concerns,
perceptions of the group IPT modality and treatment components, treatment impacts, and
challenges. We also utilize a mixed methods approach to identify the factors and mechanisms
that help explain differences in treatment outcomes.
Therefore, the aims of this study are to:
1. Explore mothers’ perspectives about participating in IPT-G in a Head Start setting,
including reasons for participation, perceptions of intervention components, challenges,
and intervention impacts; and,
2. Examine differences in demographic characteristics and responses between mothers
whose depression improved versus those who experienced worsening symptoms, or
mothers with subclinical symptoms, to identify factors and mechanisms impacting
treatment outcomes for this population

61
Methods
Study Design
This study utilized a mixed methods intervention design in which both qualitative and
quantitative data were gathered and integrated within the context of an experiment or
intervention trial (Creswell & Plano Clark, 2018). According to Creswell & Plano Clark (2018)
and Drabble et al. (2014), there are several reasons researchers may gather qualitative data to
complement a quantitative intervention trial. In this study, we utilized an explanatory sequential
design to identify factors and mechanisms that help explain differences in participant experiences
(see Figure 1). First, using a methodology called “Coding Consensus, Co-occurrence, and
Comparison” (Willms et al., 1990), we analyzed qualitative data to broadly explore mothers’
experiences of participating in IPT-G in a Head Start setting. Second, we examined similarities
and differences in participants’ demographic characteristics and experiences based on the level
of improvement in depressive symptoms that they experienced during the program.
The Healthy Moms, Healthy Kids Program
The “Healthy Moms, Healthy Kids” parent study was a cluster randomized controlled
trial funded by the Administration for Children and Families that provided a gold standard
depression treatment, IPT-G, to predominantly ethnic minority mothers of Head Start children in
South Los Angeles who were experiencing depressive symptoms (Mennen et al., 2021). Mothers
were recruited from 25 Head Start sites operated by Children’s Institute, Inc., a non-profit
multiservice agency in Los Angeles from December 2014 to June 2018. IPT-G was originally
developed by Reay et al. (2006) for women experiencing depression during the perinatal period
and 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 was extended from 8 to 12 weekly sessions

62
based on feedback from agency therapists, and food, transportation, and childcare were provided
to address potential barriers to participation. In addition, mothers with subclinical levels of
depressive symptoms were also recruited since research shows that even subclinical levels can
impact child functioning (Conners-Burrow et al., 2014, 2016). Therapy groups were also held at
Head Start sites to facilitate participation and trust. Results showed that the intervention was
effective in reducing depressive symptoms and parenting stress for mothers in the treatment
group compared to the control group, with depression scores on the CES-D declining on average
from 20.3 at baseline to 14.4 at the 3-month follow-up, which is below the cutoff for Major
Depressive Disorder (Mennen et al., 2021).
Participant Selection, Recruitment, and Data Collection
For this study, mothers were recruited from the intervention group of the parent HMHK
study, and qualitative data were collected between March and June of 2019. All previous
intervention participants were invited to participate (n=49), but many mothers could not be
reached after several attempts. Two female, bilingual Latina data collectors conducted semi-
structured interviews with 26 mothers (16 in Spanish and 10 in English). Interviews typically
lasted 45 minutes on average and were conducted in-person at the individual’s home or another
location depending on the mother’s preference. Interviews were recorded and then professionally
transcribed and Spanish interviews were professionally translated into English and checked by
the PI for accuracy. Mothers received a $40 incentive for their participation. This study was
approved by the Institutional Review Board of the University of Southern California and verbal
informed consent was obtained from all participants.

63
Instrumentation
Qualitative Interview Guide
A semi-structured interview guide was developed to explore mothers’ experiences with
the HMHK intervention, including their presenting concerns, goals for participation, perceptions
of the group facilitators and intervention content, experiences participating in a group therapy
modality with other mothers, the impacts of treatment across several domains, and challenges
they experienced during the group. The complete interview guide is included in the Appendices.
Quantitative Measures
Maternal depressive symptoms. Maternal self-report of current depressive symptoms
was assessed using the Center for Epidemiology Studies Depression Scale (CES-D; Radloff,
1977), a widely used 20-item scale that has been assessed for reliability, validity, and
applicability across diverse populations (Radloff, 1977). Mothers completed the CES-D at intake
and after the IPT group ended. For the purposes of this analysis, mothers were considered to
meet criteria for probable depression if they met the clinical cut-off of 16 or higher (Lewinsohn
et al., 1997).
Background information. Background information was also collected regarding
maternal age at intake for treatment, maternal race/ethnicity, maternal education level, household
income, whether the participant participated in an English or Spanish-speaking group, report of
cumulative trauma exposure and exposure to intimate partner violence (IPV) at intake, and the
number of sessions each participant attended. Maternal cumulative trauma exposure was
assessed using the Trauma History Questionnaire (THQ), which assesses adverse experiences in
several domains, including crime-related events, general disaster and trauma, and unwanted
physical and sexual experiences (Hooper et al., 2011). Maternal verbal and physical IPV

64
exposure was assessed using an adapted version of the original Conflict Tactics Scales (CTS)
that included other items to capture a broader range of violence exposure (Astin et al., 1995).
Data Analysis
Qualitative Data Analysis
First, qualitative data were analyzed to explore mothers’ presenting concerns and
experiences of participating in IPT-G in Head Start, including their perceptions of program
components, mechanisms, and intervention impacts. Qualitative interviews with intervention
participants were analyzed using Dedoose, Version 8.3.43. The PI used a methodology called
“Coding Consensus, Co-occurrence, and Comparison” (Willms et al., 1990) to analyze the
qualitative data. Interviews with intervention participants (n=26) were analyzed using the
following process. First, the PI and two 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 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, added new codes when
appropriate, or merged codes. 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 & Strauss, 2014). The PI then

65
reviewed the final coding and codes were assigned to describe connections between categories
and between categories and subcategories, which is known as axial coding (Corbin & Strauss,
2014). (6) The PI then compared categories to condense them into broader themes (Corbin &
Strauss, 2014).
Quantitative Data Analysis
Quantitative intervention data was analyzed using SPSS version 27.0. Univariate
statistics were calculated to capture demographic characteristics. Pre to post change scores for
depressive symptoms on the CES-D were also calculated for each participant, and if a participant
was missing a score on the CES-D for the second timepoint (n=2), the value from the subsequent
time point completed was substituted. There was also one participant who did not have any
follow-up scores on the CES-D, and this participant was dropped from the mixed method
analysis. Then mothers were categorized into three groups: (1) those with mild and moderate
levels of depressive symptoms whose symptoms improved and who then scored below the
clinical cut-off on the CES-D at follow-up, (2) those who still met criteria for depression at
follow-up, and (3) mothers who had subclinical levels of depressive symptoms during the trial.
Average pre to post change scores on CES-D were calculated for each of these three groups, and
similarities and differences in participant demographics and background information were
analyzed across the three groups.
Mixed Methods Analysis

The PI then utilized both sources of data to examine similarities and differences in
participants’ demographic backgrounds and experiences based on membership in the three
different groups to identify factors and mechanisms impacting the effectiveness of the
intervention. The qualitative themes and coding were exported from Dedoose and imported into

66
MAXQDA for mixed methods analysis. A series of joint displays of quantitative and qualitative
findings (Creswell & Plano Clark, 2018) was created using the “Interactive Quote Matrix” in
MAXQDA to examine differences in the experiences of participants whose quantitative data
indicated improvement in maternal depressive symptoms as a result of their participation in the
HMHK program versus those who remained depressed or had subclinical levels of symptoms
during the trial.
Results
Quantitative Results
Characteristics of the participants are presented in Table 3.1. Results demonstrated that
mothers who participated in qualitative interviews for this analysis completed more IPT-G
sessions (p < .01) and reported lower exposure to verbal IPV (p <.05) than mothers who did not
participate in interviews, but there were no differences in terms of maternal age, maternal
education, maternal race/ethnicity, household income, cumulative trauma exposure, physical
intimate partner violence, or whether the mother participated in an English or Spanish-speaking
IPT group. On average, mothers who completed interviews were 33.2 years of age (SD = 6.1)
and most mothers identified as Hispanic/Latinx (92.3%) and participated in Spanish-speaking
IPT therapy groups (80.8%). The mothers in this study were very underprivileged, with more
than one-third reporting that they did not complete high school and only one mother reporting
that she completed college. In addition, the families were low income, with more than half of
mothers reporting annual household incomes below $35,000. Mothers reported high levels of
cumulative trauma and endorsed more verbal IPV than physical IPV. Almost half of mothers
attended between 9-12 IPT group sessions.

67
When categorized based on their scores on the CES-D (1) 40% of mothers with
mild/moderate levels of depressive symptoms experienced a reduction in depressive symptoms
and scored below the clinical cut-off on the CES-D at follow-up, (2) 36% of mothers continued
to meet criteria on the CES-D at follow-up, and (3) 24% reported subclinical levels of depressive
symptoms on the CES-D during the intervention trial. Characteristics of participants and the
average pre to post depression change score for each of these three groups is reported in Table
3.1. Among mothers who continued to meet criteria for depression after participating in IPT-G,
five mothers reported a reduction in depression symptoms, and four reported an increase in
symptoms. For the subclinical group, two mothers reported a decrease in symptoms, and four
reported an increase in symptoms after completing the intervention.
When looking at demographic characteristics across the three groups, several differences
emerged for mothers whose depression persisted at the end of IPT-G (see Table 3.1). First,
mothers whose depression persisted had lower levels of income than the other two groups, with
over 50% reporting less than $19,999 for total household income compared to 30-33.3% among
the other two groups. This group also reported lower levels of education than the other two
groups, with over 50% having less than a high school diploma compared to 30-33.3% among the
other two groups. Furthermore, mothers in this group demonstrated higher levels of cumulative
trauma and exposure to verbal IPV than the other two groups. Among mothers whose depression
improved, a higher proportion participated in English-speaking groups, and mothers in the
subclinical group were older on average. There were similar patterns across the three groups in
terms of maternal race/ethnicity and the total number of IPT-G sessions attended.

