Mums 4 Mums: structured telephone peer-support for women experiencing postnatal depression. Pilot and exploratory RCT of its clinical and cost effectiveness.

Abstract

Postnatal depression (PND) can be experienced by 13% of women who give birth, and such women often exhibit disabling symptoms, which can have a negative effect on the mother and infant relationship, with significant consequences in terms of the child's later capacity for affect regulation. Research has shown that providing support to mothers experiencing PND can help reduce their depressive symptoms and improve their coping strategies. The Mums4Mums study aims to evaluate the impact of telephone peer-support for women experiencing PND.
The study design adopts the MRC framework for the development and evaluation of complex interventions. Health visitors in Warwickshire and Coventry Primary Care Trusts are screening potential participants at the 8-week postnatal check using either the Edinburgh Postnatal Depression Scale (EPDS > = 10) or the three Whooley questions recommended by NICE (http://guidance.nice.org.uk/CG45). The Mums4Mums telephone support intervention is being delivered by trained peer-supporters over a period of four months. The primary outcome is depressive symptomatology as measured by the Edinburgh Postnatal Depression Scale. Secondary outcomes include mother-child interaction, dyadic adjustment, parenting sense of competence scale, and self-efficacy. Maternal perceptions of the telephone peer-support are being assessed using semi-structured interviews following the completion of the intervention.
The proposed study will develop current innovative work in peer-led support interventions and telecare by applying existing expertise to a new domain (i.e. PND), testing the feasibility of a peer-led telephone intervention for mothers living with PND, and developing the relationship between the lay and clinical communities. The intervention will potentially benefit a significant number of patients and support a future application for a larger study to undertake a full evaluation of the clinical and cost effectiveness of telephone based peer-support for PND.
ISRCTN: ISRCTN91450073. The study has received a major funding grant from National Institute for Health Research (NIHR) (UK) - Research for Patient Benefit (RfPB) programme (ref: PB-PG-0407-13232).

Full text

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STUDY PROTOCOLOpen Access
Mums 4 Mums: structured telephone peer-
support for women experiencing postnatal
depression. Pilot and exploratory RCT of its
clinical and cost effectiveness
Isabela Caramlau1, Jane Barlow1, Sukhdev Sembi1*, Kirstie McKenzie-McHarg2and Chris McCabe3
Abstract
Background: Postnatal depression (PND) can be experienced by 13% of women who give birth, and such women
often exhibit disabling symptoms, which can have a negative effect on the mother and infant relationship, with
significant consequences in terms of the child’s later capacity for affect regulation. Research has shown that providing
support to mothers experiencing PND can help reduce their depressive symptoms and improve their coping strategies.
The Mums4Mums study aims to evaluate the impact of telephone peer-support for women experiencing PND.
Methods/Design: The study design adopts the MRC framework for the development and evaluation of complex
interventions. Health visitors in Warwickshire and Coventry Primary Care Trusts are screening potential participants at the
8-week postnatal check using either the Edinburgh Postnatal Depression Scale (EPDS > = 10) or the three Whooley
questions recommended by NICE (http://guidance.nice.org.uk/CG45). The Mums4Mums telephone support intervention is
being delivered by trained peer-supporters over a period of four months. The primary outcome is depressive
symptomatology as measured by the Edinburgh Postnatal Depression Scale. Secondary outcomes include mother-child
interaction, dyadic adjustment, parenting sense of competence scale, and self-efficacy. Maternal perceptions of the
telephone peer-support are being assessed using semi-structured interviews following the completion of the intervention.
Discussion: The proposed study will develop current innovative work in peer-led support interventions and
telecare by applying existing expertise to a new domain (i.e. PND), testing the feasibility of a peer-led telephone
intervention for mothers living with PND, and developing the relationship between the lay and clinical
communities. The intervention will potentially benefit a significant number of patients and support a future
application for a larger study to undertake a full evaluation of the clinical and cost effectiveness of telephone
based peer-support for PND.
Trial registration: ISRCTN: ISRCTN91450073. The study has received a major funding grant from National Institute
for Health Research (NIHR) (UK) - Research for Patient Benefit (RfPB) programme (ref: PB-PG-0407-13232).
