Key minimum elements of the program
PRISM incorporated a range of primary care and community based strategies to improve the emotional and physical health of mothers after childbirth. PRISM strategies were designed to:
- mobilise communities to provide more recognition and support for all mothers;
- strengthen and build on existing local services for mothers;
- provide new opportunities for broadening community involvement in support for mothers; and thereby,
- let all mothers know that what they do is really valued.
The key minimum elements of the PRISM intervention program included:
- Local coordination
- Education programs for maternal and child health nurses and general practitioners
- Mothers' information kits
- Befriending strategies for mothers: breaking down isolation and increasing opportunities to meet and make friends
The first element involved building in a strong sense of local co-ordination and input to enhance program implementation via appointment of project officers working in a community development role and the establishment of local steering committees.
Community development officers
A full-time Community Development Officer (CDO) was appointed in each participating intervention area, with local involvement in the selection process and interviews carried out in each municipality. Commencing in November 1998, CDOs facilitated the implementation of the PRISM program over two years in each area, within the framework provided by the program plan.
CDO duties and responsibilities included:
- liaising with local government and non-government agencies, general practitioners, maternal and child health nurses and local mental health services;
- assessing levels of local community service provision and compiling information on services for mothers, for inclusion in the kit of information for mothers;
- soliciting vouchers for services to mothers from local service providers, community agencies and businesses, for inclusion in the information kit for mothers;
- establishing supportive social networks for mothers, through local government or a community agency as appropriate;
- providing support to the local PRISM steering committee in coordinating the program (in the initial 12 month establishment phase) and the integration of the PRISM program once established, within ongoing service provision by local government or community agencies;
- detailed record keeping and documentation of program activities for the purposes of program evaluation.
Local steering committees
PRISM CDOs worked closely with a local steering committee comprised of key stakeholders. Steering committees were chaired by local government, with maternal and child health and general practitioner representation, along with relevant community agencies and organisations, and importantly, local women who had recently had babies.
PRISM steering committees provided advice, support, local knowledge and local skills to the CDO so as to shape and implement the key elements of the program and initiate additional strategies to support mothers as appropriate and feasible.
The broad terms of reference for local steering committees were:
- to promote PRISM and its objectives within the broader community;
- to oversee the establishment and implementation of the key elements of the PRISM intervention program, tailored appropriately to the local community;
- to implement other local activities consistent with the aims of PRISM, if feasible;
- to facilitate integration of the key elements of PRISM within existing service provision in the local community, once the program was established.
Becoming a steering committee member involved:
- in principle support for PRISM, its objectives and strategies;
- a preparedness and capacity to attend monthly meetings;
- a commitment to liaise with, and report back to, relevant constituencies via existing networks or organisations (eg general practice divisions, community organisations etc);
- a commitment to promoting PRISM and advocating for the project within the local community.
Education programs for maternal and child health nurses and general practitioners
The second key element in PRISM involved working with maternal and child health nurses and general practitioners in education programs designed to enhance recognition and treatment of emotional and physical health problems, and to promote their 'listening skills' and increase offers to women of 'time to talk'.
These programs also addressed what PRISM was trying to achieve in terms of mobilising the whole community around maternal health issues, alleviating what GPs and maternal and child health nurses may often feel - that they are are alone in trying to respond to women's problems at this time.
These key professionals have many contacts with women and their babies in the year after birth. They played a vital role in reinforcing the key messages of PRISM about the value of what mothers are doing, and of mothers' needs for support and time out.
The maternal and child health education program
The PRISM education program for maternal and child health teams aimed to:
1. Strengthen the capacity of the maternal and child health services in each of the intervention communities to support mothers in relation to physical and emotional health issues in the first year after childbirth, in particular by:
- enhancing recognition and treatment of emotional and physical health problems;
- promoting 'listening skills' and offers of 'time to talk'.
2. Assist the PRISM research team to build an understanding of the local context and issues currently affecting maternal and child health services in each of the intervention communities.