68
Qualitative Results
The qualitative analyses resulted in seven broad themes that included mothers’ presenting
concerns at the start of treatment, reasons for participation in the HMHK program, perspectives
on participating in a group therapy model, perceptions of the IPT group components and
facilitators, impacts of the group across several domains, and challenges impacting participants’
experiences in the program.
Presenting Concerns and Reasons for Participation
First mothers shared about their presenting concerns, or perceptions of their symptoms
and needs at the start of the HMHK program. Most mothers (73%) reported that they were
depressed or described experiencing depressive symptoms at the time they were referred to
treatment, including symptoms like tearfulness, hopelessness, fatigue, difficulty sleeping,
suicidality, and anhedonia. One mother shared:
“I felt that for me nothing had a meaning. I only wanted to be sort of like in a
globe...I wanted to be inside it and not know anything. At times I'd say and think
that I no longer wanted to live, I wanted to get in a car and die. I only wanted to
be home alone. I didn't want to know about anyone. I didn't want to go out. I had
no urge to do anything.”

Mothers also shared that they were experiencing feelings of stress, anxiety, and isolation and
concerns about their relationships with their children.
In discussing their reasons for participation, most mothers shared that they were
immediately drawn to the program’s group modality because of the social support it provided.
Mothers shared that they wanted to meet other mothers and hear their perspectives, to be able to
learn from one another. One mother stated:
“I needed to talk to someone. I was told it was going to help and I would deal
with other parents that might possibly be going through the same thing. So that's
why I decided to be in here and maybe make some lasting friendships with
someone that you kind of know better than just your family.”

69

Mothers also expressed a desire to participate in the program to help their children,
including wanting to improve their parenting and relationships with their children. Many mothers
were drawn to the name of the program (“Healthy Moms, Healthy Kids”) because they wanted to
do whatever they could to help their children succeed. One mother shared:
“I needed techniques in dealing with depression. I needed to hear others'
testimonies, how to control my anxiety and how to deal with my child.”

Perceptions of Participating in a Group Therapy Intervention
Several mothers reported that the group IPT model helped them to feel less isolated and
provided them with a sense of social support. Many mothers shared that they benefited just from
realizing that other mothers were facing similar struggles and problems. As one mother
explained:
“It was very good because you learn about everything. You learn about other’s
problems, about their capacity and their ability. Like I said, we all have problems
but many times you're not aware that others are suffering just as much as you.”

Participants also explained that the group provided support by sharing information, giving
advice, and providing emotional support and validation. One mother shared the effect of
experiencing emotional support from her group members:
“At times I would think that I would be doing the wrong thing...I felt bad
and they would tell me that it was not bad. That would let me know that I
did a good job. Nobody tells me, “Oh, you did a good job today,” like as a
mom. “Hey, you did so good today. You cleaned the house. Thank you for
cooking for us.” No one. And in the group, everyone would say that, and I
was like, “Oh! Okay.”

Mothers also shared that they experienced emotional safety within the group that allowed them
to process and express their emotions.

70
Perceptions of IPT-G Components
In addition to the importance of experiencing social support and processing and
expressing feelings, mothers shared that there were several specific activities and components of
the IPT-G curriculum that were helpful. First, mothers shared that the explicit focus on goal
setting in the beginning of treatment helped them to develop concrete goals and provided
accountability each week in terms of whether they were making progress towards their goals.
Second, mothers talked about group sessions that focused on how to improve interpersonal
communication with others, including spouses, children, and other family members. One mother
explained:
“[The topic] was about how to ask for help and how sometimes we don't ask for
help. We thought that everyone else knew that we needed help and we don't ask
for it. So, what happens is, we get frustrated, but they don't help us because we
never asked for help. I remember that one very well.”

Another participant explained how role-play was useful to practice communication
strategies for real-life problems:
“They would have us role play a confrontation amongst us, with a person whom
we had a conflict with, someone would play that role and you would see the
problem as you were living it. You were looking at it from someone else's
perspective, not as someone going through the problem, and suddenly you realize
that “I’m guilty” or if I change my attitude, she’ll also change hers.”

Mothers also reported that sessions focusing on exploring past difficult experiences,
traumas, and significant life transitions were helpful. Many mothers reported processing their
immigration experiences, early childhood traumas, or other difficult experiences. One mother
explained:
“They say that you sometimes keep things for years and I never thought I'd talk
about such things, but I did talk about it within the group. They teach you talk and
to express your inner self and your feelings. You never know if you have trauma
from childhood until you realize it then. Situations I went through which I had

71
never even talked about it with my parents, I spoke about in the group. They gave
me the confidentiality and a place to express myself.”

Perceptions of IPT-G Therapists
When discussing their perceptions of therapists that co-facilitated IPT therapy groups,
several participants shared that they trusted the therapists and that the therapists gave them the
courage to speak and share with the other mothers in the group. Many shared that the first one-
on-one assessment and goal-setting meeting with the therapist helped them develop that rapport
and then they were able to build on that in the group setting. One participant explained:
“The type of respect that they provided... The attention. The communication.
Communication was when I didn't feel well or felt something, they were there to
listen. If I felt a certain way, if I was going through something, they were there to
support me.”

Some mothers also reported that the therapists provided assistance to them outside of the
group setting, which they found helpful. Respondents reported that therapists helped in terms of
accessing resources and other services, providing instrumental support like offering a ride, or
providing emotional support during crises. However, other participants shared that they
experienced barriers to building trust with the therapists, with one mother sharing that since the
therapists “didn’t have children, they [didn’t] really know...or... understand, so I didn't feel
comfortable telling her everything.”
In addition, several mothers reported feeling more comfortable and open to discussing
their feelings of sadness and depression because of the therapists’ professional background.
Although the negative impact of stigma around mental health was noted for this community,
some mothers appeared to less impacted by stigma and instead the therapists’ professional
mental health background acted as a facilitator to their participation. For example:
“Sometimes we may feel, when we're going through various phases in life, more
so, Hispanics, think that when we go see a psychologist or something like that,

72
that it's silly, but in fact it does help us... There are times that you are going
through situations and there are things that can't be trusted for example, to a
family member, a friend. So, it's good to go with someone who's a professional to
help us.”

IPT-G Treatment Impacts
IPT-G participants noted several positive impacts of the HMHK program, including
lowered stress and depressive symptoms, positive impacts on relationships with their partners,
children, family members, and friends, increased self-awareness, and significant shifts in
character. First, several mothers described feeling a reduction in sadness after the therapy
groups:
“My goal from there was that I was always closed. I would cry a lot and my goal
was to not feel like that. At the end I was definitely a different person. I took all
the sadness out.”

Several mothers reported changes in their relationships with their partners, including
increased communication, more support from their partner, and better problem-solving. For
example:
“My husband, I wouldn't tell him anything before. Now I tell him when I'm tired,
I ask him to help with the children... If something's bothering me, I can talk to my
husband...at night is when he and I talk and that has helped me out a great deal as
well because I'm not keeping everything to myself.”

Mothers also shared impacts on their relationships with their children, including better
communication skills, spending more time with their children, and learning how to support their
children’s development and independence. One mother explained, “I don’t scream so much...I let
[my kids] do more. It’s like I learned that they are kids and I need to let them live and be
children.”
Many mothers spoke with high levels of self-awareness during interviews, reflecting on
the changes they noticed in themselves because of the HMHK program. Mothers shared that they

73
learned how to become more aware of their own thoughts, feelings, and needs, and habits or
ways of thinking that were unhelpful. One mother shared: “After I began the program and I
started looking at myself, I began to let more things out which made me say, "Wow!" and to
change many things as well.”
Challenges
Respondents shared several different types of challenges that impacted their experiences
in the HMHK program, including barriers to participation, attrition, stigma, and difficulties
ending treatment. First, mothers shared a variety of barriers to participating in IPT groups,
including other priorities in their personal lives (medical issues, caring for children, work, etc.),
scheduling difficulties, hesitation about participating in therapy, and difficulties getting along
with fellow group members. Some mothers reported significant hesitation about participating in
the IPT therapy group, and others shared that they felt a solid commitment to attending the group
therapy sessions early on. As one mother explains:
“For me they helped me 100% because it’s up to each one of us if we want to be
different. If you want to change, you’re going to attend every day. I didn’t miss
one meeting.”

Another significant factor that impacted mothers’ experiences in the program was the
high level of attrition in therapy groups. In some cases, groups were even cancelled because of
low attendance. One mother stated that “there were many [participants] when we started and
suddenly, they didn’t show up.” Another participant explained that she would prefer a smaller,
more committed group to participate in therapy, saying it should be “for those who truly want to
let their emotions out...who truly want to talk and [have] a desire to change.”

74
Furthermore, stigma presented a challenge for mothers in terms of sharing with others in
their lives that they were experiencing depressive symptoms and attending a therapy group. One
mother explained that she had to push beyond this stigma to get the family support she needed:
“I told [my kids] that I was attending a group for parents who were going through
depression and who needed help emotionally and also how to get out of
depression...I was very direct with them about what I was doing, and I never lied
to them or made-up stories. I decided that if I was going to do this, I was going to
be honest and not hide it because I had no reason to do so.”