Background
Affective disorders following childbirth range from ‘mater-
nity blues’ to postpartum psychosis, a serious condition
requiring hospitalisation [1]. Along this spectrum postna-
tal depression (PND) is classified in DSM-IV as ‘a depres-
sive condition that often exhibits the disabling symptoms
of dysphoria, emotional lability, insomnia, confusion, anxi-
ety, guilt and suicidal ideation’ [2]. A meta-analysis of 59
longitudinal and epidemiological studies showed a preva-
lence of PND in the region of 13%, ranging from 3 to 25%
of women in the year following childbirth [3]. PND has
been shown to affect both the mother and her baby,
leading to mother-infant relationship difficulties [4] and
long-term child behavioural [5-9], cognitive [10,11], and
intellectual problems [12]; particularly for boys from dis-
advantaged backgrounds [8]. The treatment of PND is a
* Correspondence: sukhdev.sembi@warwick.ac.uk
1Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry,
CV4 7AL, UK
Full list of author information is available at the end of the article
Caramlau et al. Trials 2011, 12:88
http://www.trialsjournal.com/content/12/1/88
TRIALS
© 2011 Caramlau et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

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public health priority, and recent UK National Institute for
Health and Clinical Excellence guidance recommends that
all women be screened for PND during the first eight
weeks postnatally using the three Whooley questions to
identify women experiencing difficulties [13]. It also sug-
gests that women experiencing such problems should be
offered support from health care professionals and volun-
tary organisations.
The aetiology of PND suggests the importance of a
multitude of contributing factors such as life stresses,
difficult infant behaviour, marital conflict, low maternal
self-esteem and lack of social support [14,15]. Research
has shown that factors such as the need to talk to some-
one who has experienced similar problems, lack of an
intimate friend or confidante, the need for support with-
out having to ask for it, and social isolation are all sig-
nificant in the aetiology of PND (ibid). The use of 8
‘listening visits’ by specially trained health visitors has
been identified as effective in supporting women experi-
encing PND [16]. However, the prevalence of PND is
high and there is much unmet need, particularly for
women who feel unable to admit to experiencing pro-
blems due to fears about being perceived as inadequate
or the possibility of their baby being removed from the
family. In addition, some women are not perceived to
be experiencing sufficiently severe problems to justify
additional support. This points to the potential value of
developing peer-supporters. The NHS Expert Patient
Report [17] recommends the development of lay-led
self-management training programmes in order to make
use of the knowledge and experience held by patients,
and the White Paper “Our Health, Our Care, Our Say”
[18] underlined the importance of assistive technology,
with a strong emphasis on patient education and
empowerment.
The Evidence
A review of non-biological interventions for the treat-
ment of PND identified four evaluations of the effective-
ness of peer-support interventions [19]. The first three
studies comprised evaluations of a post-partum support
group targeting both depressed and non-depressed
Canadian women [20], a Chinese evaluation of weekly
support group meetings for depressed women only [21],
and an Australian study of group-based support for
postnatally ‘distressed’ women and their partners [22].
The studies suffered from serious theoretical limitations
(such as the inclusion of both depressed and non-
depressed women) and methodological weaknesses, ren-
dering the results equivocal. The fourth study, however,
comprised a Canadian telephone-based peer-support
pilot RCT with women identified as being at high-risk
of depression [14]. The findings showed significant
group differences in depressive symptomatology at the
12-week assessment and support the provision of peer-
support to women experiencing PND.
Peer-support
Peer support has been defined as “the giving of assis-
tance and encouragement by an individual considered
equal“ [23]. Another definition states “that people who
have like experiences can better relate and can conse-
quently offer more authentic empathy and validation”.
Individuals who have similar lived experiences can often
offer practical advice and coping strategies of which
health professionals may be unaware, and it is suggested
that this non- professional approach is vital in helping
people to re-connect with their community [24]. The
most comprehensive definition of peer support within a
healthcare concept is “the provision of emotional,
appraisal and informational assistance by a created
social network member who possesses experiential knowl-
edge of a specific behaviour or stressor and similar char-
acteristics as the target population” [23].
Research to identify the ‘critical ingredients’ of peer-
support has identified three distinct factors: structure
(program structure and environment), values (belief sys-
tems) and processes (peer-support, education/advocacy)
[25]. The structural category defines how the support is
constructed and its basic rules i.e. non-coerced, lay-led,
safe, flexible informal setting, non-medical approach with
no hierarchies. The value category refers to a set of belief
systems, which include “the peer principle” (building an
equal relationship with someone who has similar life
experiences), “the helper principle” (the idea that helping
someone else can be self-healing) and “empowerment”
(discovering hope and the belief that recovery is possible,
enabling someone to take personal responsibility for
achieving their full potential). ‘Process’ refers to the way
in which peer-support is delivered, such that it enables
choice, encourages decision-making opportunities, and
develops skills through knowledge and education, reci-
procity, supportive mutual relationships, developing
awareness, and a sense of community [25,26]. The under-
lying principle in terms of incorporating peer-support
into health care is that new knowledge may be under-
stood more effectively when it is communicated by a
peer who has shared a common experience [27].
