Digital Repository Masters Projects Spring 2023 The Unseen Threat: Combatting Perinatal Depression and Anxiety Belinda Fender Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Fender, B. 2023. The unseen threat: Combatting perinatal depression and anxiety. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP The Unseen Threat: Combatting Perinatal Depression and Anxiety Project Title by Belinda Fender Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT 04/11/2023 Date Belinda Fender BSN, RN, MSN Student 04/11/2023 Student Name, Credentials Date (electronic signature) Jamie Wankier MSN, RN 04/11/2023 MSN Project Faculty Date (electronic signature) 05/25/2023 Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Date 2 The Unseen Threat – Combatting Perinatal Depression and Anxiety Belinda Fender, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing April 11, 2023 3 Abstract Perinatal depression and anxiety (PNDA) conditions are major psychological issues affecting women during the beginning of pregnancy and up to one year following the birth of a child. Due to unique stressors stemming from the military lifestyle, the prevalence of PNDA is significantly higher within the Department of Defense (DoD). This MSN project aims to outline the implementation of a PNDA support group at an Air Force Base in the West. The PNDA support group will evaluate whether identification, education, and support are effective interventions in combatting PNDA's consequences. During the literature review process, it was discovered that there is a lack of evidence-based literature relating specifically to PNDA within the DoD population; however, current evidence-based literature on general PNDA was explored to develop appropriate interventions. Through this project's implementation, the DoD's perinatal population will be screened for and educated on PNDA using support systems to strengthen the military community. An educated healthcare force and perinatal population aim to decrease the prevalence of PNDA throughout the DoD. Future recommendations include additional research, dissemination, and improvements specific to the DoD population. Keywords: Perinatal depression and anxiety, intervention, support group, Air Force Base, screener, pregnancy, evidence-based practice, education, and support 4 The Unseen Threat – Combatting Perinatal Depression Mental health conditions are often invisible to the naked eye, but their impact is indisputable (Mayo Clinic, 2019). Perinatal depression and anxiety (PNDA), defined as depression or anxiety that happens anytime during pregnancy or up to a year after birth, is a mental health condition requiring more focus and attention (Senni, 2018). PNDA conditions are major psychological issues that affect approximately 11.9% of women (Fang et al., 2022) and 10% of men worldwide (O'Brien et al., 2017), with both maternal and paternal depression experienced in 3% of couples (Smythe et al., 2022). When comparing this worldwide statistic of 21.9% of the total population with PNDA (Fang et al., 2022) to the Department of Defense's (DoD) statistic of 36%, the DoD's number continues to present a prevalent problem as the total population of servicemembers and their families struggle with PNDA (GAO, 2022). PNDA has various negative implications for individuals, families, and society (Bhat et al., 2022; Fang et al., 2022; Shuffrey et al., 2022). Bhat et al. (2022) showed that Americans experience depression and anxiety at a rate of 11-21%, which results in an annual societal cost of over $14 billion. Maternal caregivers plagued by depression during pregnancy are at a significantly heightened risk for serious medical issues, including premature labor and a fetal growth deficit (Marsay et al., 2018). PNDA are significant mental health issues affecting men and women worldwide, with a substantial prevalence among DoD beneficiaries (Fang et al., 2022; GAO, 2022; Klaman & Turner, 2016). Servicemen and women are also at an even higher risk for PNDA due to the unique stressors and risk factors introduced by the military lifestyle. Mastrangelo (2022) states that active-duty mothers have more demanding and high-risk jobs than those not in the military. Some women deploy overseas as soon as six months after birth or, for the non-birth parent, 5 sooner, including during the pregnancy (Klaman & Turner, 2016; Mastrangelo, 2022). Partner separation can lead to increased occurrences of PNDA because of the disruption in bonding and attachment between the parent and child, marital disruptions, or the lack of support during the perinatal period (Klaman & Turner, 2016; Mastrangelo, 2022). High-stress work environments of military personnel in combat zones increase the possibility of developing post-traumatic stress disorder (PTSD) in the servicemember or increased stress for the spouse, increasing PNDA symptoms (Klaman & Turner, 2016). The ongoing requirement of military families to relocate, on average, every 2-4 years, limits support systems and resources, resulting in increased feelings of isolation in military families and heightened risk factors for PNDA (Klaman & Turner, 2016). Although the effects of PNDA are significant, research has shown that effective identification, education, and support produce better outcomes for individuals suffering from this condition. Educating perinatal mothers on the signs and symptoms of PNDA leads to earlier identification and proper treatment of this issue (Sahin & Seven, 2019). When individuals effectively identify a problem, additional support or treatment opportunities are created. Fang et al. (2022) conclude that peer support groups are an efficient tool for managing and combating the adverse effects of PNDA. This MSN project will explore the various issues those suffering from PNDA can experience and the recommended interventions. Statement of Problem Healthcare providers fail to identify approximately 75% of women experiencing PNDA symptoms, and only 50% of those with PNDA-specific issues seek treatment (Biggs et al., 2019). This statistic is a significant shortfall because it is strongly recommended by the American Academy of Pediatrics (AAP) that providers administer PNDA screenings during the first, second, fourth, and sixth-month well-child checkups (Earls et al., 2019). Along with these 6 screenings, the AAP advises providers to provide support and community resources (Earls et al., 2019). In addition to the statistics of women experiencing PNDA, servicemembers and their families face unique barriers such as isolation, cultural stigmas, and acclimation issues that increase risk factors for PNDA (GAO, 2022). Therefore, medical professionals must enact interventions to combat this issue. While research has identified the significance that peer support, education, and early identification have in lessening the long-term effects of PNDA (Fang et al., 2022; Sahin & Seven, 2019), prevalence rates of PNDA remain elevated (Fang et al., 2022; O'Brien et al., 2017). Bhat et al. (2022) state that providing support decreases symptoms of PNDA that mothers experience. With appropriate education, mothers more readily identify PNDA and can obtain treatment before symptoms and effects worsen (Bhat et al., 2022). This MSN project examines an Air Force Base with a high volume of families and women with proximity to community hospitals and medical resources that are not present at every base. The problem is that there is no PNDA screening, patient education, or support related to PNDA at the referenced Air Force Base. This MSN project aims to implement screening, education, and support for perinatal moms at the Air Force base under study. Analyzing evidence-based practice (EBP) for implementing a support group, evaluating PNDA educational resources, evaluating treatment options, and evaluating proper screening resources will ensure that the objectives of this MSN project