Wellness For 2: A Feasibility and Acceptability Pilot

Study Overview
=================
Brief Summary
-----------------
The investigators are studying strategies and tools that women can use to manage stress and wellness during pregnancy. The purpose of this project is to test a technology-enhanced version of a wellness intervention for women during their pregnancy (the Mothers and Babies course; MB). The technology that the investigators will test includes wearable heart rate sensors, smartphone text message surveys, and intervention materials delivered through text message.

Detailed Description
-----------------
Perinatal early life stress (ELS) has significant consequences for mothers and their infants.(1-3) Prolonged prenatal stress places pregnant women at increased risk for depression, health risk behaviors, and poor overall health and quality of life. Likewise, fetal exposure to stress places infants at greater risk of neurodevelopmental disruptions.(4,5) Prior clinical trials led by co-PI Darius Tandon have demonstrated that pregnant women, particularly those in low income environments, demonstrate positive health and parenting benefits as a result of receiving prenatal stress reduction interventions.(6-8) The stress-reduction intervention proposed in the overarching Promoting Healthy Brains Project (PHBP), the Mothers and Babies course (MB), is a scalable, manualized evidence-based cognitive-behavioral intervention that can be adapted to meet client needs (e.g., setting, dose, timing, modality) without compromising fidelity. However, as there is substantial heterogeneity in maternal responsiveness to prenatal stress-reduction interventions, MB in its current form may be too low-intensity to improve fetal outcomes. Although a few studies have examined impact of interventions like MB on developmental outcomes, the extant evidence base does not provide strong support for intervention effects. Further, state-of-the-art neurodevelopmental methods have not been employed to detect how manipulation of early exposure to stress may effect brain:behavior patterns in early life. Advancing this is the overarching goal of the PHBP. A crucial component of the proposed work involves an enhanced version of the 12-session, one-on-one version of MB with 1) mindfulness training content; 2) inter-session text messages prompting skills reinforcement, self-monitoring, and homework reminders; 3) adaptive, real-time stress monitoring that will optimize the intervention by identifying the key point at which to deliver just-in-time stress intervention content to individual participants. The investigators will ask pregnant women to wear a long-wearing, unobtrusive wireless ECG sensor (BioStamp Research Connect; BioStamp). BioStamp sensor data will be used to detect physiological responses to stress (i.e., heart rate variability; HRV) to build a system that can be used to trigger real-time stress reduction intervention. BioStamp, a lightweight, rechargeable, and easy to use wearable device is equipped to passively and continuously measure HRV and motion. Unlike traditional wired ECG monitors, BioStamp can be worn under typical daily-living conditions (e.g., sleeping, showering, physical activity), with only minimal obtrusion in daily life (e.g., re-charging, re-applying adhesive). Led by PI Laurie Wakschlag, the overarching PBHP will harness multidisciplinary expertise from Northwestern's Institute for Innovations in Developmental Sciences (DevSci), Lurie Children's Hospital, Center for Community Health, McCormick School of Engineering, and Feinberg School of Medicine & Northwestern Medicine (Ob/Gyn, Preventive Medicine, Medical Social Sciences, and Pediatrics) to 1) adapt and pilot MB enhanced with mindfulness training content, and just-in-time feedback to participants regarding their in-the-moment stress responses, and 2) experimentally test the effects of the optimized intervention on maternal wellbeing pre- and postnatally, and postnatal neurodevelopmental health trajectories.

Official Title
-----------------
Promoting Healthy Brain Development Via Prenatal Stress Reduction: An Innovative Precision Medicine Approach: An Intervention Feasibility and Acceptability Pilot

Conditions
-----------------
Pregnancy, Prenatal Stress

Intervention / Treatment
-----------------
* Behavioral: Mothers and Babies (Enhanced)


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: 10-18 weeks gestation singleton pregnancy receiving prenatal care from a Northwestern University prenatal care clinic & planning to deliver at Northwestern Hospitals English-speaking must own a smartphone must be willing to receive text messages and respond to short online surveys using their smartphone must also agree to wear a wireless adhesive sensor daily must have WiFi internet access for the duration of their participation in the study Exclusion Criteria: have known chronic medical or pregnancy complications that may place their infant at risk for neurological disorders (e.g., HIV; acute cytomegalovirus infection (CMV); toxoplasmosis; zika virus; Phenylketonuria (PKU); chromosomal anomalies; metabolic disorder; substance use disorders) have significant mental health disorders (e.g., schizophrenia, bipolar disorder, psychosis) which could interfere with study adherence unable to wear the BioStamp Sensor due to known skin sensitivity (e.g., allergy to adhesives or silicone), current skin irritation, or broken skin at the placement site pacemaker or other sensitive medical device unable to provide informed consent, complete MB sessions, or complete study assessments in English currently participating in another MB course at the time of recruitment