Development of Mums4Mums: telephone peer-support
for mums experiencing PND
The current proposal has adapted for use in the UK a
telephone-based peer-support intervention shown to be
effective in Canada [23], to pilot its use, and provide
preliminary data on its effectiveness in reducing depres-
sive symptoms amongst women experiencing PND.
The proposal builds on an exploratory study that
examined a range of stakeholder’s views about the need
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for, and potential acceptability of, a telephone-based
peer-support intervention, their views about the poten-
tial impact of the intervention, and how it would fit into
current practice. General Practitioners (GPs) (n = 6),
health visitors (n = 7) and mothers who had recovered
from PND (n = 10) were interviewed and the results
indicated that stakeholders perceived a need for a tele-
phone-based peer-support intervention for women cur-
rently experiencing PND in the UK. It was suggested
that this would represent an additional resource for
mothers, and that a telephone-based intervention would
be acceptable due to its flexibility and use of non face-
to-face contact.
The Mums4Mums telephone support intervention was
piloted with women currently living with PND (n = 8).
The pilot study was conducted to explore key elements
of the telephone based peer-support intervention such
as training, acceptability, and recruitment. In-depth
interviews were again conducted, and the initial findings
suggested that the Mums4Mums intervention was
acceptable and potentially beneficial in supporting
women with PND.
Mums4Mums Feasibility Trial
The current study aims to test the feasibility of conduct-
ing a large-scale randomised controlled trial of a tele-
phone based peer-support intervention to reduce
depressive symptomology in women with PND.
Research Objectives
The objectives of the feasibility study are to:
i) ascertain the acceptability of a randomised control
trial for women with PND;
ii) explore effective methods of recruitment;
iii) explore the participants’ and health professionals’
views about the intervention;
iv) ascertain the acceptability of the outcome
measures;
v) identify a cost-effectiveness measure;
vi) provide an estimate of the size of change that
might be expected with such an intervention to
inform the power calculation for the larger RCT;
vii) build a working alliance with health care profes-
sionals for the larger clinical trial;
viii) make any necessary adaptations to the interven-
tion and develop a full proposal for a main RCT to
be submitted to the MRC in 2012.
Methods/Design
The study design adopts the MRC framework for the
development and evaluation of complex interventions
[28]. Ethical approval for the pilot and feasibility trial
was obtained from Coventry and Warwickshire Research
Ethics Committee (ID number 08/H1211/94).
Peer-supporters
Health visitors in Coventry and Warwickshire PCTs
identified potential participants to be trained as peer-
supporters (n = 18). They were recruited by personal
invitation using a specification that set out essential and
desirable attributes established from stakeholder consul-
tation, including that they had a) recently experienced
PND (i.e. within the last five years) b) fully recovered
from depression; c) an empathic and non-judgmental
disposition; and d) could commit the time to participate
in the training and provide the telephone support. Mul-
tiple assessments of mental health and social wellbeing
were made and their GPs were required to confirm the
suitability of individuals identified for the proposed
peer-support role. Eligible peer-supporters were invited
to attend a training programme lasting approximately
eight hours, to develop their understanding of the role
of the peer-supporter and their confidence to deliver the
intervention. The training was based on Dennis’s train-
ing manual [14], but was adapted to include other mate-
rial about active listening skills and promoting
successful behaviour change [29,30], encouraging goal-
setting and decision-making [31]. The training was pro-
vided locally, and crèche facilities were made available.
Inclusion criteria
Inclusion criteria
women >16 years of age at the time of giving birth and
who are experiencing depressive symptomatology (i.e.
EPDS > = 10 and/or clinical judgment) at or after the
8-week check, and who are potentially receptive to
receiving telephone support.
Exclusion criteria
women with a score of 23 or above on the EPDS;
women who pose a suicide risk or a risk to their chil-
dren; women receiving specialist psychiatric care or
experiencing any mental illnesses (other than PND) or
learning difficulties, or who are not able to speak Eng-
lish, or who are not accessible via the telephone. Partici-
pation in the study is only undertaken with the consent
of the participant, their health visitor, and their GP.
