1199949 research-article2023 WHE0010.1177/17455057231199949Women’s HealthRabinowitz et al. Meta-analysis The role of catastrophizing in chronic cyclical pelvic pain: A systematic review and meta-analysis Women’s Health Volume 19: 1­–16 © The Author(s) 2023 Article reuse guidelines: sagepub.com/journals-permissions https://doi.org/10.1177/17455057231199949 DOI: 10.1177/17455057231199949 journals.sagepub.com/home/whe Emily P Rabinowitz1 , MacKenzie A Sayer1 and Douglas L Delahanty1,2 Abstract Background: Dysmenorrhea (painful menstrual cramps) is one of the most common gynecological complaints in women and girls. Dysmenorrhea may be a condition itself or a result of another medical condition, including endometriosis and chronic pelvic pain. Research examining the relationship between menstrual pain ratings and catastrophizing has produced mixed results. Objective: To review and meta-analyze the relationship between catastrophizing and pain ratings of chronic cyclical pelvic pain. Design: Cross-sectional, longitudinal, and intervention studies that reported the relationship between menstrual/ pelvic pain and catastrophizing were included. Study populations had to include healthy menstruating persons or persons with a condition associated with cyclical pelvic pain including primary dysmenorrhea, endometriosis, and/or chronic pelvic pain. Data sources and methods: A systematic search of articles published since 2012 on PubMed, PsychInfo, CINHAL, and Medline was conducted in January and rerun in November of 2022. Search terms included cyclical pelvic pain, dysmenorrhea, endometriosis, pelvic pain, and catastrophizing. Data extraction was completed independently by two extractors and cross-checked for errors. A random-effects meta-regression was used to synthesize the data using restricted maximum likelihood. Results: Twenty-five studies examining 4,540 participants were included. A random effects model found a metacorrelation between catastrophizing and pain of r = .31 (95% confidence interval: .23–.40) p < .001. Heterogeneity was large and significant (I2 = 84.5%, Q(24) = 155.16, p < .001). Studies that measured general pelvic pain rather than cyclical pelvic pain specifically and those that used multi-item rather than single-item measures of pain had significantly higher correlations. Age and depression did not moderate the relationship between catastrophizing and pain. Conclusion: A systematic review and meta-analysis found that catastrophizing had a small but significant positive association with pain ratings. Patients experiencing cyclical pelvic pain may benefit from interventions targeting the psychological management of pain. Registration: This meta-analysis was registered in PROSPERO on 14 January 2022. Registration number: CRD42022295328. Plain Language Summary Severity of period pain is associated with catastrophic thinking •• 1 Dysmenorrhea, known as menstrual cramps or period pain, is a common symptom and condition for women of reproductive age. Medical and surgical treatments often do not effectively reduce dysmenorrhea. Understanding the psychological processes that reinforce dysmenorrhea may help in developing better treatments. One important  epartment of Psychological Sciences, Kent State University, Kent, D OH, USA 2 Northeast Ohio Medical University, Rootstown, OH, USA Corresponding author: Douglas L Delahanty, Department of Psychological Sciences, Kent State University, 317 Kent Hall, Kent, OH 44240, USA. Email: ddelahan@kent.edu Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 •• •• Women’s Health psychological process is catastrophizing, a thinking style in which people “catastrophize” or engage in negative thinking about how bad pain is or might become. In this study, we reviewed 25 studies of women with menstrual pain and statistically combined their results. We found that pain severity was significantly associated with higher catastrophizing. We also found that the association between pain and catastrophizing was higher in the studies that assessed general pelvic pain rather than cyclical pelvic pain specifically and those that used multi-item rather than single-item measures of pain. The relationship between pain and catastrophizing was not affected by diagnoses, age, or level of depression. Our results suggest a significant association between catastrophizing and menstrual pain ratings. Patients experiencing dysmenorrhea may benefit from interventions targeted at addressing catastrophizing. Keywords catastrophizing, dysmenorrhea, menstrual pain, pelvic pain Date received: 3 January 2023; revised: 7 August 2023; accepted: 22 August 2023 Introduction Dysmenorrhea (painful menstrual cramps) is one of the most common gynecological complaints in women and girls.1–3 Among women of reproductive age, rates of dysmenorrhea range from 16% to 92%, whereas the prevalence of severe dysmenorrhea ranges from 2% to 29%.4 Primary dysmenorrhea (PD) occurs in the absence of an identified organic disease, whereas secondary dysmenorrhea (SD) refers to cramps/pain attributed to an identifiable condition.1 One common cause of SD is endometriosis, a chronic condition affecting 6% of women in the United States, over half of whom report struggling with menstrual pelvic pain/cramping.5 Other conditions associated with SD include uterine fibroids (leiomyomas), adenomyosis, interstitial cystitis, chronic pelvic pain (CPP), and pelvic floor myalgia.6 While dysmenorrhea is often associated with (and confused with) CPP, CPP is a broad chronic pain diagnosis that refers to both noncyclical pain (i.e. pain that is not dependent on the menstrual cycle) and persistent cyclical pelvic pain (i.e. pain due to endometriosis or dysmenorrhea).7 As the primary aim of this meta-analysis is to examine the role of catastrophizing in chronic cyclical pelvic pain (CCPP), and given inconsistent definitions used in prior research, we included studies of individuals with primary and secondary dysmenorrhea and CPP (unless it was stated that individuals with dysmenorrhea or cyclical pain were excluded). Furthermore, for simplicity of reading, we refer to these studies as including individuals with CCPP. Current medical and surgical management of CCPP is limited by side effects and nonresponse.8–10 For example, a systematic review of clinical trials for the treatment of CCPP due to endometriosis found that 17%–34% of women experienced pain recurrence at follow-up time points.8 Experiencing CCPP in adolescence and early adulthood is associated with developing chronic pain later in life; this, combined with existing treatment limitations, further underscores the necessity of developing effective treatments for the management of CCPP.11,12 One reason for the limited success of medical or surgical management of CCPP may be due to the failure of these treatments to address psychological factors that contribute to and maintain cyclical pelvic pain. Like many chronic pain conditions, there is a high comorbidity of CCPP and psychopathology, specifically depression.10,13,14 For instance, almost a third of women with CCPP due to endometriosis also meet the criteria for depression.14 Despite this significant comorbidity and the existence of effective psychotherapy for many forms of chronic pain,15 research examining psychological interventions for CCPP is lacking in quantity and quality.16,17 A systematic review of 11 studies of psychological interventions for CCPP due to endometriosis found that interventions containing mindfulness, psychoeducation, or cognitive behavioral therapy appear to be effective at improving both coping with pain and symptoms of depression and anxiety, but findings are limited by the small number of studies included and methodological concerns.17 Another systematic review found only four studies of psychological or behavioral interventions for women with CCPP of unknown etiology, and the results of these interventions were inconclusive.16 In one small open trial for patients with CCPP due to PD, Payne et al. implemented five sessions of mind-body and cog­nitive-behavioral group therapy (including one session on “automatic pain thoughts and de-catastrophizing”); patients showed significant reductions in menstrual pain and catastrophizing, suggesting that catastrophizing may be a mechanism for reducing CCPP.18 Catastrophizing is defined as the tendency to “overestimate the likelihood of a negative event, and also believe that the negative event will be catastrophic.”19 A form of negative repetitive thinking, catastrophizing is linked to rumination, magnification, and helplessness/hopelessness in response to negative stimuli.20 Originally introduced as one of the cognitive distortions associated with depression, catastrophizing is significantly associated with perceived pain intensity and pain-related disability.21,22 Rabinowitz et al. Catastrophizing is one of the major mechanisms in psychological models of chronic pain. For example, the fearavoidance model of chronic pain posits that maladaptive beliefs about pain, including catastrophizing, trap patients in a cycle of fear and avoidance that ultimately increases pain intensity