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The MOMS (Making Our Mothers Stronger) Project: A Culturally Tailored Parenting Intervention for Mothers Living with HIV in the Southern USA

  • Susan L. Davies
  • Herpreet Kaur Thind
  • Jamie L. Stiller
Chapter

Abstract

The southeastern region of the United States has had the highest increase of new HIV/AIDS cases among all regions in the country and now has the highest incidence of HIV-positive women. The MOMS (Making Our Mothers Stronger) Project was a randomized, controlled behavioral trial that aimed to improve functioning of families affected by HIV by reducing childbearing stressors among HIV-positive mothers. Participants were randomly assigned to one of two intervention conditions: a Social Cognitive Theory (SCT)-based intervention (focused on reducing parenting stress) or an attention-control intervention (focused on reducing health-related stress). The parenting intervention focused on building four key skills: communicating clearly and effectively with their children, using positive and negative consequences with their children to effectively change child’s behavior, enjoying their children more by finding ways to build quality time together into their normal routine, and taking care of themselves so they can best care for their children. Post intervention, there was significant decline in parenting-related stress in both the intervention conditions. Implications and future directions based on study findings are discussed.

Keywords

African American Woman Parenting Intervention Social Cognitive Theory Parenting Skill Family System Theory 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

1 Introduction

African Americans represent a small proportion (13.6%) of the US population; however, they accounted for 50.3% of the HIV diagnosis in adolescents and adults during 2005–2008 in 37 US states (CDC 2010a). Further, the rates of HIV infection have increased among African American women; in 2006, it was approximately 15 times as high as that of Caucasian women (CDC 2010a). The estimated lifetime risk of being diagnosed with HIV is 1 in 30 for African American women compared to 1 in 588 for White females (Hall et al. 2008), making it the third leading cause of death among 35–44-year-old African American women (CDC 2010b).

1.1 HIV in the Southern USA

The Deep South region of the United States has had the highest increase of new HIV/AIDS cases among all regions in the country (Reif et al. 2006). In the six states that collectively make up the Deep South (Alabama, Georgia, Louisiana, Mississippi, North Carolina, and South Carolina), HIV incidence rates increased 36% from 2000 to 2005, while comparable rates decreased 6% in the other regions of the USA over the same period (Pence et al. 2007). In addition, the Deep South’s HIV epidemic is exponentially higher among African Americans, women, and residents of rural communities than other regions of the country (McKinney 2002). Among females in the South, African American women accounted for 70% of all HIV diagnoses during 2005–2008 (CDC 2011). Moreover, in Alabama, African American women accounted for 22% of all HIV/AIDS diagnoses and 73% of female diagnoses in 2009. Many women living with or at risk for HIV infection do not engage in high-risk sexual behaviors; their increased vulnerability stems from the risk behavior of their male partners (Kojic and Cu-Uvin 2007; amfAR 2008).

The HIV epidemic in southern states is so unique to the rest of the country. In fact, it has been said to have more in common with those of developing countries. Reasons for this are many and complex but include the fact that these states are significantly poorer compared to other states, stigma and ostracism are more common, and conservative values predominate (Konkle-Parker et al. 2008). Peterman and colleagues (2005) examined US counties with reported increases in AIDS incidence rates. Of 20 counties with this disturbing trend, 18 of them were in the southeast. These counties had a higher proportion of households headed by a single mother, a higher proportion of persons with less than a 9th grade education, a larger proportion of the population that was African American, and lower overall literacy levels. Further, these counties with the largest increases in AIDS incidence also had higher incidence rates of syphilis, age-adjusted mortality and infant mortality, and more low-birth-weight infants.

These trends will be difficult to reverse given the region’s concomitant rates of poverty and uninsured individuals, which further hinder HIV prevention and treatment efforts. Adimora and colleagues (2002) examined the role of various contextual factors (including racism, discrimination, limited employment opportunity, and resultant economic and social inequality) that may promote HIV transmission in this population. They posit that the social and economic environment of many African American communities in the Deep South discourages long-term monogamy and promotes concurrent sexual partnerships, which may, in turn, fuel the HIV epidemic in this population.