Recruitment
All health visitors within Coventry and Warwickshire Care
Trusts (PCTs) are recruiting to the study. Potential partici-
pants are screened for eligibility by the health visitors at
the 8-week postnatal check using either the Edinburgh
Postnatal Depression Scale (EPDS > = 10) or the three
Whooley questions recommended by NICE [13]. Eligible
women are then given a brief information leaflet about the
study, and women who would like further information are
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asked for their written consent for the health visitor to
give their contact details to the research team.
In addition to the recruitment method outlined above,
the study information leaflet is available within GP sur-
geries and Children’s Centres within Coventry and War-
wickshire allowing participants to self-refer into the
study by contacting the research team directly. Partici-
pants can also access information about the study using
the link at ‘Netmums’ or via the Warwick University
webpage. Eligible patients are also being referred to the
study from the ‘Improved Access to Psychological
Therapies (IAPT) waiting-list.
Following referral to the study team, a researcher
sends a full information sheet and contact with the
mother is arranged two weeks later, to discuss her parti-
cipation. Once a participant has agreed to take part and
provided consent, their details are passed onto the Clini-
cal Trials Unit at the University of Warwick for rando-
misation. The group allocation information is provided
to the researcher who then informs the participant.
Intervention group
All participants receive standard care from their GP and
health visitor. Women allocated to the intervention
group also receive telephone support calls over a period
of 4 months from peer-supporters who have been spe-
cially trained to deliver the intervention (i.e. the same
peer-supporters that delivered the pilot study interven-
tion). Outcome measures tested in the pilot phase are
being collected at baseline, 2- and 4-months.
Sample Size
A total of 30 participants are being recruited to study.
This will enable us to detect an effect size of around
0.6sd using a power of 80% and two-sided significant
level of 95%. Analysis of the data will be carried out on
an intention-to-treat basis.
Outcome Measures
The primary outcome measure is depressive symptomol-
ogy, which is being measured using the Edinburgh Post-
natal Depression Scale [32]. Secondary outcome
measures to assess maternal functioning include: Hospi-
tal Anxiety and Depression Scale [33], Parenting Sense of
Competence Scale [34], Dyadic Adjustment Scale [35],
Emotional Support Questionnaire [36] and Self-Efficacy
[37]. The Care Index [38] is being used to assess the
interaction between the mother and baby. Maternal per-
ceptions of the telephone peer-support and are being
assessed using the Peer-support Evaluation Inventory.
Process Data
In-depth, semi-structured interviews will be conducted
with a random sample of all stakeholders to establish
the acceptability and feasibility of the intervention for
participants, peer-supporters and health visitors.
Cost-Effectiveness
A prospective economic evaluation is being conducted.
The focus is on the additional costs of delivering the
training programme for the services involved. The costs
of training will be calculated using a record of the
resources employed. Unit costs for service delivery will
be taken from a national compendium (e.g. costs of
training and supervision) and multiplied by the intensity
of the service used by each family. A ‘Service Use’ Ques-
tionnaire is being used to collect data on public service
utilisation by study participants. Unit costs will be
obtained from national databases. Training, delivery and
service utilisation costs will be combined to provide an
estimate of the total health and social care cost in each
arm. The expected incremental cost-effectiveness ratio
for peer-support vs. usual care in the prevention of
PND cases will be estimated. A within-trial probabilistic
sensitivity analysis will be undertaken using non-para-
metric bootstrap method. The results will be presented
as ICERs and cost- effectiveness acceptability curves.
Scenario analyses will be used to examine the impact of
differential training and resourcing models on the
expected cost-effectiveness. The data collected in the
trial will be used to inform pre-trial modelling as part of
the design process for a future full scale RCT with eco-
nomic evaluation.
Data Analyses
i) Quantitative
Descriptive methods will be used to describe participant
characteristics, to compare the ‘refusers’ with the study
participants, and to report levels of participation and
drop out. Comparison of intervention and control group
outcome data will be provided with regard to the out-
come measures described above. The results of the sta-
tistical analyses will be used to reach some preliminary
conclusions regarding the viability and acceptability of
the intervention, the usefulness of the outcome mea-
sures being used, and the sample size required in a full
trial.
ii) Qualitative
Tape-recorded semi-structured interviews will be tran-
scribed verbatim. A thematic framework approach [39]
will be used to generate themes from the transcripts.
The embedded mixed-methods design of the study
will enable the quantitative and qualitative data to be
analysed iteratively.
