Alone Mothers Together Project

INTRODUCTION

Health promotion for mothers and children in lone-mother families is important for many reasons. First, there are almost one million (945,230) lone-mother families in Canada (Statistics Canada, 1996). One in five Canadian children under 18 years old lives in a lone-parent family (Canadian Institute of Child Health, 2000).

Second, rates of health morbidities are higher among both mothers (Avison, 1996; Lipman et al., 1997; Munroe Blum et al., 1988) and children (Judge and Benzeval, 1993; Lipman and Offord, 1996; Lipman et al., 1996; Munroe Blum et al., 1988) in lone-mother families. For example, the prevalence rates of depression in the past year reported by lone mothers is about twice that of mothers in two-parent families (9.7% vs. 4.9%) (Lipman et al., 1997).

Third, health care utilization by lone-mother families is not optimal. Based on utilization studies, about three-quarters of adults with a mental disorder do not seek treatment (Ministry of Health, 1994). Many children from lone-mother families do not get help with their difficulties due to limited availability of services (Boyle and Offord, 1988; Offord et al., 1987), and other factors that decrease participation in and completion of clinic-based programs such as parental mood, and stress (Cunningham et al., 1995; Kazdin et al., 1993; Prinz and Miller, 1994).

These considerations stimulated our wish to move clinic-based support/education groups for lone mothers into the community. While evaluations of these clinic-based groups had been positive (McNamee et al., 1995), we recognized the need to move beyond clinic-based research (Clarke, 1995; Weisz et al., 1995).

Our early clinic-based work involved support/education groups for lone (single) mothers of children and adolescents at our outpatient children’s mental health centre. These groups were developed because of the high percentage of lone-mother families among our patients (unpublished observations) and the premise that social support can contribute to improved parenting and maternal-child relationships (e.g., Cox, 1993; Crockenberg, 1981; Dumas and Wahler, 1988; Kirkham, 1993; Simons et al., 1993) and maternal health (House et al., 1998; Kaplan and Toshima, 1990). Results from two groups (14 mothers with 22 children) showed promising improvements in maternal well-being (McNamee et al., 1995).

We subsequently ran two community-based groups for lone mothers attending family practices in a regional Health Service Organization (H.S.O.). An additional 24 women with 43 children participated. Both groups showed improvements in maternal mood scores and some improvements on other measures (unpublished observations).

These community-based groups extended availability, but only to H.S.O. patients. Our goal was to provide groups broadly within the community, with integrated evaluation.

This paper reports on pilot work completed prior to undertaking a randomized controlled trial (RCT) of community-based support/education groups for lone mothers. Lone mothers with preschool-aged children (3 to 6 years old) were targeted. This group was selected because of research findings highlighting the importance of the first five or six years of life in brain development and general child development (Cyander and Mustard, 1997; Family and Work Institute, 1997). The groups were called Alone Mothers Together.

Specific pilot objectives were: (i) identification and enlistment of lone mothers into support/education groups so that more than 25% of lone mothers inquiring about the program agreed to participate; (ii) retention of mothers in groups so that more than 50% of mothers continued for more than 50% of group sessions; (iii) identification of incentives to facilitate completion of evaluations by mothers; and (iv) testing acceptability of evaluation tools.

METHODS
We began with an extended period of community collaboration and planning, and discovered the need to collaborate with key community agencies, get exposure broadly in the community, and provide a high-quality structured children’s program to assist with engaging the mothers. Collaboration and exposure within the community was done by attending community interagency meetings in various areas of Hamilton, and describing our group and distinguishing it from other groups in the community. More intensive advertising (e.g., flyers, information sessions) was done in areas where groups were held. Additional actions to enlist mothers included an Ontario Works credit for participation, snacks, transportation, and a clothing exchange. Mothers interested in the study registered either by telephone or in person at an information session.

Mothers classified themselves as lone mothers. Inclusion criteria were: (i) living in the Hamilton-Wentworth region; (ii) at least one 3-to 6-year-old child; (iii) reported income in the past year at or below the Statistics Canada low income cut-off; (iv) sufficient English to communicate; and (v) agreeable to the study. Exclusion criteria were: (i) psychosis or acute psychiatric crisis (e.g., suicidal); or (ii) extreme crisis related to an abusive or violent relationship (e.g., stalking by ex-partner). As needed, mothers in these situations were directed to appropriate services.

Manoeuvres to sustain group involvement by mothers included telephone reminders and transportation assistance (bus tickets or taxi fares during local bus strike).