and disability.23 Alternatively, Petrini and Arendt-Nielsen hypothesize that catastrophizing may be understood as an inhibitory emotional regulatory process as defined under the Behavioral Inhibition and Activation Systems (BIS/BAS) model.24 In this way, individuals engage in catastrophic thinking to avoid experiencing or managing pain.24 Intervention research suggests that reductions in catastrophizing may precede reductions in pain and disability, further highlighting the clinical utility of addressing catastrophizing in chronic pain populations.25,26 Because CCPP involves repeated, unavoidable, and predictable pain, women with CCPP may engage in anticipatory catastrophic thinking as they approach their period; during their period, women may also catastrophize menstrual pain itself. Both anticipatory and concurrent catastrophizing likely lead to increased pain from menstrual cramps. Over a third (35%) of women with CCPP due to PD and 58% of women with CCPP due to endometriosis have clinical levels of catastrophizing (defined as a score of 30 or above on the Pain Catastrophizing Scale), suggesting that catastrophizing is a common maladaptive cognitive process in this population.27 Some researchers, supported by neuroimaging and pain threshold findings, posit that repeated exposure to severe cyclical pelvic pain each month may lead to changes in the brain systems that process and cope with pain.28–31 For example, women with CCPP due to dysmenorrhea compared to healthy controls showed altered central pain processing as evidenced by more sensitivity to thermal pain and increased activation of the entorhinal cortex, a region associated with the anticipation of pain.32,33 Evidence also suggests that engaging in catastrophic thinking may inhibit successful pain modulation, possibly by triggering anticipatory anxiety or increasing attention to painful stimuli.34,35 In further support of this anticipatory effect, women with severe CCPP have a stronger emotional reaction to menstrual-related words in a modified version of the Stroop task during the late luteal (premenstrual) phase compared to during the mid-follicular phase (after menstruation).36 Thus, catastrophizing represents a critical mechanism through which women’s anticipation, expectation, attention, and worry about menstrual pain may be increased, potentially leading to increased experiences of pain. Catastrophizing may also be a mechanism that explains the association between sexual trauma and dysmenorrhea. Women with a history of sexual assault are 1.60 times more likely to have pelvic pain and 1.20 times more likely to have dysmenorrhea compared to women with no history of sexual assault.37 Sexual trauma may intensify the experience of cyclical pelvic pain because pain is localized to 3 the pelvic and genital region, and this pain could serve as a reminder of the past traumatic experience.38,39 Women with a history of sexual trauma may catastrophize both their menstrual pain and their negative emotional reactions to and/or memories of trauma, creating a negative feedback loop that increases pain.38 In addition to the role that it plays in exacerbating pain ratings, catastrophizing is also associated with the maintenance and exacerbation of depression, which, as previously mentioned, is common in patients with CCPP.10,13,14 In both nonpelvic chronic pain and CCPP samples, symptoms of depression are related to higher levels of catastrophizing, suggesting that the relationship between pain ratings and catastrophizing may be stronger in individuals experiencing depression.22,27 The present meta-analysis While both theory and available data suggest a significant positive correlation between catastrophizing and CCPP, the magnitude of this relationship is unclear. A study of women with CCPP due to endometriosis found a correlation of r = .67,40 whereas another study of women with CCPP due to CPP more broadly found a correlation of r = .52.41 Other studies reported correlations closer to r = .30.42–44 It is unclear if this variability in effect size is due to differences in study design, medical diagnosis examined, levels of depression, or other methodological differences such as the instrument used to assess pain or measure catastrophizing. Because CCPP is both a condition and a symptom of a wide variety of gynecological conditions, identifying which subpopulations have a stronger relationship between catastrophizing and pain ratings may improve recommendations for which patients would benefit from an intervention to address catastrophizing.6,45 Consequently, the present analysis is the first to directly examine the unique effects of catastrophizing on pain ratings in patients with CCPP. We also examine the extent to which this relationship is impacted by study methodology, medical diagnosis, age, depression, or history of sexual trauma. Objectives 1. To calculate the meta-correlation between catastrophizing and pain severity ratings in women with CCPP. Hypothesis 1: We hypothesized that catastrophizing and pain severity would be significantly, positively related. 2. To examine if the relationship between catastrophizing and pain ratings was moderated by the instrument used to measure catastrophizing, measure of pain severity, medical diagnosis, and age. 4 Women’s Health Hypothesis 2: We hypothesized that the relationship between catastrophizing and pain ratings would not be moderated by assessment instrument, pain, medical diagnosis, or age. 3. To test if the relationship between catastrophizing and pain severity ratings was moderated by levels of depression or history of sexual trauma. Hypothesis 3: We hypothesized that levels of depression and prior exposure to sexual trauma would moderate the relationship between catastrophizing and pain severity such that catastrophizing would be more strongly correlated with pain ratings in individuals with higher levels of depression and in those with a sexual trauma history. Method The following procedures were preregistered on PROSPERO in January 2022 (CRD42022295328) and follow PRISMA and MOOSE reporting guidelines.46,47 The PRISMA and MOOSE checklists can be found in supplemental materials. Search strategy A search of articles published after 2011 was conducted on PubMed, CINHAL, Medline, and PsychInfo in January and rerun in November of 2022. We used the following search terms to broadly capture articles addressing catastrophizing and CCPP: cyclical pelvic pain, dysmenorrhea, endometriosis, pelvic pain, and catastrophizing. A similar search strategy was used in a systematic review of treatments for CCPP.48 Consistent with prior reviews and the age range for the prevalence of dysmenorrhea and CPP, we used an age range of 6–64.4,49 While there has yet to be a meta-analysis specifically evaluating catastrophizing and cyclical pelvic pain, a large systematic review published in 2006 identified psychosocial factors as important correlates of pelvic pain.50 Later, review papers published in 2010–2011 identified psychological variables including catastrophizing as key mechanisms of pelvic pain.7,51,52 In addition, a prior meta-analysis of the association between PD and psychopathology indicated that only a minority of studies on PD were published prior to 2012.13 Due to increasing emphasis on psychosocial factors in CPP after 2011, and the large literature captured in our search of reproductive health conditions, we limited our search to articles published in the last 10 years (2012 and later). Study selection Articles retrieved from the initial searches of all databases were compiled into Covidence, a web-based platform that streamlines the production of systematic reviews.53 Two blind reviewers completed title/abstract and full-text reviews of articles to determine eligibility according to criteria. Disagreements were resolved by article discussion. Exclusion reasons were documented in Covidence. Eligibility criteria Inclusion and exclusion criteria are specified in Supple­ mental Document 1. Briefly, included studies had (1) samples of menstruating persons with CCPP or a condition known to cause cyclical menstrual pain (dysmenorrhea, endometriosis, adenomyosis, leiomyomata (fibroids), interstitial cystitis, CPP, and pelvic floor myalgia) and (2) measurement of both catastrophizing and pain. Conditions known to cause CCPP were taken from current guidelines for the differential diagnosis of secondary dysmenorrhea.6 Because we planned to measure the impact of pain measurement and specific CCPP conditions on the relationship between catastrophizing and pain, we included studies that measured both specific cyclical pelvic pain and those that measured broader pelvic or urogenital pain. Healthy samples were included if they measured dysmenorrhea specifically. Data extraction Two independent reviewers double-entered study data regarding study design, location, participant demographics, methodology, and effect size estimates into a customized Qualtrics form.54 Whenever possible, an article’s original sample descriptions were used (i.e. “women with Primary Dysmenorrhea” was coded as PD); if reviewers were unclear of the conditions