Feasibility of recruiting mother-infant dyads with mild-moderate depression to an art therapy painting group.

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Yvonne Moriarty, Claire O'Neill, Michael Robling, Carl Arroyo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1489112/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Depression in postnatal period is estimated to affect 10-20% of mothers and risks the long-term wellbeing of their infants. This study aimed to assess the feasibility of a novel dyadic mother-infant painting group for mothers with mild-moderate depression. Methods: Mothers (+infants) suffering with mild-moderate depression (measured using the Beck Depression Inventory-II) were recruited from two socioeconomically deprived urban areas in a UK city to join one of two 12-week painting groups in Autumn/Winter 2014. Groups were co-delivered by an art therapist, a specially trained health visitor and a nursery nurse. Data collection included: pre- and post-intervention interviews with mothers, session observations and focus groups with intervention staff and health visitor managers. Results: 11 mothers were approached and screened, six were referred for recruitment of which four consented and completed the pre-intervention interview. Two mothers attended almost every session and completed the post-intervention interview. Two mothers attended no sessions. One painting group was cancelled due to poor attendance. Health visitors found it difficult to determine participant eligibility and did not fully understand wider study aims, limiting recruitment. However, they identified as the appropriate professionals to approach mothers and suggested that more briefing and training sessions would be helpful. Delivering the groups in the intended non-directional approach challenged the interventionist health visitors’ normal nurturing approach. While initially apprehensive, attending mothers reported positive benefits including a sense of achievement. Relationship building with interventionists and other mothers was a key element to successful delivery. Some questions about the venue’s suitability were raised regarding the group size and babies’ age range should the group run at maximum capacity. Conclusions: Despite poor recruitment mothers benefited from session attendance and the intervention model showed some promise. However, further work is required to assess new recruitment methods for this population to enable further evaluation of the intervention model. Trial registration: N/A Depression Art Therapy Feasibility Study Complex Intervention Infant Health Figures Figure 1 Key Messages Regarding Feasibility What uncertainties existed regarding the feasibility? We examined the acceptability and feasibility to recruit to and deliver a group-based art-therapy painting intervention for mothers suffering mild-moderate depression and their infants through the health visiting service. What are the key feasibility findings? Screening and recruiting mothers through the health visiting service was challenging. Despite this, health visitors identified themselves as the appropriate profession to approach mothers. Delivering the intervention in a non-directional manor challenged interventional health visitors normal approach. Attending mothers found the intervention acceptable. What are the implications of the feasibility findings for the design of the main study? Further clarification is needed regarding assessing mothers eligibility, however despite poor recruitment attending mothers benefited from sessions showing some promise to the intervention model. In order for the intervention model to be further evaluated, screening methods need refining and further training on the intervention model needs to be considered. Background Depression is estimated to affect 10–20% of postnatal women ( 1 – 4 ) and can compromise the mothers’ wellbeing and the mother-infant relationship ( 5 ). Disruption to the mother-infant relationship can adversely affect the socio-emotional, cognitive and emotional development of infants with long-term risks to their physical and mental health ( 6 – 17 ). Recommended treatment includes psychological interventions, medication or a combination and typically focuses on treating the mother alone ( 4 ). While there is evidence that medication can relieve symptoms, some women may not wish to take medical treatment, particularly while breastfeeding, due to concerns of associated side effects ( 14 ). Furthermore, there is little evidence that either of these treatment modalities promote maternal sensitivity to infant care cues and overall reflective function that support best outcomes for offspring ( 18 ). To better support both maternal and infant long-term health, there is a need to provide treatment options that account for the importance of the mother-infant relationship. Some limited literature suggests that bidirectional interventions, which address both the mothers and infants needs together such as ‘watch, wait and wonder’ ( 19 ) and guided video interactions ( 20 ), can be effective at improving maternal and infant health outcomes ( 21 ). A small number of case studies have suggested that art therapy painting groups can have beneficial effects for both the mothers’ depression/mood and mother-infant relationship ( 22 – 26 ). This psychotherapeutic model can be adapted to incorporate a bidirectional approach, providing an additional therapeutic option for service users. Arroyo and Fowler (2013) developed and delivered a novel mother-infant non-directive art therapy painting intervention to address maternal depression and improve mother-infant interaction. The group was well attended with mothers reporting a reduction in depressive symptoms and endorsing its potential value in improving mother-infant interactions, and long-term infant health outcomes. This paper reports on the follow-on feasibility study (PATCH – Painting Art Therapy to promote Child Health) in which we further refined Arroyo and Fowler’s model in line with the MRC Framework for Evaluating and Developing of Complex Interventions ( 28 ). The aim of the PATCH study was to establish the acceptability and feasibility of delivering such an intervention within this setting and population. Methods Research Design We planned a two-centre feasibility study, where eligible postnatal mothers attended a community based art therapy group over 12-weeks. The overall aim was to assess the acceptability of the intervention and the feasibility of our evaluation design. This study received a favourable ethical opinion from South Central-Berkshire B NHS Research Ethics Committee, UK in August 2014 (Ref: 14/SC/1181). Participants: We aimed to recruit 12 mother-infant dyads identified from two socioeconomically deprived areas in Cardiff, UK eligible for Flying Start program . Mothers were required to be over 16 years of age, present with mild-moderate depression as indicated with a score between 14–28 using the Beck Depression Inventory II (BDI-II) ( 29 ), have an infant aged between 2 weeks-1 year and speak English. Measures: Participants completed a demographic questionnaire. Data was also collected on screening rates, recruitment rates and session attendance. Qualitative data was collected by the study manager YM (MSc) and qualitative lead CO’N (PhD) who were both female and had extensive training and experience of qualitative data collection with vulnerable groups and analysis. Data collection included audio recorded 30 minutes interviews with mothers (pre- and post-intervention), session observations, one-hour interventionist and health visitor managers focus groups. Semi-structured topic guides supported data collection and were developed in collaboration with the studies lay research partner. Questions focused on participant/facilitator/health visitor expectations and experiences of taking part/delivering the study. All interview/focus group data were audio recorded and transcribed verbatim. Observational data was initially captured in note format during the sessions and later word processed, expanded and elaborated on with further details. Procedures: Recruitment Participant recruitment took place over a 4-week period in October/November 2014. Potentially eligible participants were approached by ‘Flying Start’ employed Health Visitors (HV) in two socioeconomically deprived areas of Cardiff, UK. They were provided with an information sheet and told about the study and what it involved. Prior to recruitment, local HV’s were briefed on the upcoming study. Recruitment packs were distributed to 24 recruiting HV’s who were informed of the eligibility criteria. They were asked to approach any potentially eligible mothers and to keep a confidential log of those approached and reasons for non-recruitment. A further briefing session was delivered once the study opened to recruitment to address any outstanding queries. Mothers, who expressed an interest in taking part, were screened by their HV using the BDI-II. Where they met the criteria, ‘Expression of Interest’ forms were completed and sent to the study team. Mothers were contacted, their eligibility confirmed and recruited by the study manager (YM) and a baseline data collection visit (i.e. consent, demographic questionnaire, interview) arranged at a location convenient for the mothers. Mother-infant dyads were allocated to one of two groups based on their location. Intervention The intervention was based on attachment theory ( 30 ) and psychodynamic art therapy ( 31 ). It was designed as a dyadic non-directive group session in order to support the mother’s capacity for reflective functioning and promote mother-infant relationship. Sessions were facilitated by three specially trained interventionists; an Art Therapist (AT); a Health Visitor (HV); and a Nursery Nurse (NN). An intervention manual outlined the core competencies and responsibilities of each facilitator, as well as a detailed plan of the session delivery (see Table 1 ). Table 1 Overview of session activities Activity Description Length (minutes) Initial chat time This is to take place in the comfy area and can be adjusted according to the needs of the particular session. 20 Painting session This is to take place in the painting area. Should infants have had enough, please finish-up earlier. 40 Tidy-up This time should be spent doing an initial tidy-up. Please also use this time to prepare the groups paintings for chat time and set out refreshments. Mothers and NN should use this time to wash their babies. 15 Chat time This is to take place in the comfy area. This time can be used for babies to play. 25 Painting reflection The group to focus on the paintings and share observations, thoughts and experiences. 20 Weekly sessions took place between November 2014 and February 2015 with a two-week break over Christmas/New Year. Two groups were delivered simultaneously (one in each geographical location), with group 1 scheduled for Mondays and Group 2 for Thursdays. Sessions lasted 2 hours (9.30–11.30) and took place in a centrally located community hub within each geographical area. Chosen days were based on the venues availability and timings were based on a recommendation from the study patient representative to enable mothers with older children to attend alongside other commitments. Venues provided use of a large room that had available seating, access to a sink and secure storage. During delivery the interventionists subdivided the room to create distinct areas for painting/floor gallery and chat-time. Data Analysis: Descriptive data was aggregated and summarised. Qualitative data was analysed thematically ( 32 ) using NVivo11. An initial coding framework was developed by two researchers (YM, CO’N) and used to code across all data sources. Refinements and adjustments were made where required. To ensure inter-coder reliability 10% of data was double coded (CO’N) and where discrepancies were identified these were discussed until agreement was reached. Analysis was further refined until key emerging themes were identified. A dissemination meeting was held in October 2016 with health visitors, where key themes were sense-checked for accuracy. Results Descriptive data: Eight screening logs were returned. Figure 1 provides a breakdown of recruits. Recruited mothers age ranged between 20–33 years with infants ranging from 2–8 months. Mothers identified themselves and their babies as either white-British or mixed. Mother’s educational achievement ranged from none to degree level. <> Figure 1: Recruitment diagram Two mothers(+ 2) regularly attended group 1 sessions (11/12 and 12/12 sessions) with one mother(+ 1) missing one session due to a prior commitment. The third mother allocated to group 1 did not attend any sessions. Only one mother(+ 1) was recruited to group 2, therefore group 2 was not able to run and was cancelled. A taxi was arranged to transport the mother(+ 1) to attend group 1 after the first session. However, she did not take up the offer and did not attend any sessions. Qualitative data: Four participants took part in baseline interviews, and two in follow-up interviews. Observational data was collected at 2 sessions, 1 focus group took place with health visitor managers (HVM) and 1 focus group with facilitators. All data was analysed together using the same coding framework. Themes are summarised in Table 2 . Table 2 Qualitative analysis thematic overview Theme Sub-theme 1. Experience of the recruitment process Engaging