To facilitate evaluation completion, we provided flexible times (evening, weekend) and sites (mothers’ house or alternate location), and had two trained project team members involved in the evaluation, one of whom was familiar to all mothers. Measures were judged acceptable in terms of length and language.

Multiple informants and measures were used. Maternal well-being was assessed using mood (Radloff, 1977), self-esteem (Rosenberg, 1965) and social support (Cutrona and Russell, 1987). Parenting was assessed using a self-report parenting scale (Arnold et al., 1993) and an observer-rated parent-child interaction exercise (Cunningham et al., 1995). Child emotional and behavioural problems were rated by mothers (Boyle et al., 1987). A standard brief baseline measure of child language development (Dunn and Dunn, 1981) was included. All measures were chosen for their relevance to the concepts under study, the goals of the intervention, good psychometric properties, brevity and simplicity to increase acceptability to any respondents with low educational levels.

Mothers were compensated for questionnaire completion. We gave mothers and children gifts that had been donated to our program.

Two 8-week 1_ hour/session community-based client-centered support/ education pilot groups were run within subsidized housing projects, and led by two experienced group leaders. Group content included issues common to lone mothers (e.g., experiences of poverty and social isolation) and child issues (e.g., child development and behaviour management). Groups were client-centered and group participants set the agenda (vs. an agenda for each group session). This group style is very responsive to the needs of mothers since mothers bring in whatever issues are important to them on a given day. The groups provided structured therapeutic group counselling.

A parallel children’s program focusing on social, language and motor skills was provided to the preschoolers of lone mothers participating in the pilot groups. A manual was developed for each of the mothers’ and children’s groups.

Evaluation assessments were collected prior to the first group and after completion of the last group.

RESULTS
Advertising efforts attracted 20 mothers who expressed interest (n = 11 and 9 for each of the pilot groups respectively). Ten mothers agreed to participate. Eight of 10 (80%) completed more than half the group sessions. Evaluation completion (full or partial) was 100% pre-group and 60% post-group.

Table 1 shows the characteristics of mothers participating in the pilot groups (combined results). Participant mothers were on average 32.6 years old. Most felt financial pressure (90%) and all had been supported by government assistance in the past year, reflecting that the appropriate population had been reached.

Pre- and post-group evaluations for both pilot groups showed a trend for improved mood [score (mean (sd): pre-group 22.4 (8.3), post-group 13.2 (6.9), t(df) = 2.29(4) p = 0.08]. No significant differences in poor self-esteem, poor social support, or parenting were found (results not shown). Average language comprehension skills were found for the preschoolers [mean (SD) = 97.7 (8.1)].

DISCUSSION
Based on successful clinic-based support/education groups for a vulnerable population of mothers, and a move toward community-based service provision and research we undertook pilot work to see if this group intervention could be run in the community. This feasibility work focused on identification and enlistment of mothers into groups, retention of mothers in groups, and evaluation.

We established procedures for identification and enlistment of lone mothers into support/education groups, and the appropriate population was identified (Table 1). Half of the interested mothers agreed to participate. Most mothers completed more than half of the group sessions.

Evaluation tools were found to be acceptable. All mothers completed evaluation forms pre-group. Rates of post-group evaluation completion reflected less success. Some of the pre-group and post-group evaluations were only partially completed.

We successfully completed the goals set for our pilot project. This feasibility work provided the basis for proceeding to a randomized controlled trial (RCT) of the effectiveness of these groups in the community, which is now underway.

As part of the pilot study we also scored the evaluation measures for each pilot group. The data revealed a trend towards reduction in maternal depressed mood but no significant improvements in maternal self-esteem or social support or self reported parenting. The small number of mothers included in the pilot groups, and difficulties with missing data may attenuate the results. Indeed power analyses (Bryk et al., 1996; Donner and Klar, 1996) using the CES-D (Radloff, 1977), with consideration of response clustering in a group intervention as well as attrition, yield a sample size of 59 mothers assigned to groups and 59 mothers serving as controls to detect a medium effect size (Fleiss, 1986). The limited number of pilot groups sessions may also influence the results. The needs for more complete post-group data collection and to ensure data collection is as complete as possible are clear.

We encountered strong community support at our planning meetings with service providers, both for the groups and the population. Despite this support and enthusiasm, recruitment of mothers was an energy and labour-intensive process to attract small numbers. Other utilization studies of community-based services have found that lone-parent status is associated with lower participation (Cunningham et al., 2000; Kendall and Sugarman, 1997; Spoth et al., 1997). There is a need for continued creative thinking about recruitment issues.

