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3.amigas Latinas Motivando El Alma (ALMA PDF
3.amigas Latinas Motivando El Alma (ALMA PDF
Abstract
Latina immigrants are at increased risk for poor mental health. Amigas Latinas Motivando el
Alma (ALMA) is a group-based intervention to reduce symptoms of depression, anxiety, and stress
among Latina immigrants. Based on participants’ feedback and growing evidence supporting
mindfulness as a way to reduce stress and improve mental health, additional sessions of the ALMA
intervention were developed and pilot tested to provide more training on mindfulness as a coping
strategy. The feasibility and potential efficacy were evaluated in a community sample using a pre-
and post-test study design. Findings suggested that women were satisfied with the sessions and
used mindfulness strategies they learned in their daily lives. The program also reduced symptoms
of depression and anxiety (19% reduction in mean depression scores and 26% reduction in mean
anxiety scores). Further evaluation is needed to test the efficacy of the intervention.
Background
Latino immigrants face many stressors during migration and resettlement that put them at
increased risk for anxiety, depression, and other adverse mental health outcomes.1 Latina
immigrant women are particularly at risk due to the unique social, cultural, and economic
challenges they face, including migration-related trauma and added gender role expectations.2 As
Address correspondence to India J. Ornelas, PhD, MPH, Health Services, University of Washington, Seattle, WA, USA. .
Daron Ryan, MPH, Health Services, University of Washington, Seattle, WA, USA.
Serena Maurer, PhD, Department of Women Studies, University of Washington, Seattle, WA, USA.
Liliana Lengua, PhD, Center for Child and Family Well-Being, University of Washington, Seattle, WA, USA.
Bonnie Duran, DrPH, School of Social Work, University of Washington, Seattle, WA, USA.
)
Journal of Behavioral Health Services & Research, 2017. 280–291. c 2017 National Council for Behavioral Health. DOI
10.1007/s11414-017-9582-7
280 The Journal of Behavioral Health Services & Research 45:2 April 2018
such, Latina immigrant women suffer from higher rates of anxiety and depressive symptoms than
their male counterparts and are often found to have worse mental health outcomes than women in
other racial/ethnic groups.1, 3–6 These disparities are exacerbated for Latina immigrant mothers,
who are also caring for their families in the context of low education, poverty, and limited access to
social and economic resources. Latina mothers also experience higher rates of parenting-related
stress than white, non-Latina mothers.7 Therefore, there is a need for culturally relevant
interventions to promote mental health among Latina immigrant mothers.8
Amigas Latinas Motivando el Alma (ALMA), which translates to BLatina Friends Motivating
the Spirit,^ is a culturally relevant and group-based intervention developed in response to this need.
ALMA aims to improve the mental health of Latina immigrants by increasing their coping skills,
enhancing social support, and decreasing barriers to accessing mental health care, all while
incorporating the social and cultural context of immigration-related stressors. Pilot testing of the
original program in North Carolina and Washington indicated high levels of participant satisfaction
and decreased levels of stress and depressive symptoms following the intervention.9 Women
participating in these previous pilot studies also reported that they were particularly interested in
aspects of the program that focused on mindfulness approaches.
A growing body of research points to the efficacy of mind-body interventions, such as
mindfulness and yoga, in promoting physical and psychological well-being.10, 11 Mindfulness
practices encourage nonjudgmental awareness to what is happening in the present moment and
have been linked to reduced depressive and anxiety symptoms.12,13 Yoga, a physical activity
focused on stretching, balance, and breathing, has also been shown to improve mental health.14–17
Despite these promising findings, few mindfulness interventions have been evaluated among racial/
ethnic minority and immigrant communities.
Given participant interest and increasing evidence linking mindfulness practices to improved
mental health, the research team sought to further develop and pilot test additional mindfulness
content for the ALMA intervention. The present study’s aims were to assess the feasibility and
potential efficacy of a five-session mindfulness intervention to improve mental health among
Latina immigrant mothers. It was hypothesized that women would have high levels of satisfaction
with the intervention and that levels of depression, anxiety, and stress among participants would be
lower after the intervention.