with recruitment Determining participant eligibility Future recruitment 2. Engaging with sessions Managing expectations Benefits from the session 3. Intervention and its’ delivery Session content and delivering the groups Non-directive approach vs. nurturing Relationship building 4. Delivery logistics Geographical location venues Session time & length 1. EXPERIENCES OF THE RECRUITMENT PROCESS Recruitment was a major point of discussion amongst health visitor managers, participants, and facilitators due to the low number of participants. A number of challenges were reported particularly by the health visitor managers, which they felt affected their ability to engage with and recruit eligible women. These are outlined below. Engaging with recruitment: Health visitor managers described themselves as ‘middlemen’ between the study and target population but felt they lacked the information needed to help them understand the bigger picture of what the study was trying the achieve. This affected their ability to fully engage with the study and recruitment process. …they didn't have the bigger picture so therefore they don't feel the (…) connection with it. they were doing it because generally they are quite good at doing what we ask (…) but not perhaps to understand, some of them would understand. (HV4, HVM focus group) The time available for recruitment (4-weeks) was seen as too short and very limiting to allow health visitor’s time to engage with and understand the study. They further felt that the briefing presentations delivered by the study team occurred too late. As a result, their understanding of the bigger picture was delayed and as such, they felt they were not able to adequately recruit within the specified 4-week time window. In addition to this, they highlighted that not enough recruitment packs were distributed to be able to achieve the recruitment target set, particularly given the ongoing challenges they experience when engaging mothers from these challenging settings in their services more widely. You should have given a pack to everybody. Because what we've always found with groups is that you have to over-recruit them. We've always done that with everything we've run within Sure Start before Flying Start. If ever you are running a group, you have to over-recruit. And then you tend to end up with the number that you really want. So, if all the health visitors had been given a pack, then you would have stood a much better chance of recruiting mothers to that group. (HV1, HVM focus group) Determining participant eligibility: Mixed feedback was received regarding the use of the BDI-II for screening. Health visitors reported being unfamiliar with this tool. Some health visitors thought that there was a lack of training provided in how to administer it; others felt that they had no problems in using it. I think if you are going to implement a tool, you have to train person in the use of the tool, at least give them the feeling of confidence in using that tool. So really, you know, it would have been nice for you to come along to the sector meetings, that again would have been a better approach. So come to the sector meetings, see these people face-to-face, answer any queries. (HV1, HVM focus group) It was additionally felt that the BDI-II was oversensitive when compared to the Edinburgh Postnatal Depression Scale, which they used in routine practice. They felt it often did not match their professional judgement, sometimes even conflicting with it, which made it challenging for them to use when confirming participant eligibility. They just didn't seem to have people who fitted that degree of that and the criteria at that time who didn't have the children. And who weren't extremely depressed. They were a bit annoyed about the ones who were very depressed because they thought it would be have been perfect for them. (HV1, HVM focus group) Despite health visitors’ concerns with the BDI-II, mothers reported no issues in completing it. They were used to completing similar questionnaires, understood the need for personal questions and found the questionnaire acceptable. Health visitors reported the oversensitivity of the BDI-II as the main reason for poor recruitment rates. However, it was evident that health visitors were pre-selecting which women to approach based on a number of factors, including; perceived severity of depression, social/personal circumstances and perceived women’s’ motivation levels to engage. Health visitors would do an almost briefly check before offering it, is because their priorities of their life are so chaotic. (…) I suppose that's why some of the health visitors would filter what they thought was the appropriate person to be able to do it. (HV4, HVM focus group) Health visitors particularly highlighted a lack of childcare provision provided for mothers who had other children, therefor restricting mothers ability to attend. This justified their decision to not approach these women and they felt that this disadvantaged them as they were deemed as automatically ineligible. Health visitors felt this severely reduced their available recruitment pool. HV4: I suppose they are going to use their professional judgement as to who they think is going to be the person that's going to go etc. And those ones the BDI was too high. (…) RES2: And do you think they screened in their own heads who they would even try to recruit? HV4: Yes, definitely, health visitors do that with everything I'm afraid. (…) Well we make an assessment … (HVM focus group) Future recruitment: Suggestions to improve future recruitment can be summarized by three categories; 1. Amend targeted population, 2. Increase study visibility, 3. Improve communication. It was felt that recruitment would be more successful if focused on approaching specific groups where they thought it would be more likely to find women who met the eligibility criteria (this mainly related to depression level). Suggested groups included; ante-natal groups, mother & baby groups, GPs/CPNs clinics. Following on from this it was felt that if the study raised its profile and visibility there would be greater understanding of the study aims, which would make it easier for recruiting health visitors to convey key information needed for recruitment. In order to achieve this, it was suggested that promotional material should be developed, including; posters, flyers and video demonstrations of the sessions. It was also suggested that a few taster sessions could be arranged, which would provide mothers with a better understanding of what to expect within the sessions. Central to all suggestions was the importance of improving communication about the study. Health visitors stated they found it difficult to recruit, as they did not have a good understanding of the broader aims of the study. Therefore, it was suggested that health visitors needed to be provided with clearer information to allow them to successfully recruit. They suggested more briefing presentations should be held with a longer run-in period for recruitment to allow them to be able to engage with the information provided. I think there was a lack of erm, understanding, health visitors sell things very well when they know what they're selling, like everything. (…) Whether you're a car salesman, if you know the car you sell it well don't you. And I think that erm, more knowledge is, of the study would be good definitely. (…) Sometimes when they have a presentation and they can visualize it, something like that so they know exactly what they are recruiting for, why they are recruiting how they recruit. And they do need time. (…) they have to really know what they're selling to be able to put the emphasis behind it and make the mothers believe that it will make a difference, that this is a great idea. (HV4, HVM focus group) 2. ENGAGING WITH SESSIONS Managing expectations: Mothers expressed multiple reasons for wanting to take part of the group sessions. These included; having an interest in art (particularly doing art together – hand and foot prints); improved mental health; alternative to taking medication; improved bonding with their baby; support in how to interact with baby; forming new friendships (being with other similar people i.e. postnatal depression experience, new mothers); developing memories (photos/art work to take home); getting into a positive routine (in preparation of going to work/nursery); getting their baby used to other people (in preparation for nursery). Although mothers highlighted various reasons for wanting to engage with the sessions, they were uncertain whether their expectations would be met, in particular, what to expect from the type of art being created (i.e. painting, crafts) and how exactly their babies would be involved (i.e. sitting on their lap, foot and hand prints, holding paintbrush). One mother described this as attending ‘blind’, however this did not dissuade her from attending and mothers generally described themselves as open-minded regarding the activities they would be doing. Mothers discussed group sizes and expressed some concern over the group being too large, suggesting that 4 mothers + babies would be an optimal size to allow them to open up, trust each other and share feelings without being overwhelmed. Benefits from the session: Mothers who completed the sessions described taking part as beneficial for themselves and their babies. They felt the sessions supported them in developing a positive relationship with their baby and took great value from watching their baby smiling, jumping with joy and physically develop over the three months. They also discussed how taking part gave them the time and space to explore their own difficulties around stress and anxieties. This allowed them to build confidence in themselves and cope as a new mother. ... it meant that you could really get established and you could really see a change through those 12 weeks in you and the baby. I found myself feeling a lot better (...) and it was quite nice because I could compare myself to how I had been in the first few weeks, how I'd felt. (…) So it was quite nice for it to be a ...3 month period. (PID101, Follow-up interview) Although mothers initially expressed concerns over the early start of the sessions, they later described a sense of achievement and a feeling of pride in having made it out early on a Monday morning and getting their day started. They felt this set up a feeling of confidence that they could get back to normal and have a routine which would be beneficial e.g. when going back to work. Although I was, at first, a bit, erm, dubious about whether I'd make it because it started quite early in the morning, erm on a Monday, I was worried not being able to get out of bed. But actually it proved to myself that I could do that so that was quite good as well. (PID101, Follow-up interview) 3. INTERVENTION AND ITS’ DELIVERY Session content and delivering the groups: Intervention facilitators and participants liked the sessions being split into three main components (see Table 1 ). Mothers felt relaxed knowing there was some flexibility with the time of arrival. They liked that they started and ended each session with a cup of tea (this was seen as allowing them to take time to relax). They also valued that the interventionists painted with them, as this made them feel more at ease and not observed, aiding in relationship building. They did not feel pressure when painting to create something that had meaning and were happy to sometimes use the time to doodle. They found it easier to share their feelings while painting as this acted as a distraction from them. Looking back, sometimes it was more about problems you were having, or it could just be about what you’ve done all week. It could be whatever you wanted it to be. So I quite like the set-up, erm, and then the painting sort of after twenty minutes, you sit down and you paint together. And the fact that the staff were getting involved as well was really good, because I think if it’d just been the mums painting with people observing, it would have been a little bit intimidating. (PID102, Follow-up interview) Non-directive approach vs. nurturing: The intervention was designed to be delivered in a non-directive manner, however it was evident from the focus groups and session observations that the clinical interventionists did not adopt this approach. Observational data confirmed that art therapists took a non-directive approach and allowed participants to lead discussions. However, this approach was seen as very different to clinical interventionist ‘normal’ roles where they approach mothers in a nurturing and directive manor. Clinical interventionists felt that during sessions the art therapist was taking a backseat and was perceived by them as doing nothing. Consequently they felt they needed to be more directive in providing mothers with support. Health visitors felt the non-directive approach was not clarified during training and needed emphasizing in future sessions. However, mothers appreciated health visitors taking a directive and nurturing approach as this supported them in caring for their baby and allowed them to have some time to focus on themselves. They come into that room, you are friendly to them, you're happy, smiling. They get a warm welcome and there are nice things to eat. It's part of this psychological process of, you know, they've really made an effort for me. You're like an honoured guest. There are