1.2 Heightened HIV-Related Stigma in the African American Community

In addition to the concerns about physical health and death, the main issue faced by the people living with HIV (PLWH) is stigma (see Liamputtong 2013;  Chap. 1 in this volume). Research has shown that stigma associated with HIV/AIDS is greater than many other stigmatizing conditions such as mental illness and physical health problems (Crawford 1996; Corrigan et al. 2000). Moreover, HIV-related stigma is found to be significantly higher among African Americans compared to Whites (Emlet 2007). In a study in New York City, black men living with HIV/AIDS reported that stigma marks them as “just one more body” within medical and social institutions. The dynamics of stigma is so severe that it leaves those experiencing it feeling that they are “stuck in the quagmire of an HIV ghetto” (Haile et al. 2011).

Stigmatizing attitudes are associated with misconceptions and lack of knowledge of the mechanism of HIV transmission (Sengupta et al. 2010; see also Liamputtong 2013) and overestimating the risk of casual contacts (Price and Hsu 1992; Herek and Capitanio 1994). People feel uncomfortable having direct contact with PLWH. This feeling of discomfort leads to avoidance or discrimination (Herek et al. 2002). For example, in a national telephone survey, one-third respondents said they would avoid shopping at a grocery store if the owner had AIDS (Herek et al. 2002). Studies have indicated that religious beliefs can also instigate discrimination against PLWH (Fullilove and Fullilove 1999). Especially for African American women, high religiosity beliefs are associated with higher stigma since HIV/AIDS is associated with immoral behaviors and considered a curse or punishment from God (Muturi and An 2010).

Fear of HIV-related stigma is a barrier to testing among African Americans (Hutchinson et al. 2004; Payne et al. 2006; Wallace et al. 2011). It also impedes them from seeking health care and adhering to antiretroviral medication (Konkle-Parker et al. 2008). Especially in smaller communities and rural areas, the fear of being seen at a HIV clinic by someone from their neighborhood prevents them from attending HIV clinics for treatment (Kempf et al. 2010). PLWH do not disclose their status to protect themselves from stigma. However, not disclosing prevents them from receiving education, medical care, and the needed social support (Serovich 2001; Hudson et al. 2001). Lack of access or delayed access to care further results in disease progression, which increases HIV/AIDS morbidity and mortality in this population (Sengupta et al. 2010).

HIV-related stigma has several consequences that affect the physical, psychological, and social health of PLWH. It leads to feelings of loneliness, isolation, and social exclusion (Sayles et al. 2007; Vyavaharkar et al. 2010). Studies have indicated that depression is much higher among PLWH compared to the general population (Ciesla and Roberts 2001). Further among PLWH, depression is much higher among women, especially African American women (Moneyham et al. 2000; Phillips et al. 2011). Women living with HIV face extreme stress in excess to their coping abilities, which results in adverse psychological outcomes (Vyavaharkar et al. 2010).

1.3 HIV in Women and Mothers

Women, minorities, and low-income persons are more likely to contract HIV. As a result, these groups, which are already compromised by discrimination, stigma, and inadequate health insurance, experience higher mortality rates than those in other sociodemographic groups. African American low-income women are a highly vulnerable group that have the greatest unmet needs and who are also less likely to seek treatment for their HIV.

Women are already more likely than men to delay HIV medical care for themselves; having children in the household strengthens this association (Stein et al. 2000). Mothers living with HIV (MLWH) in the Deep South face a number of barriers that preclude their ability to receive optimal medical and mental health care. Lack of childcare and transportation are common obstacles to care among low-income women in the South. These structural and financial barriers are compounded by psychosocial barriers of inadequate support systems, concerns about confidentiality and heightened stigma for MLWH in the South. Stigma fuels the HIV epidemic by increasing denial and decreasing testing and treatment seeking in those living with or at high risk for HIV. High levels of perceived stigma have been associated with lower physical, psychological, and social functioning in MLWH (Clark et al. 2003; Murphy et al. 2006), as well as lower levels of disclosure (Clark et al. 2003). Stigma has a particularly strong impact on MLWH, and while this population could benefit immensely from social support, too often, they experience rejection and exclusion from their social networks (Ciambrone 2002; see  Chap. 1). Limited perceived social support significantly predicts distress in MLWHs (Hudson et al. 2001). The South’s conservative, religious culture exacerbates these problems and inhibits communities from actively addressing this growing crisis.