Methods
ALMA Mindfulness Intervention
The intervention consisted of five weekly 2-h classes, which occurred in the evening at a
community-based organization providing economic and educational opportunities to Latino
immigrants in Seattle, Washington. These opportunities included a day labor worker center, ESL
classes, job training, and leadership development. Sessions were led by a Spanish-speaking
mindfulness and yoga instructor with previous experience developing and teaching mindfulness
programs in immigrant and other underserved communities. Sessions were open to all clients of the
community-based organization, with childcare and refreshments provided at each session. Sessions
were held in the evening to accommodate participants’ work and family commitments. To
incentivize retention and overall attendance, study participants received Bwellness tote bags^ if
they attended four or more sessions. The tote bags were filled with scented candles, bath products,
and other items to encourage practicing relaxation and self-care at home.
Evidence-based yoga and mindfulness techniques served as the anchoring content for the ALMA
intervention sessions, which were adapted to be culturally relevant to Latina immigrant mothers.
The original ALMA intervention consisted of six sessions with content related to migration
stressors, identifying mental health symptoms, and coping strategies for adjusting to life in the
Table 1
ALMA intervention and evaluation session content
Session Title Content
282 The Journal of Behavioral Health Services & Research 45:2 April 2018
participants were encouraged to develop Beveryday mindfulness^ practices they could continue in
their day-to-day lives after the program ended. This included practicing mindful awareness of daily
mind patterns and their effects on participants’ interactions with their children, as well as exploring
ways to practice moments of compassion in their daily lives. Participants were also guided through
sequences of yoga poses during sessions to allow for mindfulness of the body, breath, and mind in
motion, while facilitating further physical and mental relaxation.
All instruction and materials were provided in Spanish to increase the program’s cultural
relevancy to Latina immigrant mothers. The commonly used Batención plena^ served as a
translation to convey meaning of and themes related to mindful awareness in all program sessions
and materials. Instruction built upon women’s own understanding of mindfulness, including how
they previously found moments of calm and relaxation in their daily lives. Each session
emphasized the use of these various techniques for relaxation and self-care in order to combat the
stressors of migration, resettlement, and raising children as a Latina immigrant in the USA. Latino
culture and imagery were also incorporated through vignettes, games, and creative activities to
present program topics in culturally relevant and relatable ways. Sessions included periods of
participants resting on their backs and sides to help with fatigue, lack of sleep, and physical
exhaustion. Time was also provided for discussion, socialization, and meals.
Study Procedures
All study procedures occurred on-site at the community-based organization, and staff from the
organization recruited participants from their pool of existing clients. To be eligible for the study,
women had to be at least 18 years old, Spanish-speaking, born outside of the USA and have at least
one child. All participants provided consent and all procedures were approved by the University of
Washington Human Subjects Division.
Trained bilingual interviewers administered the surveys to participants in separate sessions
before and after the intervention’s five sessions. Participants received a gift card in the amount of
20 dollars for each survey completed. During the initial meeting, the program instructor outlined
the content of the intervention and introduced mindfulness to participants by defining key terms
and asking them to share where they experience awareness and compassion in their daily lives. At
a follow-up session that was held 1 week after the final intervention session, the research team
asked the group to debrief their experience in the program by sharing their experiences and
recommendations for future programs. During this time, interviewers pulled out participants from
the larger group one-by-one to administer the final survey. Eight measures, described in detail
below, were utilized in the survey to collect data on the following: depression, anxiety, parenting
stress, perceived stress, mindful awareness, demographic characteristics, participant satisfaction,
and attendance.