will be achieved. Ways Project Contributes to Intended Recipients The issues surrounding PNDA can significantly affect many individuals and systems (Mayo Clinic, 2019). This MSN project will contribute to several recipients, including perinatal women, spouses or partners, and an Air Force Base in the Western United States. Pregnant women are at a high risk of complications, including pre-eclampsia and high-risk labor, due to 7 PNDA (Duan et al., 2019). Issues such as diminished self-care and happiness negatively affect Perinatal women experiencing PNDA (Marsay et al., 2018). Marsay et al. (2018) also mention that pregnant mothers are more susceptible to health issues that affect their babies, such as premature delivery of the baby and an underdeveloped fetus when PNDA is present. All these issues can lead to more severe health issues for mothers and their babies in the future (Duan et al., 2019; Marsay et al., 2018). Screening tools such as the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) are invaluable methods for identifying at-risk women for perinatal depression and anxiety (Marsay et al., 2018). The EPDS is specifically helpful and will be used throughout this project because it is the most prominent screening tool currently used to detect PNDA (Marsay et al., 2018). By implementing health screeners and educational resources at the Air Force Base in this project, awareness of the issues will increase, leading to added interventions. (Bhat et al., 2022; Marsay et al., 2018). Along with educating women on PNDA, identified at-risk women can also obtain referrals for further evaluation and treatment of this potential condition. PNDA affects not only the individual diagnosed or experiencing it but also the partners of those affected by this condition; therefore, additional support and education will need to be extended to spouses (O'Brien et al., 2017). Spouses of women with PNDA are at a heightened risk for also experiencing PNDA, as evidenced by 24% - 40% of partners acquiring PNDA when it is also present in their birthing partner (O'Brien et al., 2017). Effects of spousal, specifically male, PNDA include impulsive behavior, sleep disturbances, decreased work performance, alcoholism, and death (O'Brien et al., 2017). Through the employment of this project, women and their partners suffering from the effects of PNDA will understand that they are not alone and that resources are available to help them manage this mental illness. 8 Mastrangelo (2022) identified that appropriate support, identification, and management of PNDA has a positive impact on the mission readiness of the Air Force. Service members identifying PNDA and receiving treatment report increased life satisfaction and work productivity (Mastrangelo, 2022). Managing symptoms of PNDA through treatment and support systems help keep the family units intact and free of added stressors, behavioral guarding, and potential communication barriers (Mastrangelo, 2022). Strong, healthy families provide added support to the service member and allow the focus on creating an effective and prepared Air Force (Mastrangelo, 2022). By decreasing the mental ailments impacting DoD personnel and their families, the Air Force base can bolster its mission effectiveness through healthy servicemembers. Rationale for Importance of Project The identified rationales from PNDA include maternal health degradation, child health, developmental delays, and familial bonding and attachment issues (Duan et al., 2019; Fang et al., 2022; Marsay et al., 2018; Olsson et al., 2021; Shuffrey et al., 2022). According to Marsay et al. (2018), some health complications resulting from PNDA include somatic problems and a decreased sense of self-care. Additionally, other maternal issues caused by this illness include high-risk labor and pre-eclampsia (Duan et al., 2019). Maternal PNDA can result in inadequate fetal development and increased health complications for the child, such as preterm birth, intrauterine growth restriction, and low birth weight (Duan et al., 2019; Marsay et al., 2018). The effects of Maternal PNDA on children include motor, cognitive, personal-social, and communication deficits (Fang et al., 2022; Shuffrey et al., 2022). These developmental gaps are precipitated by a lack of maternal-child bonding and attachment due to a mother's decreased responsiveness and sensitivity to her infant, which stems from PNDA (Klaman & Turner, 2016; 9 Shuffrey et al., 2022). The absence of attachment causes families to endure more significant disruptions caused by behavioral problems in the future (Olsson et al., 2021). Similar to the general public, the health complications caused by PNDA can be enhanced in the military community (Klaman & Turner, 2016). PNDA exposure affects women and their families and hinders the productivity and efficiency of the military (Klaman & Turner, 2016; Mastrangelo, 2022). The frequent relocations and high-stress environments in military lifestyles result in decreased knowledge of available community resources and support systems compared to civilian lifestyles (Klaman & Turner, 2016). Therefore, military members and their partners face further challenges and barriers when experiencing PNDA (GAO, 2022; Klaman & Turner, 2016; Mastrangelo, 2022). At an Air Force Base in the Western United States, there are currently no resources to screen for signs of PNDA; therefore, this project aims to correct this identified shortfall by bridging knowledge gaps. The Air Force military base lacks a PNDA screening system, which could have detrimental effects on individual and partner's physical, behavioral, and emotional health (Mayo Clinic, 2019). Literature Review and Framework The project literature review explores the negative impacts of PNDA on perinatal moms' health and familial outcomes while researching the effectiveness of support groups and the benefits of education and screening for PNDA. Melnyk and Fineout-Overholt (2019) identified that substantial evidence-based changes occur from the guidance of change frameworks. Therefore, Rosswurm and Larrabee's six-step EBP Model will guide the framework for change throughout this master's project. 10 Framework Rosswurm and Larrabee created a six-step EBP model to guide changes in healthcare (Gawlinski & Rutledge, 2008; Rosswurm & Larrabee, 1999). The six steps of this model include assessing the problem and changes, connecting the issue to the intended results after proposing the change, analyzing best practices for change, creating a change, incorporating and appraising the implemented change, and adopting the change into everyday practice (Gawlinski & Rutledge, 2008; Rosswurm & Larrabee, 1999). In the initial step of this model, the efficiency of existing processes should be compared or benchmarked against other, similar organizations' processes to validate the deficiency and solidify a need for change (Rosswurm & Larrabee, 1999). Next, the deficiency or issue identified will have potential interventions tied to desired results (Rosswurm & Larrabee, 1999). The third step consists of conducting a literature review to obtain and synthesize evidence from scholarly sources based on best practices (Rosswurm & Larrabee, 1999). According to Rosswurm and Larrabee (1999), clinicians base streamlined change on evidence obtained from the literature review stakeholder input. Step five consists of the trial implementation of the change and close monitoring of results to monitor potential problem areas (Rosswurm & Larrabee, 1999). Iterations are essential at this step because feedback is implemented into the process, and a more efficient product is generated (Rosswurm & Larrabee, 1999). The final step in this framework is integrating the change into the healthcare facility after stakeholders approve the change (Rosswurm & Larrabee, 1999). When implementing a perinatal peer support group with education