1.4 Issues Faced by MLWHs and Their Children

While MLWHs often perceive motherhood to be their most important role, they also report that it is a significant source of their stress (Andrews et al. 1993; Van Loon 2000). Being both a primary caregiver and a patient with a condition that others do not know about puts MLWH at several disadvantages. First, they do not receive the social support that they need from family members and friends, either because others do not know of their status, and MLWHs keep them from getting too close because of their “secret,” or because others are aware of their HIV status, and choose not to provide support because of their own misguided concerns and beliefs about HIV transmission. Second, as HIV affects an individual physically, mentally, emotionally, and spiritually, MLWHs are likely to have many HIV-specific needs that they cannot meet on their own. Finally, having to keep something so significant hidden from those who could provide the needed support and resources is a very difficult task. While the disease itself rarely threatens maternal mortality for those with access to the antiretroviral therapy (HAART), the psychological toll of holding a secret so powerful that it can bring immediate ostracism, discrimination, unemployment, and even eviction and a host of other catastrophes if it were revealed, not only to oneself but to one’s children and family, is often too painful to acknowledge. Denial brings its own adverse outcomes, both physiologic and emotional.

The persistent stressors faced by the MLWHs can complicate their HIV management through the direct effects that stress can have on the immune system (Glover et al. 2010). Studies have shown that stress can influence immune system functioning and also affect the HIV symptom severity and progression of disease (Kopnisky et al. 2004; Glover et al. 2010). Other negative outcomes been reported by MLWHs with increased stress include depression and substance abuse, which further compromise their health condition (Glover et al. 2010).

A mother’s depression rarely leaves her children unscathed. Rather, maternal depression often spills over to adversely impact the family. Depression in MLWHs has also been associated with increased disruptive behaviors in their children (Pilowsky et al. 2003). Maternal depression brought on by social isolation, economic worries, and concern over children’s future well-being can significantly affect the children. An inverse relationship has been shown between levels of depression and amount of caregiver involvement, whether the parents are living with HIV or not (Webster-Stratton and Hammond 1990; Stormshak et al. 2002).

In addition to the direct toll that stress can have on MLWHs, it can have indirect adverse effects by compromising their parenting skills and general coping abilities. Poorer parenting skills in turn lead to increased child behavior problems (Tompkins and Wyatt 2008). However, research has shown that positive parenting and family management practises by MLWHs are associated with better child outcomes (Murphy et al. 2010). Further, studies have shown that a coping style of seeking social support is associated with increased survival among parents living with HIV (Lee and Rotheram-Borus 2001). These studies point to the need to strengthen parenting skills and build social support systems among MLWHs to decrease their stress and improve their functioning.

One of the most daunting barriers to participation in psycho-educational and/or support group sessions for MLWH is the fear of disclosure. Less HIV disclosure to children has also been associated with missing medical appointments (Mellins et al. 2002). MLWHs would rather miss appointments if childcare was not available than bringing their children to their clinic appointment (Kempf et al. 2010). Further, low levels of HIV disclosure to children have been associated with higher externalizing behaviors, internalizing symptoms, and increased distressing life events (Nöstlinger et al. 2006). Nonetheless, research suggests that disclosure may be protective against maternal depression (Wiener et al. 1998; Murphy et al. 2011). Disclosure may result in better mental and physical health (Pennebaker et al. 1990), in that keeping a secret may stress one’s body as well as their mind (Pennebaker et al. 1987; Imber-Black 1998). Increasing awareness and reducing concerns about stigma can help prepare MLWHs to disclose their status to their children and other support systems.

1.5 Parenting Interventions

Although the structure of families has changed dramatically over time, societal expectations of parents have not. Society still expects the parent(s) to be competent in performing its essential functions despite formidable stressors and challenges (McCubbin et al. 1997). Unfortunately, many of today’s families are inadequately prepared or unable to equip their children with essential skills to thrive within and/or outside the family. Many parents today lack effective parenting skills for optimal parent, child, and family functioning. Until these skills are learned, unconstructive patterns of behavior and interaction are repeated and reinforced. Their impact takes a significant toll on the child (i.e., anger, shame, diminished self-concept, self-regulation, social, and emotional skills), the parent (guilt, exhaustion, social isolation), and family unit (chaos, disruption, disintegration, reduced communication).

Families in every culture have the same basic goals and functions that are critical to both health and quality of life. Just like all mothers, MLWHs want the best for their children, including the opportunity to realize their fullest potential and live a healthy, safe, and satisfying life. And, just like all mothers, MLWHs struggle to protect their children from the daily assaults from poverty and violence to loneliness and fear that threaten their health and well-being (Boyce 2009). While MLWHs often report experiencing significant parenting-related stress, they also report that their children are a source of comfort for them (Wood et al. 2004). Therefore, improving parent–child connectedness could not only protect children from risk behaviors but can also benefit MLWHs by reducing their stress and improving their quality of life.