Discussion
A reduction in a woman’s depressive symptomatology
could potentially produce an improved mother-infant
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relationship in affected dyads, with significant conse-
quences in terms of the capacity of the infant for affect
regulation. This could also impact on the later emo-
tional and behavioural adjustment of the child, especially
in the case of disadvantaged boys. Poor emotional and
behavioural adjustment in the early years is associated
with a range of poor long-term outcomes including
delinquency, drug abuse, and a range of mental health
and relationship problems, which are very costly for
NHS and other services. This form of provision could
therefore have an immediate impact on health service
use and in the long-term improve a range of public
health outcomes about which there is currently consid-
erable concern, and to which postnatal depression
undoubtedly makes a significant contribution.
The proposed study will develop current innovative
work in peer-led support interventions and telecare by
applying existing expertise to a new domain (i.e. PND),
testing the feasibility of a peer-led telephone interven-
tion for mothers living with PND, and developing the
relationship between the lay and clinical communities.
The outcome of the proposed study will potentially ben-
efit a significant number of patients and support a
future application for a larger study to undertake a full
evaluation of the clinical and cost effectiveness of the
intervention.
Abbreviations
PND: Postnatal depression; MRC Framework: Medical Research Council; EPDS:
Edinburgh Postnatal Depression Score; NICE: National Institute for Health
and Clinical Excellence; DSM IV: Diagnostic and Statistical Manual of Mental
Disorders Fourth Edition; APA: American Psychiatric Association; NHS:
National Health Service; DoH: Department of Health; PCT: Primary Care Trust;
IAPT: Improved Access to Psychological Services; ICERs: Incremental Cost
Effectiveness Ratios; RCT: Randomised Control Trial.
Acknowledgements
The authors are grateful to the NIHR RfPB Programme for funding the study.
Author details
1Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry,
CV4 7AL, UK.2Department of Clinical Health Psychology, Warwick Hospital,
Lakin Road, Warwick CV34 5BW, UK.3Institute of Health Sciences & Public
Health Research, University of Leeds, Woodhouse Lane, Leeds, LS2 9JT, UK.
Authors’ contributions
JB and IC undertook the development and setting up of the study and SS
took on the role of the researcher in the second stage (pilot study). KMc
trained and supervises all the peer-supporters. All authors have read and
approved the final version of this manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 9 February 2011 Accepted: 25 March 2011
Published: 25 March 2011
References
1. Evins G, Theofrastous J: Postpartum depression: a review of postpartum
screening. Primary Care Update 1997, 4:241-245.
2.American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders. 4 edition. Washington DC: APA; 1994.
O’Hara M, Swain A: Rates and risk of postpartum depression- a meta-
analysis. International Review of Psychiatry 1996, 8:37-54.
Loh CC, Vostanis P: Perceived mother-infant relationship difficulties in
postnatal depression. Infant-and-Child-Development 2004, 13:159-171.
Alpern L, Lyons-Ruth K: Pre-school children at social risk: chronicity and
timing of maternal depressive symptoms and child behaviour problems
at school and at home. Developmental Psychopathology 1993, 5:371-387.
Beck CT: Maternal depression and child behaviour problems: a meta-
analysis. Journal of Advanced Nursing 1999, 29:623-629.
Murray L, Sinclair D, Cooper P, Ducournau P, Turner P: The socioemotional
development of 5-year old children of postnatally depressed mothers.
Journal of Child Psychology and Psychiatry and Allied Disciplines 1999,
40:1259-1271.
Sinclair D, Murray L: Effects of postnatal depression on children’s
adjustment to school: Teacher’s reports. British Journal of Psychiatry 1998,
172:58-63.
Welsh-Allis G, Ye W: Psychopathology in children of parents with
recurrent depression. Journal of Abnormal Child Psychology 1988, 16:17-28.
Sharp D, Hay DF, Pawlby S, Schmucker G, Allen H, Kumar R: The impact of
postnatal depression on boys’ intellectual development. Journal of Child
Psychology and Psychiatry 1995, 36:1315-1336.
Kurtjens S, Wolke D: Effects of maternal depression on cognitive
development of children over the first 7 years of life. The Journal of Child
Psychology and Psychiatry and Allied Disciplines 2001, 42:623-636.
Hay DF, Pawlby S, Sharp D, Asten P, Mills A, Kumar R: Intellectual problems
shown by 11 year-old Children whose mothers had postnatal
depression. Journal of Child Psychology and Psychiatry 2001, 42:871-889.
National Institute of Clinical Excellence: Antenatal and postnatal mental
health: clinical management and service guidance. 2007 [http://guidance.
nice.org.uk/CG45].