nice things to eat and you do nice things as well. It's just part of the whole awareness structure of it all, really. The parent is being nurtured. (…) That's really quite important, a cup of tea. It makes a big psychological difference. (HV1, HVM focus group) When we were having the sort of chats they'd play with the baby so you could have your cup of tea in peace which was quite a nice part of the group as well. Because as a new mum you don't often get to drink a hot cup of tea so it was quite nice. (PID101, follow-up interview) Relationship building: Interventionists and mothers perceived building good relationships between mothers and interventionists as vital to allow successful delivery. Mothers reported that this gave them confidence in themselves and encouraged them to attend and felt there was a good dynamic between interventionists making them feel comfortable to share experiences. The group dynamic/relationships were described by mothers as non-threatening and informal. It was important to mothers that interventionists got the balance right between daily chit-chat and supportive conversations as this allowed stronger relationships to be built between them. In doing so, mothers gained confidence to ask questions they perceived as ‘silly’. It's building that relationship in a non-threatening way and seeing them more in a less formal way, I guess. And feeling they've got permission in that setting to ask the stupid question that we all think are stupid when we are new mothers, and they’re not stupid at all. (HV3, HVM focus group) Mothers trusted interventionists with their babies and valued their experience and appreciated each of the interventionists’ background and skills, which they felt added to their overall experience. At the last session mothers presented interventionists with thank you cards to show their appreciation. I found it an invaluable support for me to sound off how I was feeling to people and especially to, erm the art therapist. (…) I found her input really helpful and it's really helped me through a difficult period. (PID101, follow-up interview) Mothers valued building relationships with each other and being able to attend a group with mothers with similar experiences and where depression was discussed. They could empathize and provide each other with support and advice. The group was described by mothers as a community coming together which needed stability to work (i.e. with regular attendance, a closed group, continuity of interventionists to enable relationship building). Both mothers who attended sessions, commented on how they had formed a strong friendship outside of the sessions. At the final session they painted on each other’s picture – consolidating their experiences/memory of the group together. We'd walk home from the class together and like do a bit of a longer walk because the babies would fall asleep after the class so we'd have a bit of a chat. So it was quite nice to make a friend who's had ... like you know she had a different sort of illness really but we could relate to each other in that way and be a bit of a support for each other. (PID101, follow-up interview) 4. DELIVERY LOGISTICS Geographical location: Recruitment was particularly challenging in one of the geographical areas and health visitors reported that they experienced ongoing challenges recruiting mothers from this area to any of their routinely offered services. They described this as an innate cultural barrier, unique to the area which leaves women deeply sceptical and prevents them from engaging in any group-based activities. They provided little explanation as to why this might be or how to overcome this barrier in the future. I think groups are, everybody will tell you notoriously but it is our worst area for groups… (HV4, HVM focus group) Despite recruitment challenges, health visitors, facilitators and participants all agreed that venues were centrally located and easily accessible, although the mother recruited to group 2 was unfamiliar with the exact location which may have contributed to her non-attendance. Health visitors confirmed that the venue was a bit of a walk and slightly outside of the ‘Flying Start’ area and generally not well attended by their client group. Venues: The venue used for group 1 was described as bright, but barely big enough and mothers expressed concern for their babies’ safety if there had been older babies present who were more mobile and questioned how the group would have functioned if this was the case. Furthermore, the chairs provided were unsuitable for breastfeeding due to the lack of armrests. I think if you’d had more people that room would not have worked. (…) with the health visitors and the art therapist as well, that’s quite a lot of people on that sheet painting. So I think when the babies, depending on what age they are … trying to keep tabs on wriggly babies and mums, that would have been, yes, really quite difficult. (PID102, follow-up interview) Participants and facilitators acknowledged that the very specific requirements in order to be able to deliver the intervention (i.e. large multi-functional space) made the venue choice very tricky. A few suggestions were made of other possible venues to consider in the future including; primary schools, local hubs, libraries and leisure centres. It was felt that these might provide a larger more suitable space while still fulfilling the required specification. Discussion We explored the acceptability of a painting art therapy intervention for depressed mothers attending with their babies and the feasibility of recruiting mothers to the study. One painting group was delivered to two mothers and their babies with another two mothers initially accepting the offer but not subsequently attending. This was despite plans originally to run two concurrent groups for up to six mothers each. Nevertheless, rich information about intervention acceptability and the feasibility of delivery was gained from attending mothers, group facilitators and area health visitors. This has reinforced the intervention model, while also suggesting some aspects that could be modified for future roll-out. The evaluation provides some indication of how mothers have engaged with the intervention and the value they have derived from it. A key challenge in evaluating complex public health interventions involving vulnerable populations is recruitment ( 33 , 34 ). Recruitment strategies involving known gatekeepers, such has health professionals can improve recruitment success as trusted relationships are already established ( 34 ). In our study, recruitment was via the local health visitor team who reported a high degree of familiarity and good relationships with the population of mothers experiencing depression. However, their understanding about the study may have limited their ability to commit to the study and therefore resulted in low recruitment rate. Their lack of understanding and commitment may have also been the reason why so few (n = 11/24) returned their screening logs. Peindl and Wisner (2003) further suggest that although high familiarity with the study population yields good recruitment rates, a large amount of time needs to be invested in developing relationships with recruiters to establish a network and enable them to take on this role. In this small feasibility study there was naturally some restricted ability to engage with the large local recruiting professional teams. Competing clinical commitments may also have been a barrier. It may prove more effective to work with a smaller number of health visitors who could then be better informed about the study and have a greater focus on recruitment within the allocated recruitment window. Health visitors were happy to screen women and felt they were the appropriate professionals to do so. This is in line with international literature which has recommended that those in health professional roles are best places to screen and manage women suffering with postnatal depression ( 14 , 36 ). Despite this, they expressed challenges in the application of the screening tool. We used the BDI-II as it is widely used across the literature and due to its validated cut off scores to detect mild-moderate depression ( 29 , 37 ). However, this differed to the health visitor’s normal practice. They regarded the tool to be too sensitive, felt it differed from their professional judgment and made assessing levels of depression problematic. A future study should either revisit the training required or adopt a different screening tool (e.g. Edinburgh Postnatal Depression scale ( 1 )). Practical implications Maternally reported intervention benefits were consistent with the program’s model of change. Although the study did not aim to gauge intervention effect, it does provide some support for the value of this transactional therapeutic approach, and the role it could play alongside other treatment modalities. Mothers particularly valued the benefits of the small group size and although this was an unintended consequence of poor recruitment it is important that a future study preserve the value that mothers attribute to the group size for allowing them to establish meaningful relationships with one another and the facilitators. Some of the logistics of delivering the intervention also need to be carefully considered, including the facilities required for delivering a messy painting intervention. Limitations Feedback from both participating mothers and facilitators sheds light on the extent to which the planned structure and purpose of the intervention model was delivered as intended and whether it was viewed as working as expected by theory. Mothers’ experiences of the intervention were in line with the model of change. However, the clinical interventionists found it challenging to adopt a psychodynamic approach despite selection and training to do so. This is in contrast to previous research where health visitors have delivered non-directive psychological based interventions for mothers suffering depression ( 38 , 39 ). Future work may need to reconsider the emphasis placed on the non-directive approach during intervention training. Key insights about the acceptability of painting groups and the feasibility of recruiting mothers have emerged and will inform future evaluations. Nevertheless, there are some limitations to note. With only a small number of mothers in this intervention, exploration of attendee experience and interventionist delivery are inevitably limited and some perspectives will not have been captured. As the intervention was intended to be that of larger group, some aspects of group dynamics were also inevitably restricted. How facilitators may adapt to working with a larger number of mothers would be important to explore further. Despite the reported benefits of experiencing a small group process, it is unlikely that a very small group would prove economically viable in practice and there is probably untapped potential for mothers to be experiencing a larger painting group. We have not had the opportunity to talk to women who were approached but did not attend the painting group. Nevertheless, that some health visitors were uncertain themselves about the aims and purpose of the intervention and study reveals an immediate potential barrier to successfully approaching mothers. Conclusion This feasibility study provides a clear indication about what needs to be addressed in a larger pilot study. Greater interaction with local health visiting teams may better clarify recruitment pathways, better inform them of the study purpose, and agree adequacy of screening tools. Further training for co-facilitators may address applying the therapeutic model with fidelity and adjustments to group delivery, such as timing of sessions. Abbreviations AT Art Therapist BDI-II Beck Depression Inventory II CPN Clinical Psychiatric Nurse GP General Practitioner HV Health Visitor HVM Health Visitor Manager MRC Medical Research Council NHS National Health Service NN Nursery Nurse PATCH Painting Art Therapy to promote Child Health UK United Kingdom Declarations Ethics consent to participate: This study received a favourable ethical opinion from South Central-Berkshire B NHS Research Ethics Committee, UK in August 2014 (Ref: 14/SC/1181). Consent for publication: Not applicable Availability of data and materials: The datasets generated and analysed during the current study are not publicly available but are available from the corresponding author following completion of a data access request. Competing interests: OO was employed at Flying Start Cardiff who were involved in hosting the study and identifying and referring potentially eligible mums and babies. However, OO was not involved in recruitment. CA acted as the supervising Art Therapist to the interventionists. The other authors have no conflicts of interests to declare. Funding: This work was supported by ‘The Wales School for Primary Care Research (WSPCR)’ under Grant [number 507785]. Author contributions: YM was the study manager, conducted the data collection, lead the data analysis and drafted the manuscript. CO’N was a co-applicant on the grant, contributed towards the design of the study, conducted some data collection, conducted double coding of the data, supported drafting of the manuscript. MR was a co-applicant on the grant, contributed towards the design of the study, supported drafting of the manuscript. CA was a co-applicant on the grant, contributed towards the design of the study, co-designed the intervention, acted as the supervising art therapist, commented on the final manuscript. OO was the principal investigator on the grant, maintained overall oversight and responsibility for the study delivery, contributed towards the design of the study, provided access to HV for recruitment purposes, supported drafting of the manuscript. Acknowledgements: The authors would like to thank the following people: All of the women who were approached, referred and recruited for showing an interest and giving up their time to take part. Flying Start Cardiff for agreeing to host this study and for providing support in delivery this study, with particular thanks to Gaynor Williams who ordered all of the required art equipment. The recruiting health visitors for agreeing to identify potentially eligible women. All interventionists for delivering the study according to schedule. RR, who acted as our Patient and Public Involvement (PPI) representative and provided invaluable support and helped shape the study design. Rhys Williams-Thomas for designing the study logo, which gave the study an identity. The local venues who provided access to their facilities and agreed to give up some of their space to host the study. References Cox LJ, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–6. Glover V, Onozawa K, Hodgkinson A. Benefits of infant massage for mothers with postnatal depression. Semin Neonatol [Internet]. 