and perinatal depression screeners, the MSN project aligns with the six steps of the Rosswurm and Larrabee EBP Model. The initial step addresses the high prevalence rates of PNDA that moms endure and 11 the adverse outcomes that this produces for families specific to the chosen project area. Providing moms with the proper support, education, and screening for PNDA will positively affect the identification and treatment of PNDA symptoms (Bhat et al., 2022; Fang et al., 2022; Marsay et al., 2022; Sahin & Seven, 2018). An initial literature review supports this belief and identifies effective change options to improve outcomes. Each step in the Rosswurm and Larrabee Model helps create an effective change process that can be incorporated into practice and evaluated. Once deemed effective and successful, this change will be adopted from a pilot phase into an ongoing, permanent occurrence for families at the Air Force Base in the study. The Rosswurm and Larrabee framework supports the MSN project through its proven effectiveness in creating change within the healthcare system, as evidenced by works from Traube (2017) and Salinas et al. (2021). Similar to the PNDA MSN project topic, Traube (2017) used the Rosswurm and Larrabee change model to implement an evidence-based screening instrument for postpartum depression (PPD) and evidence-based guidelines to enhance providers' identification of PPD. The Rosswurm and Larrabee framework also guided change in incorporating ultrasounds for peripheral intravenous (PIV) placements to reduce PIV attempts on patients with challenging PIV access (Salinas et al., 2021). Furthermore, utilizing a model such as this one, derived from evidence-based research aimed to deliver best practices through a thorough, iterative change process, strengthens the longevity of the implemented process improvements (Long et al., 2009; Rosswurm & Larrabee, 1999). The studies by Traube (2017) and Salinas et al. (2021) prove the Rosswurm and Larrabee model to be a successful framework for creating and implementing change. 12 Strengths and Limitations According to Gawlinski and Rutledge (2008), Rosswurm and Larrabee's EBP change model's six steps to assess and synthesize information increases the likelihood of success when implementing change. The strengths of this framework are attributed to its development using a combination of clinical experience, statistical data, and evidence-based research (Rosswurm & Larrabee, 1999). Additionally, using a repetitive process where clinicians assess, synthesize, and evaluate information to maintain the new change is another strength of this framework (Gawlinski & Rutledge, 2008). The Rosswurm and Larrabee Model's assets will be applied to this MSN project through a thorough literature review, collaboration, and evaluation while systematically enacting the steps guided by this framework. The Rosswurm and Larrabee EBP change model can be an effective process. However, the limitations to this model include the age of this model; Rosswurm and Larrabee designed this model in 1999 (Melnyk & Fineout-Overholt, 2019; Rosswurm & Larrabee, 1999). Since the creation of this model, there have been approximately 23 years of new developments in healthcare and EBP. Additionally, patient preferences and actions, one of the five concepts of evidence-based decision-making, are not addressed in this model (Melnyk & Fineout-Overholt, 2019). Including patients in a change process is essential because it allows clinicians to make well-informed decisions regarding the patients' preferences (Melnyk & Fineout-Overholt, 2019). Lastly, the barriers to change are not identified or addressed within this model, which can lead to further complications in the process (Melnyk & Fineout-Overholt, 2019). While these limitations exist, this MSN project will consider implementing additional measures such as feedback screeners to include patients' perspectives and overcoming potential barriers. 13 Analysis of Literature This MSN project addresses the PICOT question: "Does implementing a support group with structured screening and education on PNDA impact the identification and treatment of depression and anxiety within one year of giving birth?" During the analysis of the research evidence, several key points or themes were depicted that will help to answer this PICOT question. These themes are described further in the next section. Search Strategies A literature search was conducted to identify current evidence of perinatal depression using Google Scholar and Weber State University's Stewart Library's Advanced Search and Academic Search Ultimate. The following databases were used to narrow the search output: CINAHL, PubMed, MEDLINE, PsychINFO, Academic Search Ultimate, ERIC, and Health Source. Although the search was restricted to include only peer-reviewed articles from the last five years (2017-2022) to keep the information current, several older articles were included due to their unique and relevant information not found in newer articles. The search included the following keywords, which were used in various combinations to obtain results: antenatal, anxiety, base, community-based, depression, education, health, intervention, maternal, mental, mental health, meta-analysis, military, paternal, perinatal, period, postpartum, pregnancy, prevalence, qualitative, quantitative, screening, support, systematic review, and tools. The search resulted in four themes. The first theme is PNDA and its effects on women in the military community. The second theme is screener integration during the perinatal period. The third theme that resulted is education and awareness importance. Finally, the fourth theme is peer support as an effective tool to combat depression and anxiety. 14 PNDA and its Effects on Women in the Military Community Biggs et al. (2019) stated that approximately 75% of women experiencing PNDA symptoms are not identified, and only 50% of those with this mental illness actively seek treatment. Similarly, Mastrangelo (2022) reflected on a study conducted across the DoD that showed that 50% of women suffering from illnesses such as depression and anxiety refrain from seeking treatment due to stigmas. Reluctance to seek treatment often worsens PNDA and its effects (Mastrangelo, 2022). The military community is a high-risk population for mental health disparities due to factors that result from supporting the military base's mission, such as deployments (GAO, 2022; Klaman & Turner, 2016; Mastrangelo, 2022). Klaman and Turner (2016) stated that with deployments, spouses are exposed to stressors caused by constant relocating of their homes, PTSD from combat, and other factors. These factors increased the likelihood of PNDA in female members of the military population. The prevalence of PNDA is regularly monitored within society; however, the level of this mental illness is not typically measured in the military population (Klaman & Turner, 2016). Klaman and Turner (2016) performed a systematic review to track and develop these statistics. This review consisted of 10 articles chosen based on criteria that required the studies to focus on the military population while utilizing screening tools such as the patient health questionnaire, the postpartum depression screening scale, or the EPDS (Klaman & Turner, 2016). This systematic review analyzed information from eight military installations and concluded that the prevalence of PNDA in this community is between 4.6% - 50.7% (Klaman & Turner, 2016). Screener Integration During the Perinatal Period Proper identification of PNDA can further expand opportunities for appropriate support and resources available to mothers (Bhat et al., 2022). Screening mothers for PNDA can lead to 15 early detection and effective treatment (Bhat et al., 2022; Marsay et al., 2022; Sahin & Seven, 2018; Traube, 2017). Sahin and Seven (2018) performed a