Short- and Long-Term Outcomes in the Reduction of Stress and Depressive Symptoms - Case Study Example

8 February Introduction Health issues have been an important part of development strategy of the governments that contributes to the growth and expansion of the economy of the nations. In the current times, the holistic approach to health has emerged as critical factor to emphasize the prevention mechanism to reduce escalating cost of healthcare which has made it inaccessible to the poor and the under-privileged segment of society. Consequently, exercises, change in lifestyle etc. have evolved as effective ways of prevention of diseases. The article gives an important insight into the exercise plus psycho education as an important tool for reducing stress and depression amongst women of low socio-economic status. The article is pertinent as this particular segment of society faces lot of problems related to stress and depression resulting in health problems that adversely affects their work and employment scope. 2. Summary The article, ‘A randomized controlled trial of combined exercise and psycho-education for low-SES women: Short- and long-term outcomes in the reduction of stress and depressive symptoms’ by Waerden et al., is a study that was conducted on 161 Dutch low SES women with a moderately high stress level or depressive symptoms between September 2005 and May 2008. It helped evaluate the impact of interventions on their stress and depression. The group based program was divided into three categories: E or exercise only; EP or exercise with psycho education; and WLP or waiting list control condition where participants were randomly assigned. The study highlighted 8 weeks intervention with follow up after 2, 6 and 12 months respectively. It revealed that E and EP showed stress reduction in women with low education achievement. The findings are important as this group can be targeted for reducing stress and depressive symptoms. 3. Critique The study has a clear statement of goals and articulates its importance within the designated target group. The main objective of the research is to evaluate the ‘effects of multidisciplinary preventive intervention aimed at reducing stress and depressive symptoms among low-SES women’ (Waerden, et al. 85). The research is important because it addresses the gap of combining exercise with psycho social approaches for low SES women. It is highly relevant because low SES women often do not engage in preventive measures for stress or depression. Moreover, the studies so far have been accompanied by lot of questionnaires and feedbacks that required verbal skills and home assignments which have served as demotivating factors for this target groups’ participants. Thus, CBT approach was customized to suit the needs and requirements of the target group of low-SES women. It facilitated in addressing the problems of stress and depression across this segment. The study design selected was experiment based and was applied appropriately on the selected target group. For the randomized control trial, self-referred women and participants were recruited through referrals by practitioners working in and around socioeconomically deprived neighborhood, intermediaries working in social work, debt, reform, community mental health center and public health services. Thus, the study sample of participants that were finally recruited was representative of the group. This was an important step so that effective intervention for the stress and depression problems of women of low SES could be evolved. The three groups each should have had minimum of 54 participants but with 10% dropout, the groups had only 49 participants which was slightly low. The randomization was carried out fairly and the sequence and selection was concealed from the researchers and patients. However, the participants were aware of the objectives of the study and treatment but until the first session, were blinded to the treatment group to which they were to be assigned. Moreover, the stringent criteria and an exhaustive process of elimination were important ingredients that helped to select 161 participants from low SES out of the total 1383 candidates initially selected. The baseline demographic features were age, nationality, educational level, previous depressive episodes. The demographic details like employment status, net monthly family income, marital status, current depression treatment and current exercise behaviors were established at baseline and at each subsequent feedback as determined initially within short term and long term time schedule. Semi structured interview was key tool for evaluating participants’ mental health that constituted basic criteria along with women’s low SES. Semi structured interview within qualitative study becomes important tool for assessing the qualitative characteristics of the target. The recruitment strategy was appropriate for the goals of the study because it was targeting specific demographic population of low SES having mental problems like stress and depressive symptoms. The research lucidly explained the criteria for participants and how they were selected. The data was collected properly following ethical guidelines and ensuring that the selection was rigorous and participants had passed the rigorous system of the recruitment. The method of data collection was justified though slight changes were made to incorporate life events as covariates in the analysis to reduce biases regarding the differences in the experiences of life events in the E group and other groups. The drop-outs were considered and logistic regression analysis was carried out to evaluate differences in socio demographic characteristics and symptom scores for those participants who did not complete all measurement after baseline assessment. This helped to strengthen the accuracy of outcome as the drop-out rate was 10%. The reason for drop-out was not given. The outcome recorded has high validity mainly because the comprehensive statistical measures were used at each level of verification starting from eligibility measures that included 10 item version of perceived stress and 10 item version of depressive symptoms as established by Center of Epidemiological Studies Depression. The data analysis had relied on multilevel linear regression analysis to ensure missing data was handled properly and missing values were substituted by respondents’ mean score for that specific scale. Moreover, multilevel approach was useful in analyzing the changes in outcome variables between intervention conditions and moderation effects. As such, it accounted for dependency in consecutive results and fitted with available evidences across three groups. The outcome was measured to minimize bias by using CES-D scale for stress and depression score along with Cronbach’s alphas which are found to be consistent with ranges found in Dutch community. Participants’ general perceived stress was assessed using PSS. Though PSS is not a diagnostic tool but it has shown good reliability and validity. The use of Cronbach’s alpha in the study has significantly contributed towards internal consistency of the instrument. Questionnaires and interview schedule were