Depression A Spanish version of the Patient Health Questionnaire-9 (PHQ-9) was used to
measure depressive symptoms.19 The 9-item measure asks participants to report how often they
have experienced various depressive symptoms over the last 2 weeks. Responses range from 0 (Not
at all) to 3 (Almost every day), for a total score range of 0 to 27. A score of 10 or greater indicates
moderate to severe depression. This measure has been found reliable when used in a Spanish-
speaking community sample.20
Anxiety Anxiety symptoms were measured using a Spanish version of the Generalized Anxiety
Disorders-7 (GAD-7) scale.21 This 7-item scale measures symptom frequency of symptoms over
the past 2 weeks, with responses ranging from 0 (Not at all) to 3 (Nearly every day). Total scores
Parenting Stress The 17-item Likert-type Parental Stress Scale (PSS) was used to assess changes
in stress associated with parent-child interactions.23 Participants were asked to report to what
degree they agree with parenting-related statements. Negative items are reverse scored and
responses are summed for a possible score range from 18 to 90. Higher scores indicate greater
levels of parental stress. The Spanish version of this scale has been validated when used among
Spanish-speaking populations.24
Perceived Stress The Perceived Stress Scale (PSS) was used to assess each participant’s overall
stress level. The 10-item scale measures to what degree events in the participant’s life are stress-
inducing.25 Recalling the last month, participants were asked how often they experienced certain
overwhelming thoughts or feelings. Total scores range from 0 to 40, with higher scores indicating a
higher measured perceived level of stress. The PSS has been found reliable when used among
Spanish-speaking populations.26
Mindful Awareness The Mindfulness Attention Awareness Scale (MAAS) was utilized to
evaluate quality of consciousness and well-being associated with increased self-awareness.27 The
15-item measure uses a 6-point scale to ask participants how often they experience mindful
awareness, with response options ranging from 1 (Almost always) to 6 (Almost never). An average
is taken of the 15 responses for a total possible score range from 1 to 6, with higher scores
indicating greater mindful awareness. A translated version of this scale has been previously used in
Spanish-speaking community settings.28
Demographic Characteristics These questions included age, country of birth, years spent in the
USA, years spent in the Seattle, Washington area, highest level of education completed,
employment status, marital status, and languages spoken. They were also asked to report their
weekly family income, number of children, and household composition.
Attendance Research staff recorded the number of participants present for each of the five
intervention sessions and the pre- and post-intervention survey sessions. These counts include
study participants and all attendees, as sessions were not restricted to solely those who enrolled in
the study.
284 The Journal of Behavioral Health Services & Research 45:2 April 2018
Data Analysis
Descriptive statistics were used to calculate the frequencies of demographic characteristics and
mental health outcomes in the sample. Levels of depression, anxiety, parenting stress, perceived
stress, and mindful awareness were assessed among participants prior to and following the 5-week
intervention, calculating paired t tests using a 90% confidence interval. This wider confidence
interval was selected to account for the relatively small sample size. Additionally, participant
outcomes were compared across different levels of attendance.
Interviewers’ notes on participants’ open-ended survey responses during follow-up data
collection were analyzed for content and consistent themes. Responses were grouped into
categories by two members of the research team and specific quotes were chosen as examples.
Results and quotes were also presented to participants and community-based organization staff to
confirm interpretations. Quotes were ultimately translated into English for reporting and
dissemination to broader audiences.
Results
A total of 24 mothers were recruited and enrolled in the study. Descriptive statistics for
participant demographics, baseline mental health, and session attendance are presented in Table 2.
Most women in the study were Mexican (n = 19, 79%) and married (n = 15, 65%), with a mean age
of 49 and an average of 2.8 children. A majority of participants had lived in the USA for longer
than 10 years (n = 15, 62%) and were employed year-round (n = 13, 54%). Of those enrolled in the
study, 12 women (50%) came to at least four sessions and 12 women (50%) came to three or fewer.
An average of five non-enrolled participants attended each intervention session, as sessions were
open to the public regardless of whether or not they were enrolled in the study. Twenty-one
participants completed the post-intervention survey measures, resulting in an 87.5% retention rate
at follow-up.
Table 3 presents post-intervention changes in levels of stress, mindful awareness, and mental
health outcomes. There were no changes in levels of parenting stress. Although they were not
found to be statistically significant, the mean scores of depression, anxiety, perceived stress, and
mindful awareness decreased after the intervention. Moreover, changes in scores on both
depression and anxiety were greater among participants who attended a greater number of ALMA
sessions. In fact, changes in anxiety levels from baseline to post-intervention were three times
greater for participants who attended four or more sessions (a 42% decrease) compared to those
who attended three or fewer (a 13% decrease). Mean changes in participant depression scores from
baseline to post-intervention followed a similar trend, with a 26% decrease for attendees of four or
more sessions versus a 15% decrease for those who attended fewer than three sessions. However,
these differences were not statistically significant.
