For caregivers in the Bronx, the pandemic has caused unprecedented psychological distress; in addition to combating social determinants of health (SDOH), these families now face greater financial insecurity and challenges related to their school-aged children. Furthermore, social distancing requirements and limited telehealth resources for Bronx families have posed greater barriers to healthcare. Such parental distress contributes to heightened risk of transgenerational cycles of psychological stress, trauma and maltreatment. The social and economic impacts of the COVID-19 pandemic have had significant consequences for family well-being, putting parents at higher risk of experiencing distress and potentially impairing their ability to provide supportive care to their children. Although children may be less susceptible to the most damaging physical consequences of COVID-19, there are growing concerns regarding the short-and long-term impacts of pandemic-related stressors on children. The marked upheaval of family life over an extended period may make children vulnerable to mental health consequences associated with the public health crisis and infection mitigation efforts. School and childcare closures, unstable financial circumstances, social isolation and lack of support have a disproportionate, cumulative impact on parents and may undermine their capacities to provide support for their children. Importantly, a large body of evidence suggests that parental stress during times of disasters induces psychopathologies in family members including children. Further, high anxiety and depressive symptoms in parents during the pandemic have been associated with higher child abuse potential, whereas greater parental support was associated with lower perceived stress and child abuse potential. In addition to psychological impacts, stress associated with caregiving can interfere with parents' ability to maintain their own health. This multimodal study addresses key strategies to mitigate the psychological and health impact of COVID-19 in parents.
Study Design
1. Objectives We hypothesize that both the CARE program and the Valera Health app will
mitigate the psychological effects of COVID-19 while enhancing access to healthcare in
the Bronx. The study will take place at Montefiore Medical Center (MMC), the largest
health system in the Bronx, serving predominantly racial and ethnic minority individuals
from underserved families. We will focus on three vulnerable caregiver cohorts
presenting with moderate stress: a) caregivers of children with psychiatric conditions
(N=130); b) caregivers of children with autoimmune illnesses (N=130); c) caregivers who
are frontline healthcare workers at MMC (N=130). While the latter may have more
favorable SDOH than families treated at MMC, this cohort has faced unprecedented stress
during the pandemic. A RCT (Stage III, NIH model) with 3 arms will test our hypothesis:
a) CARE program alone; b) Valera Health app; c) CARE program and Valera Health app;
Study procedures will include four surveys: at study enrollment, 6-, 12- and 24-weeks
and will assess parental stress (primary outcome), reflective functioning (RF), access
to healthcare, mood and anxiety and additional parent and child clinical measures.
Smartphones and connectivity will be provided as needed.
Aim 1. To examine the efficacy of the 12-week CARE program on caregivers' emotional
health and RF. Hyp. 1. (a) Compared to the Valera Health app arm at 12- and 24-week
follow-up, participation in the CARE program will result in decreased caregiver's
perceived stress, increased RF, and improved caregiver's mood and anxiety symptoms. (b)
Therapeutic improvements in Hyp. 1a will be mediated by RF, as it reflects mentalizing
capacity.
Aim 2: To examine the efficacy of the 12-week Valera Health app on caregivers' emotional
health and access to healthcare. Hyp. 2. (a), The Valera Health app, will result in
decreased caregiver's perceived stress, increased access to healthcare, and increased
adherence to and engagement in treatment. (b) CARE program + Valera Health app arm will
be superior to CARE or Valera Health app alone on all outcome measures.
Exploratory Aim: (a) We will also explore the effects on outcome of providing technology
and connectivity to families who lack them during the study period. (b) We will explore
the relative effectiveness of our intervention among the 3 vulnerable cohorts. (c) We
will also utilize machine learning approaches to explore complex patterns as predictors
of outcome including COVID-19 illness/deaths, medical comorbidity, psychopathology,
housing, poverty, children's school status, age, family functioning, and trauma.
2. Study Timelines
Individual Subject Timeline:
Participation in this research will last about 24 weeks. Participants will partake in 12 one
hour group sessions that meet once per week. Participants will complete several surveys when
enrolled in the study and then after 6 weeks, after 12 weeks, and after 24 weeks.
Overall Timeline:
Because Investigators intend to rely on a pre-existing clinical infrastructure, Investigators
anticipate to be able to begin enrollment within the first six months of the study.
Participants will return for 6-month follow-ups. Data analysis will occur throughout the
duration of the study, along with publications and conference presentations. The likelihood
that this study will be carried out as planned is very high, as all methods and
collaborations are already in place.
Behavioral: CARE Program and Valera Application with care manager functionality
Participant will take part in 12 week CARE program and receive the Valera health application which will provide parent education materials as well as the ability to connect to their child's treatment team via care manager.
Behavioral: Valera Application with care manager functionality
Participant will receive the Valera health application which will provide parent education materials and the ability to connect to their child's treatment team via care manger.
Behavioral: CARE Program
Participant will take part in 12 week CARE program.
Behavioral: Valera Application
Participant will receive the Valera health application which will provide parent education materials.
Behavioral: CARE Program and Valera Application
Participant will take part in 12 week CARE program and receive the Valera health application which will provide parent education materials.
Inclusion Criteria:
- All participants will be primary caregivers who present with moderate level of stress
by meeting a severity score of ≥ 14 on the Perceived Stress Scale (PSS22).
- Investigators will allow primary caregivers (e.g., grandmothers and aunts) as it is
common in our patient population.
- Clinical cohorts will be active patients in the psychiatric and rheumatology clinics
in Montefiore Medical Center (MMC).
- Frontline health care providers will be those who are required to work on site at
Montefiore Medical Center (MMC).
Exclusion Criteria:
- Serious psychiatric or substance use difficulty that, in the judgement of the PI,
would preclude meaningful participation in a parent intervention.
- Active child abuse/maltreatment cases.
- Neurocognitive conditions that may prevent participants from accessing telehealth
services.
- Primary language other than Spanish or English.
- Utilized a smartphone health platform similar to the Valera app.
PRIME
Bronx, New York, United States
Investigator: Chloe Roske
chloe.roske@einsteinmed.edu
Investigator: Vilma Gabbay, MD
Chloe Roske, AB
51668472019
chloe.roske@einsteinmed.edu
Vilma Gabbay, MD, Principal Investigator
Albert Einstein College of Medicine