The program was offered locally over two full days or four half-days, as appropriate for each service, and incorporated:
- an overview of the research literature regarding the prevalence and natural history of emotional and physical health problems in the first postpartum year;
- discussion of strategies that may assist women in dealing with physical and emotional health issues in the postpartum period, with particular attention to research evidence regarding the effectiveness of a range of approaches;
- discussion of research documenting women's views and experiences of the first year after childbirth;
- review of the skills involved in 'active listening', with opportunities to practise these skills - an aspect of the program facilitated in conjunction with a clinical psychologist;
- discussion of strategies for fostering intersectoral collaboration within local communities, in particular linkages between maternal and child health and local general practitioners;
- consideration of ways that PRISM could support maternal and child health activities in each locality
Twelve months after the initial program all eight maternal and child health teams in intervention communities also participated in a further half-day refresher program (Program Outline [PDF 127KB]).
A full report [PDF 187KB] was sent to participants after the initial program, covering issues, themes and future ideas arising from the sessions with the eight participating teams. It was compiled to share the program learnings between all the teams, contributing further ideas for strengthening practice around maternal health.
Nurse participant views [PDF 532KB] about the initial program were collected via a postal survey, which indicated that they found the program helpful and positive in a variety of ways.
The general practitioner education program: GAPP - Guidelines for Addressing Postnatal Problems
The education program for general practitioners was conducted via a collaborating project embedded within PRISM and led by Associate Professor Jane Gunn at the University of Melbourne's Department of General Practice.
GAPP (Guidelines for Assessment of Postnatal Problems) was an innovative, multifaceted general practice educational program using guidelines aimed at increasing the confidence, knowledge and skills of GPs in dealing with maternal depression and physical problems after birth.
GAPP aimed specifically to increase:
- the skills of GPs to deal with postnatal problems (measured by a simulated patient evaluator);
- the knowledge of GPs about postnatal problems (measured by written questionnaire);
- the use of guidelines for postnatal care (measured by self-report);
- the confidence of GPs about postnatal problems (measured by written questionnaire);
- the number of women citing their GP as a source of help in the year after birth (measured by mail out survey as part of PRISM evaluation); and to decrease;
- the number of women citing their GP as unhelpful in the year after birth (measured by mail out survey as part of PRISM evaluation).
Two workshops were held in each PRISM intervention area - the first being an introductory evening, and the second offering GPs all of the GAPP tools and strategies, including active listening practice with a simulated patient that was facilitated by the clinical psychologist also involved in the maternal and child health education program in PRISM.
The GAPP tools included:
- a well-resourced folder comprising the latest evidence based information about the common maternal health issues;
- evidence based GAPP Guidelines [PDF 201KB] for managing postnatal problems;
- reminder stickers [PDF 24KB] which reinforced the strategy of active listening.
GPs also participated in a visit from a simulated patient, playing the role of a recent mother with some health issues. GPs' response to simulated patient visits was overwhelmingly positive.
Following the workshops GPs were encouraged to participate in post-workshop options, such as the GAPP Readings, and to spread the GAPP messages and Guidelines to peers who were unable to attend the workshops. To encourage this activity the Royal Australian College of General Practitioners (RACGP) allocated a generous number of CME points for participants of these post-workshop options.
GAPP GP Advisors (GPA) were appointed in each municipality to facilitate local GP involvement both in GAPP training and in PRISM. The GPA role evolved and expanded during the project to include one of local advocate. GPAs were involved in liaising with PRISM community development officers, GP Division staff, and MCH Team Leaders to help develop ideas for sustaining the PRISM and GAPP messages in the community, and for getting GPs and maternal and child health nurses communicating and establishing working links.