Qualitative analysis of participant feedback was grouped into four categories: most useful
content; practical application of the intervention content; how the intervention impacted their
parenting; and improvement suggestions for the program. Illustrative quotes from participants are
presented for each category in Table 4. Overall, participants reported a high level of satisfaction
with curriculum content and activities, as well as frequent use of learned techniques in their daily
lives for stress relief and relaxation. The majority of respondents indicated a desire for the program
to continue on with more frequently occurring sessions.
Discussion
This study assessed the feasibility and potential efficacy of a mindfulness intervention to reduce
depression, anxiety, and stress among Latina immigrant mothers. Participants reported decreased
Age
Younger than 45 13 54%
45 or older 11 46%
Country of birth
Mexico 19 79%
Peru 3 13%
Years lived in the USA
10 or less 9 38%
More than 10 15 62%
Education
Less than high school 12 50%
HS graduate or more 12 50%
Marital status
Single 4 17%
Married 15 65%
Divorced or widowed 4 17%
Number of Children 2.8 1.2
Weekly household income
Less than $300 6 26%
$300–$500 8 35%
$500–$700 4 17%
More than $700 5 22%
Employment status
Employed year-round 13 54%
Temporarily employed 6 25%
Currently not working 5 21%
Languages spoken
Only Spanish 5 21%
Spanish and some English 19 79%
Mental health Mean/N SD/%
Parenting stress (18–90) 38.1 9.4
Perceived stress (10–50) 27.1 3.8
Anxiety (0–21) 6.1 5.4
Mild 18 7%
Moderate 4 17%
Severe 2 8%
Depression (0–27) 6.7 5.6
Mild 17 71%
Moderate 6 25%
Severe 1 4%
Mindful awareness (1–6) 3.2 0.5
286 The Journal of Behavioral Health Services & Research 45:2 April 2018
Table 3
Pre-post intervention changes in stress, mindfulness, and mental health outcomes
Measure Pre-intervention Post-intervention Change
symptoms of depression, anxiety, and stress after receiving the intervention. To the research team’s
knowledge, this is the first study to test the feasibility of a mindfulness-based mental health
intervention among Latina immigrants. This study provides support for further developing
community-based programs that promote coping and self-care strategies within Latina immigrant
communities.
Participant Characteristics
Participant baseline scores of depression and anxiety in the sample were comparable to those
reported in national surveys of Latina immigrants. At baseline, 29.2% (n = 7) of the participants
reported experiencing moderate to high levels of depressive symptoms, which compared to 32.8%
of women who reported similar levels of depression in the Hispanic Community Health Study/
Study of Latinos.6 Overall, few studies have reported rates of anxiety among Latina immigrant
women, making it difficult to compare the findings to other samples. In this study, 25% (n = 6) of
participants reported experiencing moderate to severe anxiety symptoms. In comparison, the
National Latino and Asian American Study (NLAAS) found that the lifetime prevalence of anxiety
disorder was 21% among Latina women, including both U.S. citizens and immigrants.1 However,
this NLAAS figure only included those that have been diagnosed with an anxiety disorder,
excluding those that are undiagnosed or have not sought treatment.
The perceived stress scores in this sample were comparable to those reported in other diverse
community samples.29 However, parental stress scores were higher among participants in this study
than those in previous studies using this measure. While no previously published studies have used
the Parental Stress Scale (PSS) measure with Latina immigrant mothers, a study validating a
Spanish version of the PSS among Spanish mothers reported a mean score of 22.3, somewhat
lower than the mean in the present sample (38.1).24 Further research in larger samples should
assess levels of parental stress in this population.
288 The Journal of Behavioral Health Services & Research 45:2 April 2018
Women in this study reported low to moderate levels of mindful awareness at baseline. Similar
to parental stress, previous research utilizing the Mindful Attention Awareness Scale (MAAS)
among Latino populations is limited. Brown and Ryan, the researchers that developed the scale,
reported a mean MAAS score of 4.2 among four independent community samples of adults,
indicating a moderately high level of dispositional mindfulness and a higher mean than the present
sample (3.2).21 However, it is difficult to discern the relative value of this sample’s mean due to a
lack of research validating this scale among Spanish-speaking Latino immigrants.
Funding
This study was funded by the Center for Child and Family Well-being at the University of
Washington.
Conflict of Interest Liliana Lengua is the Director of the Center for Child and Family Well-being
which also funded the study. None of the other authors have any conflicts of interest to report.
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