In terms of ending therapy, a small portion of mothers reported having significant
difficulties moving through the termination phase and that they were re-experiencing symptoms
of stress and depression:
“I'm going to wait for that call when they say, “Hey, we have another one.” And
hopefully I could be there because honestly, I'm going back [because] I need it...I
think I need it. It's coming back, my feelings, so maybe I could go back and try it
again and feel, ‘clean’ again. You know, kind of like when you clean yourself and
you say, “Oh, I feel fine,” and other times it's, “Oh, I feel down again!”’

Mixed Methods Analysis
The mixed methods analysis sought to examine similarities and differences between
participant experiences to identify factors and mechanisms that help explain differences in
treatment outcomes. Participant responses were analyzed by group membership (e.g., mothers
whose depression improved, those whose depression persisted after treatment, and mothers with
subclinical levels of symptoms who participated in HMHK). Results are presented in a series of
joint displays (Tables 3.2, 3.3, 3.4, and 3.5).
The first joint display demonstrates differences in participants’ presenting concerns at the
start of HMHK and reasons for participation in the program (see Table 3.2). One major
difference was that many mothers whose depression improved clearly identified that they were
depressed at the start of treatment, saying things like “I knew I had depression” or “I was under a

75
certain depression level.” In contrast, some mothers in the persistently depressed group reported
not realizing their symptoms were abnormal. For example, one participant explained: “When I
heard others talking about [depression], I felt that I may have had it and I just never noticed,” and
another mother recalled her reaction when she was told she met the clinical cut-off on the
depression screener: “It made me laugh because I said, "Well no, that's how I always feel.”’
When discussing their experiences, many mothers referenced unseen cultural and societal
expectations that influenced this experience, with one mother saying, “It seems as if moms keep
[their feelings] to themselves because we are moms and are supposed to.” In contrast, mothers in
the subclinical symptom group reported feeling subclinical levels of sadness and stress. In terms
of reasons for participation, mothers whose depression improved talked about wanting to be in
community with “other moms with similar problems to [theirs],” often to learn from their
experiences. Mothers with persistent depression reported wanting to combat “solitude” and
overcome a lack of family support, whereas mothers in the subclinical symptom group reported
wanting to “make lasting friendships” and “meet different people.”
The second joint display demonstrates differences in participants’ perceptions of
participating in a group modality, IPT-G components, and IPT-G therapists (see Table 3.3).
Mothers whose depression improved reported high levels of emotional safety and that it was
helpful to be in a group to “bounce ideas off each other” or “give...advice as to how to best
handle what we were going through at the moment.” Mothers with persistent depression reported
varying levels of emotional safety, with some mothers sharing that they were able to “vent” and
others saying they felt “ashamed of talking about [their] problems.” In terms of the specific
components of the IPT-G intervention, all mothers reflected on the positive impact of setting
concrete goals at the start of the group, however mothers whose depression improved and those

76
in the subclinical symptom group reported making more progress and recalled more specific
goals, whereas some mothers in the persistent depression group had more difficulty remembering
their goals and assessing their progress, saying things like “I don’t remember very well” and “I
think it was to get out of depression.” Mothers in all groups shared that the IPT-G component
focused on improving interpersonal relationships was helpful, but mothers whose depression
improved were able to share more specific examples of group activities used to promote these
skills and ways that they continue to practice them. Mothers across all three groups discussed the
importance of the IPT-G component focused on processing adversities and major life events,
although mothers in the subclinical symptom group mentioned this component more often and
two specifically discussed how this was helpful in processing immigration experiences. In terms
of IPT-G therapists, mothers whose depression improved reported high levels of trust, similarly
to those in the subclinical symptom group, with the persistent depression group demonstrating
more variability.
The third joint display demonstrates differences in participants’ perceptions of HMHK
treatment impacts across several domains (see Table 3.4). Mothers whose depression improved
shared concrete examples of symptom relief, like “I’m not depressed anymore, lying down” and
“had it not been for [the group], I would still be taking medication for depression,” whereas those
in the persistent depression group shared the powerful effect of sharing their feelings in group
and “not hold anything in,” which provided “a big release,” with only a couple mothers sharing
that the reduction in their symptoms persisted. Mothers in the subclinical symptom group shared
that they experienced relief after sharing their feelings, which helped them to “keep moving
forward.” Mothers across all three groups also reported changes in their parenting and their
relationships with their partner, mostly frequently in terms of using less harsh parenting (less

77
screaming and yelling), however mothers whose depression improved reported a wider range of
impacts in this area and more specific examples of changes in their parenting, like one mother
who shared: “I’m not arguing with [my children] throughout the day to pick up after
themselves.” Mothers across all three groups also reported changes in their relationships with
their partners, specifically in their ability to ask for and receive help. Lastly, mothers whose
depression decreased identified that the group caused them to develop greater self-awareness and
insight into their own internal experiences, with one mother stating: “I recognized many things
which I couldn’t see on my own about myself.” Mothers in the persistent depression and
subclinical symptom groups expressed a greater level awareness of their role in interpersonal
conflicts and parenting, and the importance of emotional expression and self-knowledge for
overall health and well-being.
Lastly, the fourth joint display demonstrates differences in perceptions of challenges in
the HMHK program across the three groups in terms of barriers to engagement, attrition over
time, stigma, and termination challenges (see Table 3.5). For mothers whose depression
improved, many experienced no barriers to engagement or felt their depression made it difficult
to attend at times, and many recalled how they overcame specific challenges to participate in the
group (e.g., a disapproving spouse, medical appointments, work schedule, etc.). Mothers in the
persistent depression group reported challenges related to getting along with therapists and other
group members, as well as scheduling difficulties, and mothers in the subclinical group endorsed
that they often were unable to attend due to their children’s schedules. In terms of attrition,
mothers across all three groups shared the impact of losing group members and even of having
groups cancelled due to low attendance. One major difference that emerged was that mothers in
the persistent depression group reported more difficulties expressing their own feelings due to

78
stigma than either of the other two groups, with mothers stating things like: “there are hidden
things which you don’t discuss with anyone,” “I [was] embarrassed because others found out
about my personal life,” and “sometimes one doesn’t want to admit [it] and says, “everything is
fine.” Mothers in the subclinical group discussed the presence of stigma in the community and
how their participation in the group helped them combat it, for example explaining that going to
therapy “doesn’t necessarily mean that you’re crazy, it simply means that you need someone to
talk to.”
Discussion
This study used an inductive approach to explore the experiences of ethnic minority Head
Start mothers who participated in the “Healthy Moms, Healthy Kids” program, which
implemented an adapted IPT-G intervention for mothers experiencing depressive symptoms.
This study is the first to explore the perspectives of a majority non-White sample about
participating in any IPT modality, which is important to understand the effectiveness of using
IPT with ethnic minority populations. In addition, a mixed methods approach was used to
examine similarities and differences in demographic characteristics and responses between three
subgroups who participated in IPT-G: 1) mothers whose depressive symptoms improved after
treatment, 2) mothers whose depressive symptoms persisted, and 3) mothers with subclinical
levels of depressive symptoms who participated in the intervention. This analysis provided rich
information about factors and mechanisms that may help explain differences in treatment
outcomes. Furthermore, the use of joint displays to systematically and visually examine
similarities and differences in the qualitative responses for each of the three subgroups allows
important meta-inferences to be drawn for each group (Fetters & Molina-Azorin, 2019).

79
First, for mothers whose depressive symptoms improved, the majority reported acute
onset of their depression and clearly identified feeling depressed at the start of treatment. They
appeared to demonstrate more active reasons for participation (i.e., wanting to learn from others’
experiences) and reported more specific IPT treatment goals as well. Although mothers in this
group also acknowledged the impact of stigma, they reported high levels of emotional safety and
trust in the IPT group facilitators, which allowed them to share and process their emotional
experiences, which is one of the hypothesized IPT mechanisms (Lipsitz & Markowitz, 2013).
They also emphasized the importance of IPT-G components focused on improving
communication in interpersonal relationships, which is a second proposed mechanism in IPT
(Lipsitz & Markowitz, 2013). As expected, mothers in this group identified more progress
towards their goals and specific positive impacts of the intervention across a range of areas,
including depressive symptom relief, specific improvements in their relationships with their
children and partners, and gains in self-awareness. Although mothers in this group reported
barriers to participation, they actively overcame these barriers through problem-solving and
demonstrated a high commitment to the group. Mothers in this group appeared to possess greater
levels of goal-directed behavior that promoted their success in treatment.
Second, mothers in the persistent depression group reported more generalized depressive
symptoms and lack of social support was a key motivator for participation in IPT-G. Mothers in
this group had lower levels of income and education at intake and reported higher levels of
cumulative trauma and exposure to verbal IPV than the other two groups. Mothers in this group
expressed more normalization of depression in their presenting concerns and referenced the
impact of societal and cultural expectation for mothers. Mothers in this group also expressed
varying levels of emotional safety and trust in the facilitators, and while many discussed the