Parent-training interventions have been shown to be effective in numerous settings and populations. Reid and colleagues (2001) used home observations of parent–child interactions and parent reports of parenting practices and child behavior problems to demonstrate that a parent-training intervention showed positive changes in both mothers (more positive, less critical, more consistent, and more competent in their parenting) and children (exhibited fewer behavior problems) in a large multiethnic population of families enrolled at a Head Start Center. This is important because changing these interactions early will continue to shape more positive future interactions throughout the lifespan.

In summary, being a mother while living with HIV can be both rewarding and a significant source of stress. HIV-related stressors and life adversities faced by the MLWHs can compromise immune function, complicate HIV management, increase risk for depression, decrease parenting skills, and reduce coping abilities. Poorer parenting skills in turn lead to increased child behavior problems, which exacerbates maternal stress. Thus, it is crucial for MLWHs to limit stressors and learn more adaptive ways to cope with adversities that cannot be avoided. There is a clear need for interventions to decrease maternal stress among MLWHs. An underutilized approach for doing so is to improve parenting skills among MLWHs.

2 Theoretical Frameworks

The MOMS Study was guided by tenets of two theoretical frameworks: Family Systems Theory and Social Cognitive Theory. First, we used Family Systems Theory to increase our understanding of the complex familial issues that challenged optimal family functioning in our population. Then, we used Social Cognitive Theory to develop the program components.

Most family theories (including Family Systems Theory and Family Development Theory) are grounded in the fundamental notion of dynamic interaction, which states that the individual and his/her environment interact in ways that change both. Development is not seen as linear but spiral, where this constant interaction and reciprocal influence leads to future interactions that have been influenced by the perception of past interactions. Bowen’s (1978) Family Systems Theory (FST) is a comprehensive model of human behavior that represents a family’s emotional and relational life. FST posits several constructs that shape family functioning that are particularly relevant to the life circumstances of MLWHs. First, all families can be characterized on a continuum of differentiation that reflects each family member’s tolerance for individuality and intimacy. A well-differentiated individual demonstrates intact personal boundaries and effective problem-solving skills, while an undifferentiated person may largely base his or her decisions on the attitudes and opinions of significant others.

FST further asserts that the nuclear family is the emotional system, which functions as one emotional unit rather than many individuals with their own emotions. Because the actions of one affect everyone else, anxiety is infectious, easily passed from one person to another in the group. The concept of emotional cutoff reflects how, in the presence of excessive emotional intensity, a family member separates from the rest of the family or vice versa. This occurs when individuals behave in such a way that they are cut off emotionally from the rest of the family. HIV, homosexuality, disapproval of partner choice, and addiction are common situations leading to emotional cutoff. The multigenerational transmission process reflects how family functioning is repeated over several generations. FST proposes that the transmission of pathology transcends generations and affects the patterns of familial behavior, such that in dysfunctional families, each generation creates members with increasingly poorer differentiation, leaving them highly vulnerable to anxiety and fusion (Goldenberg and Goldenberg 1991; Coco and Courtney 1998).

With this insight, we used Social Cognitive Theory to guide the development of specific intervention components most likely to enhance maternal self-efficacy and build key parenting skills. According to Bandura’s (1986) Social Cognitive Theory (SCT), human behavior is best explained by triadic reciprocal determinism in which the three primary behavioral determinants (behavior, cognitive and other personal factors, and environmental influences) interact to influence each other bidirectionally. While SCT does not assume that all sources have equal influence or act simultaneously to shape behavior, it does argue that these factors are not independent of one another nor are they static. Rather, they are reciprocal and dynamic. Another central construct of SCT is observational or social learning, which states that people learn by watching the behavior (and subsequent consequences) of others. These SCT constructs were translated into specific intervention strategies in the MOMS parenting intervention (described in the intervention section below).

3 The MOMS (Making Our Mothers Stronger) Project

MOMS was developed to address the concerns shared by mothers living with HIV during their clinic visits, who expressed a sense of being overwhelmed by the competing demands of being a parent and living with a serious health condition. Unlike most secondary prevention trials that aim to reduce HIV transmission and reinfection via sexual risk reduction strategies, MOMS aimed to enhance quality of life issues by focusing on the specific needs of mothers and children affected by the HIV epidemic. While MOMS was designed for women across the sociodemographic spectrum, our population closely reflects that of the larger population of persons living with HIV in the USA: predominantly those of color (88% African American) and of low socioeconomic status (SES). As such, our intervention aims to meet the stress reduction needs of mothers living with HIV and the stresses of stigma, multiple responsibilities, very limited resources, and, frequently, discrimination. The Institutional Review Board at the University of Alabama at Birmingham, USA, approved the study.