cohort study encompassing 23 cities and 23 hospitals (n=497). Data from the study was collected in two phases (Sahin & Seven, 2018). In the first phase, face-to-face interviews were conducted in 15-20 minute sessions (Sahin & Seven, 2018). In the second phase, members were interviewed over the phone to assess the EPDS and the Beck Depression Inventory (BDI) (Sahin & Seven, 2018). Sahin and Seven (2018) found that there was not a significant correlation between the BDI and EPDS (p=0.254); however, there was a level of significance between psychological support, family support, and their EPDS scores (p<0.05). Additionally, Sahin and Seven (2018) stated that mothers should be screened for postpartum depression during the prenatal and postpartum periods. Bhat et al. (2022) conducted a systematic review that involved 49 articles from 10 countries (n=49). Approximately 31.9% of the studies in the Bhat et al. (2022) systematic review provided screening during both the prenatal and postpartum periods, and 42.6% were only conducted postpartum; the last 25.5% were not completed at a specific time. The EPDS and the Hospital Anxiety Depression Scale (HADS) were used across various studies to screen for depression and anxiety (Bhat et al., 2022). The EPDS and HADS screenings help decrease PNDA and provide intervention methods (Bhat et al., 2022). Bhat et al. (2022) conclude that screenings increase awareness of PNDA while providing avenues to educate women on its effects and treatment routes. The results of the EPDS and HADS screening methods by Bhat et al. (2022) were similar to those of the Marsay et al. (2022) qualitative study. Marsay et al. (2022) showed that the impact of in-person screeners (n=55) on early identification of PNDA decreased the overall effects of PNDA. The study by Marsay et al. (2022) used depression screening tools like the EPDS, Whooley questions, and NetScid. Additionally, multiple individuals in the 16 Marsay et al. (2022) study analyzed results to determine the validity and reliability of the study results. Education and Awareness Importance Screening for PNDA identifies the presence of an issue and opens avenues for further education and treatment of this condition (Bhat et al., 2022; Philpott et al., 2019; Sahin & Seven, 2018). Depression can manifest anytime from the beginning of pregnancy throughout the first year postpartum (Sahin & Seven, 2018). Bhat et al. (2022) highlighted the importance of intervening during this period and noted that awareness and screenings for anxiety and depression are most effective when conducted through a community-based initiative. In the Bhat et al. (2022) study, 82% of the screenings occurred at home, and the remaining 18% were held within the community. The results of this systematic review by Bhat et al. (2022) provided data that, through the implementation of screening, maternal caregivers become more educated and aware of factors such as depression and anxiety. A systematic review by Philpott et al. (2019) included 34 studies with participants (n=7694) across 19 countries and included multiple interventions, including lifestyle-oriented programs. Philpott et al. (2019) found a decrease in anxiety after a couple of hours post-implementation of this intervention. Eight weeks following the implementation of the lifestyle-oriented training, the general health questionnaire identified a significant reduction in anxiety levels (p=0.001) (Philpott et al., 2019). Sahin & Seven (2018) stated that starting intervention methods and education is vital. Without necessary education and interventions, the family can be negatively impacted (Duan, 2019; Olsson et al., 2021). A cohort study which was performed by Olsson et al. (2021) analyzed 1,000 women across six waves (based on age) for 20 years in Australia (n=1000). Olsson et al. (2021) examined depression and anxiety symptoms and parental-infant bonding using tools such as the EPDS. According to 17 Olsson et al. (2021), authors demonstrated that depression and anxiety lead to a higher prevalence of maternal rejection of the infant during the perinatal period. Peer Support as an Effective Tool to Combat Depression and Anxiety Fang et al. (2022) stated that incorporating peer support for women experiencing PNDA during the perinatal period can significantly improve health outcomes. Health outcomes improved because peer support allows women to communicate and bond with others affected by similar, relatable experiences (Fang et al., 2022). During the beginning of pregnancy and up to one year following the birth of the child, peer support is an effective tool in combating PNDA (Fang et al., 2022; Marsay et al., 2022; O'Brien et al., 2017; Senni, 2018). During the perinatal period, the paternal caregivers also require support to cope with depression and anxiety (O'Brien et al., 2017). An integrative review conducted by O'Brien et al. (2017) aimed to detect paternal depression and anxiety across 13 articles. This study by O'Brien et al. (2017) resulted in four themes emphasizing that care should be provided to the family instead of solely from a maternal point of view. A meta-analysis by Fang et al. (2022) analyzed 16 studies (n=3154) conducted in eight countries during the perinatal period. According to Fang et al. (2022), implementing peer support significantly (p<0.00001) decreased the prevalence of perinatal depression. Peer support was enacted in individual, group, face-to-face, telephone/internet-based, and various methods (Fang et al., 2022). Peer support is most effective during the postpartum stage (p<0.00001) as compared to the prenatal stage (p=0.23) and the perinatal stage (p=0.02) (Fang et al., 2022, pp. 80). A similar qualitative study by Marsay et al. (2022) included participants (n=55) across three phases in South Africa. This study found that women receiving support for PNDA noticed 18 positive mood changes (Marsay et al., 2022). Marsay et al. (2022) stated that openly discussing the effects of PNDA with others helps to alleviate stress. Through screeners and peer support, the impact of PNDA on women can be lowered, decreasing the likelihood of adverse reactions perpetuating in children (Shuffrey et al., 2022). Summary of Literature Review Findings and Application to the Project The Mayo Clinic (2019) stated that mental health issues, including depression and anxiety, could lead to severe cognitive and physical problems if not identified and corrected. These mental ailments are significant issues affecting mothers and fathers during the perinatal period and can lead to adverse health outcomes for the caregivers and the child (Mayo Clinic, 2019). Evidence suggested that interventions such as peer support, education, and screeners are necessary to increase awareness so depression and anxiety can decrease (Fang et al., 2022; O'Brien, 2017; Sahin & Seven, 2019; Shuffrey et al., 2022). Klaman and Turner (2016) stated that women in a military environment are exposed to an increased prevalence of factors leading to PNDA compared to individuals outside of this environment. Along with factors seen outside military environments, such as increased stress, financial issues, education shortfalls, lack of support, and domestic violence, the military environment introduces deployments, living displacements, and potential exposure to combat (Klaman & Turner, 2016; Mastrangelo, 2022). Similar to PTSD, mental illnesses like depression and anxiety are typically unnoticed until affected individuals receive the tools to become cognizant of their presence; this lack of awareness can pose a significant problem (Mayo Clinic, 2019). The research evidence examined in this paper indicates that a lack of detection and education methods leads to a greater magnitude of depression and anxiety (Fang et al., 2022; O'Brien, 2017; Sahin & Seven, 2019; Shuffrey et al., 2022). 