80
importance of emotional catharsis in the group, few reported a persistent decrease in their
symptoms. Interestingly, mothers with persistent depressive symptoms also expressed greater
difficulty sharing feelings in group due to stigma, compared to the other two groups. It appears
that mothers in this group had greater difficulty processing emotions, and possibly also accessing
social support within and outside of the therapy group, which are two key mechanisms in IPT
(Lipsitz & Markowitz, 2013).
Third, mothers in the subclinical group shared a different perspective than the other two
groups. Mothers in this group reported subclinical levels of sadness and stress at enrollment and
reported benefiting from the emotional support provided by the group and the IPT-G components
focused on interpersonal functioning and discussing the impact of early life experiences.
Although mothers in this group had subclinical levels of depressive symptoms, they still reported
positive gains in treatment, including improved communication with partners and children, and
greater self-awareness. However, the average pre- to post-change on the CES-D for this group of
mothers was positive, raising concerns about whether participating in a depression treatment
group contributed to increased symptomatology and whether IPT-G is effective for mothers with
subclinical levels of depressive symptoms. Alternatively, it could be that mothers in this group
became more willing to acknowledge symptoms due to their participation in the program.
In looking across the results from the three groups, there is evidence pointing to possible
mediators and moderators that help explain differences in treatment outcomes. In terms of
mechanisms or mediators operating in the IPT-G intervention, it appears that there are some
differences from the IPT mechanisms put forth by Liptsitz & Markowitz (2013) and from Grote
et al.’s findings (2021). First, results from this study show that experiencing emotional safety in
the group format was crucial in order for participants to then feel comfortable processing

81
emotions and experiencing social support within the group, which are two of the proposed IPT
mechanisms (Lipsitz & Markowitz, 2013). For example, mothers who experienced a reduction in
depression symptoms reported greater levels of emotional safety with both the IPT-G facilitators
and with the other group members, whereas those who experienced persistent depressive
symptoms were more likely to report a lack of trust. The establishment of emotional safety was
not proposed by Lipsitz & Markowitz (2013) as a mechanism in IPT, but it appears that this is an
integral part of the group IPT modality. In addition, whereas Grote et al. (2021) found mixed
support for the mechanism of enhancing social support in the individual IPT model, this appears
to be a key mechanism in IPT-G, which is aided by the group format in which participants share
and develop connections. Furthermore, the IPT-G mechanisms focused on improving
interpersonal skills and reducing interpersonal distress (Lipsitz & Markowitz, 2013) were highly
endorsed by all three groups as promoting positive change in relationships, although greater
gains were seen among mothers whose symptoms improved. It may be that the focus on
interpersonal distress and skills is helpful, but not sufficient to treat depression and reduce
depressive symptoms among this population of mothers.
In terms of moderators influencing treatment outcomes, results show that factors like
lower socioeconomic status, higher levels of exposure to trauma and IPV, and stigma may have
limited treatment engagement and ultimately, program effectiveness for some mothers. Mothers
whose depression persisted reported higher levels of cumulative trauma and exposure to verbal
IPV, which may have contributed to difficulties establishing trust and emotional safety within the
group. Greater exposure to verbal IPV may have also moderated the effectiveness of IPT
components focused on improving interpersonal communication and reducing interpersonal
distress. In addition, research shows that cultural stigma can have a negative impact on the

82
utilization of mental health services (Bracke et al., 2019), and study findings raise important
questions about the impact of cultural and societal norms and stigma on progress in IPT and
other mental health treatments. There may be links between trauma exposure in this sample,
particularly verbal IPV, and the cultural norms and stigma mothers shared. It would be helpful
to implement broad prevention strategies aimed at reducing stigma and increasing safety in
community-based settings before recruiting mothers for mental health treatment,
including mental health literacy programs, cultural competence training, and family engagement
campaigns (Corrigan, 2004), as well as actively addressing safety, trauma, societal norms, and
stigma within the IPT model itself.
Strengths and Limitations
This study has several strengths. First, this study utilized both quantitative and qualitative
data in the context of an intervention trial to understand factors and mechanisms influencing
treatment outcomes in the “Healthy Moms, Healthy Kids” program. This is especially useful
since the parent intervention trial was small and therefore it was not possible quantitatively to
examine treatment mechanisms. Second, in-depth semi-structured interviews were conducted
with all mothers from the intervention group that consented, providing rich information about
their lived experiences. Third, this study utilized an innovative tool called the “Interactive Quote
Matrix” to visualize and deeply interact with the qualitative material.
There are also limitations to this study that should be acknowledged. First, although this
study includes the perspectives of many HMHK participants, we were unable to interview all
mothers from the intervention group. Those who were interviewed attended significantly more
IPT group sessions on average, and therefore findings and conclusions likely do not represent the
views and experiences of all mothers who participated in HMHK. Second, this study was

83
conducted within an intervention trial with Latinx and Black mothers in South Los Angeles, and
the findings may not generalize to other populations and settings.
Conclusion
This study sought to explore low-income, ethnic minority mothers’ experiences of
participating in IPT-G in a Head Start setting to broadly understand their presenting concerns,
perceptions of the group IPT modality and treatment components, treatment impacts, and
challenges, and to identify the factors and mechanisms that help explain differences in treatment
outcomes for this population. This study adds to the existing literature by examining a group IPT
modality, exploring the experiences of an ethnic minority sample, and utilizing an inductive
qualitative approach to identify a broad range of themes. Overall, findings show that the
establishment of emotional safety in IPT-G was a key mechanism of change for those whose
depression improved, which allowed participants to process their emotions and experience
meaningful social support. It appears that IPT-G components focused on improving interpersonal
functioning were also helpful, but not sufficient in this sample to lead to a reduction in
depression, particularly for mothers who also endorsed high rates of verbal aggression in
intimate relationships. Furthermore, factors like low socioeconomic status and stigma also
appeared to limit program effectiveness for some mothers.

84
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Table 3.1
Participant characteristics (n=26)

Total sample
(n=26)
Not depressed
at follow-up
a
(n=10)
Depressed at
follow-up
b
(n=9)
Subclinical
group
c
(n=6)

M (SD), n
(%)
M (SD), n (%) M (SD), n (%) M (SD), n (%)
Age (yrs) 33.2 (6.1) 32.7 (4.3) 32.9 (7.9) 35.7 (6.0)
Race/Ethnicity

Hispanic or Latinx 24 (92.3) 9 (90.0) 8 (88.9) 6 (100.0)
Black/African American 2 (7.7) 1 (10.0) 1 (11.1) 0 (0.0)
Other 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Household income
Below $10,000 3 (8.3) 0 (0.0) 3 (33.3) 0 (0.0)
$10,000 to $19,999 7 (26.9) 3 (30.0) 2 (22.2) 2 (33.3)
$20,000 to $34,999 7 (26.9) 2 (20.0) 2 (22.2) 2 (33.3)
$35,000 to $49,999 2 (7.7) 1 (10.0) 0 (0.0) 1 (16.7)
Refused 7 (26.9) 4 (40.0) 2 (22.2) 1 (16.7)
Educational level
Below high school 4 (15.4) 2 (20.0) 2 (22.2) 0 (0.0)
Some high school 6 (23.1) 1 (10.0) 3 (33.3) 2 (33.3)
High school diploma 8 (30.8) 4 (40.0) 1 (11.1) 2 (33.3)
Some college 7 (26.9) 3 (30.0) 3 (33.3) 1 (16.7)
Bachelor’s degree 1 (3.8) 0 (0.0) 0 (0.0) 1 (16.7)
Trauma exposure
Cumulative trauma 5.1 (4.0) 5.1 (3.8) 6.5 (4.7) 4.0 (2.7)
IPV Exposure (verbal) 5.8 (6.1) 5.4 (5.7) 9.0 (7.4) 2.7 (1.9)
IPV Exposure (physical) 0.5 (1.0) 0.8 (1.3) 0.5 (1.1) 0.2 (0.4)
HMHK group language
Spanish 21 (80.8) 7 (70.0) 8 (88.9) 5 (83.3)
English 5 (19.2) 3 (30.0) 1 (11.1) 1 (16.7)
Group sessions attended
1-4 sessions 5 (19.2) 2 (20.0) 1 (11.1) 2 (33.3)
5-8 sessions 9 (34.6) 3 (30.0) 4 (44.4) 1 (16.7)
9-12 sessions 12 (46.2) 5 (50.0) 4 (44.4) 3 (50.0)
Depression change score -14.8 (9.3) -0.1 (10.7) 3.7 (5.8)
a
Mothers with mild/moderate depressive symptoms at intake who scored below the cutoff of 16 on the CES-D
after the group ended.
b
Mothers with mild/moderate depressive symptoms at intake who continued to score at 16 or above on the CES-D
after the group ended.
c
Mothers with subclinical levels of symptoms on the CES-D during the trial.

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Qualitative
analysis:
What were
mothers’
experiences in
HMHK and
perceptions of
program impacts?
Mixed methods
study:
Which factors
and mechanisms
help explain
differences in
treatment
outcomes?
Qualitative data
collection:
(Subset of 26
mothers who
participated in
IPT-G)
Quantitative
Pre-Test
Results
(maternal
depression)
Quantitative
Post-Test
Results
(maternal
depression)
Figure 3.1 Explanatory Sequential Mixed Methods Design

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Table 3.2
Joint display of participants’ presenting concerns and reasons for participation by treatment progress.