The target population for the MOMS Project included women who were over 18 years of age, HIV-positive, and a primary caregiver of a child between 4 and 12 years of age. Knowing we would need broad support in accessing and engaging this very hard-to-reach population, we placed high priority on developing our recruitment strategies. We collaborated with all local HIV organizations as our community partners, which included three HIV/AIDS community agencies, three health care clinics specializing in HIV care, and a statewide HIV coalition. We invited their involvement from the beginning and sought their expertise and input on program promotion, participant recruitment, and intervention content. In addition, we created a Community Leadership Advisory Board, composed of community health advocates and key staff from our partner agencies. This Board provided ongoing guidance to the MOMS study team throughout the project period. From the front lines of patient care and case management, these individuals were an invaluable asset, making suggestions that often turned out to be crucial. Their input ensured that our intervention was responsive to the social and cultural characteristics of the participants, enabling us to more effectively engage mothers living with HIV into care.

Focus groups were conducted with women from the target population and the members of the advisory committee. In addition, semi-structured interviews were conducted with HIV service providers. Data obtained from this formative research helped to determine the perceived needs of HIV-positive mothers, desired intervention content, intervention process, and structure. The project advisors reviewed all MOMS session materials and even participated in mock intervention sessions, providing a friendly audience as well as invaluable feedback as our health educators were practicing intervention delivery.

The MOMS Project was a pretest-posttest, randomized-controlled behavioral trial that aimed to improve functioning of families affected by HIV by reducing childbearing stressors among HIV-positive mothers. Participants (N  =  106) were randomly assigned to one of two intervention conditions: a Social Cognitive Theory (SCT)-based intervention focused on reducing parenting stress (“Parenting Skills for MOMS”) or an attention-control intervention focused on reducing health-related stress (“Healthy MOMS”). The primary outcome of the trial was positive parenting skills; secondary outcomes included maternal stress, parenting self-efficacy, depression, and physical and mental health status.

Because of the dearth of existing resources for MLWHs, it was important that both interventions provided meaningful information and assistance to better cope and function with their HIV. So, while the study used an attention-control design, both interventions were significantly above and beyond “usual care” for MLWHs. Perhaps most important, both groups received the social support aspect inherent in small group-based intervention programs. However, the attention-control condition did not receive any parenting-specific information or skills training to enhance their parenting skills, which was the primary outcome of the study.

Through weekly 2½-h sessions over a 6-week period, participants came together for small group sessions of five to eight women and one health educator. Each cohort of women was stable and did not allow for new participants joining the group midway through the sequence of sessions. This design enhanced group cohesion, trust, and confidentiality and provided a safe environment for the expression of thoughts and feelings. During the first intervention session, ground rules were presented and discussed; these include items such as “Whatever we hear in this room stays in this room,” “Listen, be nonjudgmental, and keep an open mind on issues” and were designed to maximize confidentiality and respect for individuals within the group. All participants were able to appreciate the shared experience of dealing with HIV while also functioning as a parent. Incentives such as timers, toys, games, candles, inspirational books, framed poems, recipes, and exercise bands were provided at each session to both intervention groups to encourage participants to continue at home what they learned in their sessions. Table 18.1 provides an overview and objectives of each group session for each intervention condition.
Table 18.1

MOMS intervention overview

MOMS parenting skills intervention

Healthy MOMS intervention

Session 1: Communicating expectations

Session 1: Effective communication

Learning objectives:

Learning objectives:

Identify age-appropriate expectations for children

Identify barriers to communicating needs and concerns to health care providers

Demonstrate appropriate techniques for active listening and reflective statements

Identify strategies to most effectively communicate her needs and concerns and have her questions answered

Describe child behavior using clear and descriptive words

Identify points to an effective telephone call with a health care provider

Exhibit ability to draft family purpose statement

Theme/inspiration: Differences in teaching vs. punishment; set realistic and appropriate expectations for children

Theme/inspiration: “Most important is hearing what isn’t being said”

Session 2: Focus on discipline

Session 2: Adherence

Learning objectives:

Learning objectives:

Demonstrate appropriate strategies to communicate effectively with their children

Identify personal barriers to following health care provider’s advice

Demonstrate appropriate use of positive and negative consequences

Identify strategies for improving adherence to health care provider’s advice

Develop a plan for establishing ground rules

Identify personal barriers to following prescription protocol

Demonstrate ability to be consistent in applying strategies

Identify strategies for improving prescription adherence

Identify the importance of keeping her providers advised about her adherence

Theme/inspiration: Children only know after we teach them, and “teaching” requires more than just “telling”

Theme/inspiration: “Incurable simply means you have to go inside to find the cure”

Session 3: Building and maintaining social support/contemplating disclosure

Session 3: Nutrition

Learning objectives:

Learning objectives:

Present and receive feedback on communication basics

Identify special nutritional needs of individuals living with HIV.

