This study was approved by the Research Ethics Board of the Faculty of Health Sciences at McMaster University, Hamilton, Ont.
Single mothers with young children were recruited through advertisements in community flyers at various locations (e.g., family physicians' offices, libraries, shelters) in Hamilton, Ont. The advertisements asked mothers if they were “feeling alone” and “parenting on their own.” Interested mothers who contacted the research program coordinator were told about the study and were assessed for eligibility. Eligibile mothers were those who had at least one child 3–9 years old, were able to speak English, had no acute psychiatric crisis (e.g., psychotic or suicidal behaviour) or threat of violence (e.g., stalking by ex-partner) and gave informed written consent to participate in the trial. They were asked to complete questionnaires during a home visit and were then randomly assigned to the intervention or control group. Randomization was done in blocks of 4, with numbers generated by a random-numbers table and sealed in opaque envelopes. It was not possible to conceal the group allocation from the participating mothers.
Mothers assigned to the intervention arm of the trial were asked to participate in a 10-week program of group sessions (1.5 hours per week) that provided social support and education; their children attended an activity-based group program during the sessions. Each support group comprised 6–10 women and 2 leaders, and sessions were held in a community location (e.g., public housing project, church hall). A manual was used to guide the structure, content and implementation of the program as well as the training of the leaders. Content covered 2 thematic areas: child-related (e.g., child development and behaviour, behaviour management, school involvement, child welfare agencies) and maternal (e.g., social isolation, stress and coping, personal care and development, relationships, grief, economic disadvantage). There was no specified order for introducing content; experience with similar groups20,22,41
has shown that all content areas are covered over the course of the program. We chose this format because it responds to maternal needs by allowing participants to bring urgent concerns to the group in a timely fashion. Leaders used group processes to create a therapeutic milieu, drew on cognitive behavioural techniques and provided structured group counselling. In our study, we used a pool of 3 leaders; each had previous group training and experience, underwent specific training for this program, participated in weekly supervision and, throughout the study, were videotaped at random leading their groups.
Group sessions were held on weekdays either in the morning (9:30–11:00 am) or in the evening (6:00–7:30 pm). To enhance participation in the group sessions, mothers received weekly phone reminders as well as bus tickets or taxi fare to assist with transportation. In addition, mothers and children attending sessions were given snacks (day groups) or dinner (evening groups).
Mothers allocated to the control arm of the trial were given a standard list of community resources and the option to attend the program of group sessions at the end of follow-up period.
Assessment data were collected from all participants by interviewers working in pairs; at least one of the interviewers was blind to the mothers' group allocation. Data were collected during home visits at baseline (before the intervention period) and at 3 follow-up visits (after the intervention period and at 3 and 6 months). At each visit, mothers and children received gifts of appreciation for their participation (e.g., retail gift certificates, children's books, craft supplies).
A total of 117 mothers were eligible and agreed to participate in the study; 59 were randomly assigned to the intervention arm and 58 to the control arm (). One mother in the control arm was withdrawn from the study immediately after randomization because she did not return calls. The sample size was selected to provide adequate power (1 – β ≥ 0.80) to detect medium standard effects (0.50), allowing for 20% attrition and some clustering of effects within groups.
Fig. 1: Flow of participants through the trial. R = randomization. *Mothers in the intervention arm attended 10 weekly group sessions (1.5 hours per week) during which they received social support and education; mothers in the control arm were given a (more ...)
The concepts and outcome measures used in the study are described in an online appendix (available at www.cmaj.ca/cgi/content/full/173/12/1451/DC1
). The outcome measures were maternal well-being (mood,42,43
and social support45
) and parenting;46
the measures were chosen for their relevance to the program objectives and for the simplicity, brevity, acceptability and general applicability.
We estimated means and variances for selected variables and compared them between the intervention and control groups. In addition, we used linear regression analysis to test differences in outcome measures before and after the program; we adjusted for group differences by including “treated for nerves or nervous condition” and “wages or salaries as source of financial support” as covariates (participants who did not report whether they had been treated for nerves were coded as the modal value [yes]).
To assess the effect of the program over the follow-up period, we used MLwiN47
to model growth trajectories. In growth curve analysis, developmental outcomes are modelled as a function of time to establish individual-level trajectories, showing a starting point (baseline) and change per unit of time or growth (slope) for each person.48
This modelling made it possible to compare differences between the intervention and control groups in their baseline values and the rates of change. Because of the extended follow-up period and nonlinear pattern of growth (decelerating rates of change), we used the square root of time (in months) to model outcomes. The covariates “treated for nerves” and “wages or salaries as source of financial support” were included in the models at baseline.