Status at
Post-Treatment
a
Participant Responses
Not depressed
at follow-up
(n=10)
• Presenting concerns: Mothers clearly identified feeling depressed at intake,
5/10 identified acute experiences that triggered their depression (e.g., car
accident, cancer, separation from spouse, child diagnosed with autism, etc.),
discussed feeling that depression was taboo
• Reasons for participation in HMHK: to be in a group with mothers who had
experienced similar problems, wanting to receive help

Depressed at
follow-up (n=9)
• Presenting concerns: mothers report depressive symptoms, some mothers
shared that they didn’t believe in depression or didn’t realize what they
were feeling was abnormal (normalization of depression), isolation a big
factor, talking about feelings is taboo
• Reasons for participation in HMHK: feeling isolated, needing others to talk
to

Mothers with
subclinical
symptoms
(n=6)
• Presenting concerns: Mothers felt they were experiencing low levels of
sadness or more often, stress
• Reasons for participation in HMHK: To learn new things, meet people

a
Mothers were split into three groups based on the change in their depressive symptoms on the CES-D
over the course of treatment.

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Table 3.3
Joint display of participants’ perceptions of participating in IPT by treatment progress.
Status
Post-
Treatment
a
Participant Experiences
Not
depressed
at follow-up
(n=10)
• Group modality: high levels of emotional safety, reported learning from others’
experiences in similar situations, benefit of perspective-taking
• IPT-G components:
o Goals: all reported making progress towards goals chosen at beginning of
treatment, many very specific (e.g., enrolling in school, filing for divorce,
being more active)
o Interpersonal skills: Mothers recalled specific activities like role-playing a
conflict to improve communication, praising others, and learning to forgive
o 1 mother mentioned processing prior trauma and 1 mentioned processing
deaths in the family
• Therapists: Mothers reported high levels of trust in the therapists, reported they
created a safe space for the group with confidentiality rules
Depressed at
follow-up
(n=9)
• Group modality: varying levels of emotional safety, some expressed difficulty
sharing their feelings in group (1 mother stated she would prefer individual
therapy)
• IPT-G components:
o Goals: mothers reported making some progress, some reported difficulty
remembering
o Interpersonal skills: Mothers recalled the importance of expressing feelings
in relationships
o 1 participant mentioned the importance of judging the gravity of a problem
• Therapists: Mothers’ trust in the therapists varied, most reported feeling
comfortable but some had difficulty connecting or were reticent at first
Mothers
with
subclinical
symptoms
(n=6)
• Group modality: helped them re-appraise the severity of their own problems after
hearing about others’ experiences, experiencing emotional support was helpful
• IPT-G components:
o Goals: All reported making progress towards goals, many were specific
(e.g., returning to school, improving credit, losing weight, etc.)
o Interpersonal skills: Mothers discussed how they learned to approach their
children differently, how to provide mutual support in relationships
o Several mothers mentioned the importance of considering early life
experiences, traumas, and transitions, 2 specifically mentioned immigration
• Therapists: Mothers reported that the therapists made them feel comfortable to
share in group
a
Mothers were split into three groups based on the change in their depressive symptoms on the CES-D
over the course of treatment.

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Table 3.4
Joint display of participants’ reports of treatment impacts by treatment progress.

Status at
Post-
Treatment
a
Participant Perceptions
Not depressed
at follow-up
(n=10)
• Symptom relief: participants reported improvements in sadness and stress,
being able to get out of bed, feeling calmer, and experiencing catharsis in
group sessions
• Relationships:
o Children: 9/10 mothers reported improvements in their relationships with
their children, including better communication, increased patience, more
quality time
o Partners: Improvements in asking for help
• Self-awareness: mothers said the group helped them develop more self-
awareness, insight into themselves (concrete examples)
Depressed at
follow-up
(n=9)
• Symptom relief: participants shared that they experienced catharsis in group
sessions where they vented and felt release, fewer statements about sustained
gains
• Relationships:
o Children: mothers reported less yelling, more playing with children,
reflections are more general
o Partner: Improvements in asking for help
o Self-awareness: mothers demonstrated self-awareness about interpersonal
conflicts, parenting, and importance of self-expression
Mothers with
subclinical
symptoms
(n=6)
• Symptom relief: mothers reported experiencing healing and relief, being able
to focus more on the future, being more communicative and open,
experiencing catharsis in group sessions
• Relationships:
o Children: mothers reported less yelling, 1 mother spoke at length about
learning to support’s adolescent son’s independence
o Partners: Improvements in asking for help
• Self-awareness: mothers demonstrated self-awareness about interpersonal
conflicts, parenting, and importance of self-expression
a
Mothers were split into three groups based on the change in their depressive symptoms on the CES-D
over the course of treatment.

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Chapter Four
Conclusions, Implications, and Future Directions
Introduction
The goal of this mixed method multi-study was to examine the effectiveness and
implementation of the “Healthy Moms, Healthy Kids” (HMHK) program and identify effective
mechanisms in the depression screening process and IPT-G intervention to further adapt the
program for low-income, ethnic minority Head Start mothers. The HMHK parent study was the
first intervention trial to show that providing an evidence-based depression treatment for mothers
in Head Start was effective in treating mothers with high levels of symptoms (Mennen et al.,
2021). Earlier work has focused on building staff capacity to address maternal depression in
Head Start (Beardslee et al., 2010), and has used patient navigation to connect Head Start
mothers with outside mental health services (Diaz-Linhart et al., 2016; Silverstein, Diaz-Linhart,
Grote, et al., 2017). More recently, studies have shown that providing mental health treatment in
Head Start can reduce depressive symptoms among mothers with subclinical levels of symptoms
(Silverstein et al., 2018; Silverstein, Diaz-Linhart, Cabral, et al., 2017). However, the parent
HMHK study was the first to demonstrate efficacy in reducing depressive symptoms among
Head Start mothers who meet criteria for probable Major Depressive Disorder (MDD) (Mennen
et al., 2021). Overall, these efforts provide preliminary evidence that providing maternal mental
health services may be effective in Head Start.
However, no studies have explored the implementation of these programs to determine
whether they are feasible in real-world practice, or broadly explored participants’ experiences in
the intervention to promote adaptation of IPT-G for vulnerable mothers. Research from
implementation science shows that intervention efficacy is not always sufficient to promote

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widespread adoption and use in the community (Damschroder et al., 2009). There are several
factors, from participant-level factors to staff and broader organizational and community-level
factors that influence whether an intervention will be translated into real-world settings (Gaglio
et al., 2013). Unfortunately, research shows that on average it takes 17-20 years for evidence-
based treatment and interventions to become part of routine practice, and that only 50% of
interventions ever make it this far (Bauer & Kirchner, 2020). Applied fields of study like social
work must prioritize health equity and public impact and focus on promoting the dissemination
and implementation of interventions to reach the most vulnerable members of our society. This
dissertation provides critical information about the implementation effectiveness of the HMHK
program and elucidates the factors and mechanisms that impacted treatment outcomes for this
population of low-income, ethnic minority mothers. Most importantly, this dissertation utilized a
transformative mixed methods approach (Mertens, 2009) to create scholarship that promotes
social justice. This approach was utilized to elevate the voices of HMHK participants and
paraprofessional Head Start workers and inform quantitative intervention and implementation
results.
Each of the two papers in this dissertation were written with the goal of publication in
peer-reviewed journals. Because these studies are among the first to explore the effectiveness
and implementation of an innovative two-generation mental health intervention for ethnic
minority Head Start mothers, the findings are relevant to several bodies of literature and practice.
Therefore, possible audiences for Study 1 include: Administration and Policy in Mental Health
and Mental Health Services Research, Families, Systems, and Health, or Journal of Healthcare
for the Poor and Underserved. Study 2 will be targeted toward Psychotherapy Research, Journal

95
of Community Psychology, Social Work in Mental Health, or American Journal of
Psychotherapy.
Key Findings of Dissertation Studies
Study 1: Implementation of the “Healthy Moms, Healthy Kids” Program in Head Start:
An Application of the RE-AIM QuEST Framework
The first dissertation paper used the RE-AIM QuEST framework (Forman et al., 2017) to
comprehensively assess the implementation outcomes of the HMHK program in two distinct
areas: (1) universal maternal depression screening by paraprofessional Head Start staff, and (2)
the provision of IPT therapy groups in a Head Start setting. This paper also moved beyond
simply assessing RE-AIM implementation outcomes (the “what”) to also identify important
factors impacting implementation (the “why”) (Forman et al., 2017). This paper’s strength draws
from its use of rich qualitative and quantitative data to fully investigate the outcomes of Reach,
Effectiveness, Adoption, Implementation, and Maintenance in these two phases of the HMHK
program. Overall, this paper utilized qualitative interview data from 52 stakeholders (including
26 HMHK participants and 27 staff involved in implementation), 176 meeting minutes from the
implementation period, intervention data from the parent intervention trial, and administrative
data including records of depression screenings, staff training logs, and demographic information
for Head Start mothers served by the partner agency. This paper is the product of a significant
collaboration between academic researchers at USC and a community-based child and family
services agency, Children’s Institute, Inc.
Findings showed that performance was higher for universal maternal depression
screening in two of the four RE-AIM domains (i.e., Reach and Adoption) and higher for IPT
therapy groups in only one of the five RE-AIM domains (i.e., Effectiveness). Overall,