specified, they also examined study descriptive data to determine if additional conditions were included in the sample. If articles reported on a longitudinal study, the correlation coefficient from the first timepoint was used. In case-control designs, the correlation within the cases relevant to the study was used. Whenever possible, the correlation between dysmenorrhea and catastrophizing was extracted. When not available, data from other pain measures were used (such as ratings of CPP). If multiple pain indices were reported, we used the scale with the highest reliability and validity (e.g. the Brief Pain Inventory compared to a single item VAS). If necessary, correlations for the catastrophizing subscales were averaged to create an effect size estimate for the total scale. If a study used only the pain subscale of a health-related quality of life (HRQOL) instrument, the sign of the correlation was inverted such that higher catastrophizing was related to worse pain-related HRQOL. Effect sizes were converted to Pearson’s r correlations using standard formulas for Spearman’s rho,55 chi-square,56 and odds ratios.57 If an Rabinowitz et al. included study did not provide sufficient information for an effect size estimate, the corresponding author was contacted. If the author did not provide the necessary information prior to the completion of the review, the study was excluded due to lack of data availability. Assessment of risk of bias The Appraisal tool for Cross-Sectional Studies (AXIS), a 20-item critical appraisal tool, was used to evaluate the quality of each study.58 Each study was evaluated by independent raters, and disagreements were processed identically to data extraction. Because current guidelines caution against using summary scores to rate study quality, we reported the ratings for each study on each of the 20 items.59 Meta-analysis Data analysis was conducted using the “meta” and “metafor” packages in RStudio (https://www.r-project.org). Meta-regressions used mixed effects models to estimate the meta-correlation between catastrophizing and pain rating.60,61 Our review used Pearson’s r correlation coefficient because it is the recommended approach for metaanalysis.60,61 Heterogeneity between the studies’ effect sizes was assessed using the Q and I statistics as well as by examining the forest plot.62 We also created a funnel plot to evaluate for publication bias. For the meta-regressions with categorical moderators (i.e. medical condition, study design), a minimum of 10 studies per category was required.61,63 When less than 10 studies existed, a narrative review was conducted. To conduct the moderation analyses on depression, the sample symptom mean was extracted from each study. However, because there was significant variability in instruments used for symptom measurement, mean values were converted to standardized scores using a common metric derived from an item response theory analysis.64 A standardized metric is available for 11 depression instruments including the Beck Depression Inventory (BDI), Center for Epidemiologic Studies Depression Scale (CESD), and Hospital Anxiety and Depression Scale (HADS).64 Studies that used an instrument not included in the standardized metric were not included; a total of 10 studies were needed to conduct the meta-regression. As part of our narrative review, we documented if studies assessed anxiety symptoms to explore other potential moderators. Results A systematic search using PubMed, PsychInfo, CINHAL, and Medline yielded 9,294 studies. After removing duplicates, 4,838 studies were screened at title-abstract review, 5 947 were screened in full-text review, and 25 were included in the final analysis (see Figure 1 for PRISMA Diagram). Of the studies excluded at full-text review, 92% (N = 852) were excluded for not measuring catastrophizing, 3.6% (N = 33) were excluded for nonoriginal data (i.e. post hoc analyses of data already in the review), and 3% (N = 28) reported to measure both catastrophizing and pain but did not report sufficient data or respond to data inquiries. Finally, 0.7% (N = 6) of studies were excluded because their study population did not meet inclusion criteria, and 0.3% (N = 3) of studies were excluded for not measuring pain. Study characteristics Descriptive information for each study is presented in Table 1 and summarized in Table 2. Most studies were observational (N = 16), followed by intervention (N = 8) and case-control designs (N = 1). Thirteen studies assessed general pelvic pain (using instruments such as the Brief Pain Inventory), whereas 12 studies specifically assessed cyclical pelvic pain (e.g. ratings of menstrual pain/cramps). Thus, we conducted two meta-analyses: 1) an overall correlation with all 25 studies and 2) a meta-correlation including studies of cyclical pelvic pain specifically. There was also significant heterogeneity in the diagnoses included in the samples of the studies; only five studies had a sample solely comprised of participants with PD; thus, we were unable to conduct a separate meta-correlation for these studies. However, 11 studies included participants with endometriosis, allowing for additional examination of this condition. There was considerable variability regarding what measurement tools assessed pain ratings. Among the studies that used multi-item instruments, the most common was the Brief Pain Inventory (Table 2). Yosef et al.43 described using a VAS CPP rating that participants “were asked to specifically differentiate from dysmenorrhea, deep or superficial dyspareunia, dyschezia, or back pain.” The data for dysmenorrhea specifically were not available. Excluding the above paper did not significantly impact the overall meta-correlation (r = .31 (95% confidence interval (CI): .22–.40), p < .001) I2 = 85.2%, Γ = .17, Tau2 = .03, H = 2.60, Q(23) = 154.92, p < .001), thus we kept it in the analysis. Catastrophizing was most frequently measured by the pain catastrophizing scale (PCS, N = 19, Table 2). Analysis of heterogeneity A fixed-effects model demonstrated that there was considerable heterogeneity across all studies, I2 = 84.5%, Q(24) = 155.16, p < .0001, and H = 2.54. The forest plot (Figure 2) also demonstrated significant heterogeneity across studies. Thus, we conducted a random-effects 6 Women’s Health Figure 1.  PRISMA flow diagram showing inclusion and exclusion of relevant studies. model to estimate the meta-correlation and to account for this heterogeneity.63 Significant heterogeneity was also observed in the fixed-effects model of the studies of cyclical pelvic pain (N  =  12): I2 = 89.3%, Q(11) = 102.90, p < .0001, and H = 3.06. Meta-correlation A random effects model found that the overall meta-­ correlation was r = .31 (95% CI: .23–.40), p < .001. The variance of the true effect size (Γ)2 was. 03 and Γ was Country United Kingdom USA USA Australia USA Country USA Croatia Ireland Canada Sweden USA Country UK Canada Multiple Study Abokhrais et al.40 As-Sanie et al.41 Bridger et al.65 Bryant et al.66 Chao et al.67 Study Chen et al.68 Cosic et al.69 Durand et al.70 Flynn et al.71 Grundström et al.72 Hellman et al.73 Study Horne et al.74 Jarrell et al.75 Kapadi and Elander76 Cross-sectional Intervention Intervention Study Design Case-Control Cross-sectional Intervention Cross-sectional Longitudinal Cross-sectional Study Design Intervention Cross-sectional Intervention Cross-Sectional Intervention Study Design Table 1.  Summary of included studies. PD Patients needing laparoscopy, including endometriosis and CPP CPP, excluding endometriosis Condition(s) Dysmenorrhea with or without Silent Blatter Pain CPP and suspicion of endometriosis CPP, excluding endometriosis + PD None None Dysmenorrhea CPP, endometriosis Condition(s) CPP CPP CPP Endometriosis, abdominal and/or pelvic floor myofascial dysfunction adenomyosis, pelvic adhesions, ovarian remnants, vulvodynia Endometriosis Condition(s) 145 61 305 N 147 37 24 892 147 678 N 14 170 6 219 27 N 24.55 (7.87) 33 (7.5) 30.3 (8.15) Age Mean or Median (SD) 24.35 (6.21) 25 37.7 (7.9) N/A 26.9 28 (7.6) Age Mean or Median (SD) 41.5 (7.95) 36 (14) 49 34.8 (11.3) 35.76 (9.08) Age Mean or Median (SD) N/A N/A 64.71% Contraception (% usage) 0% 54% 100% 31.3% 0% N/A Contraception (% usage) N/A N/A N/A N/A 36.36% Contraception (% usage) Menstrual pain VAS 6.79 (1.55) MPQ-SF 2.97 (2.04) Menstrual VAS* 5.15 (3.85) Pain Measure M (SD) Menstrual VAS 73.10 (13.60)* Pain sensitivity questionnaire 4.6 BPI-severity 47.08 (17.05) Menstrual pain VAS 5.51 (1.80) *Yes/no pain during menses 51.02% Yes *Average menstrual pain NRS N/A Pain Measure M (SD) SF-36 Pain subscale 42.12 (23.50) BPI-severity 5.55 (2.0) MPQ total 6.67 (2.56) BPI 5.06 (2.22) BPI N/A Pain Measure, M(SD) CSQ-C 18.63 (8.90) PCS 23.58 (13.6) PCS 27.3 (12.93) Catastrophizing Measure M (SD) PCS 15.46 (9.80) PCS 9.66 PCS 26.17 (10.93) PCS 16.78 (11.72) PCS 20.38 (13.37) PCS 18.3 (12.8) Catastrophizing Measure M (SD) PCS 26.93 (15.39) CSQ-C 20.96 PCS 27.8 (11.48) PCS N/A PCQ 26.04 (12.61) Catastrophizing Measure, M (SD) .52 .63 (Continued) .49 .53 .11 r .19 .34 .23 .45 .14 .05 r .43 .48 -.07 r Rabinowitz et al. 