While this feasibility study was successfully completed, moving clinic-based services into the community raises a number of important issues including engagement, expectations and coverage. Individuals who come to clinics are generally asking for help and ready to engage in treatment. The level of readiness for change (Prochaska et al., 1992; Prochaska et al., 1994) or agreement to engage in therapeutic activities appears to be much lower in the community. In terms of expectations, clinic attenders are often asked to complete multiple questionnaires as part of their registration at a clinic or during the course of assessment or treatment. Participants in community-based activities do not have the same expectations and may be less ready to do so. The response burden to community participants must be carefully considered, and explanations for questionnaire completion must be clear and explicit. Coverage refers to the number of individuals in the community who constitute the population of interest (here lone mothers) compared with the number who actually participate in the program. Community-based projects that provide better coverage stand a better chance of having a broad impact on the community.

The results of our pilot work showed it was feasible to undertake an RCT of community-based support/education groups for lone mothers of preschoolers. In addition, close attention to the tradeoffs between acceptability and attractiveness of the intervention program versus the burden of participation defined by intensity, duration and structure of the intervention must be considered in future community work.

ACKNOWLEDGEMENTS
The authors wish to thank Dr. H. MacMillan, Dr. C. Cunningham and Ms. M. Friedrich for assistance.

REFERENCES
Arnold PS, O’Leary SG, Wolfe LS, Acker MM. The Parenting Scale: A measure of dysfunctional parenting in discipline situations. Psychological Assessment 1993; 5: 137-144.
Avison WR. Family structure and mental health. In: A. Money (ed.), Social Stressors, Personal and Social Resources, and Their Health Consequences. Washington, DC: NIMH; 1996.
Boyle MH, Offord DR, Hofmann HG, Catlin GP, Byles JA, Cadman DT, et al. Ontario Child Health Study: I. Methodology. Arch Gen Psychiatry 1987; 44: 826-831.
Boyle MH, Offord DR. Prevalence of childhood disorder, perceived need for help, family dysfunction and resource allocation for child welfare and children’s mental health services in Ontario. Can J Behav Sci 1988; 44: 374-388.
Bryk A, Raudenbush S, Congdon R. Hierarchical linear and nonlinear modelling with the HLM/2L and HLM/3L programs. Scientific Software International Inc; 1996.
Canadian Institute of Child Health. The Health of Canada’s Children, 3rd edition. Canada: Canadian Institute of Child Health; 2000.
Clarke B. Improving the transition from basic efficacy research to effectiveness studies: methodologic issues and procedures. J Consult Clin Psychol 1995; 63: 718-725.
Cox AD. Befriending young mothers. Brit J Psychiatry 1993; 163: 6-18.
Crockenberg SB. Infant irritability, mother responsiveness and social support influence in the security of mother-infant attachment. Child Development 1981; 52: 857-865.
Cunningham CE, Bremner R, Boyle M. Large group community-based parenting programs for families of preschoolers at risk for disruptive behaviour disorder: Utilization, cost-effectiveness, and outcome. J Child Psychol and Psychiatry 1995; 36: 1141-1159.
Cunningham CE, Boyle MH, Offord DR, Racine Y, Hundert J, Secord M. Tri-Ministry Study: Correlates of school-based parenting course utilization. J Consul Clin Psychol 2000; 68: 1-6.
Cutrona CE, Russell DW. The provision of social relationships and adaptation to stress. Personal Relationships 1987; 1: 37-67.
Cyander M, Mustard F. Brain development, competence and coping skills. In Entropy: Founder’s Network Report in Support of the Canadian Institute for Advanced Research 1997; Spring, 1(1): 5-6.
Donner A, Klar N. Statistical considerations in the design and analysis of community intervention trials. J Clin Epidemiology 1996; 49: 435-439.
Dumas JE, Wahler RG. Predictors of treatment outcome in parent training: mother insularity and socioeconomic disadvantage. Behavioural Assessment 1988; 5: 301-313.
Dunn LM, Dunn LM. Peabody Picture Vocabulary Test - Revised Manual for Forms L and M. American Guidance Service, Minnesota, USA, 1981.