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implementation was more successful for universal maternal depression screening and there were
difficulties with the RE-AIM domains of implementation and maintenance across both
components (universal maternal depression screening and the provision of IPT therapy groups).
First, findings for universal maternal depression screening will be discussed. Screening was able
to reach a large portion of the target population, with 85% of mothers consenting to screening on
the first attempt. However, there were concerns about higher rates of refusal among English-
speaking mothers, and several barriers to screening were identified, including stigma and fear of
DCFS reprisal. Adoption of depression screening by paraprofessional Head Start staff was
universal, since the partner agency mandated compliance, however additional staff roles adopted
screening due to concerns about the quality of screening by Head Start staff. Implementation of
depression screening was extremely challenging, and rates of screening participation and positive
screenings differed by staff role and within Head Start workers themselves, with rates of mothers
meeting criteria for mild depression ranging from 0% to 46%. Several barriers to screening
implementation were identified, including several related to logistical issues like having a private
space and to staff-level factors like attitudes, engagement style, and openness towards mental
health. At the conclusion of HMHK, the partner agency did not continue maternal depression
screening in Head Start, and many of the reasons related to the difficulties in implementation and
lack of buy-in from staff.
Second, we will discuss the RE-AIM findings for the implementation of IPT therapy
groups. Reach of the intervention was low, with only 16.8% of eligible mothers ultimately
choosing to participate. The intervention was more effective in reaching Latinx and Spanish-
speaking mothers compared to English-speaking and Black/African American mothers, and there
were several barriers to reach, including stigma and competing needs for families. For mothers

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who did participate, the intervention was very effective in reducing depression and parenting
stress, and although quantitative results showed no impacts on parenting, several mothers shared
that the intervention improved their communication and relationships with their children.
Adoption of the intervention was also very difficult, primarily because the partner agency’s Head
Start division did not have mental health staff that could take on the additional role of running
IPT therapy groups and instead, therapists from the mental health division of the agency were
trained. Future programs should consider how to build capacity internally in Head Start programs
or create partnerships with other organizations like mental health agencies to provide parental
mental health services. Site adoption was also problematic, since many Head Start sites did not
have appropriate spaces to host confidential therapy groups or provide childcare. Implementation
of IPT groups was variable, with Spanish-speaking groups being more successful and many
groups suffering from high levels of attrition. Unfortunately, there were no plans to continue
IPT-G in this setting at the end of the trial, particularly since it was difficult to identify
appropriate staff to lead groups and engaging mothers in groups presented a challenge.
Overall, implementing universal maternal depression screening appeared to be more
effective due to the top-down approach to compliance adopted by agency leadership, however
there was still significant variation in screening accuracy, buy-in from frontline staff remained
low, and the agency was unable to sustain screening. One implication from these results is that
implementation efforts should include frontline staff as collaborators much earlier on in the
process, and that top-down approaches to implementation may not be effective in creating real,
sustainable buy-in from staff. In terms of IPT therapy groups, although the intervention itself was
effective in reducing depression and stress and participants reported being satisfied with the
program, effective implementation in Head Start settings is simply not possible without

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significant additional investments in human resources, either by hiring additional mental health
therapists or creating partnerships with outside mental health agencies.
Study 2: Group Interpersonal Psychotherapy for Ethnic Minority Head Start Mothers with
Depressive Symptoms: A Mixed Method Study of Experiences and Mechanisms
The second dissertation study sought to explore low-income, ethnic minority mothers’
experiences of participating in IPT-G in a Head Start setting to broadly understand their
presenting concerns, perceptions of the group IPT modality and treatment components, treatment
impacts, and challenges. A mixed methods approach was also utilized to identify the factors and
mechanisms that help explain differences in treatment outcomes among participants who
demonstrated reductions in depression after IPT-G compared to participants whose depressive
symptoms did not decrease or those who had subclinical levels of symptoms. There are several
hypothesized mechanisms in IPT, including: 1) enhancing social support, 2) decreasing
interpersonal stress, 3) facilitating emotional processing, and 4) improving interpersonal skills
(Lipsitz & Markowitz, 2013). Although IPT has been considered a gold standard treatment for
depression for decades (Ravitz et al., 2019), there has been only one prior qualitative study
examining participants experiences and possible mechanisms of change in IPT, and this study
utilized a deductive approach, examined an individual IPT modality, and recruited a majority
White sample (Grote et al., 2021). Therefore, three major strengths of this second dissertation
study are the use of an inductive qualitative approach that privileged participants’ experiences,
examination of a group IPT modality, and recruitment of an ethnic minority sample comprised
predominantly of low-income, Latinx mothers.
Overall, broad qualitative analyses resulted in seven themes that included mothers’
presenting concerns at the start of treatment, reasons for participation in the HMHK program,

99
perspectives on participating in a group therapy model, perceptions of the IPT group components
and facilitators, impacts of the group across several domains, and challenges impacting
participants’ experiences in the program. Results of the mixed methods analysis showed
differences in possible mediators and moderators that help explain differences in treatment
outcomes among mothers whose depression improved, those whose depression persisted, and
those with subclinical levels of symptoms.
In terms of mechanisms or mediators operating in the IPT-G intervention, it appears that
experiencing emotional safety in the group was a prerequisite for participants to then feel
comfortable processing emotions and experiencing social support within the group, which are
two of the proposed IPT mechanisms (Lipsitz & Markowitz, 2013). Mothers whose depression
improved over the course of HMHK reported higher levels of emotional safety, and those whose
depression persisted reported varying levels of emotional safety, with some mothers saying they
felt ashamed to talk about their problems. Therefore, in the IPT-G modality, the dynamics of the
group and sense of trust is paramount in allowing the proposed IPT mechanisms to function as
intended. In addition, the IPT-G components focused on improving interpersonal skills and
reducing interpersonal distress (Lipsitz & Markowitz, 2013) were highly endorsed by all three
groups as promoting positive change in relationships, although it appears that these components
were not sufficient to promote a reduction in depressive symptoms for all mothers. Mothers
whose depression improved shared more concrete examples of how they used IPT interpersonal
skills like asking for help and were more likely to endorse that they continue to use the skills in
their relationships.
In terms of moderators influencing treatment outcomes, results show that factors like
lower socioeconomic status, higher levels of exposure to trauma and IPV, and stigma may have

100
limited treatment engagement and ultimately, program effectiveness for some mothers. For
example, mothers whose depression improved reported actively overcoming barriers to
participation through problem-solving and demonstrated a high commitment to the group. In
contrast, mothers with persistent depressive symptoms expressed greater difficulty sharing
feelings in group due to stigma, compared to the other two groups, and voiced unspoken norms
about expectations for mothers. Mothers in this group also reported lower socioeconomic status
and higher levels of cumulative trauma and exposure to verbal IPV, which may have contributed
to difficulties establishing trust and emotional safety within the group.
Limitations
There are some limitations to this dissertation study that should be noted. First, this
dissertation gathered data from a wide variety of key stakeholders, including mothers who
participated in the HMHK intervention and staff involved in implementation at multiple levels.
All possible stakeholders were recruited to participate; however, many intervention participants
could not be reached and similarly, the PI was unable to contact several staff members involved
in implementation who had since left the partner agency. Therefore, the thoughts and perceptions
reported in each of these two studies may not represent the views of all stakeholders. Second,
although this dissertation attempted to focus on the needs of a specific marginalized community
(low-income, ethnic minority Head Start mothers), there were several pieces of data that were
unavailable that could have shed further light on the HMHK program’s ability to promote health
equity. For example, data on racial/ethnic background was unable for mothers who were
screened for depression or for staff who conducted screening.

101
Implications and Recommendations
Based on the results of the first dissertation study, it appears that the HMHK program
was effective in treating depression among the group of mothers who enrolled in the
intervention, but that widespread adoption within Head Start may be limited by several factors.
Future efforts to co-locate parental mental health services within Head Start would need to focus
on gaining buy-in from Head Start staff and building staff capacity around mental health.
Although Head Start is conceptualized as a “two-generation” program that provides
comprehensive services to children and families, findings from the dissertation revealed a
tension between Head Start being “two-generation” in vision versus in reality. For example, the
role of Head Start Family Service Workers (FSWs) is to comprehensively assess each child and
family’s needs across a variety of domains and support families throughout the year to reach
goals collaboratively identified by the FSW and the family (Frankel, 1997). However, FSWs in
this study reported having high caseloads and often struggled to maintain regular contact with
families. For many of them, the addition of utilizing a standardized depression tool to screen
mothers for depression often felt like a burden and was considered outside of their role as an
FSW.
Efforts to infuse a family mental health focus in Head Start should therefore prioritize
providing broad mental health training to FSWs and their supervisors and directly addressing
stigma around mental health in marginalized communities of color. In addition, future efforts
should identify ways to build capacity in terms of adding more mental health staff within Head
Start. Although the specific Head Start sites in this study had mental health specialists on staff,
many of them were responsible for assessing and linking dozens of children to services.
Therefore, they were not in a position to take on the additional job of running IPT therapy

102
groups. Unfortunately, the challenge of building capacity to address mental health in Head Start
is not new (Piotrkowski et al., 1994; Yoshikawa & Zigler, 2000), and efforts should focus on
how to allocate additional funding and resources to Head Start sites to reduce caseloads for
FSWs, invest in training opportunities, and hire additional mental health specialists. Until there is
a significant investment from the federal government in building capacity for family mental
health and other presenting issues, Head Start staff may continue to attempt to cover all areas of
need with too few resources, particularly in underserved communities like south Los Angeles.
Based on the results of the second dissertation study, it appears that there is evidence
supporting two of the four proposed mechanisms of IPT (Lipsitz & Markowitz, 2013), namely
processing emotions and experiencing social support, but that in IPT-G the establishment of
emotional safety in the group setting is a prerequisite for therapeutic impact. One of the key
differences among mothers whose depression improved and those whose depression persisted
was the level of emotional safety they experienced, and this was often impacted by internalized
stigma about mental health and societal norms and expectations for mothers, which prevented
some mothers from developing trust with the IPT-G facilitators or with other members of the
group. Mothers who had difficulty establishing this sense of safety were also more likely to
report higher levels of lifetime trauma and current exposure to verbal intimate partner violence
(IPV). And although all participants endorsed the importance of reducing interpersonal distress
and improving interpersonal communication, the other two proposed mechanisms operating in
IPT, these did not appear sufficient to reduce depression.
In considering the causes of mental distress and depression for this population, it is
critical to consider the role of compounding stressors like poverty, trauma, racism and sexism
experienced as ethnic minority woman, being low-income, and for many mothers in this study,