19 Project Methodology This MSN project aims to implement a support group with structured education and perinatal depression screening for perinatal women at an Air Force base in the western United States. Four deliverables have been developed to aid in informing and introducing the support group while promoting the success of this project. The deliverables for this project include (a) a presentation given to participants and stakeholders outlining the topics of discussion during the support group, (b) an accompanying infographic to the presentation that will include facts about PNDA, resources for PNDA, and topics of discussion during the support group, (c) the EPDS, a tool that will screen for the presence and severity of depression, and (d) a participant feedback pre-, six-month, and post-intervention survey, which will assess the success of the project. The effects of PNDA on pregnant women, spouses, and the Air Force Base can be identified and alleviated through the project deliverables. Description and Development of Project Deliverables The Family Advocacy Nurse (FAN) will utilize four deliverables throughout this project. These deliverables will assist the FAN in providing screening and education of PNDA while measuring the project's success. A detailed explanation of each deliverable has been included below. Stakeholder Presentation Prezi (n.d.) states that effective presentations should be persuasive, memorable, and engaging. Presentations allow others to visualize a project's road map (Prezi, n.d.). The first deliverable in this study is the stakeholder presentation (see Appendix A). The presentation will provide a detailed overview to the stakeholders about PNDA and the proposed project. This 20 deliverable will allow the stakeholders to visualize the topics and information that outline the importance of the proposed project and aims to gain stakeholder buy-in for the support group. The stakeholders include the Family Advocacy Officer (FAO), military units, command sections, the Family Advocacy Intervention Specialist (FAIS), psychologists, and the clinic staff, which includes nurses and primary care managers. The FAO oversees all Family Advocacy activities on the military base. Family Advocacy is the organization on the military base that implements programs to support military families and is the office that houses the FAN; thus, they will be the primary implementor for this project. The stakeholder presentation aims to gain support and approval from the FAO to develop and conduct the PNDA support group. Additionally, military units and command sections in charge of the active-duty military members on the base will gain information from the presentation about the support group to disseminate to the units they oversee, which will help the FAN gain participants for the support group. The clinic nurses and primary care managers on the base will be responsible for creating referrals for participants to see specialists such as psychologists if needed. The FAIS works with the FAN in the Family Advocacy office and will help provide primary education about behavioral health throughout the support group. A psychologist is a stakeholder who will serve as a support group resource by providing treatment to clients with severe cases of PNDA. Infographic The second deliverable in this study is an educational infographic (see Appendix B). This infographic aims to increase awareness so individuals suffering from PNDA understand the resources available to them. An infographic helps to promote positive learning (Bicen & Beheshi, 2017). This deliverable will contain educational information from a literature search on best practices for identifying and seeking treatment for PNDA. The infographic deliverable will 21 include support organizations that can be contacted 24/7 for anyone needing immediate assistance. The support organizations include Open Doors, Postpartum Support International, and the Substance Abuse and Mental Health Services Administration (Open Doors, n.d.; Postpartum Support International, n.d.; United States Department, n.d.). Representatives from these organizations will be brought into the support group to discuss their organization's services. Additionally, providing educational information on the symptoms and intervention options for PNDA aims to broaden awareness and education on this topic. This deliverable will be administered during the support group interactions and distributed to the different units/commands and clinics on the base so all military families on the Air Force Base can access information on PNDA and the support group. An infographic was chosen for this project because it allows vast amounts of information to be condensed into an easy-to-read visual graphic (Bicen & Beheshti, 2017). Edinburgh Postnatal Depression Scale The third deliverable used for this study is the EPDS (see Appendix C). Clinicians use this assessment screening tool to assess for indications of PNDA (Levis et al., 2020). The EPDS is a 10-question assessment rated on a 0-3 scale, with 0 as the minimum score and 30 as the maximum (Levis et al., 2020). According to Levis et al. (2020), a score of 10 or higher or specific answers to highly sensitive questions may indicate the presence of PNDA. The FAN will administer the EPDS at the beginning of the study to determine if there is an indication of PNDA in participants. Pre-, Six-Month, and Post-Intervention Survey The fourth deliverable utilized during this study is a pre-, six-month, and postintervention survey (see Appendix D). The FAN will administer a survey at the beginning of the 22 support group, after a participant has remained active in the support group for six months, and at the support group's conclusion (one calendar year after the birth of the participant's child). This deliverable will help to establish a baseline to assist in gauging the impact of information taught, the efficiency of information dissemination, and other feedback from participants. Additionally, the survey will help measure the effectiveness of the support group after project implementation. Jones et al. (2013) state that surveys are an excellent method to obtain statistics for large numbers of people. Staff must design surveys to solicit measurable information for evaluation (Jones et al., 2013). Plan and Implementation Process This MSN project utilizes the Rosswurm and Larrabee six-step EBP model (Rosswurm & Larrabee, 1999). The Rosswurm and Larrabee EBP model applies an iterative process that the FAN will use as a framework to assess, synthesize, and evaluate information (Gawlinski & Rutledge, 2008; Rosswurm & Larrabee, 1999). The six steps of the Rosswurm and Larrabee model include assessing the problem, tying interventions to ensure they meet the intended results of the study, analyzing best practices, creating change, appraising the implemented change, and adopting the change into everyday practice (Gawlinski & Rutledge, 2008; Rosswurm & Larrabee, 1999). The MSN project aligns with the Rosswurm and Larrabee six-step EBP model through the assessment of the PNDA problem and the connection of PNDA to the intended results using the PNDA support group. Other steps of the EBP model align with this MSN project, including a thorough literature review, creating change through the PNDA support group, appraising the change through evaluation surveys, and then adopting the change into permanent practice during the evaluation process (Rosswurm & Larrabee, 1999). Utilizing the six steps of the Rosswurm and Larrabee model will help achieve the project's aim of 23 incorporating change into the lives of families and creating lasting change in everyday practice on the Air Force Base through education and awareness (Rosswurm & Larrabee, 1999). The FAN will develop the stakeholder presentation, which will be shown to stakeholders to gain buy-in. Following the development of this deliverable, the FAN will meet