2002;7(6):495–500. Available from: https://doi.org/10.1053/siny.2002.0154 . Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal Depression: A Systematic Review of Prevalence and Incidence. Am Coll Obstet Gynaecol. 2005;106(5):1071–83. National Institute for Health and Care Excellence. Antenatal And Postnatal Mental Health: Clinical Management and Service Guidance (CG192). NICE Clin Guidel [Internet]. 2014; Available from: http://www.nice.org.uk/nicemedia/live/11004/30433/30433.pdf%5Cnguidance.nice.org.uk/cg45 . Murray L, Cooper P, Hipwell A. Mental health of parents caring for infants. Arch Womens Ment Health. 2003;6(SUPPL. 2):71–7. Atkinson L, Paglia A, Coolbear J, Niccols A, Parker KC, Guger S. Attachment security: a meta-analysis of maternal mental health correlates. Clin Psychol Rev [Internet]. 2000;20(8):1019–40. Available from: https://doi.org/10.1016/S0272-7358(99)00023-9 . Bifulco A, Figueiredo B, Guedeney N, G LL, Hayes S, Muzik M, et al. Maternal attachment style and depression associated with childbirth: Preliminary results from a European and US cross-cultural study. Br J Psychiatry. 2004;184(SUPPL):46):s31–7. Carter AS, Garrity-Rokous FE, Chazan-Cohen R, Little C, Briggs-Gowan MJ. Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social-emotional problems and competencies. J Am Acad Child Adolesc Psychiatry [Internet]. 2001;40(1):18–26. Available from: http://dx.doi.org/10.1097/00004583-200101000-00012 . Ertaş D, Kardar M. Anisotropic Scaling in Depinning of a Flux Line. Phys Rev Lett [Internet]. 1994 Sep 19;73(12):1703–6. Available from: https://doi.org/10.1103/PhysRevLett.73.1703 . Feldman R. Parent-infant synchrony and the construction of shared timing; physiological precursors, developmental outcomes, and risk conditions. J Child Psychol Psychiatry. 2007;48(3–4):329–54. Goodman SH, Gotlib IH. Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychol Rev [Internet]. 1999;106(3):458–90. Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/ 0033-295X.106.3.458. Martins C, Gaffan EA. Effects of early maternal depression on patterns of infant-mother attachment: A meta-analytic investigation. J Child Psychol Psychiatry Allied Discip [Internet]. 2000;41(6):737–46. Available from: https://doi.org/10.1017/S0021963099005958 . Moshe M, Feldman R. Maternal and infant heart rhythms and mother–infant synchrony. In: Biennial conference of the World Association for Infant Mental Health. Paris, France; 2006. O’Hara M, McCabe J. Postpartum Depression: Current Status and Future Directions. Annu Rev Clin Psychol. 2013;9:379–407. Stein A, Lehtonen A, Harvey AG, Nicol-Harper R, Craske M. The influence of postnatal psychiatric disorder on child development: Is maternal preoccupation one of the key underlying processes? Psychopathology. 2009;42(1):11–21. Teti DM, Gelfand DM. Maternal cognitions as mediators of child outcomes in the context of postpartum depression. In: Murray L, Cooper PJ, eds., editor. Postpartum Depression and Child Development. New York: Guilford Press; 1997. pp. 136–64. Van Doesum KTM, Riksen-Walraven JM, Hosman CMH, Hoefnagels C. A randomized controlled trial of a home-visiting intervention aimed at preventing relationship problems in depressed mothers and their infants. Child Dev. 2008;79(3):547–61. Barlow J, McMillan AS, Kirkpatrick S, Ghate D, Barnes J, Smith M. Health-Led Interventions in the Early Years to Enhance Infant and Maternal Mental Health: A Review of Reviews. Child Adolesc Ment Health. 2010;15(4):178–85. Cohen NJ, Muir E, Lojkasek M, Muir R, Parker CJ, Barwick M, et al. Watch, wait, and wonder: Testing the effectiveness of a new approach to mother-infant psychotherapy. Infant Ment Health J. 1999;20(4):429–51. Velderman MK, Bakermans-Kranenburg MJ, Juffer F, Van Ijzendoorn MH. Effects of attachment-based interventions on maternal sensitivity and infant attachment: Differential susceptibility of highly reactive infants. J Fam Psychol. 2006;20(2):266–74. Beebe B, Lackmann FM. Infant research and adult treatment: Co-constructing interactions. Hillsdale: The Analytic Press; 2005. Ponteri A. The effect of group art therapy on depressed mothers and their children. Art Ther J Am Art Ther Assoc. 2001;18(3):148–57. Sluckin A. Humans are conversational from birth: Systemic therapy, developmental psychology and the artistic metaphor. Hum Syst J Syst Consult Manag. 1999;10(1):11–23. Hosea H. “The Brush’s Footmarks”: Parents and infants paint together in a small community art therapy group. Int J Art Ther. 2006;11(2):69–78. Perry CD. Does treating maternal depression improve child health management? The case of pediatric asthma. J Health Econ. 2008;27(1):157–73. Kersting A, Fisch S, Arolt V. Outpatient psychotherapy for mothers - A new treatment. Arch Womens Ment Health. 2003;6(1):65–9. Arroyo C, Fowler N. Before and after: A mother and infant painting group. Int J Art Ther Inscape [Internet]. 2013;18(3):98–112. Available from: http://dx.doi.org/10.1080/17454832.2013.844183 . Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. BMJ. 2021;374(2018):1–11. Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation; 1996. Bowlby J. A secure base: parent-child attachment and healthy human development. London: Routledge; 1988. Hall P. Painting together. In: Case C, Dalley T, editors. Art Therapy with Children: From Infancy to Adolescence. Hove & New York: Routledge; 2007. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2013;3(2):77–101. Smith LJ. How ethical is ethical research? Recruiting marginalized, vulnerable groups into health services research. J Adv Nurs. 2008;62(2):248–57. Bonevski B, Randell M, Paul C, Chapman K, Twyman L, Bryant J, et al. Reaching the hard-to-reach: A systematic review of strategies for improving health and medical research with socially disadvantaged groups. BMC Med Res Methodol. 2014;14(42). Peindl KS, Wisner KL. Successful recruitment strategies for women in postpartum mental health trials. J Psychiatr Res. 2003;37(2):117–25. Alexandrou F, Sakellari E, Kourakos M, Sapountzi-Krepia D. Health visitors’ perceptions on their role to assess and manage postpartum depression cases in the community. Heal Soc Care Community. 2018;26(6):995–1000. Beck AT, Ward AH, Mendelson M, Mock J, Erbaugh J. An Inventory for Measuring Depression. Arch Gen Psychiatry. 1961;4(6):561–71. Morrell CJ, Slade P, Warner R, Paley G, Dixon S, Walters SJ, et al. Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: Pragmatic cluster randomised trial in primary care. BMJ. 2009;338(7689):276–9. Holden JM, Sagovsky R, Cox JL. Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. BMJ. 2009;298(6668):223–6. Flying Start. 2017. Welsh Government [Internet]. [cited 2019 May 28]. Available from: https://gweddill.gov.wales/topics/people-and-communities/people/children-and-young-people/parenting-support-guidance/help/flyingstart/?lang=en . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1489112","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":96329348,"identity":"947c75de-21e7-4d82-9393-cf467bb5130b","order_by":0,"name":"Yvonne Moriarty","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYBACgwMMDAfAjOMNQJJNgp+9ASyRgFOLJUSLAYPBmQNgLZI9BwhosYcoMGCQnAFSxMZAWIvZ8d6HB37u+ZPYL/n44eeKMgsJHgbmhx8Y29Jwazlz3OBgzzODxDbpNGPJM+ckgFrYjCUY23Jwa7mRxnCA5wBISw6DZGObRJ09UJCBsa0CpxYDoJaDf0BaJM8w/wRqAdrC/o2glsNgWyR42CQhWnhAtuB2mMGZYwyHZQ4YG7fxpJlZNoD8wsxTLJFwDrf3DY63MX98c0BOto398OObDWV1Ejzs7Rs/fChLxqkFBhwb4ExmBnyxggD2RKgZBaNgFIyCkQoAk1RUlp3jOR4AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-7608-4699","institution":"Cardiff University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yvonne","middleName":"","lastName":"Moriarty","suffix":""},{"id":96329349,"identity":"8ecacda6-5aac-42c5-8028-87f4d4926626","order_by":1,"name":"Claire O'Neill","email":"","orcid":"","institution":"Swansea University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Claire","middleName":"","lastName":"O'Neill","suffix":""},{"id":96329350,"identity":"65f44910-1c8b-4f08-9490-acbc3d2073f9","order_by":2,"name":"Michael Robling","email":"","orcid":"","institution":"Cardiff University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Robling","suffix":""},{"id":96329351,"identity":"1595b0fc-ff48-4ec5-ad2c-c74862106afc","order_by":3,"name":"Carl Arroyo","email":"","orcid":"","institution":"Independent","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Carl","middleName":"","lastName":"Arroyo","suffix":""},{"id":96329352,"identity":"e078fe7d-3f56-4f26-919b-acf361a95b7e","order_by":4,"name":"Orion Owen","email":"","orcid":"","institution":"Cardiff and Vale UHB: Cardiff and Vale University Health Board","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Orion","middleName":"","lastName":"Owen","suffix":""}],"badges":[],"createdAt":"2022-03-25 12:21:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1489112/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1489112/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":20075946,"identity":"0ef3c3df-3ebd-449d-a1df-aecac8369cd1","added_by":"auto","created_at":"2022-04-07 16:18:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":95346,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eRecruitment diagram\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"PATCHFigure1BMCPilotandfeasibilitystudies.png","url":"https://assets-eu.researchsquare.com/files/rs-1489112/v1/14674ba59fc13f0c9c65e672.png"},{"id":29697617,"identity":"ba73149e-16b5-43f5-91e9-1ac4536d7cd4","added_by":"auto","created_at":"2022-11-30 03:50:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":492810,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1489112/v1/14394a7b-ab92-40a1-b7d4-74bb07a2e54e.pdf"},{"id":20075947,"identity":"d67f117e-1b35-4b7f-ab6b-644874c27723","added_by":"auto","created_at":"2022-04-07 16:18:58","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":38444,"visible":true,"origin":"","legend":"","description":"","filename":"PATCHCOREQchecklist25.03.2022.docx","url":"https://assets-eu.researchsquare.com/files/rs-1489112/v1/d2f59a1b62bb2a9946725e1e.docx"}],"financialInterests":"","formattedTitle":"Feasibility of recruiting mother-infant dyads with mild-moderate depression to an art therapy painting group.","fulltext":[{"header":"Key Messages Regarding Feasibility","content":"\u003col\u003e\n\u003cli\u003eWhat uncertainties existed regarding the feasibility?\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWe examined the acceptability and feasibility to recruit to and deliver a group-based art-therapy painting intervention for mothers suffering mild-moderate depression and their infants through the health visiting service.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n\u003cli\u003eWhat are the key feasibility findings?\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eScreening and recruiting mothers through the health visiting service was challenging. Despite this, health visitors identified themselves as the appropriate profession to approach mothers. Delivering the intervention in a non-directional manor challenged interventional health visitors normal approach. Attending mothers found the intervention acceptable.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n\u003cli\u003eWhat are the implications of the feasibility findings for the design of the main study?