BACKGROUND
An intervention designed for women with disabilities living in rural areas who experience depression, this project's purpose is to decrease depressive symptoms experienced by women with disabilities through the use of self-management strategies. The Center for Research on Women with Disabilities designed and implemented this project at nine centers for independent living. The overall goal was to develop and evaluate a program that can be used in rural centers for independent living throughout the nation.
IDENTIFY STAKEHOLDERS
Those involved in operation initiatives included staff at the Center for Research on Women with Disabilities (CROWD) at the Baylor College of Medicine, staff at nine centers for independent living (CIL) in nine different states, women with disabilities who co-led the sessions, consultants specializing in depression management, and mental health counselors.
Those served by the initiative included women with disabilities who participate in the self-management program, families of the women with disabilities, and staff at the centers for independent living. The intended users of the evaluation include stakeholders involved in the operations and those served by the initiative. Additional stakeholders include centers for independent living nationwide, other organizations serving people with disabilities, disability researchers, and health professionals.
DESCRIBE THE PROGRAM
The project goal is to decrease the incidence of depression among women with disabilities living in rural areas. Women with disabilities living in rural areas are at high risk for developing depression, which is more common for women with disabilities than for other women and represents a common secondary condition. Women with disabilities often do not receive treatment for depression. Studies have shown that depression can be linked to stress, pain, lack of social support, and limited mobility among women with disabilities. Women living in rural areas also face many barriers to independent living including poverty, social isolation, limited transportation, housing difficulties, unemployment, and lack of access to health care. These barriers can influence feelings of depression.
The intervention consists of eight sessions designed to increase the participant?s understanding of depression and improve self-management skills. The first step of the project was to recruit and select 10 centers for independent living in rural areas to implement the intervention. Ultimately nine participated in the project. Each selected center then recruited, screened, and enrolled women with disabilities as participants in the intervention. All participants had to demonstrate at least mild depression as determined by a depression inventory to be a part of the program.
Each session was co-led by a center staff member with a disability and another woman with a disability. The leaders received extensive training by CROWD and followed the program manual. A mental health professional was available in each community to address any concerns that might arise during the intervention. The sessions were based on Lynn Rehm?s Self-Management Therapy for Depression, which involves mini-lectures related to depression, goal-setting, group discussion, and homework including daily mood logs. The program also incorporated rural and disability-specific information and activities for increasing social connectedness and self-efficacy. Other activities included monitoring and daily mood rating, self-monitoring positive activities, and self-statements, and rewarding progress toward goals.
The project was funded by a grant from the National Institute on Disability and Rehabilitation Research. In addition to funds, the resources required to implement the project included staff time to develop and oversee the intervention, meeting space and facilitators to conduct the sessions. These resources were made available by CROWD and/or the centers for independent living.
The theoretical model that is the basis for the intervention was designed to increase depression self-management skills, self-efficacy, and social connectedness, all of which are hypothesized to reduce depression.
FOCUS THE EVALUATION DESIGN
The evaluation purpose was to determine if women with disabilities benefitted from the depression self-management intervention. CROWD staff, the nine participating centers, disability researchers, mental health professionals, and other centers for independent living across the nation can then use the evaluation results. These results, too, provide the basis for developing and disseminating training materials that can be used by all centers for independent living. There also were plans for a web-based program to make the intervention more available.
The specific evaluation questions were related to the participant?s self-management skills, self efficacy, social connectedness, and depression level. Surveys were used for the evaluation. Questionnaires were given to participants to evaluate the intervention effectiveness in each of four areas. Each questionnaire was given to the participants before the intervention (pre-test), after the intervention (post test), and three months later (follow-up). The specific questionnaires are listed below.
Self management skills
- Self-Control Questionnaire
Self-efficacy
- Generalized Self-Efficacy Scale
Social connectedness
- Medical Outcome Study Social Support Scale
- Social Connectedness Scale
- Social Integration subscale of the CHART-SF
Depression
- Beck Depression Inventory
- Center for Epidemiologic Studies Depression (CESD-10)
The evaluation used an experimental design, comparing two groups within each of the nine centers for independent living. Each participant was randomly assigned to one of the two groups. The treatment group participated in the depression self-management intervention. The control group was put on a waiting list and participated in the intervention at a later date. Each group completed pre-test, post-test, and follow-up questionnaires. Additional evaluation data was collected from the questionnaires completed at the end of each session and from participants? qualitative feedback.
GATHER CREDIBLE EVIDENCE
The credibility of the evaluation procedures and evidence gathered depends partly on the program implementation in each of the nine centers for independent living. Special efforts were taken to ensure that each group received the same information. Leaders were given an extensive manual that contained a carefully scripted presentation for each of the eight sessions. In addition, one co-leader from each site participated in an intensive training program. Leaders also had weekly contact with CROWD staff.
The source of evidence came mostly from the self-report questionnaires. These questionnaires used in the pre-test, post-test and follow-up were all tested and validated inventories to produce quality data in the appropriate amount.
The center for independent living staff and co-leader were responsible for administering the questionnaires to participants, handling data, and delivering data to CROWD staff for further analysis. Proper protocol for maintaining reliability and confidentiality was followed.
MAKE SENSE OF THE DATA AND JUSTIFY CONCLUSIONS
The evaluation component of the project examined the efficacy of the depression self-management group intervention program by comparing data from women in the two groups. Data from the questionnaires was then analyzed. A general linear mixed models analysis tested the following hypothesis: Rural women with disabilities who participate in a program consisting of traditional center for independent living services plus a depression self-management intervention will report lower levels of depression and higher levels of self-efficacy, social connectedness, and depression self-management skills compared to rural women with disabilities who participate in a program of traditional CIL services only. It was expected that women in the depression self-management intervention group, when compared to women in the comparison group, would demonstrate improvements on those variables immediately after the intervention program and would maintain those improvements at follow-up.
USE THE INFORMATION TO CELEBRATE, MAKE ADJUSTMENTS, AND COMMUNICATE LESSONS LEARNED.
Once the intervention and evaluation was complete, the results and materials for replication were disseminated. The dissemination plan was designed to achieve the following goals:
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Strengthen the capacity of rural center for independent living and disability service providers (including but not limited to rehabilitation organizations, advocacy groups, and university offices of disability) to better serve the psychosocial needs of women with disabilities
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Strengthen the capacity of mental health professionals (psychiatrists, psychologists, social workers, and licensed counselors) and organizations that provide mental health services (including but not limited to rural county mental health associations), to better identify and more effectively respond to the mental health needs of rural women with disabilities
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Educate individual rural women with disabilities on how to recognize, prevent, and self-manage their own depression and know when to seek professional help
To disseminate the outcomes of this project to rural women with disabilities and rural CIL counselors, research results were prepared in non-technical language and focused on useful, usable aspects of the findings relevant to the everyday experiences of rural women with disabilities. Staff also developed self-help materials to help educate rural women with disabilities on what they can do to prevent and self-manage depression. Research participant feedback dictated the form these materials took. The website included tips for preventing depression, and the Association of Programs for Rural Independent Living (APRIL) disseminated this material to all of the rural centers for independent living. A monograph in the form of a final research report, which detail the research methods and summarize the research findings, also was written and published.