View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by King's Research Portal King’s Research Portal DOI: 10.1186/s12905-019-0744-z Document Version Publisher's PDF, also known as Version of record Link to publication record in King's Research Portal Citation for published version (APA): Chomat, A. M., Andersson, N., Menchu, A. I., Ramirez-Sea, M., Pedersen, D., Bleile, A., ... Araya Baltra, R. (2019). Women’s circles as a culturally safe psychosocial intervention in Guatemalan indigenous communities: a community-led pilot randomised trial. BMC Women's Health, 19(1), [53]. https://doi.org/10.1186/s12905-019- 0744-z Citing this paper Please note that where the full-text provided on King's Research Portal is the Author Accepted Manuscript or Post-Print version this may differ from the final Published version. 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BMC Women's Health (2019) 19:53 https://doi.org/10.1186/s12905-019-0744-z RESEARCHARTICLE Open Access Women’s circles as a culturally safe psychosocial intervention in Guatemalan indigenous communities: a community-led pilot randomised trial Anne Marie Chomat1,2* , Aura Isabel Menchú2, Neil Andersson1,3, Manuel Ramirez-Zea4, Duncan Pedersen5ˆ, Alexandra Bleile6, Paola Letona4 and Ricardo Araya6 Abstract Background: Indigenous Maya women in Guatemala show some of the worst maternal health indicators worldwide. Our objective was to test acceptability, feasibility and impact of a co-designed group psychosocial intervention (Women’s Circles) in a population with significant need but no access to mental health services. Methods: A parallel group pilot randomised study was undertaken in five rural Mam and three periurban K’iche’ communities. Participants included 84 women (12 per community, in seven of the communities) randomly allocated to intervention and 71 to control groups; all were pregnant and/or within 2 years postpartum. The intervention consisted of 10 sessions co-designed with and facilitated by 16 circle leaders. Main outcome measures were: maternal psychosocial distress (HSCL-25), wellbeing (MHC-SF), self-efficacy and engagement in early infant stimulation activities. In-depth interviews also assessed acceptability and feasibility. Results: The intervention proved feasible and well accepted by circle leaders and participating women. 1-month post- intervention, wellbeing scores (p-value 0.008) and self-care self-efficacy (0.049) scores were higher among intervention compared to control women. Those women who attended more sessions had higher wellbeing (0.007), self-care and infant-care self-efficacy (0.014 and 0.043, respectively), and early infant stimulation (0.019) scores. Conclusions: The pilot demonstrated acceptability, feasibility and potential efficacy to justify a future definitive randomised controlled trial. Co-designed women’s groups provide a safe space where indigenous women can collectively improve their functioning and wellbeing. Trial registration: ISRCTN13964819. Registered 26 June 2018, retrospectively registered. Keywords: Maternal mental health, Indigenous women, Guatemala, Participatory research, Women’scircles,Co-design, Cultural safety Background emotional, and social development [1–4]. Maternal mental Perinatal mental disorders – depression, anxiety and som- health has been linked to reduced responsiveness in care- atic disorders – can be detrimental to women’shealth, giving and higher rates of behavioral problems in children pregnancy outcomes and infant neurological, cognitive, [5] and young adults [6]. Maternal anxiety – which indi- genous women may be at increased risk for [7] – has been * Correspondence: [email protected]; [email protected] associated with preterm birth [8] and, in low-income set- ˆ Postmortem tings, maternal depression has been associated with low 1Participatory Research at McGill (PRAM), Department of Family Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges-3rd floor, Suite 300, birth weight, childhood stunting, higher rates of diarrheal Montréal, QC H3S 1Z1, Canada diseases and poor cognitive development in young chil- 2 CIET International Guatemala, 5ª calle 14-35, apartamento 304, Edificio Las dren [1, 9]. Tapias, zona 3, Quetzaltenango, Guatemala Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Chomat et al. BMC Women's Health (2019) 19:53 Page 2 of 15 A systematic review reported perinatal mental disorders requested a group intervention – Women’s Circles – were common in low- and lower-middle-income countries that could help and provide support for women in their (LMIC), affecting 16% of pregnant women and 20% of communities, following earlier involvement in a partici- women in the postpartum period [10]. Indigenous women patory research project with the lead author of this experience higher rates of partner abuse than paper [17]. In each community, local leaders steered non-indigenous women, for whom partner violence is an group processes. We chose a participatory research ap- especially strong predictor of poor mental health [11]. proach [33, 34] to optimize community engagement and Protective factors include relative social and economic ad- optimize cultural safety, acceptability and feasibility. vantage, formal education, secure employment, reproduct- ive health services, belonging to the ethnic majority, and Trial design having a respectful, trustworthy intimate partner [10]. The design was a parallel group pilot randomised study. Women may also be better able to counter stress if they have high self-esteem and self-efficacy [12], effective social Setting support [13], and an ability to problem-solve [8]. Five rural Mam communities in San Juan Ostuncalco Guatemala’s indigenous women manifest some of the municipality (25 km from Quetzaltenango city; popula- worst health indicators worldwide [14]; three in four live tion 1000-4000) and three periurban K’iche’ communi- below the poverty line [15]. Women of childbearing age ties in Quetzaltenango city (population 4000-16,000) living in indigenous areas show the highest rates of de- were selected as study sites, based on prior collabora- pression and anxiety in the country [16]. In rural indigen- tions with the first author and local women leaders’ ous Mam communities in the Western Highlands, lower expressed interest in participating. household wealth, psychological distress, ineffective social support, inequality in decision-making, and experience of violence were consistent determinants of maternal stress, Co-design assessed via salivary cortisol, and infant stunting in the Ten six-hour workshops scheduled monthly with 16 cir- first 6 months of life [17]. Guatemala’s national health sys- cle leaders defined the transdiagnostic (addresses a range tem provides limited access to mental health services; of mental health issues) intervention. Circle leaders col- there are no formal mental health promotion and preven- lectively chose a project name and logo; developed a the- tion programs, and limited involvement of service users ory of change; mapped community needs, resources, and and families in mental health systems [18, 19]. The Guate- stakeholders; and pilot tested group methodologies. malan civil war and long history of racial discrimination Group activities drew on games (dinámicas), art-based places indigenous populations at an additional disadvan- methods (drawing, role play, music) and group psycho- tage in terms of access to health services [20, 21]. social therapy (active listening, emotion management, Recent research has demonstrated the feasibility of breathing and relaxation exercises, problem solving, psychosocial interventions for perinatal mental health in popular education) to build trust, self-esteem, and social ’ non-specialized health-care settings using psychoeduca-