\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFurther clarification is needed regarding assessing mothers eligibility, however despite poor recruitment attending mothers benefited from sessions showing some promise to the intervention model. In order for the intervention model to be further evaluated, screening methods need refining and further training on the intervention model needs to be considered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eDepression is estimated to affect 10\u0026ndash;20% of postnatal women (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and can compromise the mothers\u0026rsquo; wellbeing and the mother-infant relationship (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Disruption to the mother-infant relationship can adversely affect the socio-emotional, cognitive and emotional development of infants with long-term risks to their physical and mental health (\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecommended treatment includes psychological interventions, medication or a combination and typically focuses on treating the mother alone (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). While there is evidence that medication can relieve symptoms, some women may not wish to take medical treatment, particularly while breastfeeding, due to concerns of associated side effects (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Furthermore, there is little evidence that either of these treatment modalities promote maternal sensitivity to infant care cues and overall reflective function that support best outcomes for offspring (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo better support both maternal and infant long-term health, there is a need to provide treatment options that account for the importance of the mother-infant relationship. Some limited literature suggests that bidirectional interventions, which address both the mothers and infants needs together such as \u0026lsquo;watch, wait and wonder\u0026rsquo; (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and guided video interactions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), can be effective at improving maternal and infant health outcomes (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A small number of case studies have suggested that art therapy painting groups can have beneficial effects for both the mothers\u0026rsquo; depression/mood and mother-infant relationship (\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This psychotherapeutic model can be adapted to incorporate a bidirectional approach, providing an additional therapeutic option for service users.\u003c/p\u003e \u003cp\u003eArroyo and Fowler (2013) developed and delivered a novel mother-infant non-directive art therapy painting intervention to address maternal depression and improve mother-infant interaction. The group was well attended with mothers reporting a reduction in depressive symptoms and endorsing its potential value in improving mother-infant interactions, and long-term infant health outcomes.\u003c/p\u003e \u003cp\u003eThis paper reports on the follow-on feasibility study (PATCH \u0026ndash; Painting Art Therapy to promote Child Health) in which we further refined Arroyo and Fowler\u0026rsquo;s model in line with the MRC Framework for Evaluating and Developing of Complex Interventions (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The aim of the PATCH study was to establish the acceptability and feasibility of delivering such an intervention within this setting and population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Design\u003c/h2\u003e \u003cp\u003eWe planned a two-centre feasibility study, where eligible postnatal mothers attended a community based art therapy group over 12-weeks. The overall aim was to assess the acceptability of the intervention and the feasibility of our evaluation design. This study received a favourable ethical opinion from South Central-Berkshire B NHS Research Ethics Committee, UK in August 2014 (Ref: 14/SC/1181).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants:\u003c/h2\u003e \u003cp\u003eWe aimed to recruit 12 mother-infant dyads identified from two socioeconomically deprived areas in Cardiff, UK eligible for Flying Start program\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e. Mothers were required to be over 16 years of age, present with mild-moderate depression as indicated with a score between 14\u0026ndash;28 using the Beck Depression Inventory II (BDI-II) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), have an infant aged between 2 weeks-1 year and speak English.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eMeasures:\u003c/h2\u003e \u003cp\u003eParticipants completed a demographic questionnaire. Data was also collected on screening rates, recruitment rates and session attendance. Qualitative data was collected by the study manager YM (MSc) and qualitative lead CO\u0026rsquo;N (PhD) who were both female and had extensive training and experience of qualitative data collection with vulnerable groups and analysis. Data collection included audio recorded 30 minutes interviews with mothers (pre- and post-intervention), session observations, one-hour interventionist and health visitor managers focus groups. Semi-structured topic guides supported data collection and were developed in collaboration with the studies lay research partner. Questions focused on participant/facilitator/health visitor expectations and experiences of taking part/delivering the study. All interview/focus group data were audio recorded and transcribed verbatim. Observational data was initially captured in note format during the sessions and later word processed, expanded and elaborated on with further details.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eProcedures:\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section4\"\u003e \u003ch2\u003eRecruitment\u003c/h2\u003e \u003cp\u003eParticipant recruitment took place over a 4-week period in October/November 2014. Potentially eligible participants were approached by \u0026lsquo;Flying Start\u0026rsquo; employed Health Visitors (HV) in two socioeconomically deprived areas of Cardiff, UK. They were provided with an information sheet and told about the study and what it involved.\u003c/p\u003e \u003cp\u003ePrior to recruitment, local HV\u0026rsquo;s were briefed on the upcoming study. Recruitment packs were distributed to 24 recruiting HV\u0026rsquo;s who were informed of the eligibility criteria. They were asked to approach any potentially eligible mothers and to keep a confidential log of those approached and reasons for non-recruitment. A further briefing session was delivered once the study opened to recruitment to address any outstanding queries.\u003c/p\u003e \u003cp\u003eMothers, who expressed an interest in taking part, were screened by their HV using the BDI-II. Where they met the criteria, \u0026lsquo;Expression of Interest\u0026rsquo; forms were completed and sent to the study team. Mothers were contacted, their eligibility confirmed and recruited by the study manager (YM) and a baseline data collection visit (i.e. consent, demographic questionnaire, interview) arranged at a location convenient for the mothers. Mother-infant dyads were allocated to one of two groups based on their location.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section4\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eThe intervention was based on attachment theory (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and psychodynamic art therapy (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). It was designed as a dyadic non-directive group session in order to support the mother\u0026rsquo;s capacity for reflective functioning and promote mother-infant relationship. Sessions were facilitated by three specially trained interventionists; an Art Therapist (AT); a Health Visitor (HV); and a Nursery Nurse (NN). An intervention manual outlined the core competencies and responsibilities of each facilitator, as well as a detailed plan of the session delivery (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of session activities\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLength (minutes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eInitial chat time\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis is to take place in the comfy area and can be adjusted according to the needs of the particular session.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003ePainting session\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis is to take place in the painting area. Should infants have had enough, please finish-up earlier.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eTidy-up\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis time should be spent doing an initial tidy-up. Please also use this time to prepare the groups paintings for chat time and set out refreshments. Mothers and NN should use this time to wash their babies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eChat time\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis is to take place in the comfy area. This time can be used for babies to play.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003ePainting reflection\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe group to focus on the paintings and share observations, thoughts and experiences.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWeekly sessions took place between November 2014 and February 2015 with a two-week break over Christmas/New Year. Two groups were delivered simultaneously (one in each geographical location), with group 1 scheduled for Mondays and Group 2 for Thursdays. Sessions lasted 2 hours (9.30\u0026ndash;11.30) and took place in a centrally located community hub within each geographical area. Chosen days were based on the venues availability and timings were based on a recommendation from the study patient representative to enable mothers with older children to attend alongside other commitments. Venues provided use of a large room that had available seating, access to a sink and secure storage. During delivery the interventionists subdivided the room to create distinct areas for painting/floor gallery and chat-time.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003eDescriptive data was aggregated and summarised. Qualitative data was analysed thematically (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) using NVivo11. An initial coding framework was developed by two researchers (YM, CO\u0026rsquo;N) and used to code across all data sources. Refinements and adjustments were made where required. To ensure inter-coder reliability 10% of data was double coded (CO\u0026rsquo;N) and where discrepancies were identified these were discussed until agreement was reached. Analysis was further refined until key emerging themes were identified. A dissemination meeting was held in October 2016 with health visitors, where key themes were sense-checked for accuracy.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eDescriptive data:\u003c/h2\u003e\n\u003cp\u003eEight screening logs were returned. Figure\u0026nbsp;1 provides a breakdown of recruits. Recruited mothers age ranged between 20\u0026ndash;33 years with infants ranging from 2\u0026ndash;8 months. Mothers identified themselves and their babies as either white-British or mixed. Mother\u0026rsquo;s educational achievement ranged from none to degree level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026lt;INSERT FIGURE 1 HERE\u0026gt;\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldUnderline\"\u003eFigure 1: Recruitment diagram\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eTwo mothers(+\u0026thinsp;2) regularly attended group 1 sessions (11/12 and 12/12 sessions) with one mother(+\u0026thinsp;1) missing one session due to a prior commitment. The third mother allocated to group 1 did not attend any sessions. Only one mother(+\u0026thinsp;1) was recruited to group 2, therefore group 2 was not able to run and was cancelled. A taxi was arranged to transport the mother(+\u0026thinsp;1) to attend group 1 after the first session. However, she did not take up the offer and did not attend any sessions.\u003c/p\u003e\n\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n\u003ch2\u003eQualitative data:\u003c/h2\u003e\n\u003cp\u003eFour participants took part in baseline interviews, and two in follow-up interviews. Observational data was collected at 2 sessions, 1 focus group took place with health visitor managers (HVM) and 1 focus group with facilitators. All data was analysed together using the same coding framework. Themes are summarised in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eQualitative analysis thematic overview\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTheme\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSub-theme\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e1. Experience of the recruitment process\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEngaging with recruitment\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDetermining participant eligibility\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFuture recruitment\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2. Engaging with sessions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eManaging expectations\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBenefits from the session\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e3. Intervention and its\u0026rsquo; delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSession content and delivering the groups\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon-directive approach vs. nurturing\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRelationship building\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e4. Delivery logistics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeographical location\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003evenues\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSession time \u0026amp; length\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003e1. EXPERIENCES OF THE RECRUITMENT PROCESS\u003c/h2\u003e\n\u003cp\u003eRecruitment was a major point of discussion amongst health visitor managers, participants, and facilitators due to the low number of participants. A number of challenges were reported particularly by the health visitor managers, which they felt affected their ability to engage with and recruit eligible women. These are outlined below.