Distinguish between types of support

Identify several high calorie and protein food options to incorporate into their usual meals.

Identify and maintain social support network

Discuss the healthy food pyramid

Increase ability to seek and request help

Identify several barriers and strategies to overcome barriers to good nutrition.

Identify the pros and cons of disclosure

Identify safe and healthy food storage and preparation techniques

Increase awareness of feelings and beliefs about disclosure

Evaluate the consequences of disclosing to particular people

Theme/inspiration: “Good parenting takes time”

Theme/inspiration: “Love is a fruit in season at all times and within reach of every hand”

Session 4: Taking care of yourself

Session 4: Physical activity

Learning objectives:

Learning objectives:

Identify stressors and use strategies to make a coping plan

Identify benefits of regular physical activity

Demonstrate ability to let go of grudges

Increase understanding of the barriers they perceive that keep them from regular activity

Practice relaxation technique

Learn strategies for overcoming these identified barriers

Identify good things about themselves and increase knowledge of self-care

Increase knowledge about methods of safe exercise

Practice positive mom-child connections

Increase use of stress-reducing strategies

Theme/inspiration: “Conflicts are inevitable. Anger, grudges, hurt, and blame are not”

Theme/inspiration: “There is no better exercise for the heart than reaching down and lifting someone up”

Session 5: Focus on me/my children

Session 5: Sexual health risk reduction

Learning objectives:

Learning objectives:

Demonstrate appropriate techniques for parenting in high-stress situations

Identify the benefits to their own and other’s health by reducing risky sexual activity

Demonstrate their ability to describe and understand emotions

Show increased knowledge about STDs and HIV reinfection; dispel common myths about barrier methods of protection

Encourage open communication about death with children

Demonstrate skills necessary to reduce risky behaviors (i.e., proper condom and barrier use skills)

Evaluate knowledge of future planning

Identify high, low, and no risk sexual activities and benefits of barrier protection

Demonstrate ability to set goals for children

Develop more positive attitudes toward using protection consistently

Theme/inspiration: “Staying calm is the key to curbing your child’s poor behavior”

Theme/inspiration: “The secret of good health for both mind and body is not to mourn for the past, nor to worry about the future, but to live the present moment wisely and earnestly”

Session 6: How far we’ve come and graduation

Session 6: Stress reduction

Learning objectives:

Learning objectives:

Compare past and current views of “discipline”

Increase knowledge of ways to positively react to stress

Demonstrate knowledge of disciplinary strategies and terminology

Review and recognize what you have learned since the first MOMS session

Identify gifts and strengths of other moms in the group

Celebrate your accomplishments and those of your group members

Participate in a graduation ceremony to show successful completion of the program

Theme/inspiration: “How far we’ve come.”

Theme/inspiration: “There comes a time when you learn to step right into and through your fears because you know that whatever happens, you can handle it and to give in to fear is to give away the right to live life on your terms.”

3.1 MOMS Parenting Skills Intervention

The parenting intervention included some general topics related to parenting and also included some components to address the specific needs of MLWHs and their children. Social Cognitive Theory guided the development of individual program components. The intervention focused on building four key skills: (1) communicating clearly and effectively with their children, (2) using positive and negative consequences with their children to effectively change child’s behavior, (3) enjoying their children more by finding ways to build quality time together into their normal routine, and (4) taking care of themselves so they can best care for their children.

The parenting intervention aimed to improve communication and monitoring skills of MLWHs. Effective communication involves listening to children and giving them clear instructions of what is expected from them. Further, moms were taught effective discipline strategies to teach their children desirable behavior, while changing the unwanted behavior. Parents are responsible for setting family rules and implementing consistent disciplinary strategies to make sure that those rules are followed. The participating moms were taught how they can establish some ground rules in their home and can use positive and negative consequences to reinforce the desired behavior in their children. The self-control activity was used to teach moms how they can handle frustrating or challenging situations. Further, moms were encouraged to teach their children self-control. By learning and exercising self-control, children can make appropriate decisions and choose behaviors that are more likely to have ­positive outcomes. These parenting skills can help MLWHs manage children’s misbehavior in high-risk situations such as school and community settings.

