Mums on the Move: A pilot randomised controlled trial of a home-based physical activity intervention for mothers at risk of postnatal depression
Introduction
Substantial evidence demonstrates that physical activity is an effective strategy to prevent (Schuch et al., 2018) and treat (Schuch et al., 2016) depressive symptoms in the general population. Although far fewer studies have investigated the effect of physical activity on depressive symptoms amongst postpartum women, there is some evidence of a similar effect in this group (Pritchett et al., 2017). The global prevalence of postnatal depression (PND) is estimated to be approximately 17% (Shorey et al., 2018), with many women remaining undiagnosed and untreated (Pearlstein et al., 2009). PND can have severe impacts on mothers (Lee and Chung, 2007), infants (e.g. cognitive, behavioural, emotional developmental problems (Murray, 1992)), and family members (Boath et al., 1998). Limitations to current treatments for PND (e.g. medication, psychotherapy) include barriers related to access, expense, and perceived stigma (Dennis and Chung-Lee, 2006, Fonseca et al., 2015), as well as low acceptability and potential side-effects of anti-depressant medications (Chabrol et al., 2004, Berle and Spigset, 2011, Bet et al., 2013). Further, these methods (medication and psychotherapy) are generally utilised once a mother has been clinically diagnosed with PND, which discounts the path of prevention.
Given that physical activity has potential to both treat and prevent PND, it is important to identify strategies to promote engagement in physical activity amongst postnatal women, particularly those at-risk of PND. Most postnatal women are not active enough for health benefits (Coll et al., 2016) and often cite barriers to physical activity above and beyond those of the general population (e.g. inability to leave the house, lack of transport, childcare, and time) (Evenson et al., 2009, Saligheh et al., 2016). Therefore, home-based physical activity programs may be more suitable for this population group. However, few home-based physical activity interventions targeting women at risk of PND exist in the literature (Daley et al., 2009).
We previously conducted a proof of concept study (Teychenne et al., 2018) to test the perceived feasibility and acceptability of a multi-component home-based intervention among 11 postpartum women with heightened depressive symptoms. The intervention included free exercise equipment (treadmill) use at home for 12 weeks (to overcome key barriers to physical activity in this population group including being housebound) and access to a purposely-designed smartphone web-based application (web-app). This was the first study of its kind in Australia which provided home-based exercise support for women known to face multiple barriers in participating in out-of-home exercise during the early postpartum period. Postpartum women perceived the program to be convenient, flexible, acceptable and useful in overcoming key barriers to physical activity. They also perceived that it increased their physical activity and improved their psychological health. Quantitative data supported this, showing a significant reduction in depressive symptoms over time (Edinburgh Postnatal Depression Scale (EPDS) score mean difference = -7.6). Given the proof of concept study was limited by a small sample and pre-post study design, there is need for further testing of the intervention by utilising a larger, randomised controlled trial (RCT) design.
Therefore, the aim of this study was to examine the feasibility and acceptability of a multi-component home-based physical activity intervention delivered to mothers at risk of PND, and to examine changes in health behaviours (physical activity, sedentary behaviour, sleep, diet) and indicators of mental health (depressive and anxiety symptoms) following the intervention.
Section snippets
Design
The study was a pilot RCT comprising two groups (1:1; intervention and control group) with a 12-week intervention period (see Fig. 1). This study was approved by the University Human Research Ethics Committee (DU-HREC-2018-139) and registered with Australian New Zealand Clinical Trials Registry (ACTRN12618001453279). We have reported against the CONSORT guidelines (Schulz, Altman, Moher et al., 2010; see Supplementary Material for checklist).
Participants
In July to October 2018, women were recruited to this
Intervention
Intervention participants were provided with the Mums on the Move home-based physical activity intervention. This included provision of home exercise equipment (free treadmill or stationary bicycle hire based on personal preference), a logbook for goal setting and self-monitoring, access to an online forum for social support (facilitated by a research assistant with a PhD in behavioural epidemiology) and web-app access (purposely designed by the research team to provide motivational and
Measures
Self-report online surveys were used to assess health behaviours (physical activity, sedentary behaviour, sleep, diet) and indicators of mental health (depressive and anxiety symptoms) at baseline and follow-up (12-weeks), and program feasibility and appeal (in intervention group at follow-up only). Due to our ethics committee request to monitor depressive symptoms more frequently, we also collected data on self-reported depressive symptoms, as well as physical activity and sedentary behaviour,
Feasibility and acceptability
Feasibility was assessed in three ways. 1) Intervention group participants completed three survey items in the follow-up survey, adapted from Teychenne et al. (2018) that assessed web-app usage as well as their views on maintaining physical activity after the intervention (items detailed in Table 2). 2) Participants’ logbooks (to assess, for example, compliance, reported calories expended, duration and frequency of treadmill/stationary bicycle use based on exercise equipment display). 3)
Device-measured physical activity and sedentary behaviour
Physical activity and sedentary behaviour were assessed using an ActiGraph accelerometer (MTI Actigraph Model AM7164-2.2C (Sasaki et al., 2011, Troiano et al., 2014)), shown to be valid and reliable for assessing physical activity and sedentary behaviour in adults, and is comparable to other commercially available accelerometers (Sasaki et al., 2011). Participants were instructed to wear the accelerometer on the right hip during waking hours for seven consecutive days, removing only for
Recruitment, retention and engagement
Recruitment was undertaken from July to October 2018 (12-weeks). Fig. 1 presents participant flow through the study. A total of 1,614 interested participants were screened, 262 met full entry criteria, 68 consented to participate and 62 of those were randomised into either an intervention (n=32) or control (n=30) group. Of those randomised, one participant in the intervention and five from the control group did not provide any follow-up data (intervention=97% retention; control=83%).
Discussion
This pilot RCT showed that a home-based physical activity intervention involving cost-free exercise equipment hire is feasible, well-accepted and effective in increasing initial engagement of physical activity amongst postpartum women experiencing heightened depressive symptoms, yet physical activity behaviour change was not sustained, and nor did it result in changes in mental health outcomes.
Recruitment via social media (particularly Facebook) was an efficient strategy to engage potential
Conclusion
These findings indicate that a home-based physical activity program involving cost-free exercise equipment hire may be effective in increasing initial engagement of physical activity amongst postpartum women experiencing heightened depressive symptoms. However, additional strategies may be needed to enhance maintenance of physical activity behaviour change and promote reductions in PND symptoms.
Funding sources
This project was funded by the Institute for Physical Activity and Nutrition (IPAN), Deakin University.
Ethical approval
This study was approved by the University Human Research Ethics Committee (DU-HREC-2018-139)
Clinical trial registry
Australian New-Zealand Clinical Trial Registry: ACTRN12618001453279. Retrospectively registered 29th August 2018. http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001453279.
Declaration of Competing Interest
The authors declare no competing interests.
Acknowledgements
We gratefully acknowledge the assistance provided by Ms Jaimie-Lee Maple during recruitment.
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