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
Female

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Other
Intervention Model: Single Group Assignment
Interventional Model Description: All participants engaged in the Mothers & Babies Intervention while wearing a biosensor.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Mothers and Babies (Enhanced)<br>The course is a manualized stress-reduction intervention with an integrated tech suite designed for timely detection and response to stress. Based on Cognitive-Behavioral Therapy & attachment theory, MB is divided into 3 sections: Pleasant Activities; Thoughts; Contact with Others. Each module has been enhanced with mindfulness as a strategy to help center participants and facilitate practice of skills. Participants receive skills training in each of the three sections as tools to improve and manage their mood. The MB course emphasizes developing & strengthening the bond with the baby. The technology enhancement includes wearing a BioStamp sensor, and text message-based extra intervention content. Participants get worksheets linked to the 12 sessions. | Behavioral: Mothers and Babies (Enhanced)<br>* The course is a manualized stress-reduction intervention with an integrated tech suite designed for timely detection and response to stress. Based on Cognitive-Behavioral Therapy & attachment theory, MB is divided into 3 sections: Pleasant Activities; Thoughts; Contact with Others. Each module has been enhanced with mindfulness as a strategy to help center participants and facilitate practice of skills. Participants receive skills training in each of the three sections as tools to improve and manage their mood. The MB course emphasizes developing & strengthening the bond with the baby. The technology enhancement includes wearing a BioStamp sensor, and text message-based extra intervention content. Participants get worksheets linked to the 12 sessions.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Usability/Wearability Feedback | Participants will also be asked to provide survey feedback regarding the sensor's usability and wearability, and responding to the Environmental Momentary Assessments (EMAs). | At post-intervention (approx. week 13) | 
| Intervention Acceptability | All participants will complete a brief intervention rating checklist after completing each MB module (3 total). Additional acceptability information will be ascertained during the exit interview and survey at the end of the intervention to assess participants' overall ratings of the MB course, whether they would recommend the intervention to similar women, and suggestions for intervention modifications. | After each of the 12 MB sessions (approx. weekly during weeks 2-13) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Intervention fidelity | MB intervention fidelity delivered by facilitators will be measured by collecting data on a) intervention session completion and b) fidelity of intervention implementation. Facilitators will completed an intervention Facilitator Fidelity Rating Form immediately at the end of each visit. The fidelity rating form will measure 1) How much of each topic was covered; 2) How well the participant understood each topic; 3) participant engagement in each topic; 4) Any challenges when discussing the topic. | After each of the 12 MB sessions (approx. weekly during weeks 2-13) | 
| Ecological Momentary Assessment Subjective Stress Ratings | In-field, self-report EMAs will measure participants' negative and positive emotion, stress, and other factors (e.g., health behaviors) that may influence sensor readings. These surveys, delivered via text message, contain 4 questions on a 5-pt Likertscale from 'not at all' to 'very much', one on a 7-pt Likert scale from 'not at all' to 'very much', six on a binary yes/no scale, six on a visual analog scale from 'not at all' to 'extremely', and four for elaboration. | Five times daily for approx. weeks 1-13, and one week per month afterward until birth | 
| Objective stress response | Investigators will continuously collect raw ECG and accelerometer data from the BioStamp Sensor. | Continuously during the intervention (approx. weeks 2-13) | 
| Perceived Stress (State Trait Anxiety Inventory) | 40 questions about stress and anxiety-related feelings on a 4-pt Likert scale from 'Almost Never' to 'Almost Always'. | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Perceived Stress (Life events scale distress rating) | 28 questions about the undesirability/negativity of a variety of life events that could happen to the participant or someone close to them on a 4-pt Likert scale from 'Not at all' to 'Very much'. | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Perceived Stress (Perceived stress scale) | 10 questions about emotions on a 5-pt Likert scale of 'Never' to 'Very Often' | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Depression symptoms (behavioral activation depression scale) | 25 questions about depressive feelings and behaviors on a 7-pt Likert scale from 'Not at All' to 'Completely' | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Perceived stress (Prenatal Distress Questionnaire) | 17 questions about feeling bothered, worried, or upset on a 3-pt Likert scale from 'Not at all' to 'Very much'; Three open-ended questions to elaborate. | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Depression symptoms (PROMIS depression) | 28 questions about depression-related thoughts and feelings on a 5-pt Likert scale from 'Never' to Always' | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Depression symptoms (negative mood regulation scale) | 30 questions about depression-related thoughts and feelings on a 5-pt Likert scale from 'Strong disagreement' to 'Strong agreement'. | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Depression symptoms (MOS social support survey) | 19 questions on feelings of support from others on a 5-pt Likert scale from 'None of the time' to 'All of the time'. | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Depression symptoms (Experiences Questionnaire) | 20 questions about thoughts and feelings on a 5-pt Likert scale from 'Never' to 'All the time'. | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Depression symptoms (Edinburgh depression scale) | 10 questions about negative emotions on a 4-pt Likert scale from 'No/Never' to 'Yes/A lot'. | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Depression symptoms (Prenatal Health Behavior Scale) | 24 questions about diet, exercise, and drug use on a 5-pt Likert scale from 'Never' to 'Very Often' | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Intervention skills (five facet mindfulness questionnaire) | 39 questions about mindfulness behaviors on a 5-pt Likert scale from 'Never or very rarely true' to 'Very often or always true' | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 
| Intervention skills (MB skills use survey) | 35 questions about intervention skill use frequency (5-pt Likert scale from 'Every Day' to 'Not at all'), helpfulness and enjoyability (3-pt Likert scales from 'Not at all' to 'Very') | Day 1, post-intervention (approx. week 13), 1 month prior to, and 1 month after delivery | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
prenatal maternal stress, mindfulness, stress reduction, health sensing, mhealth