with the FAO to receive approval to conduct the project. The FAN will oversee this support group and use the stakeholder presentation to enlighten stakeholders on the 36% of the DoD members who suffer from PNDA (GAO, 2022) compared to the nationwide 21.9% of individuals suffering from PNDA (Fang et al., 2022). A stakeholder presentation (see Appendix A) and an infographic (see Appendix B) will be distributed during the initial education and disseminated to various units/commands and clinics on the Air Force Base to help gain buy-in for the study. Once the presentation and infographic are sent and reviewed by organizations on the base, the FAN will begin to recruit diverse staff, including the FAIS, clinic nurses, primary care physicians, and psychologists, who will assist with the support group. The clinic nurses and primary care physicians will assist the FAN in contacting or referring families currently being seen in the medical clinic and at a heightened risk for potential PNDA to the support group. The client recruitment will include mothers who are pregnant or within the first year postpartum. The clinic nurses, primary care physicians, and FAN will instruct the mothers about this support group's existence and encourage them to attend. Once a client agrees to attend the support group, the FAN, clinic nurse, or primary care physician will share the date and location of the group with the client and add the client's name to a shared electronic document of group registration. The FAN will conduct the bi-monthly support group at a facility on the Air Force Base referred to as the Military and Family Readiness Center (MFRC), a centrally located community center on the installation. This location is ideal because it is separate from the medical facility 24 and facilitates many of the main functions of the Air Force Base. This separation from the medical facility will attempt to reduce any negative stigmas or fears preventing participants from seeking vital help. During this first session, attendees will complete a consent allowing the FAN and other healthcare professionals with need-to-know access to the patient's protected health information. Also, during the initial and each subsequent session of the support group, the FAN will administer and review the EPDS (see Appendix C) to determine the possible prevalence of depression and changes throughout the program. Participants who score high on the EPDS will be assisted and referred to a psychologist. Along with the EPDS, a pre-implementation survey (see Appendix D) will be given during the first session to assess initial knowledge and symptoms. The FAN will give the six-month implementation survey to participants after six months of active participation in the group and the post-implementation survey at the conclusion of the program. The duration of the MSN project begins with the initial contact and is then extended to one calendar year after the birth of a participant's child. The FAN will review the data obtained from the EPDS and the pre-, six-month, and post-implementation survey deliverables to evaluate the effectiveness of the support group. Following an evaluation process conducted by the FAN, feedback obtained from the stakeholders and deliverables in this project will create changes to the program, and future implementation will be discussed. Interdisciplinary Teamwork Collaboration of healthcare workers on the Air Force Base is necessary to provide high levels of care. The success of this MSN project depends on multi-agency collaboration and participant engagement to occur to provide effective interventions. Through an interdisciplinary 25 teamwork effort, the effects of PNDA can be lessened. The team members involved in this MSN project are described in the content below. Family Advocacy Nurse. The FAN will oversee the entire project and be responsible for establishing the project and recruiting stakeholders and participants. The FAN will administer the pre-, six-month, and post-implementation surveys and EPDS as assessment tools for every participant. The FAN will also recommend that participants work with clinic nurses and primary care physicians to receive referrals to specialists such as psychologists, social workers, or outside support groups. The FAN will evaluate information obtained from the assessment tools to identify improvements or shortcomings. Following the study's conclusion, the FAN is responsible for evaluating and coordinating the adoption of the project into permanent practice. Family Advocacy Officer. The FAO oversees and coordinates the operations of the Family Advocacy Program. The Family Advocacy Program, which includes the New Parent Support Program (NPSP), is a military organization focusing on preventing child abuse through education and intervention. The NPSP works with many of the Air Force Base's pregnant women and families with children under three years old to provide support and education about parenting. The FAN will enroll participants from the NPSP into the support group. Because the FAO oversees the staffing and resources of the Family Advocacy Program, the FAO will need to provide approval for the FAN to conduct the support group. The FAO will be informed of evaluation outcomes, so additional consent to continue implementing the support group may be provided if the support group is deemed effective. The FAO will not have any additional involvement in the support group. Family Advocacy Intervention Specialist. The FAIS is a licensed social worker who works alongside the FAN in the Family Advocacy clinic. The FAIS specializes in prevention and 26 provides patients with mental and behavioral health education. The FAIS's role will be to attend support group meetings to discuss and educate participants on effective coping strategies for managing PNDA or any other stressors that participants identify. Clinic Nurses and Primary Care Physicians. The clinic nurses and primary care physicians in the medical clinic will take an active role in this project. In the medical facility, these individuals oversee the routine care given to patients. The clinic nurses and primary care physicians will help to identify eligible participants for the PNDA support group, educate potential participants on the support group, and help register participants for the support group. The clinic nurses and primary care physicians can also submit outpatient referrals for patients to be seen by psychologists or other support organizations as deemed necessary through the initial assessment and support group process conducted by the FAN and FAIS. Psychologist. The FAN will consult with the Psychologist if a patient survey indicates a high EPDS score. The Psychologist will attend the support group quarterly to outline all aspects of PNDA to the group. Along with the FAN, the Psychologist will detail the effect that PNDA has on families and the importance that interventions can have in combatting PNDA. Unlike the FAIS, the Psychologist will provide personal sessions to patients who score high on their EPDS or have severe cases of PNDA. Timeline Multiple tasks will occur to ensure the MSN project follows a smooth timeline. The first item on the timeline will involve the FAN spending two weeks developing the stakeholder presentation that outlines the PNDA support group and its importance. Once developed, the FAN will coordinate a 30-minute briefing with the FAO to discuss implementing a support group on the Air Force Base. Once approval is received, the FAN will gather stakeholders, including 27 military units, command sections, a FAIS, a psychologist, clinic nurses, and primary care managers for an interdisciplinary meeting. During this one-hour meeting, the stakeholder presentation will outline the issues of PNDA and potentially gain buy-in from these stakeholders. Once buy-in is acquired, the FAN, clinic nurses, primary care