\u003c/p\u003e\n\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n\u003cp\u003eEngaging with recruitment:\u003c/p\u003e\n\u003cp\u003eHealth visitor managers described themselves as \u0026lsquo;middlemen\u0026rsquo; between the study and target population but felt they lacked the information needed to help them understand the bigger picture of what the study was trying the achieve. This affected their ability to fully engage with the study and recruitment process.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip;they didn't have the bigger picture so therefore they don't feel the (\u0026hellip;) connection with it. they were doing it because generally they are quite good at doing what we ask (\u0026hellip;) but not perhaps to understand, some of them would understand.\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec15\" class=\"Section4\"\u003e\n\u003cp\u003e(HV4, HVM focus group)\u003c/p\u003e\n\u003cp\u003eThe time available for recruitment (4-weeks) was seen as too short and very limiting to allow health visitor\u0026rsquo;s time to engage with and understand the study. They further felt that the briefing presentations delivered by the study team occurred too late. As a result, their understanding of the bigger picture was delayed and as such, they felt they were not able to adequately recruit within the specified 4-week time window. In addition to this, they highlighted that not enough recruitment packs were distributed to be able to achieve the recruitment target set, particularly given the ongoing challenges they experience when engaging mothers from these challenging settings in their services more widely.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYou should have given a pack to everybody. Because what we've always found with groups is that you have to over-recruit them. We've always done that with everything we've run within Sure Start before Flying Start. If ever you are running a group, you have to over-recruit. And then you tend to end up with the number that you really want. So, if all the health visitors had been given a pack, then you would have stood a much better chance of recruiting mothers to that group.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section4\"\u003e\n\u003cp\u003e(HV1, HVM focus group)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section4\"\u003e\n\u003ch2\u003eDetermining participant eligibility:\u003c/h2\u003e\n\u003cp\u003eMixed feedback was received regarding the use of the BDI-II for screening. Health visitors reported being unfamiliar with this tool. Some health visitors thought that there was a lack of training provided in how to administer it; others felt that they had no problems in using it.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think if you are going to implement a tool, you have to train person in the use of the tool, at least give them the feeling of confidence in using that tool. So really, you know, it would have been nice for you to come along to the sector meetings, that again would have been a better approach. So come to the sector meetings, see these people face-to-face, answer any queries.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section4\"\u003e\n\u003cp\u003e(HV1, HVM focus group)\u003c/p\u003e\n\u003cp\u003eIt was additionally felt that the BDI-II was oversensitive when compared to the Edinburgh Postnatal Depression Scale, which they used in routine practice. They felt it often did not match their professional judgement, sometimes even conflicting with it, which made it challenging for them to use when confirming participant eligibility.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThey just didn't seem to have people who fitted that degree of that and the criteria at that time who didn't have the children. And who weren't extremely depressed. They were a bit annoyed about the ones who were very depressed because they thought it would be have been perfect for them.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section4\"\u003e\n\u003cp\u003e(HV1, HVM focus group)\u003c/p\u003e\n\u003cp\u003eDespite health visitors\u0026rsquo; concerns with the BDI-II, mothers reported no issues in completing it. They were used to completing similar questionnaires, understood the need for personal questions and found the questionnaire acceptable.\u003c/p\u003e\n\u003cp\u003eHealth visitors reported the oversensitivity of the BDI-II as the main reason for poor recruitment rates. However, it was evident that health visitors were pre-selecting which women to approach based on a number of factors, including; perceived severity of depression, social/personal circumstances and perceived women\u0026rsquo;s\u0026rsquo; motivation levels to engage.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHealth visitors would do an almost briefly check before offering it, is because their priorities of their life are so chaotic. (\u0026hellip;) I suppose that's why some of the health visitors would filter what they thought was the appropriate person to be able to do it.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section4\"\u003e\n\u003cp\u003e(HV4, HVM focus group)\u003c/p\u003e\n\u003cp\u003eHealth visitors particularly highlighted a lack of childcare provision provided for mothers who had other children, therefor restricting mothers ability to attend. This justified their decision to not approach these women and they felt that this disadvantaged them as they were deemed as automatically ineligible. Health visitors felt this severely reduced their available recruitment pool.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHV4: I suppose they are going to use their professional judgement as to who they think is going to be the person that's going to go etc. And those ones the BDI was too high.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section4\"\u003e\n\u003cp\u003e(\u0026hellip;)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRES2: And do you think they screened in their own heads who they would even try to recruit?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHV4: Yes, definitely, health visitors do that with everything I'm afraid. (\u0026hellip;) Well we make an assessment \u0026hellip;\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section4\"\u003e\n\u003cp\u003e(HVM focus group)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec23\" class=\"Section4\"\u003e\n\u003cp\u003eFuture recruitment:\u003c/p\u003e\n\u003cp\u003eSuggestions to improve future recruitment can be summarized by three categories; 1. Amend targeted population, 2. Increase study visibility, 3. Improve communication.\u003c/p\u003e\n\u003cp\u003eIt was felt that recruitment would be more successful if focused on approaching specific groups where they thought it would be more likely to find women who met the eligibility criteria (this mainly related to depression level). Suggested groups included; ante-natal groups, mother \u0026amp; baby groups, GPs/CPNs clinics. Following on from this it was felt that if the study raised its profile and visibility there would be greater understanding of the study aims, which would make it easier for recruiting health visitors to convey key information needed for recruitment. In order to achieve this, it was suggested that promotional material should be developed, including; posters, flyers and video demonstrations of the sessions. It was also suggested that a few taster sessions could be arranged, which would provide mothers with a better understanding of what to expect within the sessions. Central to all suggestions was the importance of improving communication about the study. Health visitors stated they found it difficult to recruit, as they did not have a good understanding of the broader aims of the study. Therefore, it was suggested that health visitors needed to be provided with clearer information to allow them to successfully recruit. They suggested more briefing presentations should be held with a longer run-in period for recruitment to allow them to be able to engage with the information provided.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think there was a lack of erm, understanding, health visitors sell things very well when they know what they're selling, like everything. (\u0026hellip;) Whether you're a car salesman, if you know the car you sell it well don't you. And I think that erm, more knowledge is, of the study would be good definitely. (\u0026hellip;) Sometimes when they have a presentation and they can visualize it, something like that so they know exactly what they are recruiting for, why they are recruiting how they recruit. And they do need time. (\u0026hellip;) they have to really know what they're selling to be able to put the emphasis behind it and make the mothers believe that it will make a difference, that this is a great idea.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section4\"\u003e\n\u003cp\u003e(HV4, HVM focus group)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\n\u003ch2\u003e2. ENGAGING WITH SESSIONS\u003c/h2\u003e\n\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n\u003ch2\u003eManaging expectations:\u003c/h2\u003e\n\u003cp\u003eMothers expressed multiple reasons for wanting to take part of the group sessions. These included; having an interest in art (particularly doing art together \u0026ndash; hand and foot prints); improved mental health; alternative to taking medication; improved bonding with their baby; support in how to interact with baby; forming new friendships (being with other similar people i.e. postnatal depression experience, new mothers); developing memories (photos/art work to take home); getting into a positive routine (in preparation of going to work/nursery); getting their baby used to other people (in preparation for nursery).\u003c/p\u003e\n\u003cp\u003eAlthough mothers highlighted various reasons for wanting to engage with the sessions, they were uncertain whether their expectations would be met, in particular, what to expect from the type of art being created (i.e. painting, crafts) and how exactly their babies would be involved (i.e. sitting on their lap, foot and hand prints, holding paintbrush). One mother described this as attending \u0026lsquo;blind\u0026rsquo;, however this did not dissuade her from attending and mothers generally described themselves as open-minded regarding the activities they would be doing. Mothers discussed group sizes and expressed some concern over the group being too large, suggesting that 4 mothers\u0026thinsp;+\u0026thinsp;babies would be an optimal size to allow them to open up, trust each other and share feelings without being overwhelmed.\u003c/p\u003e\n\u003cdiv id=\"Sec27\" class=\"Section4\"\u003e\n\u003ch2\u003eBenefits from the session:\u003c/h2\u003e\n\u003cp\u003eMothers who completed the sessions described taking part as beneficial for themselves and their babies. They felt the sessions supported them in developing a positive relationship with their baby and took great value from watching their baby smiling, jumping with joy and physically develop over the three months. They also discussed how taking part gave them the time and space to explore their own difficulties around stress and anxieties. This allowed them to build confidence in themselves and cope as a new mother.\u003c/p\u003e\n\u003cp\u003e...\u003cem\u003eit meant that you could really get established and you could really see a change through those 12 weeks in you and the baby. I found myself feeling a lot better (...) and it was quite nice because I could compare myself to how I had been in the first few weeks, how I'd felt. (\u0026hellip;) So it was quite nice for it to be a ...3 month period.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section4\"\u003e\n\u003cp\u003e(PID101, Follow-up interview)\u003c/p\u003e\n\u003cp\u003eAlthough mothers initially expressed concerns over the early start of the sessions, they later described a sense of achievement and a feeling of pride in having made it out early on a Monday morning and getting their day started. They felt this set up a feeling of confidence that they could get back to normal and have a routine which would be beneficial e.g. when going back to work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlthough I was, at first, a bit, erm, dubious about whether I'd make it because it started quite early in the morning, erm on a Monday, I was worried not being able to get out of bed. But actually it proved to myself that I could do that so that was quite good as well.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec29\" class=\"Section4\"\u003e\n\u003cp\u003e(PID101, Follow-up interview)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\n\u003ch2\u003e3. INTERVENTION AND ITS\u0026rsquo; DELIVERY\u003c/h2\u003e\n\u003cdiv id=\"Sec31\" class=\"Section3\"\u003e\n\u003ch2\u003eSession content and delivering the groups:\u003c/h2\u003e\n\u003cp\u003eIntervention facilitators and participants liked the sessions being split into three main components (see Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Mothers felt relaxed knowing there was some flexibility with the time of arrival. They liked that they started and ended each session with a cup of tea (this was seen as allowing them to take time to relax). They also valued that the interventionists painted with them, as this made them feel more at ease and not observed, aiding in relationship building. They did not feel pressure when painting to create something that had meaning and were happy to sometimes use the time to doodle. They found it easier to share their feelings while painting as this acted as a distraction from them.