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PRISM was the culmination of almost a decade of research beginning in 1989 that mapped the experiences of Victorian women as they became mothers, and documented concerning levels of maternal physical and emotional ill-health after childbirth. This research included: 1989
Survey of Recent Mothers
Follow-up
Study of Women's Emotional Well-being and Experiences of Motherhood 1994
Survey of Recent Mothers Life
as a Mother Project (LAMP) Mothers
in a New Country (MINC) Study The evidence and knowledge gained from this work informed the strategies implemented and evaluated in PRISM. In summary: Depression affects around one in six or seven women following the birth of a baby - 10,000 women in Victoria every year. 95% of women report one or more health problems in the first six months after childbirth, with the most common problems being exhaustion, backache, perineal pain, sexual problems and urinary incontinence. These problems are common in both Australian-born and immigrant women and often go undetected, despite frequent contacts with primary health care services. Women often find it hard to find someone to talk to about these issues and few women actively seek help from health professionals. Women who do find someone who listens with empathy describe this as very helpful. Isolation, lack of support and few opportunities for time out from infant care are key issues for women experiencing depression and other health problems. Click here [PDF] for a list of the publications arising from the previous descriptive studies that led to PRISM.
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The development of PRISM was also informed by the accumulating evidence from randomised trials - conducted in Australia and elsewhere - to reduce maternal depression and improve physical health in the year after birth. At the time PRISM commenced, the evidence in support of the approach taken in PRISM can be summarised as follows:
1.
Regier D et al. The NIMH depression awareness, recognition and treatment
program Am J Psychiatry 1988; 145:1351-57. Systematic reviews of relevant trials have been completed and published, summarising the current evidence about:
Click here to see summary tables [PDF] providing information about the design and intervention of the trials reviewed in the paper, and a reference listing [PDF]] of all the trials, up-to-date at 23 March 2004.
Click here [PDF] to read more about the background to PRISM in a comprehensive overview of the study rationale and evolution, including our efforts to obtain funding for the conduct of the trial.
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PRISM was designed as a cluster randomised trial, meaning that participating communities accepted a 50:50 chance of being an intervention community (implementing PRISM strategies to support mothers) and a 50:50 chance of being a comparison community (continuing with usual postnatal care for women). 'Cluster' randomised means that it was whole communities, in this case municipalities, which were randomised rather than individuals. Sixteen communities have participated in PRISM: eight in the Melbourne metropolitan area and eight in rural areas of Victoria. Four Melbourne and four rural municipalities are intervention communities, and four Melbourne and four rural municipalities are comparison communities. The important benefit of the randomised trial design is that it allows us to answer the question – does the PRISM intervention work? – with confidence. More about the design of PRISM: A paper describing the design in full - the trial protocol - has been published.
A second paper describing design issues in PRISM was published in 2004.
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Evaluation has involved:
Click here [PDF] for more detailed information about evaluation strategies in PRISM.
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There were a number of steps in getting started in PRISM. Perhaps the most important were those taken to gather information about local government areas in Victoria, to inform eligible municipalities about the trial, to invite expressions of interest in participation and then to provide more in-depth project briefings in each interested municipality concerning the rationale for PRISM, what participation would involve and to answer questions about the trial - prior to a formal Memorandum of Understanding being signed. Information gathering about municipalities in Victoria Thirty-three of the 78 municipalities in Victoria were eligible to participate in PRISM on the basis that their annual numbers of births fell between 300 and 1500. A range of information about these 33 eligible communities was collected prior to our approaches to local councils. This included compilation of publicly available information about each local government area (such as Council Annual Reports, Municipal Public Health Plans, Community Service Directories and organisational charts identifying key decision makers), documentation of relevant health service activity (Maternal and Child Health Services, special outreach programs for mothers and babies and General Practice Division projects focused on pregnancy, birth and the postnatal period). Australian Bureau of Statistics data on each local government area were also compiled to provide a socio-demographic profile of each community, and the most recent data on numbers of births in each municipality was requested from the Victorian Perinatal Data Collection Unit, within the Department of Human Services. An information package for local government about PRISM The 33 eligible local government authorities, comprising 17 rural and 16 metropolitan areas of the state, were all sent a letter of invitation accompanied by an information package about the trial and a form for expression of interest in a formal project briefing. This invitation package was sent to the Mayor, the Chief Executive Officer and the Community Services Manager in all 33 municipalities. Click here [PDF] for a copy of the Information Package sent to local government. Briefing meetings in municipalities around Victoria Twenty-six municipalities submitted written expressions of interest in receiving a more detailed briefing about PRISM with the Research Team. All briefings were held in local communities, mostly at municipal offices. The briefings were interactive sessions which enabled not only the presentation of more detailed information about the trial, but also provided an opportunity for local government participants to ask questions and for the research team to develop further understanding of service provision and local issues in each municipality. Click here [PDF] for more details about the briefing sessions. Memorandum of Understanding (MoU) At the end of each local briefing session, a proposed joint Memorandum of Understanding between the University and each local government area agreeing to participate was discussed. Subsequently, 21 municipalities submitted signed MoUs to the University. Click here [PDF] for a copy of the generic MoU used in PRISM. Selection of the final set of 16 participating communities A number of considerations affected the selection of sixteen communities for participation in PRISM, including ensuring an adequate sample size, program costs and available resources, concern to minimise contamination across adjoining local government boundaries between intervention and comparison areas, and capacity to match communities in pairs on a limited number of criteria (geographic size, number of births and levels of infrastructure support and activity). Importantly, we included the minimum number of communities that would enable us to detect with confidence a meaningful effect on depression prevalence and the maximum number of communities our budget/resources would allow. A detailed description of the selection process employed is included in the PRISM design paper (reference available here soon). Public Randomisation A public launch of PRISM at which the randomisation of the sixteen communities was undertaken, took place in Melbourne in June 1998. As part of a commitment to public discussion of the rationale for conducting PRISM as a community randomised trial and to provide a forum for discussion of evaluation of social interventions, representatives of all participating areas were invited to take part in a half-day workshop, preceding the randomisation. Click here [PDF] for a copy of the PRISM Launch Program. More about establishing partnerships to implement PRISM. A paper describing in more detail our approaches to local government and the process of establishing partnerships to implement PRISM has been published.
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Contact us at: mchr@latrobe.edu.au
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The
importance of community-based interventions in mental health had been
argued by Regier et al. (1) because only a minority
seek professional help for mental health problems, when they do they turn
to the primary health sector; even when help is sought mental health problems
are under-recognised in primary care. These arguments were reinforced
by the difficulties of identifying women at high risk of depression after
birth. (2)