103
being an immigrant. Societal expectations and discrimination impact experiences for all low-
income ethnic minority mothers in mental health treatment, and this study demonstrates the
importance of clearly addressing those challenges before and during treatment. Although the
HMHK program was effective for mothers who enrolled on average, this study provides insight
into additional adaptations and considerations to promote intervention efficacy for all mothers.
For example, future efforts should focus on developing intervention modules and content that
directly address trauma and IPV and challenge stigma and societal norms and expectations
around motherhood. It may also be helpful to implement broad prevention strategies aimed at
enhancing safety and reducing stigma in community-based settings before recruiting mothers for
mental health treatment, including mental health literacy programs, cultural competence training,
and family engagement campaigns (Corrigan, 2004), as well as addressing these topics within
IPT itself.
Conclusion
In conclusion, this mixed method multi-study comprehensively examined the
implementation of the “Healthy Moms, Healthy Kids” program in the areas of both universal
maternal depression screening and the provision of IPT therapy groups and sought to identify
effective mechanisms and factors affecting treatment outcomes to further adapt the program for
low-income, ethnic minority Head Start mothers. Grounded in the transformative paradigm, this
study sought to undertake systematic inquiry to promote social justice and inform action,
privilege the lived experiences of stakeholders with lower levels of power in traditional research,
and combine qualitative data regarding community perspectives with quantitative data
demonstrating outcomes that have credibility in the larger research community. Results have
several implications for research, practice, and policy, particularly around building capacity to

104
address family mental health in Head Start and adapting IPT-G to address the harmful effects of
trauma, stigma, and societal norms and expectations around motherhood experienced by low-
income, ethnic minority mothers.

105
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II. Appendices

a. Interview Guide for IPT Group Participants
b. Interview Guide for Mental Health Therapists
c. Interview Guide for Family Service Workers
d. Interview Guide for Family and Community Partnership Specialists
e. Interview Guide for Agency Leadership

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A. Interview Guide for IPT Group Participants

[READ TO PARTICIPANT] Thank you for taking the time to speak with me today. My name is
_________ and I am here representing USC and Children’s Institute. I’m going to ask you some
questions about your experiences in the therapy group “Healthy Moms, Healthy Kids.” We are
interested in learning about how to improve the therapy group, and there is no one better
qualified to teach us than those of you who participated. There are no right or wrong answers
and we are grateful to hear anything you have to share. The interview will last approximately
one hour, and it will be audio recorded. Afterwards, the recording will be transcribed. I will take
a few notes, which will be kept in a secure location and they will not have your name attached to
them. All of your responses will be kept confidential. If you feel uncomfortable answering a
question, feel free to say so and we can move on to the next question. You can also stop the
interview at any time. At the end of the interview, you will receive a $40 gift card. Do you have
any questions before we begin? Do you agree to participate, and may I record our discussion?
Thank you.

Questions about depression screening:
1) Do you remember filling out a form asking you questions about your feelings, health, and
relationships with others when you enrolled your child at CII? (If no, skip to question 2)
a) In this conversation, who was it that told you about the group and talked with you about
the screening form (FSW, researcher, etc.)?
b) What was it like for you to be asked about your personal feelings, particularly about
feelings of sadness or feelings of depression? Tell me a little bit about how this meeting
went.
c) Did the person who talked with you read the questions aloud or have you fill out the
questionnaire by yourself? What was this experience like for you?
d) When you were told that you had depression, did you know then what that was? Or was
e) that the first time you had heard that?
f) At the time, did you identify as having depression?
i) What does depression mean to you?
g) Would you recommend any specific changes in the way we talk with mothers about
sensitive topics like depression?
Questions about the IPT group:

2) Now I am going to move on to some questions about the therapy group itself. Why did you
join the group?
a) What specifically did you hope to gain from participating in the group?

3) What were your individual goals for the group (that you established in that first session with
the therapist?)
a) What progress have you made in your opinion?

4) What did you think of how your facilitators led the group?
a) To what extent did you feel you could trust the facilitators and what did they do
specifically to build trust with you?

116
b) What helped or prevented you from feeling you could share your feelings with them?

5) What were your experiences of participating in the therapy group?
a) To what extent did you find the group meetings helpful?

6) How did you feel about participating in therapy in a group with other mothers?
a) What made the experience positive or negative? Please feel free to share any specific
moments that come to mind.
b) Would you be more or less likely to participate in the group if you could join at any time
(and other participants could join at any time as well)? This would reduce wait time to
join a group, but could mean that the group participants may change somewhat over
time).

7) Take a moment to think about the topics that were discussed in the group.
a) Were there particular topics that were helpful to you?
b) Were there any other topics you would have liked to talk about in the group?

8) Do you think participating in the group had an impact on your relationships with your
children, partner, family, and friends?
a) If so, in what ways did it affect these relationships?

9) About how many group sessions/meetings did you attend?
a) Were you able to complete the group? Why or why not?

10) Did you experience anything that made it difficult or challenging for you to participate in the
therapy group? If so, what challenges did you face?
a) Ask follow-up probes about themes that came up in pre interviews, including barriers like
childcare, transportation, etc., cultural or linguistic differences, difficulty disclosing due
to stigma, fear of DCFS involvement, etc. For example, was childcare a challenge for you
in participating in the group?
b) In what ways did you deal with these challenges and/or in what ways did the agency help
you in addressing them?

11) Do you still keep in contact with mothers from the group?

12) Would you recommend the group to other mothers?
a) How would you describe the group to a friend or acquaintance?

13) Is there anything else we haven’t talked about that you would like to add?

[READ TO PARTICIPANT] Thank you so much for speaking with me today. I learned a lot from
what you told me. If you have any additional questions concerning this research or your
participation in it, please feel free to contact the USC research office or myself at any time. You
can also contact me if there is any additional information you would like to add. Here is my card
with my name, phone number, and e-mail address. If you would like, I can also provide you with

117
a summary of our findings at a later time. (If they are interested, record their name and contact
information on a separate sheet of paper).

118

B. Interview Guide for Therapists/Mental Health Staff

[READ TO PARTICIPANT] Thank you for taking the time to speak with me today. My name is
___________ and I am here representing USC. I’m going to ask you some questions about the
“Healthy Moms, Healthy Kids” program. We are interested in learning about your experiences
in leading an IPT group and your overall thoughts about the HMHK program. There are no
right or wrong answers and we are grateful to hear anything you have to share. The interview
will last between thirty minutes and an hour, and it will be audio recorded. Afterwards, the
recording will be transcribed and then deleted. I will take a few notes, which will be kept in a
secure location and they will not have your name attached to them. All of your responses will be
kept confidential. If you feel uncomfortable answering a question, feel free to say so and we can
move on to the next question. You can also stop the interview at any time. Do you have any
questions before we begin? Do you agree to participate, and may I record our discussion? Thank
you.

1) Can you tell me a little bit about yourself and how you came to be involved as a therapist
with the “Healthy Moms, Healthy Kids” program?

2) What was your experience in providing IPT-Group?

a) How many IPT groups did you run?

3) What are your perceptions of how the IPT-Group worked in addressing needs of this
particular group of mothers?

4) From your perspective as a therapist, what do you see as the strengths of the intervention?

a) The weaknesses?

5) What specific intervention content did you find to be helpful or effective? (For example,
certain modules)
a) Was there content that was less helpful?

6) Do you feel that there is anything that should be added to the group in order to better address
mothers’ needs?

7) What challenges did you experience in conducting the group?

a) Tell me a little bit about a specific challenge you faced and what happened.

8) To what extent were concerns about billing requirements, scheduling problems, lack of
appropriate space to host groups, pacing of the model, attrition, etc. barriers in leading the
IPT group?

9) To what extent was engagement with mothers a challenge?

119

a) Ask follow-up probes about themes that came up in pre interviews for mothers, including
barriers like childcare, transportation, etc., cultural or linguistic differences, difficulty
disclosing due to stigma, fear of DCFS involvement, etc.
i) For example, to what extent do you think childcare was a barrier for mothers in
participating in the group?

10) From your perspective, how well were the barriers to implementing IPT addressed?
a) In what ways were barriers addressed or not addressed?

11) What would you recommend to better engage mothers in the group?

12) We’ve discussed challenges, were there any specific successes you experienced in providing
this group?

13) To what extent did you feel supported by your supervisor and the IPT trainer?

14) Is there anything else that you would like to share with us?

[READ TO PARTICIPANT] Thank you so much for speaking with me today. I learned a lot from
what you told me. If you have any additional questions concerning this research or your
participation in it, please feel free to contact the USC research office or myself at any time. You
can also contact me if there is any additional information you would like to add. Here is my card
with my name, phone number, and e-mail address. If you would like, I can also provide you with
a summary of our findings at a later time. (If they are interested, record their name and contact
information on a separate sheet of paper).