objective measures that maximized response from target group. Interviews were important factors that reinforced the validity of the measures used. The similar measurement methods were applied across the groups to reduce any biases and enhance validity of the outcome. The most important potential sources of bias could not be addressed as study did not include the category, psycho-education only and that the participants for control program were set free after four months that made it difficult to monitor or test long term follow up. Most importantly, the energy level of participants of different group was also not assessed. Consequently, dose of intervention could not be determined for its efficacy in individual cases. Data collection and analysis was appropriate and followed rigorous procedure using extensive statistical tools. The researchers were meticulous in their explanation for excluding groups as they believed that previous studies with such conditions delineate the need to include it this time. The discussions covered objectives and limitations comprehensively. It covered four limitations: control participants were free after four months for interventions; psycho education only or P was not included; effect sizes for groups were small at priori power calculation; women in E groups experienced more life events in the 12 month’s period than women in other groups. But this was later amended by using life events as covariates in the analysis. This was vital to the findings as it also helped to reduce the biases caused by diverse life events across different groups within 12 months’ time that was assigned for feedback on the intervention measures. The findings of the studies are very important for the public mainly because the target group selected did not like using interventions for stress and depression. The results show how the target group can be motivated for taking effective interventions so that they can reduce stress and depressive symptoms for higher productive growth. It was also seen that the women of low SES see therapy as social stigma and therefore, presenting the intervention strategy as a course significantly increased its attraction. It also indicated that the intervention strategy needs to incorporate compensation like reimbursement of expenses as important barriers for this target group are financial cost, transportation and time. Thus, reimbursements for transportation, childcare etc. may make it possible for women belonging to low-SES to take part in intervention programs. The intervention is an important tool to improve and improvise participants’ productive outcome resulting in their improved socio-economic status. The study was justified because previous results had neither included exercise with CBT approach nor the women of low-SES was considered. This target group becomes pertinent as they are more prone to stress and depression due to their low socio-economic status. Moreover, lack of time and resources compound their problems that adversely impact their employment scope and lower their productivity due to deteriorating health issues. EWW or exercise without worry intervention was developed to counter the negative impacts of the life events and inculcate confidence and improve resilience to stressful conditions. The package satisfied the requirements and expectations of the target group who were reluctant to undertake intervention measures earlier. Beside this, EWW did not have any homework or elaborate skilled feedback system that greatly facilitated participants to take part in all activities related to the study. The study becomes all the more important as it revealed that EWW best responded to the needs of women of low SES who also had low education level. This is a relevant point and needs to be exploited across this segment of society for developing higher self-esteem, leading to improved work outcome. The findings and the conclusions of the study were substantiated by relevant claims. It was the first trial study that was followed up for 12 months thus, considerably adding to the credibility and validity of the outcome. The study findings largely conformed to the previous results of the effectiveness of exercise or CBT approach on the mental health. The combined strategy as intervention tool enhanced the scope of the study and showed that effect of treatment also applied to the preventive measures. Most importantly, the reduced depression level in control groups reflects that improvements can be observed in moderate to severe cases of depression also. The study also highlights important aspects of exercise and CBT approach that inculcates confidence building and sense of success through one’s command ‘of a challenging pursuit’ (Waerden et al. 86). Exercise and cognitive behavioral techniques focus on positive thinking, social activities, pleasant activities etc. along with exercise that rejuvenate body and soul thereby, motivating participants to become more positive and be happy. Last but not the least important are the ethical considerations that are intrinsic part of research. They promote trust and confidence building which are vital aspects of qualitative research. It is important that researcher is culturally competent and conforms to the cultural ideologies so that he/she is able to gain the trust of the participants. At the same time, maintaining the confidentiality of information is important. The researchers in the study had well acquainted the participants with the details of the objectives of the study and the details of the treatments and the interventions that would be used. Informed consent was taken as it acknowledges the awareness of the participants with the research guidelines, objectives and procedures. The study was approved by Medical Review Ethics Committee of Maastricht University in the Netherlands. The framework of the study was designed and developed to suit the objectives that take care of the potential conflicts of interests across the stakeholders. It is detailed enough and incorporates relevant research variables and criteria to study the target group within the broad spectrum of its objectives and goals. Hence, the study was a good subject for review. 4. Conclusion The study is very relevant for the low SES group with low education level who are not able to contribute constructively to the development of the nation. In fact, their health problems adversely impact growth processes because of the extra expenditure that government has to spend on their healthcare. The mental health issues like stress and depression are prevalent amongst this group which can be addressed through the study’s intervention strategies. They can be widely exploited to improve the mental health of the poor and enhance their confidence level so that they are better equipped to serve the interests of the government as well as their own. (words: 2126) Reference Van der Waerden, J.E.B., Hoefnagels, Cees., Hosman, Clemens M.H., Souren, Pierre M., & Jansen, M. W. J. ‘A randomized controlled trial of combined exercise and psycho-education for low-SES women: Short- and long-term outcomes in the reduction of stress and depressive symptoms.’ Social Science & Medicine 91 (2013): 84-93. Read More