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLooking back, sometimes it was more about problems you were having, or it could just be about what you\u0026rsquo;ve done all week. It could be whatever you wanted it to be. So I quite like the set-up, erm, and then the painting sort of after twenty minutes, you sit down and you paint together. And the fact that the staff were getting involved as well was really good, because I think if it\u0026rsquo;d just been the mums painting with people observing, it would have been a little bit intimidating.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec32\" class=\"Section3\"\u003e\n\u003cp\u003e(PID102, Follow-up interview)\u003c/p\u003e\n\u003cdiv id=\"Sec33\" class=\"Section4\"\u003e\n\u003ch2\u003eNon-directive approach vs. nurturing:\u003c/h2\u003e\n\u003cp\u003eThe intervention was designed to be delivered in a non-directive manner, however it was evident from the focus groups and session observations that the clinical interventionists did not adopt this approach. Observational data confirmed that art therapists took a non-directive approach and allowed participants to lead discussions. However, this approach was seen as very different to clinical interventionist \u0026lsquo;normal\u0026rsquo; roles where they approach mothers in a nurturing and directive manor. Clinical interventionists felt that during sessions the art therapist was taking a backseat and was perceived by them as doing nothing. Consequently they felt they needed to be more directive in providing mothers with support. Health visitors felt the non-directive approach was not clarified during training and needed emphasizing in future sessions. However, mothers appreciated health visitors taking a directive and nurturing approach as this supported them in caring for their baby and allowed them to have some time to focus on themselves.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThey come into that room, you are friendly to them, you're happy, smiling. They get a warm welcome and there are nice things to eat. It's part of this psychological process of, you know, they've really made an effort for me. You're like an honoured guest. There are nice things to eat and you do nice things as well. It's just part of the whole awareness structure of it all, really. The parent is being nurtured. (\u0026hellip;) That's really quite important, a cup of tea. It makes a big psychological difference.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec34\" class=\"Section4\"\u003e\n\u003cp\u003e(HV1, HVM focus group)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhen we were having the sort of chats they'd play with the baby so you could have your cup of tea in peace which was quite a nice part of the group as well. Because as a new mum you don't often get to drink a hot cup of tea so it was quite nice.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec35\" class=\"Section4\"\u003e\n\u003cp\u003e(PID101, follow-up interview)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec36\" class=\"Section4\"\u003e\n\u003ch2\u003eRelationship building:\u003c/h2\u003e\n\u003cp\u003eInterventionists and mothers perceived building good relationships between mothers and interventionists as vital to allow successful delivery. Mothers reported that this gave them confidence in themselves and encouraged them to attend and felt there was a good dynamic between interventionists making them feel comfortable to share experiences. The group dynamic/relationships were described by mothers as non-threatening and informal. It was important to mothers that interventionists got the balance right between daily chit-chat and supportive conversations as this allowed stronger relationships to be built between them. In doing so, mothers gained confidence to ask questions they perceived as \u0026lsquo;silly\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt's building that relationship in a non-threatening way and seeing them more in a less formal way, I guess. And feeling they've got permission in that setting to ask the stupid question that we all think are stupid when we are new mothers, and they\u0026rsquo;re not stupid at all.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec37\" class=\"Section4\"\u003e\n\u003cp\u003e(HV3, HVM focus group)\u003c/p\u003e\n\u003cp\u003eMothers trusted interventionists with their babies and valued their experience and appreciated each of the interventionists\u0026rsquo; background and skills, which they felt added to their overall experience. At the last session mothers presented interventionists with thank you cards to show their appreciation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI found it an invaluable support for me to sound off how I was feeling to people and especially to, erm the art therapist. (\u0026hellip;) I found her input really helpful and it's really helped me through a difficult period.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec38\" class=\"Section4\"\u003e\n\u003cp\u003e(PID101, follow-up interview)\u003c/p\u003e\n\u003cp\u003eMothers valued building relationships with each other and being able to attend a group with mothers with similar experiences and where depression was discussed. They could empathize and provide each other with support and advice. The group was described by mothers as a community coming together which needed stability to work (i.e. with regular attendance, a closed group, continuity of interventionists to enable relationship building). Both mothers who attended sessions, commented on how they had formed a strong friendship outside of the sessions. At the final session they painted on each other\u0026rsquo;s picture \u0026ndash; consolidating their experiences/memory of the group together.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe'd walk home from the class together and like do a bit of a longer walk because the babies would fall asleep after the class so we'd have a bit of a chat. So it was quite nice to make a friend who's had ... like you know she had a different sort of illness really but we could relate to each other in that way and be a bit of a support for each other.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec39\" class=\"Section4\"\u003e\n\u003cp\u003e(PID101, follow-up interview)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec40\" class=\"Section2\"\u003e\n\u003ch2\u003e4. DELIVERY LOGISTICS\u003c/h2\u003e\n\u003cdiv id=\"Sec41\" class=\"Section3\"\u003e\n\u003ch2\u003eGeographical location:\u003c/h2\u003e\n\u003cp\u003eRecruitment was particularly challenging in one of the geographical areas and health visitors reported that they experienced ongoing challenges recruiting mothers from this area to any of their routinely offered services. They described this as an innate cultural barrier, unique to the area which leaves women deeply sceptical and prevents them from engaging in any group-based activities. They provided little explanation as to why this might be or how to overcome this barrier in the future.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think groups are, everybody will tell you notoriously but it is our worst area for groups\u0026hellip;\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec42\" class=\"Section4\"\u003e\n\u003cp\u003e(HV4, HVM focus group)\u003c/p\u003e\n\u003cp\u003eDespite recruitment challenges, health visitors, facilitators and participants all agreed that venues were centrally located and easily accessible, although the mother recruited to group 2 was unfamiliar with the exact location which may have contributed to her non-attendance. Health visitors confirmed that the venue was a bit of a walk and slightly outside of the \u003cem\u003e\u0026lsquo;Flying Start\u0026rsquo;\u003c/em\u003e area and generally not well attended by their client group.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec43\" class=\"Section4\"\u003e\n\u003ch2\u003eVenues:\u003c/h2\u003e\n\u003cp\u003eThe venue used for group 1 was described as bright, but barely big enough and mothers expressed concern for their babies\u0026rsquo; safety if there had been older babies present who were more mobile and questioned how the group would have functioned if this was the case. Furthermore, the chairs provided were unsuitable for breastfeeding due to the lack of armrests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think if you\u0026rsquo;d had more people that room would not have worked. (\u0026hellip;) with the health visitors and the art therapist as well, that\u0026rsquo;s quite a lot of people on that sheet painting. So I think when the babies, depending on what age they are \u0026hellip; trying to keep tabs on wriggly babies and mums, that would have been, yes, really quite difficult.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec44\" class=\"Section4\"\u003e\n\u003cp\u003e(PID102, follow-up interview)\u003c/p\u003e\n\u003cp\u003eParticipants and facilitators acknowledged that the very specific requirements in order to be able to deliver the intervention (i.e. large multi-functional space) made the venue choice very tricky. A few suggestions were made of other possible venues to consider in the future including; primary schools, local hubs, libraries and leisure centres. It was felt that these might provide a larger more suitable space while still fulfilling the required specification.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe explored the acceptability of a painting art therapy intervention for depressed mothers attending with their babies and the feasibility of recruiting mothers to the study. One painting group was delivered to two mothers and their babies with another two mothers initially accepting the offer but not subsequently attending. This was despite plans originally to run two concurrent groups for up to six mothers each. Nevertheless, rich information about intervention acceptability and the feasibility of delivery was gained from attending mothers, group facilitators and area health visitors. This has reinforced the intervention model, while also suggesting some aspects that could be modified for future roll-out. The evaluation provides some indication of how mothers have engaged with the intervention and the value they have derived from it.\u003c/p\u003e \u003cp\u003eA key challenge in evaluating complex public health interventions involving vulnerable populations is recruitment (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Recruitment strategies involving known gatekeepers, such has health professionals can improve recruitment success as trusted relationships are already established (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). In our study, recruitment was via the local health visitor team who reported a high degree of familiarity and good relationships with the population of mothers experiencing depression. However, their understanding about the study may have limited their ability to commit to the study and therefore resulted in low recruitment rate. Their lack of understanding and commitment may have also been the reason why so few (n\u0026thinsp;=\u0026thinsp;11/24) returned their screening logs. Peindl and Wisner (2003) further suggest that although high familiarity with the study population yields good recruitment rates, a large amount of time needs to be invested in developing relationships with recruiters to establish a network and enable them to take on this role. In this small feasibility study there was naturally some restricted ability to engage with the large local recruiting professional teams. Competing clinical commitments may also have been a barrier. It may prove more effective to work with a smaller number of health visitors who could then be better informed about the study and have a greater focus on recruitment within the allocated recruitment window.\u003c/p\u003e \u003cp\u003eHealth visitors were happy to screen women and felt they were the appropriate professionals to do so. This is in line with international literature which has recommended that those in health professional roles are best places to screen and manage women suffering with postnatal depression (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Despite this, they expressed challenges in the application of the screening tool. We used the BDI-II as it is widely used across the literature and due to its validated cut off scores to detect mild-moderate depression (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). However, this differed to the health visitor\u0026rsquo;s normal practice. They regarded the tool to be too sensitive, felt it differed from their professional judgment and made assessing levels of depression problematic. A future study should either revisit the training required or adopt a different screening tool (e.g. Edinburgh Postnatal Depression scale (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)).