7 Japan United Kingdom Canada Country USA Brazil USA Australia USA Country Canada China Italy Kato42 Keogh et al.77 Keizer et al.78 Study Payne et al.18 Poli-Neto et al.79 Schrepf et al.80 Sewell et al.81 Tomakowsky et al.82 Study Yosef et al.43 Yu et al.83 Zarbo et al.44 Cross-sectional Cross-sectional Longitudinal Study Design Cross-sectional Longitudinal Longitudinal Intervention Intervention Study Design Cross-sectional Longitudinal Cross-sectional Study Design Endometriosis Dysmenorrhea CPP including endometriosis Condition(s) Pelvic and/or urogenital pain CPP, dysmenorrhea, dyspareunia, noncyclical pelvic pain, lower abdominal pain, dyschezia, dysuria Urologic CPP syndrome CPP + dysmenorrhea, endometriosis PD Condition(s) Lumbopelvic pain PD PD Condition(s) 162 43 619 N 117 113 233 21 20 N 108 52 186 N N/A 22.86 (1.98) 34.5 (7.6) Age Mean or Median (SD) 36.12 (16.60) 29 40.5 28.2 (6) 20.9 (2.2) Age Mean or Median (SD) 40.4 (12.6) 21.92 (5.81) 18.99 (1.59) Age Mean or Median (SD) N/A 0% N/A Contraception (% usage) N/A N/A N/A 0% 0% Contraception (% usage) N/A 0% N/A Contraception (% usage) MPQ-SF total 23.04 (12.09) *Menstrual VAS 6.77 (1.53) VAS CPP2 5.8 (3.2) Pain Measure M (SD) BPI-severity 4.74 (2.14) Genitourinary pain index-pain severity 18.8 (5.7) Menstrual VAS 4 *VAS 76.4 (22.1) Menstrual pain NRS 8 (1.12) Pain Measure M (SD) Yes/no pain during menses 41% yes Menstrual pain VAS* 53.05 (20.85) Menstrual VAS 3.84 (.95) Pain Measure, M(SD) PCS 11.76 (12.77) Cognitive emotion regulation questionnaire—short version: catastrophizing subscale 5.07 (2.5) PCS Catastrophizing Measure M(SD) PCS 22.30 (14.78) PCS 30 CSQ-C 14.1 (8.8) PCS 32.8 (10.8) PCS 19.75 (12.1) Catastrophizing Measure M (SD) PCS 21.17 (10.28) PCS 5.6 (4.9) CSQ-C 9.83 (4.78) Catastrophizing Measure, M (SD) r .09 .12 .3 .27 .01 .34 r .61 .38 .31 .56 -.23 r CPP: chronic pelvic pain; N/A: not available; PD: primary dysmenorrhea; SD: standard deviation; BPI: Brief Pain Inventory; PCQ: Pain Catastrophizing Questionnaire; PCS: Pain Catastrophizing Scale; MPQ: McGill Pain Questionnaire; SF-Short Form; CSQ-C: Coping Strategies Questionnaire- Catastrophizing Subscale; NRS: Numeric Rating Scale; VAS: Visual Analogue Scale. *Study reported information for timing of assessment in relation to the menstrual cycle phase. Country Study Table 1. (Continued) 8 Women’s Health Rabinowitz et al. 9 Table 2.  Study characteristics. Study design   Cross-sectional correlational   Longitudinal correlational  Intervention  Case-control Study location  USA  Canada  Australia   United Kingdom  Multiple  Brazil  Ireland  Italy  Japan  Sweden  China Pain instrument   Single-item menstrual pain   Brief pain inventory   McGill pain questionnaire   Chronic pelvic pain single item   SF-36 pain subscale   Genitourinary pain index   Pain sensitivity questionnaire Catastrophizing instrument   Pain catastrophizing scale   Coping strategies questionnaire-catastrophizing   Pain catastrophizing questionnaire   Cognitive emotion regulation questionnaire N % 12 4 8 1 48 16 32 4 8 4 2 3 2 1 1 1 1 1 1 32 16 8 12 8 4 4 4 4 4 4 12 5 3 2 1 1 48 20 12 8 4   4 19 4 1 1 76 16 4 4 N = 25. estimated to be .16, I2 = 84.5% and H = 2.54, Q(24)  =  155.16, p < .001. Among those studies that specifically evaluated cyclical pelvic pain (N = 12), the meta-correlation was r = .21 (95% CI: .09–.33), p = .003. The variance of the true effect size (Γ)2 was .03 and Γ was estimated to be .16, I2 = 89.3% and H = 3.06, Q(11) = 102.90, p < .001 (see Supplemental Figure 1 for a forest plot of this meta-correlation). Moderation analyses We first explored if the relationship between catastrophizing and pain ratings was moderated by differences in the measurement of pain and/or measurement of catastrophizing. Because 76% of studies used the PCS, there was not enough variability in measures to test whether the instrument for assessing catastrophizing moderated the relationship between catastrophizing and pain ratings. Eleven studies used multi-item scales to measure pain and fourteen used a single-item instrument. Studies that used multi-item instruments had a higher correlation between pain and catastrophizing (r = .44) than studies that used a single-item instrument measure of pain (r = .24, Qm(1,23) = 8.19, p = .01; Table 3). Measurement differences accounted for 31% of the variance in effect sizes. All the studies that evaluated ratings of cyclical pelvic pain specifically (and all of the studies that examined specifically PD) used single-item measures. Studies that measured general pelvic pain had higher correlations between pain and catastrophizing (r = .43) than those that measured cyclical pelvic pain specifically (r = .22, Qm(1,23) = 11.05, p < 01; Table 3). Measurement of cyclical pelvic pain versus general CPP accounted for 34% of the variance in effect size, and the cyclical pelvic pain-specific correlation was significant (p = .003). As expected, many studies assessed women with a variety of medical conditions including PD, urologic CPP syndrome, and endometriosis (see Table 1). Because endometriosis is a leading cause of CCPP, we examined whether the correlation between catastrophizing and pain was different for samples that included individuals with endometriosis compared to those that did not; the moderation analysis was not significant (Qm(1,23) = 1.76, p = .20, Table 3). There was also no significant effect of the average age of the sample on the relationship between pain ratings and catastrophizing (b = .01, SE = .01; Qm(1,21) = 2.30, p = .14; Table 3). Nine studies had sufficient data to convert average depression levels to a standardized metric and examine the impact of depression on the relationship between catastrophizing and CCPP (Supplemental Table 1). Although analyses required ten studies for adequate power, we conducted exploratory moderation analyses to see whether existent studies suggested a need to control for depression; the moderation was not significant (b = −.003, SE = .02; Qm (1,7) = .04, p = .85; Table 3). History of sexual trauma was assessed in only three studies, all of which used different definitions of sexual trauma.41,43,80 Although not enough studies existed for analysis, our narrative review found that the presence of childhood and adult sexual trauma was positively associated with pain severity in two studies,43,80 and that those with “major” childhood sexual abuse had significantly higher pain catastrophizing levels than those with no abuse or “mild” abuse history.41 Finally, while many studies assessed anxiety (Supple­ mental Table 2), they used noncomparable measures, thus preventing a moderation analysis using anxiety scores. In our narrative review, we observed that higher anxiety scores were significantly associated with both higher catastrophizing and pain ratings in nearly all studies (Supplemental Table 2). In addition, as shown in Table 1, only 44% of articles (11/25) reported data on participants’ use of contraceptives, with many of the 11 studies simply limiting their samples to participants not on contraceptives. 10 Women’s Health Figure 2.  Forest plot of all studies. PR: Pearson’s r correlation coefficient, 95% CI is the 95% confidence interval around each correlation. Black boxes represent the correlation for each study; size of each box indicates the influence of the correlation on the model. The solid black line indicates a correlation of zero. The dotted line and the diamond indicate the meta-correlation. Publication bias and study quality assessment Examination of the funnel plot (Figure 3) indicated a relatively symmetrical distribution of the effect sizes, and Egger’s regression test of asymmetry was not significant (t = .19, df(22), p = .85), suggesting that the results of this meta-analysis were not substantially impacted by publication bias. AXIS ratings for each study are presented in Supple­ mental Table 3. Very few studies conducted either an a priori or post hoc power analysis. Furthermore, as can be seen in Table 1, many studies had small sample sizes which are susceptible to bias. Most studies were also conducted in English-speaking countries and findings may differ in other regions. Furthermore, few studies characterized participant refusals or missing data which may pose a risk of bias. Some studies were missing basic data including demographics and descriptive statistics, limiting the utility and generalizability of those studies. Finally, most studies recruited convenience samples receiving outpatient gynecological services which may limit the generalizability of results to populations who are unable to obtain specialized medical care. However, the predominance of heterogeneous clinical samples suggests that these results would be relevant to gynecologists and other providers in outpatient settings. Discussion The meta-correlation between catastrophizing and pain ratings was r = .31 (p < .001), although there was significant heterogeneity across studies; 84.5% of the variability in the effect sizes was due to between-study variability, which is considered a high level of heterogeneity.84 There were higher correlations between pain and catastrophizing among studies that measured general pelvic pain (r = .43) versus cyclical pelvic pain specifically (r = .22), and those that used multi-item (r = .43) rather than Rabinowitz et al. 11 Table 3.  