THE IMPACT OF GUIDED IMAGERY ON SLEEP QUALITY IN MOTHERS OF PRETERM INFANTS

Linda Schaffer, PhD, RNLois Howland, DrPh, RN

Nancy Jallo, PhD, RN Kathy James, DNSC, RN

Dale Glaser, PhDRita Pickler, PhD, RN

Acknowledgements

Research supported in part by The Doris A. Howell Foundation For Women’s Health Research

Background• Sleep is associated with important health outcomes including

immunity, longevity, and the quality of life (Howard, 2006)

• Poor sleep quality has been associated with the onset of depressive symptoms in post-partum women (Dennis & Ross, 2005)

• Mothers of preterm infants are at an increased risk of poor sleep quality (Lee & Kimble, 2009)

• Maternal mental distress (perceived stress, state anxiety, and depressive symptoms) is prevalent in this population (Davis,

Edwards, Mohay, & Wollin, 2003; Voegtline and Stifter, 2010; Shaw, Clements & Poehlmann, 2011) and interferes with maternal caretaking activities (Field, 2010)

• Few tested interventions to help improve sleep quality in this vulnerable population (Lee & Kimble, 2009)

• Relaxation guided imagery (RGI) has been effective in reducing stress, anxiety, and depression in other populations (Alves-Apostolo & Kolcaba, 2009)

Purpose/Study AimsPurpose:This study examined the effects of an 8-week (RGI) intervention and self-report measures of maternal mental distress on sleep quality in mothers of hospitalized preterm infants. Aims: • Describe maternal and infant factors associated with self-

reported sleep quality;• Examine the association between self-reported measures of

sleep quality and maternal mental distress (perceived stress, depressive symptoms, and state anxiety); and

• Evaluate the relationship of an 8-week RGI intervention with sleep quality in mothers of hospitalized preterm infants.

Methods• Theoretical framework- Transactional model of stress and coping

(Lazarus & Folkman,1984)

• Design- Secondary data analysis from a prospective, repeated measures, feasibility study

• Population- Sample of 20 mothers ≥ 18 years of age of currently hospitalized preterm infants in Southern California; 23-32 weeks gestation at the time of birth; not using RGI, being treated for chronic immune or psychiatric disorders, or taking systemic steroids,

• Recruitment- Participants recruited between April 2010 and September 2010; signed university and sponsoring hospital IRB approved consent

• Procedures- Demographic questionnaire, self-report measures, and brief interview

• Intervention- Mothers received a CD of three 20-minute RGI recordings and were asked to listen at least once daily for 8-weeks

Construct Measure Method for Obtaining Information

Scale Cronbach’s α

Stress The Perceived Stress Scale (PSS) (Cohen, Kamarck, & Mermelstein, 1983)

Self-Report 10 items (5-level response)

0.616

Depressive Symptoms

The Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977)

Self-Report 20 items(4-level response)

0.796

State Anxiety

The State -Trait Anxiety Inventory (STAI) (Spielberger, Gorsuch, & Lushene, 1970)

Self-Report State-20 items(4-level response)

0.830

Social Support

The Duke-UNC Functional Social Support Questionnaire(FSSQ) (Broadhead, Gehlbach, De Gruy, & Kaplan (1988)

Self-Report 8 items (5-level response)

0.935

Sleep Quality

The Pittsburg Sleep Quality Index (PSQI) (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989)

Self-Report 19 items(4-level response)

0.830

Neonatal Morbidity

The Neonatal Medical Index (NMI) (Korner et al., 1993)

Chart Extraction 10 items (5-point scale)

Gestational Age

Chart Extraction

Measures

Sample CharacteristicsMaternal Sample:• Mean Age (years) = 27.3 years (SD 6.4, range 18-37)• Race/Ethnicity = 60% White; 50% Hispanic• Educational Level = 85% > high school• Marital Status = 50% single, never married• Total Family Income = 50% < $30,000• Employment Status = 70% not employed• Parity = 35% multipara• Mean weekly R-GI listening frequency = 4.46 (SD 1.1, range 2-7)

Infant Sample:• Mean gestational age = 28 weeks (SD 2.3, range 24-32 weeks)• Mean Neonatal Morbidity Index score = 4.46 (SD 1.1, range 2-7)

Self-Reported Mean Scores of Maternal Mental Distress, Social Support, and Sleep Quality at Baseline and Week 8

Variable Baseline Scoreµ (SD)Range(N=20)

Week 8 Scoreµ (SD)Range(N=19)

Sleep Quality 9.79 (3.94) 4-17

8.04 (3.57) 1-14

Perceived Stress 19.55 (5.75) 10-28

17.79 (5.80) 9-28

State Anxiety 42.05 (13.40) 21-67

39.42 (12.79) 20-62

Depressive Symptoms 18.45 (11.90) 1-45

14.61 (11.79)§

0-38

Social Support 34.05 (5.39) 25-40

33.74 (8.69) 10-40

§ N = 18

Pearson Correlations of Maternal Mental Distress and Social Support with Sleep Quality at Baseline and at Week 8

VariableMean PSQI score at

baseline r (p-value)

(N=20)

Mean PSQI score at Week 8

r (p-value) (N=19)

Depressive

Symptoms

.496 (.026)* .343 (.164)§

State Anxiety .324 (.164) .391 (.098)

Perceived Stress .321 (.167 ) .419 (.074)

Social Support -.462 (.040)* -.126 (.608) * p<.05 § N=18

Relationship Between RGI Use Frequency and Quality of Sleep at Week 8

Summary• Participants reported high baseline levels of mental distress• CES-D scores >16 (55%)• Mean STAI score of 42 (SD 2.99) compared with a mean score of 37.6

(SD 9.1) among community-dwelling women (Marteau & Bekker, 1992)

• Mean PSS score of 19.6 (SD 1.3) compared to 13.0 (SD 6.4) in a general female population (Cohen & Williamson, 1988)

• Majority reported poor sleep quality (PSQI scores ≥ 5) at baseline and Week 8

• Better sleep quality (lower PSQI scores) at baseline was associated with mothers who were older (r=-.488, p=.029) and household incomes >$30,000 compared to household incomes of < $30,000 (t(18)=2.43, p=.026)

• There was a negative medium relationship between mean weekly RGI CD use and sleep quality scores at Week 8 (r = -.255)

• As average amount of time spent listening to the CD increased, PSQI scores decreased indicating improving sleep quality

Participant Comments Related to Effects of RGI on Sleep Quality

• “I fall asleep when listening.”• “Put me in a relaxed state; I fall asleep at the end.”• “Track 1 puts me to sleep; track 2 puts me to sleep faster.”• “It hypnotizes me; the voice is so calming it puts me to sleep.”• “I’ve used the CD a couple of times a week at bedtime to help me

sleep.” • “Still helps me fall asleep.” • “When I was stressed out, they helped me to sleep.”• “Fall asleep became so relaxed.”• “I’ve never been able to listen to the whole track,

because it always puts one to sleep.”• “I put on track 2 and then fell asleep.”

Limitations

• Small, heterogeneous sample size • Missing data (one participant withdrew at week 8 and did

not complete self-report measures; another did not complete one page of the CES-D at week 8 so it could not be used)• Other potentially confounding activities (internet blogging,

use of Facebook, and activities provided by the NICU social work staff) that mothers used to cope with stress were not measured

Implications for Future Research

• Further exploration of RGI intervention with a randomized control trial design and adequate sample size

• Use of precise measurement methods such as actigraphy and sleep diaries