Dennis CL: The effect of peer-support on postpartum depression: a pilot
randomised controlled trial. Canadian Journal of Psychiatry 2003, 45:61-70.
Miller AR, Barr RG, Eaton WO: Crying and motor behaviour of six-week-old
infants and postpartum maternal mood. Paediatrics 1993, 92:551-558.
Cope C, Lawrence S: Training and supporting health visitors in working
with postnatal depression. 2007, commissioned by Warwickshire Primary
Care Trust.
Department of Health: The Expert Patient: A New Approach to Chronic
Disease Management for the 21st Century. 2004 [http://www.dh.gov.uk/].
Department of Health: National Service Framework for Children, Young
People and Maternity Services. 2004 [http://www.dh.gov.uk/
prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/
digitalasset/dh_4090523.pdf].
Dennis CL: Treatment of postpartum depression, part 2: a critical review
of nonbiological interventions. Journal of Clinical Psychiatry 2004,
65:1252-65.
Fleming AS, Klein E, Corter C: The effects of a social support group on
depression, maternal attitudes and behavior in new mothers. Journal of
Child Psychology and Psychiatry 1992, 33:685-698.
Chen CH, Tseng YF, Chou FH, Wang SW: Effects of support group
intervention in postnatally distressed women: a controlled study in
Taiwan. Journal of Psychosomatic Research 2000, 49:395-399.
Morgan M, Matthey S, Barnett B, Richardson C: A group programme for
postnatally distressed women and their partners. Journal of Advanced
Nursing 1997, 26:913-920.
Dennis CL: Peer support within a health care context: a concept analysis.
International Journal of Nursing Studies 2003, 40:321-32.
Mead S, MacNeil C: Peer support: What makes it unique. 2004.
Clay S, Schell B, Corrigan PW, Ralph RO, (ed): On Our Own, Together: Peer
Programs for People with Mental Health Vanderbilt University Press: Nashville;
2005.
Campbell J: The historical and philosophical development of peer-run
programs. In On Our Own, Together: Peer Programs for People with Mental
Health. Edited by: Clay S, Schell B, Corrigan PW, Ralph RO. Vanderbilt
University Press: Nashville; 2004.
Dennis CL: Postpartum depression peer-support: Maternal perceptions
from a randomised control trial. International Journal of Nursing Studies
2009.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Caramlau et al. Trials 2011, 12:88
http://www.trialsjournal.com/content/12/1/88
Page 5 of 6

Page 6

28.Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P,
Spiegelhalter D, Tyrer P: Framework for design and evaluation of complex
interventions to improve health. British Medical Journal 2000, 321:694-696.
Anderson B, Funnell M: The Art of Empowerment Alexandria: American
Diabetes Association; 2000.
Rollnick S, Mason P, Butler C: Health Behavior Change: a guide for
practitioners London: Churchill Livingstone; 2002.
Egan G: The skilled helper: a systematic approach to effective helping Pacific
Grove: CA: Brooks/Cole; 1998.
Cox JL, Holden JM, Sagovsky R: Detection of postnatal depression:
Development of the 10-item Edinburgh Postnatal Depression Scale.
British Journal of Psychiatry 1987, 150:782-786.
Zigmund AS, Snaith RP: The Hospital Anxiety and Depression Scale. Acta
Psychiatrica Scandinavica 1983, 67:361-70.
Johnston C, Mash EJ: A measure of parenting satisfaction and efficacy.
Journal of Clinical Child Psychology 1989, 18:167-175.
Spanier G: Measuring dyadic adjustment: New scales for assessing the
quality of marriage and similar dyads. Journal of Marriage and the Family
1976, 38:15-28.
Zemore R, Shepel LF: Effects of breast cancer and mastectomy on
emotional support and adjustment. Social Science and Medicine 1989,
28:19-27.
Ware JE, Sherbourne CD Jr: The MOS 36-item short-form health survey
(SF-36). I. Conceptual framework and item selection. Medical Care 1992,
30:473-83.
Crittenden PM: CARE-Index: Coding Manual. Miami, Florida 1979
[http://www.patcrittenden.com/images/CARE-Index.pdf].
Ritchie J, Spencer L: Qualitative data analysis for applied policy research.
In Analyzing Qualitative Data. Edited by: Bryman A, Burgess RG. London:
Routlegde; 1994.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
doi:10.1186/1745-6215-12-88
Cite this article as: Caramlau et al.: Mums 4 Mums: structured telephone
peer-support for women experiencing postnatal depression. Pilot and
exploratory RCT of its clinical and cost effectiveness. Trials 2011 12:88.
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