Tests of moderation. Categorical Moderators Test of Moderation Heterogeneity Statistics Γ2 = .02 Γ= .14 I2 = 78.01% H2 = 4.55 R2 = 30.78% Γ2 = .02 Γ= .13 I2 = 76.61 H2 = 4.28 R2 = 33.72 Γ2 = .03 Γ= .17 I2 = 84.00% H2 = 6.25 R2 = 0.00%   Moderator Present Moderator Absent Single-item measurement k = 25 r = .24 k = 14 r = .44 k = 11 Qm(1,23) = 8.19 p = .01 Measured menstrual pain k = 25 r = .22 k = 12 r = .43 k = 13 Qm(1,23) = 11.05 p = .003 Endometriosis k = 25 r = .37 k = 11 r = .26 k = 14 Qm(1,23) = 1.76 p = .20   Continuous moderators Age k = 23 b = .0097 Qm(1,21) = 2.30 p = .14 Depression k = 9 b = −.003 Qm(1,7) = .04 p = .85   Γ2 = .03 Γ= .17 I2 = 81.36% H2 = 5.36 R2 = 6.19% Γ2 = .03 Γ= .16 I2 = 77.43 H2 = 4.43 R2 = 0.00 CI: confidence interval; b: meta-regression coefficient for continuous moderators; k: # of studies; r: meta correlation. Figure 3.  Funnel plot. PR: Pearson’s r correlation. The dotted line in the center indicates the meta-correlation. The two diagonal lines indicate ±1.95 standard error. Each study is plotted with a circle corresponding to its correlation on the X-axis and Standard Error on the Y-axis. The absence of bias is indicated by a balanced funnel within the SE line. single-item measures of pain (r = .24). Average age and depression scores did not moderate the relationship between catastrophizing and pain. Despite the prevalence of cyclical pelvic pain as a primary complaint and symptom across many reproductive health conditions, only 12 studies (48%) measured cyclical pelvic (i.e. menstrual) pain specifically, and only five studies had samples composed solely of participants with PD. While the heterogeneity of conditions in the studies reviewed is not surprising given that CCPP is both a condition itself and a common symptom of many gynecological, urological, and gastrointestinal conditions,6,45 our review indicates a substantial need for more research into the relationship between catastrophizing and cyclical pelvic pain. The correlation between catastrophizing and cyclical pelvic pain (r = .21) was lower than the correlation between catastrophizing and pain in studies that assessed general pelvic pain (r = .43), perhaps suggesting that the cyclical pelvic pain samples lowered the overall meta-correlation (r = .31). While the magnitude of our correlations is small, it is consistent a prior meta-analysis of 49 studies which found that the correlation between general chronic pain intensity and catastrophizing was r = .29 (95% CI: .25– .32).22 While some studies reported when (in the menstrual cycle) the assessment was conducted, we were not able to explore this as a possible moderator; it is likely that women 12 who were menstruating during the time of assessment may have rated pain and catastrophizing differently than participants who were retrospectively responding. Despite these limitations, the correlation between catastrophizing and cyclical pelvic pain was still significant, providing justification for future investigation of this topic with better methodology. The observed correlation between pain ratings and catastrophizing was significant and consistent in magnitude with other meta-analyses of adults experiencing pain.22 However, the relatively small correlation may be explained by a number of variables including measurement variability, the use of single-item pain measurements, and potential conceptual overlap of pain and catastrophizing scales. Measurement variability accounted for the largest percentage in effect size variability and may have affected the overall correlation The relationship between catastro­ phizing and pain was significantly lower in studies with single-item assessments than studies that used multi-item indices. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommends single-item numerical rating scales for the measurement of pain intensity while more comprehensive measures are recommended for assessing “pain interference”85; for this reason, pain catastrophizing may have a stronger relationship to pain interference than pain intensity. However, five of the 11 multi-item studies used the pain severity subscale of the Brief Pain Inventory which is an average rating of pain severity at its worst, least, average, and current level, a subscale that may produce similar results as single-item measures of pain.86,87 It is also possible that the difference between single- and multi-item correlations is a statistical artifact rather than a reflection of true differences in the relationship between catastrophizing and pain because single-item pain ratings produce less variability than multi-item scales.88 Alternatively, there is conceptual overlap between measures of pain interference and catastrophizing which may have inflated the correlation for some studies. For example, the total score of the McGill Pain Questionnaire used in three studies included four questions assessing the “affective” component of pain where individuals rate the extent to which their pain is “fearful,” “punishing-cruel,” “tiring-exhausting,” or “sickening.”89 These items are likely highly related to catastrophizing due to their similarity to anxiety, hopelessness, and helplessness. Nevertheless, we found that both the single- and multi-item pain scales were significantly correlated with catastrophizing, which suggests a robust association. Unexpectedly, depression did not moderate the relationship between catastrophizing and pain ratings. This may be due to small sample size or range restriction; the standardized values of average depression scores ranged from 57.1 to 67.8 units, which limited the ability to detect moderation. However, the average depression scores Women’s Health included in our analyses are above the standardized population average for this metric (M = 50, SD = 10).64 Therefore, our nonsignificant interaction term indicates that catastrophizing impacts pain ratings similarly for populations at varying levels of moderate-to-severe depression. Our findings further suggest that catastrophizing is a useful treatment target even in patients with higher levels of depression.13,14 The current review found only three studies that met our inclusion criteria and evaluated trauma history. Two studies reported that sexual trauma was associated with increased pain severity and one study found that child sexual abuse was linked to higher catastrophizing levels, suggesting that those with a sexual trauma history may have a stronger relationship between catastrophizing and pain.41,43,80 Given the increasing calls for trauma-informed reproductive health care and the impact that trauma has on psychological mechanisms of pain, this review highlights a major absence of trauma-informed research on CCPP.38,90 Strengths and limitations To our knowledge, this is the first meta-analysis of the relationship between catastrophizing and CCPP. Our review searched four large databases, used a comprehensive definition of CCPP, and examined critical moderators. While there is a significant range in the observed effect sizes, this is likely reflective of the heterogeneous clinical population with CCPP.6,45 In addition, small sample sizes for the moderation analyses may have limited statistical power to detect effects. Future research would benefit from the inclusion of instruments to measure psychopathology and trauma exposure to examine these factors in more depth. Furthermore, we were unable to account for the effects of contraceptive use because the majority of studies did not provide information on contraceptive use in their samples. Also, because the majority (75%) of studies used the PCS, we were unable to explore if the instrument used to measure catastrophizing was a significant moderator. While the PCS remains a common and clinically relevant instrument in chronic pain research and practice, theoretical and empirical work has begun to question the extent to which the PCS accurately captures catastrophic thinking processes as well as the construct validity of catastrophizing in general.20,24,91,92 Future research would benefit from improved measurement of catastrophizing and other cognitive distortions. Conclusion In summary, we found that, among women with CCPP, the overall correlation between pain ratings and catastrophizing was r = .31 and this relationship was consistent across differences in medical diagnosis, age, and level of depression. Because CCPP may be a risk factor for the Rabinowitz et al. development of future chronic pain disorders, addressing the link between catastrophizing and CCPP may not only reduce menstrual pain but also the likelihood of a chronic pain condition later in life.12,93 Future research would benefit from improved assessment of catastrophizing, pain, history of sexual trauma, and psychopathology. In addition, research could examine the feasibility, efficacy, and scalability of mental health interventions that address catastrophizing and may reduce CCPP such as psychoeducation classes94 or brief smartphone-delivered interventions.95 Overall, our results reiterate the impact that mental health variables have on CCPP, adding to the growing evidence for integrated behavioral and reproductive health care.96 Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Author contributions Emily P Rabinowitz: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing. MacKenzie A Sayer: Conceptualization; Data curation; Investi­ gation; Writing – review & editing. Douglas L Delahanty: Conceptualization; Supervision; Writing – review & editing. Acknowledgements Not applicable. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was made possible in part by support from the Kent State University Open Access Publishing Fund and support from Kent State University Department of Psychological Sciences. Competing interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Registration This meta-analysis was registered in PROSPERO on 14 January 2022. Registration number: CRD42022295328 (https://www.crd. york.ac.uk/prospero/display_record.php?RecordID=295328). 13 ORCID iD Emily P Rabinowitz https://orcid.org/0000-0002-1931-1824 Supplemental material Supplemental material for this article is available online. References 1. Proctor M and Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ 2006; 332: 1134–1138. 2. Ju H, Jones M and Mishra GD. Premenstrual syndrome and dysmenorrhea: symptom trajectories over 13 years in young adults. Maturitas 2014; 78(2): 99–105. 3. Wang L, Yan Y, Qiu H, et al. Prevalence and risk factors of primary dysmenorrhea in students: a meta-analysis. Value Health 2022; 25(10): 1678–1684. 4. Ju H, Jones M and Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev 2014; 36: 104–113. 5. Fuldeore MJ and Soliman AM. Prevalence and symptomatic burden of diagnosed endometriosis in the United States: national estimates from a cross-sectional survey of 59,411 women. Gynecol Obstet Invest 2017; 82(5): 453–461. 6. Osayande AS and Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician 2014; 89: 341–346. 7. Daniels JP and Khan KS. Chronic pelvic pain in women. BMJ 2010; 341: c4834. 8. Becker CM, Gattrell WT, Gude K, et al. Reevaluating response and failure of medical treatment of endometriosis: a systematic review. Fertil Steril 2017; 108(1): 125–136. 9. Marjoribanks J, Ayeleke RO, Farquhar C, et al. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev 2015; 2015: CD001751. 10. Till SR, As-Sanie S and Schrepf A. Psychology of chronic pelvic pain: prevalence, neurobiological vulnerabilities, and treatment. Clin Obstet Gynecol 2019; 62(1): 22–36. 11. Li R, Li B, Kreher DA, et al. Association between dysmenorrhea and chronic pain: a systematic review and metaanalysis of population-based studies. Am J Obstet Gynecol 2020; 223(3): 350–371. 12. Li R, Kreher DA, Jusko TA, et al. Prospective association between dysmenorrhea and chronic pain development in community-dwelling women. J Pain 2021; 22(9): 1084– 1096. 13. Bajalan Z, Moafi F, MoradiBaglooei M, et al. Mental health and primary dysmenorrhea: a systematic review. J Psychosom Obstet Gynaecol 2019; 40(3): 185–194. 14. Delanerolle G, Ramakrishnan R, Hapangama D, et al. A systematic review and meta-analysis of the Endometriosis and Mental-Health Sequelae; The ELEMI Project. Womens Health 2021; 17: 1–16. 15. Sturgeon JA. Psychological therapies for the management of chronic pain. Psychol Res Behav Manag 2014; 7: 115– 124. 16. Champaneria R, Daniels JP, Raza A, et al. Psychological therapies for chronic pelvic pain: systematic review of randomized controlled trials. Acta Obstet Gynecol Scand 2012; 91(3): 281–286. 14 17. Van Niekerk L, Weaver-Pirie B and Matthewson M. Psychological interventions for endometriosis-related symp­ toms: a systematic review with narrative data synthesis. Arch Womens Ment Health 2019; 22(6): 723–735. 18. Payne LA, Seidman LC, Romero T, et al. An open trial of a mind-body intervention for young women with moderate to severe primary dysmenorrhea. Pain Med 2020; 21: 1385–1392. 19. Pike AC, Serfaty JR and Robinson OJ. The development and psychometric properties of a self-report Catastrophizing Questionnaire. R Soc Open Sci 2020; 8: 201362. 2 0. Flink IL, Boersma K and Linton SJ. Pain catastrophizing as repetitive negative thinking: a development of the conceptualization. Cogn Behav Ther 2013; 42(3): 215–223. 21. Beck AT. Thinking and depression: I. Idiosyncratic content and cognitive distortions. Arch Gen Psychiatry 1963; 9: 324–333. 22. Rogers AH and Farris SG. A meta-analysis of the associations of elements of the fear-avoidance model of chronic pain with negative affect, depression, anxiety, pain-related disability and pain intensity. Eur J Pain 2022; 26(8): 1611– 1635. 23. Crombez G, Eccleston C, Van Damme S, et al. Fear avoidance model of chronic pain: the next generation. Clin J Pain 2012; 28(6): 475–483. 24. Petrini L and Arendt-Nielsen L. Understanding pain catastrophizing: putting pieces together. Front Psychol 2020; 11: 603420. 25. Campbell CM, McCauley L, Bounds SC, et al. Changes in pain catastrophizing predict later changes in fibromyalgia clinical and experimental pain report: cross-lagged panel analyses of dispositional and situational catastrophizing. Arthritis Res Ther 2012; 14: R231. 26. Racine M, Moulin DE, Nielson WR, et al. The reciprocal associations between catastrophizing and pain outcomes in patients being treated for neuropathic pain: a cross-lagged panel analysis study. Pain 2016; 157(9): 1946–1953. 27. Evans S, Dowding C, Olive L, et al. Pain catastrophizing, but not mental health or social support, is associated with menstrual pain severity in women with dysmenorrhea: a cross-sectional survey. Psychol Health Med 2022; 27: 1410–1420. 28. Evans S, Mikocka-Walus A, Olive L, et al. Phenotypes of women with and without endometriosis and relationship with functional pain disability. Pain Med 2021; 22: 1511– 1521. 29. Tu CH, Niddam DM, Chao HT, et al. Brain morphological changes associated with cyclic menstrual pain. Pain 2010; 150(3): 462–468. 30. Tu CH, Niddam DM, Yeh TC, et al. Menstrual pain is associated with rapid structural alterations in the brain. Pain 2013; 154(9): 1718–1724. 31. Wu T-H, Tu C-H, Chao H-T, et al. Dynamic changes of functional pain connectome in women with primary dysmenorrhea. Sci Rep 2016; 6: 24543. 32. Ploghaus A, Narain C, Beckmann CF, et al. Exacerbation of pain by anxiety is associated with activity in a hippocampal network. J Neurosci 2001; 21: 9896–9903. Women’s Health 33. Vincent K, Warnaby C, Stagg CJ, et al. Dysmenorrhoea is associated with central changes in otherwise healthy women. Pain 2011; 152(9): 1966–1975. 34. Ellingson LD, Stegner AJ, Schwabacher IJ, et al. Catastro­ phizing interferes with cognitive modulation of pain in women with fibromyalgia. Pain Med 2018; 19: 2408–2422. 35. Weissman-Fogel I, Sprecher E and Pud D. Effects of catastrophizing on pain perception and pain modulation. Exp Brain Res 2008; 186(1): 79–85. 36. Acevedo SF. Using a menstrual emotional stroop task test (MEST) to measure emotional responses to menstrual cycle pain. MOJ Anat Physiol 2017; 3: 122–128. 37. Hassam T, Kelso E, Chowdary P, et al. Sexual assault as a risk factor for gynaecological morbidity: an exploratory systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 255: 222–230. 38. Sharp TJ and Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin Psychol Rev 2001; 21: 857–877. 39. Spiegel DR, Chatterjee A, McCroskey AL, et al. A review of select centralized pain syndromes: relationship with childhood sexual abuse, opiate prescribing and treatment implications for the primary care physician. Health Serv Res Manag Epidemiol 2015; 2: 1–12. 40. Abokhrais IM, Denison FC, Whitaker LHR, et al. A twoarm parallel double-blind randomised controlled pilot trial of the efficacy of Omega-3 polyunsaturated fatty acids for the treatment of women with endometriosis-associated pain (PurFECT1). PLoS One 2020; 15: e0227695. 41. As-Sanie S, Clevenger LA, Geisser ME, et al. Pain catastrophizing in women with chronic pelvic pain and its relationship to pain experience and childhood sexual abuse. J Reprod Med 2016; 61: 545–551. 42. Kato T. Effects of flexibility in coping with menstrual pain on depressive symptoms. Pain Pract 2017; 17(1): 70–77. 43. Yosef A, Allaire C, Williams C, et al. Multifactorial contributors to the severity of chronic pelvic pain in women. Am J Obstet Gynecol 2016; 215(6): 760.e1–760.e14. 44. Zarbo C, Brugnera A, Dessì V, et al. Cognitive and personality factors implicated in pain experience in women with endometriosis: a mixed-method study. Clin J Pain 2019; 35(12): 948–957. 45. Vercellini P, Somigliana E, Viganò P, et al. Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach. Gynecol Endocrinol 2009; 25(3): 149–158. 46. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71. 47. Brooke BS, Schwartz TA and Pawlik TM. MOOSE reporting guidelines for meta-analyses of observational studies. JAMA Surg 2021; 156: 787–788. 48. Won HR and Abbott J. Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach. Int J Womens Health 2010; 2: 263–277. 