MLWHs face many physical, psychological, financial, and social issues that are difficult to manage on their own. The parenting intervention encouraged moms to identify and build their social support networks. The program emphasized that moms can improve their quality of life by accessing social support and most importantly, being comfortable asking for help for themselves and their children.

The parenting intervention also focused on strategies to reduce stress faced by MLWHs. The first step to alleviate stress is to recognize stressors and the symptoms of stress. In addition to the health condition, things like past regrets, painful memories, and feeling of guilt can lead to stress. Therefore, the intervention emphasized the need to resolve grudges and conflicts. Other stress-reducing activities included relaxation and deep breathing exercises. Moms were also encouraged to take care of themselves so that they can take care of their children. While coping with HIV and raising children, it is important that MLWHs are able to manage their own emotions.

Recognizing the difficulty many MLWHs have in deciding whether or not to disclose their status to their children (Tompkins 2007: see also  Chap. 8 in this volume), this was a priority focus of the parenting intervention. There are pros and cons of HIV self-disclosure, in that it both causes and alleviates tension (Smith et al. 2008) and that it can lead to increased receipt of social support from some individuals and stigma, shame, and/or rejection by others. Because there is no clear answer on whether it is beneficial to disclose or not, our intervention discussed the factors that contribute to better decision-making regarding disclosure. Other topics specific to the need of MLWHs included talking with children about death and planning for the future, planning for what will happen and who will take care of their children if something happens to them.

With SCT as its foundation, the MOMS Parenting Intervention incorporated goal setting, role modeling, skills practise with guided feedback, self-monitoring via homework assignments, and reinforcement. Educational activities, problem solving, group discussion, and social support were employed to increase participants’ ability to cope with various issues related to living with HIV.

3.2 Healthy MOMS Intervention

The attention-control condition provided up-to-date information and education related to living optimally with HIV. Gleaned from formative focus groups conducted to obtain input on the needs of our intended audience, the Healthy MOMS intervention included the topics of medication adherence, nutrition, physical activity, and STDs and HIV and was directly responsive to expressed desires for enhanced knowledge in each of these areas. Additionally, information about effective communication techniques, risk reduction strategies, and strategies for coping with stress are components of the intervention that were indicated as important by women in the focus groups. Finally, there are a number of aspects of the intervention group structure and process that were designed to meet the needs expressed by women and service providers. Sessions were formatted to address each participant as a whole person rather than solely focusing on the topic of HIV; for example, each session involves a “cut and paste” activity, which entails self-reflection about various aspects of the participants’ lives.

The content of the health-focused intervention provided HIV-infected mothers with the following information: (1) improving their overall health by maintaining a healthy diet and being physically active, (2) adhering to medication regimens and keeping clinic appointments, (3) being knowledgeable about their condition so that they can better communicate with health care providers, (4) and maintaining an awareness of their sexual and physical anatomy. Broad ranges of strategies were used including educational activities, problem solving, group discussion, self-reflection, and social support building.

4 Preliminary Quantitative and Qualitative Findings

4.1 Preliminary Quantitative Findings for Parenting Stress Reduction

While the final dataset is still being prepared for analysis of primary intervention outcomes, a preliminary analysis was conducted to examine intervention effects on maternal stress as measured by the Parental Stress Index–Short Form (PSI/SF). The PSI/SF is a 36-item scale with three subscales: parental distress, parent–child dysfunctional interaction, and difficult child (each with a range of scores from 12 to 60). The Total Stress Index (PSI) is calculated by summing subscale scores (range of scores, 36–180). The PSI/SF has a reliability coefficient of 0.91 (Abidin 1995). The normal range of PSI scores (e.g., 15th–80th percentile) ranges from 27 to 144; scores of 162 and over (≥90th percentile) are considered clinically relevant levels of stress (Abidin 1995). Analyses indicate that (1) both intervention conditions experienced a statistically significant decline in parental stress levels at the post-intervention follow-up visit, compared to baseline scores (82.9  ±  18.5 vs. 79.2  ±  19.4; p-value ≤0.0001) and (2) while MLWHs in the parenting-focused intervention achieved higher decreases in PSI-SF scores than those who participated in the health-focused intervention, these differences were not statistically significant.