physicians, and unit commands will seek out participants and educate potential participants on the PNDA support group. Upon registration of participants, the support group sessions will begin. The FAN will host the first support group. These occur on the first and third Wednesday of the month. Every session will last an hour, and during every meeting, the participants will complete the EPDS tool, which takes approximately 5-10 minutes. Along with the EPDS, a preimplementation survey will be given during the first session to assess knowledge and symptoms. After every session, the FAN will review the EPDS to assess the need for additional assistance or consultation with the on-base Psychologist. If required, the participant will meet with the clinic staff, including their primary care physician and clinical nurses, for 30 minutes for an assessment before obtaining a referral to an off-base psychologist. If the participant would rather see the onbase Psychologist, the participant will be directed to the medical clinic to schedule an appointment. The FAN will continue to administer the six-month and post-implementation surveys to participants after six months of active participation and at the conclusion of the program. This MSN project will be implemented for an entire year and assessed for impact and efficiency. The FAN will review the data retrieved from the support group to determine the effectiveness of the overall support group implementation. Once the support group is reviewed and deemed effective, it will become a permanent addition to the Family Advocacy Program. 28 The complete timeline for this project allocates approximately 14 months for planning, implementation, and evaluation (see Figure 1). Figure 1 Timeline Note. This timeline outlines the implementation period of the MSN project during the planning, implementation, and conclusion stages. Plan for Evaluation of Project Jones (2016) states that it is the inherent duty of nurses to measure outcomes; therefore, this project will utilize the deliverables to evaluate the impact of the support group during the study period. The FAN will administer the EPDS every session and record each participant's results to assess for mental health changes in participants when identifying probable PNDA. The FAN tracks the results of the EPDS throughout the study and will use the data to determine if the bi-monthly support group sessions reflect a decrease in EPDS scores. The FAN will review and compare the participants' pre-, six-month, and post-implementation surveys' results to determine 29 the impact of the support group. The answers to the survey will be rated on a weighted scale. The FAN will then meet with the stakeholders to present pre-, six-month, and post-implementation surveys and EPDS results. The FAN and stakeholders will work together to identify any shortcomings of the PNDA support group and establish a plan for correcting the shortcomings. If there are no identified areas of improvement, or once the identified areas of improvement have been addressed, the PNDA support group will be adopted into permanent practice within the Family Advocacy Program. Ethical Considerations Melnyk and Fineout-Overholt (2019) state that all members of the support group staff must be well-versed in ethics and participants' rights. The inherent responsibility is to ensure the security of patients and their information (Melnyk and Fineout-Overholt, 2019). The PNDA support group will be offered to all perinatal women associated with the Air Force Base. The group remains entirely voluntary; any participant can exit the study without judgment. One method to address ethical considerations is ensuring the security and privacy of every study participant. The personal health information of consented participants will be managed on a secured device and protected by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Centers for Disease, 2022). Only individuals listed on the consent who have a need-to-know will have access to this information. Staff will assess and treat each participant equally without bias or discrimination. Unless risk for imminent harm to self or others (suicidal/homicidal plan or intent) is identified, staff will honor each participant's right to self-determination and will not force any participant to undergo treatment or contact support services if they do not wish. Additionally, the FAN will counteract bias by constantly communicating with team members and ensuring that chart information 30 remains objective. The FAN will also ensure that each team member is educated on ethics to embody ethical principles through open and ongoing discussions throughout the project's implementation. Discussion Mental health issues are challenging to identify, as evidenced by numerous patients affected by PNDA (Senni, 2018). This issue is a significant problem within the DoD, which reflects a staggering 14.1% increase in PNDA cases compared to individuals outside of the DoD (Fang et al., 2022; GAO, 2022; Klaman & Turner, 2016). During the perinatal period, healthcare providers do not always correctly identify women experiencing PNDA symptoms (Biggs et al., 2019). Therefore, these women do not recognize possible PNDA symptoms or seek needed treatment (Biggs et al., 2019). Research has shown that effective identification, education, and support produce better outcomes for individuals suffering from PNDA (Fang et al., 2022; Sahin & Seven, 2019). This section will outline the delivery tools used to disseminate the information. The study's strengths, limitations, implications, and recommendations and their significance to the nursing practice will also be discussed. Evidence-based Solutions for Dissemination Evidence-based information is vital because it allows information to be disseminated to a broader population of stakeholders with additional solutions based on best practices that can be incorporated (Ross-Hellauer et al., 2020). After this project's development, the project will be presented to faculty and peers at Weber State University utilizing an oral and poster presentation. The oral and poster presentation will include a quick synopsis of the project's relevance to the intended recipients, the plan for change, including what theoretical framework guided the change 31 process, evidence-based practice recommendations for how the change will be executed, and evaluated after implementation. Additionally, the project findings related to project relevancy and proposed changes to combat the identified issue of PNDA prevalence rates, inability to correctly identify PNDA, and decreased knowledge of PNDA symptoms and treatments discussed throughout this project will be presented to the stakeholders previously mentioned in this paper through an oral and PowerPoint presentation. This presentation to the stakeholders will aim to enlist adequate buy-in and support for implementing the project. Following the 14 months of the implementation of this project, the FAN will compile the results obtained from the evaluation surveys, prevalence rates, and changes in EPDS scores throughout the support group's implementation. An additional concluding presentation will be presented to the FAO through a PowerPoint presentation to include project results and discuss changes that may need to occur for the future of this project's ongoing applicability and effectiveness. A detailed report will also be developed, including feedback received from the stakeholder presentation, infographic, EPDS, and the pre-, six-month -, and post-intervention survey used throughout the project to guide any further changes that may be necessary. Once the project's future is defined for the Air Force Base in the West, the next goal is to disseminate this project further to provide PNDA education and awareness to the entire DoD, eventually including all military installations. The FAN and FAO will present the results of this project to the Air Force Medical Readiness Agency (AFMRA), which oversees all Family Advocacy Programs across the Air Force. The end goal of this project is to be disseminated throughout the Air Force Family Advocacy Programs with the help of AFMRA and eventually throughout the entire DoD to expand treatment rates and education for PNDA to all service members and their families. 