49. Armour M, Ferfolja T, Curry C, et al. The prevalence and educational impact of pelvic and menstrual pain in Australia: a national online survey of 4202 young women aged 13-25 years. J Pediatr Adolesc Gynecol 2020; 33(5): 511–518. Rabinowitz et al. 50. Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ 2006; 332: 749–755. 51. Alappattu MJ and Bishop MD. Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain. Phys Ther 2011; 91(10): 1542–1550. 52. Meltzer-Brody S and Leserman J. Psychiatric comorbidity in women with chronic pelvic pain. CNS Spectr 2011; 16(2): 29–35. 53. Veritas Health Innovation. Covidence systematic review software, 2022, www.covidence.org 54. Qualtrics XM, 2022, https://www.qualtrics.com 55. Rupinski MT and Dunlap WP. Approximating Pearson product-moment correlations from Kendall’s Tau and Spearman’s rho. Educ Psychol Meas 1996; 56: 419–429. 56. Rosenberg MS. A generalized formula for converting chisquare tests to effect sizes for meta-analysis. PLoS One 2010; 5: e10059. 57. Chinn S. A simple method for converting an odds ratio to effect size for use in meta-analysis. Stat Med 2000; 19: 3127–3131. 58. Downes MJ, Brennan ML, Williams HC, et al. Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ Open 2016; 6: e011458. 59. Hopewell S, Boutron I, Altman DG, et al. Incorporation of assessments of risk of bias of primary studies in systematic reviews of randomised trials: a cross-sectional study. BMJ Open 2013; 3: e003342. 60. Balduzzi S, Rücker G and Schwarzer G. How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health 2019; 22(4): 153–160. 61. Harrer M, Cuijpers P, Furukawa TA, et al. Doing metaanalysis with r: a hands-on guide. 1st ed. Chapman & Hall, 2021, https://www.routledge.com/Doing-Meta-Analysiswith-R-A-Hands-On-Guide/Ha… (accessed 8 December 2021). 62. Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, et al. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods 2006; 11: 193–206. 63. Deeks J, Higgins J and Altman D (eds). Chapter 10: analysing data and undertaking meta-analyses. In: Cochrane handbook for systematic reviews of interventions. Cochrane, 2021, https://training.cochrane.org/handbook/current/chapter-10 (accessed 3 January 2022). 64. Wahl I, Löwe B, Bjorner JB, et al. Standardization of depression measurement: a common metric was developed for 11 self-report depression measures. J Clin Epidemiol 2014; 67(1): 73–86. 65. Bridger C, Prabhala T, Dawson R, et al. Neuromodulation for chronic pelvic pain: a single-institution experience with a collaborative team. Neurosurgery 2021; 88: 819–827. 66. Bryant C, Cockburn R, Plante AF, et al. The psychological profile of women presenting to a multidisciplinary clinic for chronic pelvic pain: high levels of psychological dysfunction and implications for practice. J Pain Res 2016; 9: 1049–1056. 67. Chao MT, Abercrombie PD, Santana T, et al. Applying the RE-AIM framework to evaluate integrative medicine group 15 visits among diverse women with chronic pelvic pain. Pain Manag Nurs 2015; 16(6): 920–929. 68. Chen CX, Carpenter JS, Ofner S, et al. Dysmenorrhea symptom-based phenotypes: a replication and extension study. Nurs Res 2021; 70(1): 24–33. 69. Cosic A, Ferhatovic L, Banozic A, et al. Pain catastrophizing changes during the menstrual cycle. Psychol Health Med 2013; 18(6): 735–741. 70. Durand H, Monahan K and McGuire BE. Prevalence and impact of dysmenorrhea among university students in Ireland. Pain Med 2021; 22: 2835–2845. 71. Flynn MJ, Campbell TS, Robert M, et al. Intranasal oxytocin as a treatment for chronic pelvic pain: a randomized controlled feasibility study. Int J Gynaecol Obstet 2021; 152(3): 425–432. 72. Grundström H, Larsson B, Arent-Nielsen L, et al. Pain catastrophizing is associated with pain thresholds for heat, cold and pressure in women with chronic pelvic pain. Scand J Pain 2020; 20: 635–646. 73. Hellman KM, Roth GE, Dillane KE, et al. Dysmenorrhea subtypes exhibit differential quantitative sensory assessment profiles. Pain 2020; 161(6): 1227–1236. 74. Horne AW, Vincent K, Hewitt CA, et al. Gabapentin for chronic pelvic pain in women (GaPP2): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2020; 396: 909–917. 75. Jarrell J, Ross S, Robert M, et al. Prediction of post­ operative pain after gynecologic laparoscopy for non­acute pelvic pain. Am J Obstet Gynecol 2014; 211(4): 360.e1– 360.e8. 76. Kapadi R and Elander J. Pain coping, pain acceptance and analgesic use as predictors of health-related quality of life among women with primary dysmenorrhea. Eur J Obstet Gynecol Reprod Biol 2020; 246: 40–44. 77. Keogh E, Cavill R, Moore DJ, et al. The effects of menstrual-related pain on attentional interference. Pain 2014; 155(4): 821–827. 78. Keizer A, Vandyken B, Vandyken C, et al. Predictors of pelvic floor muscle dysfunction among women with lumbopelvic pain. Phys Ther 2019; 99: 1703–1711. 79. Poli-Neto OB, Oliveira AMZ, Salata MC, et al. Strength exercise has different effects on pressure pain thresholds in women with endometriosis-related symptoms and healthy controls: a quasi-experimental study. Pain Med 2020; 21: 2280–2287. 80. Schrepf A, Naliboff B, Williams DA, et al. Adverse childhood experiences and symptoms of urologic chronic pelvic pain syndrome: a multidisciplinary approach to the study of chronic pelvic pain research network study. Ann Behav Med 2018; 52: 865–877. 81. Sewell M, Churilov L, Mooney S, et al. Chronic pelvic pain—pain catastrophizing, pelvic pain and quality of life. Scand J Pain 2018; 18: 441–448. 82. Tomakowsky J, Carty JN, Lumley MA, et al. The role of social constraints and catastrophizing in pelvic and urogenital pain. Int Urogynecol J 2016; 27(8): 1157–1162. 83. Yu S, Wei W, Liu L, et al. The hypertrophic amygdala shape associated with anxiety in patients with primary dysmenorrhea during pain-free phase: insight from 16 surface-based shape analysis. Brain Imaging Behav 2022; 16(5): 1954–1963. 84. Higgins JPT and Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539–1558. 85. Dworkin RH, Turk DC, Farrar JT, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005; 113(1–2): 9–19. 86. Atkinson TM, Mendoza TR, Sit L, et al. The Brief Pain Inventory and its “pain at its worst in the last 24 hours” item: clinical trial endpoint considerations. Pain Med 2010; 11(3): 337–346. 87. Cleeland CS. The Brief Pain Inventory user guide, 2009, https:// oml.eular.org/sysModules/obxOml/docs/ID_363/bpi.pdf 88. Goodwin LD and Leech NL. Understanding correlation: factors that affect the size of r. J Exp Educ 2006; 74: 251–266. 89. Melzack R. The short-form McGill Pain Questionnaire. Pain 1987; 30: 191–197. 90. Owens L, Terrell S, Low LK, et al. Universal precautions: the case for consistently trauma-informed reproductive health­ care. Am J Obstet Gynecol 2022; 226(5): 671–677. Women’s Health 91. Crombez G, De Paepe AL, Veirman E, et al. Let’s talk about pain catastrophizing measures: an item content analysis. PeerJ 2020; 8: e8643. 92. Turner JA and Aaron LA. Pain-related catastrophizing: what is it? Clin J Pain 2001; 17: 65. 93. Westling AM, Tu FF, Griffith JW, et al. The association of dysmenorrhea with noncyclic pelvic pain accounting for psychological factors. Am J Obstet Gynecol 2013; 209(5): 422.e1–422.e10. 94. Darnall BD, Sturgeon JA, Kao MC, et al. From Catastro­ phizing to Recovery: a pilot study of a single-session treatment for pain catastrophizing. J Pain Res 2014; 7: 219–226. 95. Kristjánsdóttir ÓB, Fors EA, Eide E, et al. A smartphonebased intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial. J Med Internet Res 2013; 15: e2249. 96. Crawford JN, Weitzen SH and Schulkin J. Integrated women’s behavioral health: recent literature and proposed framework. Prof Psychol Res Pract 2022; 53: 50–58.
1185405 research-article2023 WHE0010.1177/17455057231185405Women’s HealthSomerville et al. Advancing Maternal Health Equity – Original Research Article An evaluation of the feasibility and acceptability of sister circles as an anxiety intervention for pregnant Black women Women’s Health Volume 19: 1­–16 © The Author(s) 2023 Article reuse guidelines: sagepub.com/journals-permissions https://doi.org/10.1177/17455057231185405 DOI: 10.1177/17455057231185405 journals.sagepub.com/home/whe Keaton Somerville1 , Tiffany Rowell1, Robert Stadulis1, Debra Bell2 and Angela Neal-Barnett1 Abstract Background: Black women and their infants face heightened health risks during pregnancy, labor, and delivery that, for many, cost them their lives. Such health risks during this critical period are linked to increased rates of anxiety among Black pregnant and postpartum women. Black women also endure racism when seeking support from mental health and healthcare providers, which further contributes to pregnancy and postpartum-related anxiety. Evidence on sister circles has demonstrated that this indigenous form of healing may provide Black pregnant and postpartum women with the support and skills needed to cope with stressors associated with mental and physical health concerns and racism. Objective: Our study aimed to evaluate the feasibility and acceptability of the Birthing Beautiful Babies Sisters Offering Support, a sister circle