Co-design of group psychosocial health intervention for indigenous women in Guatemala

INTERVENTION: Women leaders known to the PI requested a group intervention that could help women in their communities. Local leaders steered group processes. The participatory research approach involved initial needs assessment and co‐design, co‐development, and co‐implementation of the intervention with the 16 circle leaders. This enabled optimizing community‐level engagement with the intervention and ensured that the research and intervention were culturally safe, locally relevant, and respectful of local values. Ten one‐day workshops scheduled monthly enabled the circle leaders to co‐design the intervention. They collectively chose a project name and logo; developed a theory of change; mapped community needs, resources, and stakeholders; and pilot‐tested group methodologies. Individual and group activities drew from a broad range of evidence‐based and local approaches including cognitive behavioural therapy (CBT) (emotional self‐management, problem‐solving, cognitive reframing), interpersonal therapy (IPT) (learning‐through‐play, communication strengthening, role plays, art‐based methods), educational (popular education, sharing among women), and mindfulness‐based (rituals, breathing and relaxation exercises, guided meditation). Methods included both psychological and mental health promotion approaches. All were adapted by the women to be used locally. Local resources and practices complemented these activities. Finally, women’s interest in developing livelihood‐sustaining skills prompted us to also incorporate productive activities (i.e. doll making, crochet, cooking) as a form of vocational therapy and potential small‐scale income generation. The intervention was transdiagnostic, addressing a range of mental health issues, and was intended to foster reflection and dialogue. The 10 sessions of the group psychosocial intervention followed a fixed format. Pre‐sessions involved toy‐making of dolls, books or rattles mothers could use to stimulate and play with their infant CONDITION: Maternal psychosocial health and wellbeing ; Mental and Behavioural Disorders INCLUSION CRITERIA: 1. Pregnant or under two years postpartum 2. At least one of the following conditions: socioeconomic disadvantage, domestic violence, difficult interpersonal relationships, poor social support, psychological distress. These criteria were based on known risk factors, circle leaders’ assessment of what constituted maternal vulnerability, and prior research in nearby Mam communities PRIMARY OUTCOME: A questionnaire assessed the following four measures of psychosocial health and functioning (primary outcomes) at baseline and at one‐month post‐intervention:; 1. Maternal symptoms of depression and anxiety over the last month, measured using the Hopkins Symptom Checklist‐25 (HSCL‐25), a symptom inventory composed of a 10‐item anxiety cluster, a 13‐item depression cluster, and two additional somatic symptoms. Each item scores on a scale from one (not at all) to 4 (extremely); item scores can be summed to provide an estimate of the severity of anxiety and depression symptomatologies. A higher score indicates greater distress; 2. Maternal wellbeing, measured using the Mental Health Continuum Short Form (MHC‐SF), comprised of 14 items representing the three dimensions of wellbeing: emotional, social and psychological. Each item scores on a scale from zero (never) to four (always), based on experiences in the previous month, allowing for continuous assessment of positive mental health. A higher score indicates greater wellbeing; 3. Self‐efficacy, measured using a four‐item subscale measuring self‐efficacy in childcare (feeding, caring and cleaning, playing and talking, helping recover from illness) and a four‐item subscale measuring self‐efficacy in self‐care (overcoming daily problems; staying calm when worried, nervous, or afraid; finding reliable people for support; dedicating time to herself). Each item scores on a scale from zero (I can’t do it) to three (I can do it), allowing for continuous assessment of childcare self‐efficacy, self‐care self‐efficacy, and total self‐efficacy. A higher score indicates greater self‐efficacy; 4. Mother’s engagement in early infant stimulation, measured using six items from the UNICEF Multiple Indicator Cluster Survey Early Child Development module capturing adult‐child interactions, assessing whether mothers engaged with her infant in six different activities (e.g., reading, singing, playing, talking) over the preceding three days. Each item scored as zero (no) or one (yes). The cumulative number of activities was used as a continuous variable for analyses. Only those women who had a child under two years old participated in this questionnaire. A higher score indicates greater involvement in early infant stimulation activities SECONDARY OUTCOME: 1. Acceptability was assessed in post‐intervention focus groups and in‐depth interviews, when participants were asked whether they were satisfied with the intervention, would recommend it to other women, and would have preferred it to be any different. Participants were also asked to report on their (or other women’s) barriers to participation; circle leaders were asked what strategies they used to overcome these; 2. Intervention feasibility was assessed during post‐intervention focus groups and in‐depth interviews. Circle leaders were asked whether they felt comfortable in their ability to lead the Women's Circles, had received enough training and support, felt that implementation logistics were appropriate (i.e. session frequency, location and length, materials, compensation), and what they might change. Objective data included: rate of circle leader retention, rate of women participant retention, and number of sessions attended