Family and Work Institute. I am your child: The new brain research and your child’s healthy development. New York, 1997.
Fleiss JL. The Design and Analysis of Clinical Experiments. Wiley; 1986.
House JS, Landis KR, Umberson D. Social relationships and health. Am Assoc Advanc Sci 1998; 241: 540-545.
Judge K, Benzeval M. Health inequalities: new concerns about the children of single mothers. BMJ 1993; 306: 677-680.
Kaplan RM, Toshima T. The functional effects of social relationships on chronic illness. In: Saranson BR, Sarason IB, Pierce GR, Editors. Social Support: An Interactional View. New York: John Wiley; 1990; 472-453.
Kazdin AE, Mazurick JL, Bass D. Risk for attrition in treatment of antisocial children and families. J Clin Child Psychol 1993; 22: 2-16.
Kendall PC, Sugarman A. Attrition in the treatment of childhood anxiety disorders. J Consul Clin Psychol 1997; 65: 883-888.
Kirkham MA. Two-year follow-up of skills training with mothers of children with disabilities. Am J Ment Retard 1993; 5: 509-520.
Lipman EL, Offord DR. Psychosocial morbidity among poor children in Ontario. In: G. Duncan & J. Brooks-Gunn (eds.), Consequences of Growing Up Poor. Russell Sage Foundation, New York, 1996; 239-287.
Lipman EL, Offord DR, Dooley MD. What do we know about children from single-mother families? Questions and answers from the National Longitudinal Survey of Children and Youth. In: Growing Up in Canada. National Longitudinal Survey of Children and Youth. Human Resources Development Canada, Statistics Canada, Ottawa, Ontario; 1996; Catalogue No. 89-550-MPE.
Lipman EL, Offord DR, Boyle MH. Sociodemographic, physical and mental health characteristics of single mothers in Ontario: results from the Ontario Health Supplement. CMAJ 1997; 156: 639-645.
McNamee JE, Lipman EL, Hicks F. A single mothers’ group for mothers of children attending an outpatient psychiatric clinic: preliminary results. Cdn J Psychiatry 1995; 40: 383-388.
Mental Health in Ontario. Selected Findings from the Mental Health Supplement to the Ontario Health Survey, Ministry of Health, Ontario. Queen’s Printer for Ontario; 1994.
Munroe Blum H, Boyle MH, Offord DR. Single-parent families: child psychiatric disorder and school performance. J Am Acad Child and Adolesc Psychiatry 1988; 27: 214-219.
Offord DR, Boyle MH, Szatmari P, Rae-Grant NI, Links PS, Cadman DT, et al. Ontario Child Health Study: II. Six-month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry 1987; 44: 832-836.
Prinz RJ, Miller GE. Family-based treatment for childhood antisocial behavior: Experimental influences on dropout and engagement. J Consul Clin Psychol 1994; 62: 645-650.
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviours. Amer Psychol 1992; 47: 1102-1114.
Prochaska JO, Velicer WR, Rossi JS, Goldstein MG, Marus BH, Rakowski W et al. Stages of change and decisional balance for 12 problem behaviours. Health Psychol 1994; 13: 39-46.
Radloff LS. The Centre for Epidemiologic Studies Depression (CES-D) Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement 1977; 1: 385-401.
Rosenberg M. Society and the Adolescent Self-Image. New York (USA): Princeton University Press; 1965.
Simons RL, Beaman J, Conger RD, Chao W. Stress, support and antisocial behaviour traits as determinants of emotional well-being and parenting practices among single mothers. J Marriage Family 1993; 55: 857-865.
Spoth R, Redmond C, Kahn JH, Shin C. A prospective validation study of inclination belief, and context predictors of family-focused prevention involvement. Fam Process 1997; 36: 403-429.
Statistics Canada. Census Families by Presence of Children, 1996 Census. 1996 Census Nation Table, 1996.
Weisz JR, Donenberg GR, Hans SS, Weiss B. Bridging the gap between laboratory and clinic in child and adolescent psychotherapy. J Consult Clin Psychol 1995; 63: 688-701.

CORRESPONDENCE & REPRINTS
Dr. Ellen L. Lipman, Canadian Centre for Studies of Children at Risk, Hamilton Health Sciences, Chedoke Campus, Patterson Bldg., P.O. Box 2000, Hamilton, Ontario, L8N 3Z5, Telephone: (905) 521-2100, Ext. 77359, FAX: (905) 574-6665, E-mail: lipmane@mcmaster.ca

SUPPORT
This work was supported by the Hospital for Sick Children’s Foundation, Grant # XG98006. Dr. Lipman was supported by an Intermediate Research Fellowship from the Ontario Mental Health Foundation. Dr. Boyle was supported by a Medical Research Council Scientist Award.