\u003c/p\u003e \u003cdiv id=\"Sec46\" class=\"Section2\"\u003e \u003ch2\u003ePractical implications\u003c/h2\u003e \u003cp\u003eMaternally reported intervention benefits were consistent with the program\u0026rsquo;s model of change. Although the study did not aim to gauge intervention effect, it does provide some support for the value of this transactional therapeutic approach, and the role it could play alongside other treatment modalities. Mothers particularly valued the benefits of the small group size and although this was an unintended consequence of poor recruitment it is important that a future study preserve the value that mothers attribute to the group size for allowing them to establish meaningful relationships with one another and the facilitators. Some of the logistics of delivering the intervention also need to be carefully considered, including the facilities required for delivering a messy painting intervention.\u003c/p\u003e \u003cdiv id=\"Sec47\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eFeedback from both participating mothers and facilitators sheds light on the extent to which the planned structure and purpose of the intervention model was delivered as intended and whether it was viewed as working as expected by theory. Mothers\u0026rsquo; experiences of the intervention were in line with the model of change. However, the clinical interventionists found it challenging to adopt a psychodynamic approach despite selection and training to do so. This is in contrast to previous research where health visitors have delivered non-directive psychological based interventions for mothers suffering depression (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Future work may need to reconsider the emphasis placed on the non-directive approach during intervention training.\u003c/p\u003e \u003cp\u003eKey insights about the acceptability of painting groups and the feasibility of recruiting mothers have emerged and will inform future evaluations. Nevertheless, there are some limitations to note. With only a small number of mothers in this intervention, exploration of attendee experience and interventionist delivery are inevitably limited and some perspectives will not have been captured. As the intervention was intended to be that of larger group, some aspects of group dynamics were also inevitably restricted. How facilitators may adapt to working with a larger number of mothers would be important to explore further. Despite the reported benefits of experiencing a small group process, it is unlikely that a very small group would prove economically viable in practice and there is probably untapped potential for mothers to be experiencing a larger painting group. We have not had the opportunity to talk to women who were approached but did not attend the painting group. Nevertheless, that some health visitors were uncertain themselves about the aims and purpose of the intervention and study reveals an immediate potential barrier to successfully approaching mothers.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis feasibility study provides a clear indication about what needs to be addressed in a larger pilot study. Greater interaction with local health visiting teams may better clarify recruitment pathways, better inform them of the study purpose, and agree adequacy of screening tools. Further training for co-facilitators may address applying the therapeutic model with fidelity and adjustments to group delivery, such as timing of sessions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArt Therapist\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBDI-II\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBeck Depression Inventory II\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical Psychiatric Nurse\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Practitioner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Visitor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHVM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Visitor Manager\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Research Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNursery Nurse\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePATCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePainting Art Therapy to promote Child Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received a favourable ethical opinion from South Central-Berkshire B NHS Research Ethics Committee, UK in August 2014 (Ref: 14/SC/1181).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available but are available from the corresponding author following completion of a data access request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOO was employed at Flying Start Cardiff who were involved in hosting the study and identifying and referring potentially eligible mums and babies. However, OO was not involved in recruitment.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCA acted as the supervising Art Therapist to the interventionists.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe other authors have no conflicts of interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by \u003cem\u003e\u0026lsquo;The Wales School for Primary Care Research (WSPCR)\u0026rsquo;\u003c/em\u003e under Grant [number 507785].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYM was the study manager, conducted the data collection, lead the data analysis and drafted the manuscript. CO\u0026rsquo;N was a co-applicant on the grant, contributed towards the design of the study, conducted some data collection, conducted double coding of the data, supported drafting of the manuscript. MR was a co-applicant on the grant, contributed towards the design of the study, supported drafting of the manuscript. CA was a co-applicant on the grant, contributed towards the design of the study, co-designed the intervention, acted as the supervising art therapist, commented on the final manuscript. OO was the principal investigator on the grant, maintained overall oversight and responsibility for the study delivery,\u0026nbsp;contributed towards the design of the study, provided access to HV for recruitment purposes, supported drafting of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the following people: All of the women who were approached, referred and recruited for showing an interest and giving up their time to take part. Flying Start Cardiff for agreeing to host this study and for providing support in delivery this study, with particular thanks to Gaynor Williams who ordered all of the required art equipment. The recruiting health visitors for agreeing to identify potentially eligible women. All interventionists for delivering the study according to schedule. RR, who acted as our Patient and Public Involvement (PPI) representative and provided invaluable support and helped shape the study design. Rhys Williams-Thomas for designing the study logo, which gave the study an identity. The local venues who provided access to their facilities and agreed to give up some of their space to host the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCox LJ, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. 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Arch Womens Ment Health. 2003;6(1):65\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArroyo C, Fowler N. Before and after: A mother and infant painting group. Int J Art Ther Inscape [Internet]. 2013;18(3):98\u0026ndash;112. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1080/17454832.2013.844183\u003c/span\u003e\u003cspan address=\"10.1080/17454832.2013.844183\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. BMJ. 2021;374(2018):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation; 1996.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowlby J. A secure base: parent-child attachment and healthy human development. London: Routledge; 1988.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall P. Painting together. In: Case C, Dalley T, editors. Art Therapy with Children: From Infancy to Adolescence. Hove \u0026amp; New York: Routledge; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2013;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith LJ. How ethical is ethical research? Recruiting marginalized, vulnerable groups into health services research. J Adv Nurs. 2008;62(2):248\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonevski B, Randell M, Paul C, Chapman K, Twyman L, Bryant J, et al. Reaching the hard-to-reach: A systematic review of strategies for improving health and medical research with socially disadvantaged groups. BMC Med Res Methodol. 2014;14(42).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeindl KS, Wisner KL. Successful recruitment strategies for women in postpartum mental health trials. J Psychiatr Res. 2003;37(2):117\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlexandrou F, Sakellari E, Kourakos M, Sapountzi-Krepia D. Health visitors\u0026rsquo; perceptions on their role to assess and manage postpartum depression cases in the community. Heal Soc Care Community. 2018;26(6):995\u0026ndash;1000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck AT, Ward AH, Mendelson M, Mock J, Erbaugh J. An Inventory for Measuring Depression. Arch Gen Psychiatry. 1961;4(6):561\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrell CJ, Slade P, Warner R, Paley G, Dixon S, Walters SJ, et al. Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: Pragmatic cluster randomised trial in primary care. BMJ. 2009;338(7689):276\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolden JM, Sagovsky R, Cox JL. Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. BMJ. 2009;298(6668):223\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlying Start. 2017. Welsh Government [Internet]. [cited 2019 May 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://gweddill.gov.wales/topics/people-and-communities/people/children-and-young-people/parenting-support-guidance/help/flyingstart/?lang=en\u003c/span\u003e\u003cspan address=\"https://gweddill.gov.wales/topics/people-and-communities/people/children-and-young-people/parenting-support-guidance/help/flyingstart/?lang=en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Depression, Art Therapy, Feasibility Study, Complex Intervention, Infant Health, ","lastPublishedDoi":"10.21203/rs.3.rs-1489112/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1489112/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Depression in postnatal period is estimated to affect 10-20% of mothers and risks the long-term wellbeing of their infants. This study aimed to assess the feasibility of a novel dyadic mother-infant painting group for mothers with mild-moderate depression.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Mothers (+infants) suffering with mild-moderate depression (measured using the Beck Depression Inventory-II) were recruited from two socioeconomically deprived urban areas in a UK city to join one of two 12-week painting groups in Autumn/Winter 2014. Groups were co-delivered by an art therapist, a specially trained health visitor and a nursery nurse. Data collection included: pre- and post-intervention interviews with mothers, session observations and focus groups with intervention staff and health visitor managers.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 11 mothers were approached and screened, six were referred for recruitment of which four consented and completed the pre-intervention interview. Two mothers attended almost every session and completed the post-intervention interview. Two mothers attended no sessions. One painting group was cancelled due to poor attendance. Health visitors found it difficult to determine participant eligibility and did not fully understand wider study aims, limiting recruitment. However, they identified as the appropriate professionals to approach mothers and suggested that more briefing and training sessions would be helpful. Delivering the groups in the intended non-directional approach challenged the interventionist health visitors’ normal nurturing approach. While initially apprehensive, attending mothers reported positive benefits including a sense of achievement. Relationship building with interventionists and other mothers was a key element to successful delivery. Some questions about the venue’s suitability were raised regarding the group size and babies’ age range should the group run at maximum capacity. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Despite poor recruitment mothers benefited from session attendance and the intervention model showed some promise. However, further work is required to assess new recruitment methods for this population to enable further evaluation of the intervention model.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e N/A\u003c/p\u003e","manuscriptTitle":"Feasibility of recruiting mother-infant dyads with mild-moderate depression to an art therapy painting group.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-04-07 16:18:56","doi":"10.21203/rs.3.rs-1489112/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"41800e40-7208-4bf0-96ce-f3db977e50be","owner":[],"postedDate":"April 7th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-11-30T03:50:04+00:00","versionOfRecord":[],"versionCreatedAt":"2022-04-07 16:18:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1489112","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1489112","identity":"rs-1489112","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}