32 Publication of the findings will be considered after the implementation of this project but will not be the priority for disseminating information discovered throughout this project. Instead, real-world implementation and evaluation of this project will be prioritized. Publication of research can help disseminate information to a larger audience quickly (Ross-Hellauer et al., 2020). However, waiting until the project has been implemented, changes have been made, and the project has proven to be an effective resource in enhancing PNDA education, support, and identification will support more effective and valid results. Significance to Advance Nursing Practice This MSN project can significantly benefit nurses and organizations caring for women during the perinatal period by increasing provider education and awareness of PNDA prevalence rates, support benefits, and appropriate interventions (Fang et al., 2022). The effects of PNDA are often overlooked (Biggs et al., 2019); therefore, through the implementation of this project, nurses will be better equipped to educate women so that they can identify symptoms of PNDA and seek out professional help. Medical professionals working to implement this project by providing an opportunity for peer support, education on PNDA and its effects, and increased identification of this condition will help to decrease the negative impacts that PNDA has on individuals, families, and society discussed previously. The negative impacts affected include health conditions, decreased familial bonding and attachment, and increased societal costs (Bhat et al., 2022; Fang et al., 2022; Sahin & Seven, 2019; Shuffrey et al., 2022). If implemented to its fullest potential, this MSN project will help thousands of women across the DoD combat PNDA. Implications One of the strengths of this MSN project is the usage of Rosswurm and Larrabee's sixstep EBP Model (Rosswurm & Larrabee, 1999). The Rosswurm and Larrabee EBP model guides 33 the framework for change and is a strength because of the iterative process that the FAN will use to assess, evaluate, and synthesize information (Gawlinski & Rutledge, 2008; Rosswurm & Larrabee, 1999). This EBP model will allow the FAN to create an efficient support group that produces vital, positive outcomes (Rosswurm & Larrabee, 1999). The knowledgeable and diverse staff recruited is another strength of the MSN project. Having diverse stakeholders invested in improving the quality of life for the participants through education and support will lead to efficient, lasting change (Long et al., 2009). The limitations of this project lie in its implementation. There is currently limited data on any PNDA groups administered within the Family Advocacy Program, so starting this program on the military installation will prove difficult unless the FAN considers all facets of the military culture and PNDA. This limitation can be reduced by conducting an extensive literature review on PNDA. An additional limitation is the small sample size of the test project. The GAO (2022) identifies more than 200,000 dependents within the DoD. During the test project, only a small fraction <1% of this population will be included in the project sampling. A limitation of implementing the project on a larger scale is the bureaucracy that will need to be navigated with AFMRA to officially get funding and approval for the PNDA project to be implemented DoDwide. This obstacle can be addressed through survey data and information gained through the project evaluation. The project statistics will provide data showing effectiveness, or lack thereof, and will be used to make further recommendations. Another limitation is the limited outreach of the project. Because this issue affects the entire DoD, the project implementation will take significant time before it can be disseminated throughout the entire DoD. This specific limitation will be addressed once project results are disseminated and implemented to larger populations after the first trial of the project. The final limitation is getting participants for the study. The 34 FAN will combat this by disseminating information to the military community with assistance from the military units and command sections and communications with NPSP clients. Implementing this project will support nursing knowledge because the FAN will work with other healthcare professionals to develop best practices to combat PNDA. The PNDA support group will be created and administered through collaboration and following evidencebased practice. The information in the project will increase the knowledge of the DoD nurses caring for individuals affected by PNDA. By increasing the knowledge of PNDA among DoD nurses, a more significant healthcare force will be available to the DoD population trained to identify the prevalence of PNDA. The DoD nurses will also provide education and intervention options to this population, hopefully decreasing this overwhelming issue within the DoD. Recommendations Large amounts of research are available for the PNDA topic; however, during the literature review, very little research was discovered that applies to this project's targeted population. Klaman and Turner (2016) note that the prevalence of PNDA in the military population is between 4.6% - 50.7%. The GAO (2022) also approximates this percentage to be 14.1% higher than the non-DoD population. This project will assist in combatting the issue of PNDA across the DoD; however, more evidence-based research must be conducted and published to highlight this issue's existence and severity. Before the implementation stage, this MSN project will be disseminated to the content expert, peers, and instructor for a final review. The feedback will be reviewed and incorporated before the FAN implements the project. The implementation of the project is the next step. During this step, an iterative process will be in place so that the effectiveness of the information can be constantly evaluated and fine-tuned to promote the efficiency of this project. 35 Conclusions PNDA is a mental illness often overlooked within the DoD (GAO, 2022). The literature review conducted for this project highlights the shortfall in evidence-based research regarding PNDA, especially within the DoD. This literature review discovered that equipping moms with support, education, and screening for PNDA will positively affect the treatment and identification of PNDA symptoms (Bhat et al., 2022; Fang et al., 2022; Marsay et al., 2022; Sahin & Seven, 2018). Through implementing this MSN project at the Air Force Base, countless women in the perinatal period will receive education and support on PNDA. 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Development of a quality improvement initiative to screen for postpartum depression. https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=4431&context =dissertations United States Department of Health and Human Services. (n.d.). SAMHSA's National Helpline. https://www.samhsa.gov/find-help/national-helpline 41 Appendix A Stakeholder Presentation 42 43 44 45 46 Appendix B Infographic 47 Appendix C Edinburgh Postnatal Depression Scale Note. Reproduced from Edinburgh Postnatal Depression Scale (EPDS) by J. L. Cox, J. M. Holden, and R. Sagovsky, 1987, British Journal of Psychiatry, 150(1). https://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf. Image used with the permission of Authors. 48 Appendix D Pre-, Six-Month -, and Post-Intervention Survey