120
C. Interview Guide for Family Service Workers (FSWs)

[READ TO PARTICIPANT] Thank you for taking the time to speak with me today. My name is
___________ and I am here representing USC. I’m going to ask you some questions about the
“Healthy Moms, Healthy Kids” program. We are interested in learning about your experiences
in screening mothers for depression and your overall thoughts about the program. There are no
right or wrong answers and we are grateful to hear anything you have to share. The interview
will last between thirty minutes and an hour, and it will be audio recorded. Afterwards, the
recording will be transcribed and then deleted. I will take a few notes, which will be kept in a
secure location and they will not have your name attached to them. All of your responses will be
kept confidential. If you feel uncomfortable answering a question, feel free to say so and we can
move on to the next question. You can also stop the interview at any time. Do you have any
questions before we begin?

1. What were your experiences in screening mothers for depression?
a. How did you feel about asking mothers about this sensitive subject?

2. What difficulties did you experience in screening mothers?

3. Did you feel qualified or trained enough to conduct the screening?

a. Is there anything that would have made you feel more supported in conducting
screenings?

4. How would you introduce the screening measure to mothers?
a. What were their reactions?

5. Thinking back, how many of the mothers that you screened ended up meeting criteria for
depression?
a. To what extent did you feel that maybe some of the mothers who were actually
depressed did not meet criteria on the screening?

6. What are your perceptions of how well the IPT-Group addressed mothers’ needs?

7. Do you think this could continue to be an effective intervention for depressed mothers?

a. Why or why not?

8. From your perspective as a Family Service Worker, what do you see as the strengths of
the intervention?
a. The weaknesses?

9. In your opinion, what were the barriers to implementing IPT-Group?

10. From your perspective, how well were these barriers addressed?

121
a. In what ways were these barriers addressed?
b. In what ways were they not addressed?

11. Is there anything else that you would like to share with us?

[READ TO PARTICIPANT] Thank you so much for speaking with me today. I learned a lot from
what you told me. If you have any additional questions concerning this research or your
participation in it, please feel free to contact the USC research office or myself at any time. You
can also contact me if there is any additional information you would like to add. Here is my card
with my name, phone number, and e-mail address. If you would like, I can also provide you with
a summary of our findings at a later time. (If they are interested, record their name and contact
information on a separate sheet of paper).

122
D. Interview Guide for Family and Community Partnership (FCP) Specialists

[READ TO PARTICIPANT] Thank you for taking the time to speak with me today. My name is
___________ and I am here representing USC. I’m going to ask you some questions about the
“Healthy Moms, Healthy Kids” program. We are interested in learning about your perceptions
of the program as a Family and Community Partnership (FCP) Specialist. There are no right or
wrong answers and we are grateful to hear anything you have to share. The interview will last
about thirty minutes, and it will be audio recorded. Afterwards, the recording will be transcribed
and then deleted. I will take a few notes, which will be kept in a secure location and they will not
have your name attached to them. All of your responses will be kept confidential. If you feel
uncomfortable answering a question, feel free to say so and we can move on to the next question.
You can also stop the interview at any time. Do you have any questions before we begin? Do you
agree to participate, and may I record our discussion?

1) When did you become involved in the Healthy Moms, Healthy Kids program and what was
your role?
a) What was your role as an FCP Specialist?

2) What do you consider to be the greatest needs facing families in the agency’s Head Start
program?
a) To what extent do you think depression is a problem for mothers of children in Head
Start?

3) Overall, what were your experiences in supervising FSWs who screened mothers for
depression?
a) What are your opinions about having FSWs do depression screening?
b) What challenges did you notice in screening mothers for depression?
c) What facilitated successful depression screening?

4) Did you feel that you and your team of FSWs were provided with sufficient support and
training to screen mothers for depression?
a) Why or why not?
b) Is there anything that would have made you and your team feel more supported or
equipped to conduct screenings?

5) During implementation, rates of positive depression screenings differed, with some FSWs
reporting that no one met criteria, and other FSWs reporting a higher rate of positive
screenings. What do you think might explain this?

6) What were your perceptions of “Healthy Moms, Healthy Kids” therapy group?

a) What was your understanding of the group’s goals?

7) What are your perceptions of how well the therapy groups addressed mothers’ needs?

8) Do you think this could continue to be an effective intervention for Head Start mothers?

123

a) Why or why not?

9) In your opinion, what were (or could be) the barriers to implementing IPT-Group?
a) Ask follow-up probes about themes that came up in pre interviews for mothers, including
barriers like childcare, transportation, etc., cultural or linguistic differences, difficulty
disclosing due to stigma, fear of DCFS involvement, etc.
i) For example, to what extent do you think childcare was a barrier for mothers in
participating in therapy groups?

10) From your perspective, how well were these barriers addressed?
a) In what ways were these barriers addressed?
b) In what ways were they not addressed?

11) Is there anything else you would like to share with us?

[READ TO PARTICIPANT] Thank you so much for speaking with me today. I learned a lot from
what you told me. If you have any additional questions concerning this research or your
participation in it, please feel free to contact the USC research office or myself at any time. You
can also contact me if there is any additional information you would like to add. Here is my card
with my name, phone number, and e-mail address. If you would like, I can also provide you with
a summary of our findings at a later time. (If they are interested, record their name and contact
information on a separate sheet of paper).

124

E. Interview Guide for Agency Leadership

[READ TO PARTICIPANT] Thank you for taking the time to speak with me today. My name is
_________ and I am here representing USC. I’m going to ask you some questions about your
perspective on the implementation of the “Healthy Moms, Healthy Kids” program. We are
interested in learning about the process of the implementation, and what barriers or facilitators
impacted its ultimate success or failure. There are no right or wrong answers and we are
grateful to hear anything you have to share. The interview will last between thirty minutes and
an hour, and it will be audio recorded. Afterwards, the recording will be transcribed and then
deleted. I will take a few notes, which will be kept in a secure location and they will not have
your name attached to them. All of your responses will be kept confidential. If you feel
uncomfortable answering a question, feel free to say so and we can move on to the next question.
You can also stop the interview at any time. Do you have any questions before we begin?

1. What do you consider to be the greatest needs facing families in the agency’s Head Start
program, or in other agency programs?
a. To what extent is depression a problem for mothers of children in Head Start?

2. What do you know about the “Healthy Moms, Healthy Kids” study?

3. What was your role in the study?
a. How did you become involved?
b. What is your role in the agency now?

4. From your perspective, to what extent does the IPT group fit with the agency’s cultures
and priorities?

5. What are your perceptions of how effective HMHK was in addressing mothers’ needs?

6. What successes did you see in the implementation of HMHK in this community based
setting?
a. In contrast, what were the barriers to implementing IPT-Group?

7. Specifically, to what extent were organizational factors a challenge?
a. In what ways?

8. To what extent did outside factors like policies and funding requirements impact the
implementation of the program?
a. In what ways?

9. In what ways has the agency changed in the past five years and how do you think this
may have impacted the HMHK implementation?

125
10. From your perspective, how well were barriers to implementation addressed? In what
ways were they successfully addressed or not addressed? How would you have liked
these barriers to be addressed?

11. If you currently play a decision-making role, how likely do you think it is that you or the
agency will continue providing IPT-group to mothers of Head Start children?

12. Are there ways that you would want to adapt or change the program?

13. Is there anything else that you think is important to tell us?

[READ TO PARTICIPANT] Thank you so much for speaking with me today. I learned a lot from
what you told me. If you have any additional questions concerning this research or your
participation in it, please feel free to contact the USC research office or myself at any time. You
can also contact me if there is any additional information you would like to add. Here is my card
with my name, phone number, and e-mail address. If you would like, I can also provide you with
a summary of our findings at a later time. (If they are interested, record their name and contact
information on a separate sheet of paper).

Abstract (if available)

Abstract Maternal depression disproportionally affects low-income, ethnic minority mothers of young children, and can lead to poor child outcomes in a variety of domains, including parent-child relationship quality, child behavior problems, and school readiness skills. Although intervention researchers have developed several efficacious treatments for depression over the past several decades, utilization of these treatments among low-income ethnic minority mothers in community settings remains limited. Two-generation programs in Head Start offer a unique opportunity to provide evidence-based mental health services for mothers that may have difficulty accessing and utilizing treatment. This dissertation study utilizes a transformative mixed methods approach to evaluate the implementation effectiveness of the “Healthy Moms, Healthy Kids” (HMHK) program, which provided a gold standard evidence-based treatment for depression (Group Interpersonal Psychotherapy) in Head Start. Paper 1 assesses HMHK implementation outcomes and factors impacting implementation using the mixed methods RE-AIM QuEST framework. Paper 2 explores mothers’ experiences in the HMHK intervention, and uses a mixed methods approach to identify factors and mechanisms that impacted treatment outcomes. Taken together, these findings will be used to develop recommendations for researchers, practitioners, and policymakers regarding how to further adapt IPT-Group and other mental health treatments for use in Head Start to best address the needs of low-income minority mothers experiencing depression.

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Asset Metadata

Creator Palmer Molina, Abigail (author)

Core Title Effectiveness and implementation of a maternal depression treatment in a Head Start setting: a mixed method study

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Degree Conferral Date 2022-05

Publication Date 04/15/2022

Defense Date 03/08/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Head Start,implementation science,interpersonal psychotherapy (IPT),maternal depression,mixed methods,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Traube, Dorian E. (committee chair), Mennen, Ferol E. (committee member), Palinkas, Lawrence A. (committee member), Saxbe, Darby (committee member)

Creator Email acpalmer@usc.edu,palmer.abigail@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC110964905

Unique identifier UC110964905

Document Type Dissertation

Format application/pdf (imt)

Rights Palmer Molina, Abigail

Type texts

Source 20220415-usctheses-batch-925 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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