Evaluation of GAPP
GAPP used a pre-test-post-test design. The main outcomes were pre-specified and used data obtained from a number of perspectives using written self-report as well as the ratings of trained observers (simulated patients). Self-report was used in three ways: asking GPs about their knowledge, skills and attitudes in the pre/post GAPP surveys, asking them to apply the knowledge in the pre/post GAPP survey and asking them to list what they had derived from the program on feedback evaluation forms. GPs competence to use their knowledge about postnatal problems was assessed by trained simulated patient evaluators seen by the GP during their usual clinic setting.
The full report is available on request from the Primary Health Care Research and Information Service.
Several papers have been submitted for publication and details of these will be included here once they are published.
Gunn J, Southern D, Chondros P, Thomson P, Robertson K. Guidelines for Assessing Postnatal Problems: introducing evidence based guidelines in Australian general practice. Family Practice 2003; 20: 382 - 389
Mothers' Information Kits
An important resource for the PRISM intervention program was the information kit provided to all mothers giving birth. The kit aimed to provide information to mothers designed to acknowledge their needs for information about their own health and recovery after birth, for support, for time out and for access to relevant local services.
The PRISM kit contained:
- two brochures outlining some of the common difficulties of being a mother - one relating to emotional wellbeing [PDF 707KB], the other to physical health problems [PDF 723KB] - and including strategies for dealing with these which other mothers have found helpful;
- a locality guide for mothers with a listing of relevant local services, activities and supports for mothers and babies, specific to each local community (examples - 'Glenelg Shire for Mothers' [PDF 744KB] and 'Maroondah for Mothers' [PDF 651KB];
- an information leaflet for fathers [PDF 506KB] emphasising the important role they play in their baby's life and outlining ways in which they can provide support for their partners as they recover from the birth;
- a voucher booklet specific to each community, containing vouchers donated by local organisations and businesses (e.g. free session/s at the local occasional childcare centre, free entry to the local swimming pool, a free coffee at a local café, etc.). (example voucher booklets - 'City of Greater Bendigo' [PDF 257KB] and 'Shire of Melton.' [PDF 260KB])
Befriending strategies for mothers: breaking down isolation and increasing opportunities to meet and make friends
The inclusion of 'befriending' as a key element in PRISM derived from the evidence that social isolation is a contributing factor in depression for many women, combined with recognition that standard strategies for overcoming isolation (first-time mothers' groups, support groups for mothers with depression, nursing mothers' groups, etc.) were not meeting the needs of all mothers for support.
The aim from the outset of the project was therefore to consider strategies enabling mothers to broaden their social networks in ways that did not rely on participation in groups. We did not begin with a specific definition of 'befriending' beyond the view that the aim should be to promote opportunities for mothers to meet other people in settings/ways that enabled them to make new contacts on a one-to-one basis, (rather than in a group context). We also recognised that ideas for befriending strategies were likely to vary, and to do so appropriately, depending on the community context in which PRISM was occurring.
Thus the concept of 'befriending' in PRISM recognised that:
- groups are not a solution to isolation for all women (not all women like groups; they may be difficult to get to with an older child, or a baby that is sick, unsettled or cries a lot; some groups may seem too baby-focused or too targeted on 'problems' for some women);
- another strategy for reducing isolation is to have opportunities to make friends;
- friends are made in a range of contexts, many of them opportunistic;
- friendship involves doing things together and meeting each other's needs (mutual and reciprocal relationships);
- friends do not have to be the same age or at the same life stage;
- 'befriending' can be facilitated in various ways: via a setting (eg a local café), via a facilitator (eg a maternal and child health nurse) or via an activity (pram walks).
Importantly, in tune with PRISM's universal approach, befriending was a strategy conceived for all mothers, in recognition that every mother needs support.
A range of befriending strategies flowered in communities during the implementation of PRISM. Examples included:
- Befriending in PRISM [PDF 257KB]
- Program of resources, information and support for mothers (example 1) [PDF 802KB]
- Program of resources, information and support for mothers (example 2) [PDF 747KB]
- Program of resources, information and support for mothers (example 3) [PDF 1MB]
- Program of resources, information and support for mothers (example 4) [PDF 599KB]