These findings suggest that the group support component may be more beneficial in reducing parental stress levels than the educational elements (parenting skills vs. general health). Group support interventions have been shown to enhance social support, improve overall coping capabilities, and reduce the burden of stress among HIV-infected individuals. Further, a supportive environment in which HIV-infected mothers can learn to cope with life stressors can promote healthier parenting behaviors (Hansell et al. 1998), which may account for the decrease in parenting stress that was seen in both groups. This is consistent with previous studies that suggest that a supportive environment can be beneficial in relieving the burden of HIV-related stressors (Friedland et al. 1996), such as the burden of caregiver stress (Silver et al. 2003).

4.2 Post-intervention Qualitative Focus Group Findings

Qualitative methods were used to compliment quantitative analyses in describing overall program effects and identifying the most useful elements of each behavioral intervention for mothers living with HIV. We conducted post-intervention focus groups (N  =  4) to elicit participants’ (N  =  16) perceived responses to MOMS participation. Two focus groups were conducted with participants from each intervention condition. Constant comparison analyses of transcripts by three independent coders led to the development of a codebook outlining primary and supporting themes.

Participants from both groups expressed significant emotional benefits from the group support and connection (meeting new people, having others identify with their experiences). Both groups expressed that the MOMS sessions provided a sense of community, which was highly valued in this previously isolated population. Participants stated how MOMS gave them a chance to really relax and just “be” in a room where everyone knew the familiar stressors that they were dealing with. The group sessions also gave them a place where they could talk openly about the intense feelings they often have but seldom share because few of them knew other HIV-positive mothers before the MOMS program. They also described how the MOMS staff went out of their way to make them feel comfortable and how the recruiter’s gentle persistence in a way that showed true concern for their well-being was what led them to enroll in MOMS, despite their initial hesitation and fears.

While the above themes were echoed in every focus group across intervention conditions, there were a few notable differences between intervention conditions. Benefits identified only by the parenting intervention participants included acquired parenting skills (i.e., family management, less harsh discipline, consistent use of rewards and consequences) and increased acceptance of their child (and feeling “at peace” with their child). Benefits expressed only by the health-focused intervention participants included better medication adherence and increased reliance on prayer as a coping tool. While intervention content varied greatly, participants in both ­conditions valued the group support, experience of sharing, trusting group members, and being a resource for others. Using a qualitative, phenomenological approach to gain insight on participant experiences in this way can inform future efforts to engage similarly vulnerable, socially isolated populations currently underserved for HIV and other services.

Results of the preliminary quantitative analyses and the qualitative focus group discussions together suggest that relief of social isolation and validation of self-worth may have a more therapeutic effect than anything else covered in the MOMS intervention sessions, including stress management exercises, medication adherence education, parenting skills training, and communication building activities. And not only do they benefit from this, their children do as well. Future interventions to support MLWHs should focus on reducing stress, increasing coping skills, and fostering supportive networks. While the educational and problem-solving activities are an important part of the intervention, the peer-based support system provides an equally vital component: a sense of community for this previously isolated population.

5 Conclusion

While the science related to HIV continues to make tremendous gains, HIV unfortunately continues to spread, especially among those most vulnerable, as the result of insufficient physical resources or political will to expand education, to increase awareness, and to provide testing and counseling services (Plowden et al. 2005).

It is imperative that African American mothers living with or at risk for HIV in the southern USA be given priority in future research, policy, and practise. Recruitment and intervention strategies must be identified that take into account the unique stressors and strengths of this population and the communities in which they live. Because MLWHs are more likely to experience multiple stressors that negatively affect parenting skills, increased efforts are needed to decrease parenting-related stress among MLWHs.

Preliminary analyses indicate that both MOMS intervention conditions (“Parenting Skills for MOMS” and “Healthy MOMS”) decreased parental stress levels significantly over baseline levels. Further work is needed in both the research and practise arenas to reduce childrearing stressors among MLWHs, improve their social support networks, and ultimately improve functioning of families affected by HIV.

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Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Susan L. Davies
    • 1
    • 2
    • 3
  • Herpreet Kaur Thind
    • 4
  • Jamie L. Stiller
    • 4
  1. 1.Department of Health Behavior, School of Public HealthUniversity of Alabama at BirminghamBirminghamUSA
  2. 2.UAB Center for AIDS ResearchUniversity of Alabama at BirminghamBirminghamUSA
  3. 3.Center for the Study of Community HealthUniversity of Alabama at BirminghamBirminghamUSA
  4. 4.School of Public HealthUniversity of Alabama at BirminghamBirminghamUSA

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