cognitive behavioral therapy-based stress and anxiety intervention for Black pregnant and postpartum women. Design: Our study employed a mixed-methods framework. Methods: Descriptive analyses, paired samples t-test, and open and selective coding were conducted. We utilized the following measures: Penn State Worry Questionnaire–Abbreviated, Kessler Psychological Distress Scale, PregnancyRelated Anxiety Scale, focus booklet, and focus group discussion. Results: Participants reported experiencing moderate levels of worry and distress and low levels of pregnancy-related anxiety prior to the start of the Birthing Beautiful Babies Sisters Offering Support intervention. Eighty women participated in Birthing Beautiful Babies Sisters Offering Support. Eleven focus groups were conducted to assess their experience. Participants reported a perceived increase in their knowledge about panic attacks and stress and ability to manage stressors effectively. They found that all completed activities contributed to their development and application of skills. They reported they enjoyed Birthing Beautiful Babies Sisters Offering Support because of the supportive environment, openness, and emphasis on sisterhood. Participants provided helpful feedback about the structure and flow of the intervention. Conclusion: Limitations of the present study and future directions are discussed. Keywords anxiety disorders, Black women, maternal health, mental health, psychotherapy Date received: 1 December 2022; revised: 10 May 2023; accepted: 14 June 2023 Introduction Black women and their infants face heightened health risks during pregnancy, labor, and delivery that cost many their lives.1 For example, in the USA, Black pregnant women are five times more likely to die from pregnancy-related complications than White women.2 Similarly, Black 1 Kent State University, Kent, OH, USA Birthing Beautiful Communities, Cleveland, OH, USA 2 Corresponding author: Keaton Somerville, Kent State University, 600 Hilltop Drive, Kent, OH 44242, USA. Email: ksomerv5@kent.edu Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 infants are twice as likely to die before their first birthday than their White, Asian, and Hispanic counterparts.3 Furthermore, the awareness of these racial health disparities is a painstaking reality for Black women, which likely contributes to the growing rates of pregnancy-related anxiety in this population. Black women have a high risk of experiencing perinatal and postnatal mood and anxiety disorders (PMADs), such as anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder.4 In recent decades, Black pregnant women and mothers, including celebrities such as Serena Williams and Taraji P. Henson, have become vocal about the importance of mental health support for this community.5,6 Despite their wants for mental health care, Black women continually experience difficulty gaining access to quality providers that are both culturally responsive and aware of their own implicit biases.7–9 Multiple studies have shown that mental health care providers may be uncomfortable talking about race-based topics or hold negative attitudes and beliefs about Black Americans, which affects how they interact with their patients and which treatments they provide.10,11 Regarding receiving mental health care during pregnancy and birth, Black women report greater provider mistreatment and discrimination, based on insurance and race, than White women.12–14 These stressful racialized experiences likely also contribute to the growing rates of anxiety among Black women.4,15–19 Sister circle interventions One anxiety intervention that may be effective and address the unique needs of Black women is sister circles. Sister circles can be defined as “support groups that build upon existing friendships, fictive kin networks, and the sense of community among [Black] females” (p. 1).20 Importantly, sister circles are unstructured, and they promote relationship-building.20 A Black woman may be exposed to various forms of sister circles throughout her life that naturally develop within her community and organizations.21 She may also be exposed to more organized and structured sister circles in her school or workplace. For example, sister circles have been used to increase cultural values and beliefs, improve academic performance, and reduce disruptive behaviors in school among Black adolescent girls.22–24 Within collegiate and professional spaces, multiple sister circles were created to not only provide support but also to serve as a form of resistance to the oppression that Black women face daily.25–30 While these forms of sister circles were successful in targeting their various goals, few studies have evaluated the effectiveness of the sister circle format as a manualized, culturally relevant group intervention for Black women. One example is the Prime-Time Sister Circles Women’s Health (PTSC) intervention.31 The PTSC used a cognitive behavioral modality integrated with the values and beliefs salient to midlife Black women to reduce their health-risk behaviors. Findings from both the original and replication studies revealed increases in physical activity and reductions in stress.31,32 Another example of a manualized sister circle is the Sisters Offering Support (SOS) intervention developed by Neal-Barnett et al.20 SOS was developed as an early intervention for anxious professional Black women. It is unique because it utilizes cognitive behavioral techniques infused with cultural aspects to educate Black women about anxiety, cognitive restructuring, and progressive muscle relaxation. Birthing Beautiful Babies Sisters Offering Support theoretical framework Considering the various uses of the sister circles for Black women across the lifespan to address mental and physical health risks and concerns, we believe that this format would be beneficial for Black pregnant and postpartum women experiencing stress and anxiety. To the best of our knowledge, sister circles have not been utilized with Black perinatal samples. Thus, we developed the Birthing Beautiful Babies Sisters Offering Support (BBB SOS) intervention to address specific pregnancy and cultural concerns of this population to reduce pregnancy-related anxiety. It is grounded in cognitive behavioral therapy (CBT) because it is one of the most effective treatments for anxietyrelated disorders.33 CBT emphasizes the importance of changing thinking and behavioral patterns and improving physical symptoms of anxiety through skill use.34 Within the context of BBB SOS, the overarching goals of the sister circle were to educate pregnant women about anxiety, stress, and panic attacks and help them challenge maladaptive thoughts, learn how to manage their emotions, and engage in positive behavioral changes. In order to maximize the potential effectiveness of the CBT framework with the present study’s sample of Black women, we followed recommendations from studies35,36 that encouraged the use of “gender-race-specific modifications and infusion” (p. 269).20 Since sister circles are peer-supported interventions, we felt it was best to have women from the community serve as facilitators. Specifically, we utilized Black perinatal support persons (i.e. doulas) who were well-trained on all aspects of the prenatal and postpartum periods and shared the general experience of being a Black woman. Furthermore, while the participants were learning common CBT strategies (e.g. visualization, goal setting, and progressive muscle relaxation), there were also discussions about culturally relevant stressors, including racial discrimination, stereotypical images of Black women in the media, health, nutrition, hair care, and hair health. Somerville et al. Research indicates that stereotypical images of Black women as strong, angry, and promiscuous are associated with increased anxiety.37–39 Further, in addition to anxiety, Black women report high rates of obesity.40 BBB SOS provides prenatal yoga and nutrition, which helps Black women combat their many health outcomes and risks,41,42 including obesity, preeclampsia, and hypertension, which are heavily influenced by poor diet and limited exercise.43,44 Black women also experience specific hair care needs and restrictions during pregnancy.45 BBB SOS provides solutions for Black women with natural or relaxed hair that remedy hair-related stress and anxiety.46 Research underscores that for Black women, hair is culturally important and significant47,48 and a potential source of anxiety as textured hair is associated with discrimination.49 Present study The primary objective of this study is to evaluate the feasibility and acceptability of BBB SOS, a manualized culturally relevant stress and anxiety intervention for Black pregnant and postpartum women using a mixed-methods framework. Our research question is: will Black pregnant and postpartum women perceive the BBB SOS sister circle anxiety intervention to be helpful? We opted to use a mixed-methods design as we believe the complementary quantitative and qualitative data would (1) answer our primary research question and (2) provide substantial and specific feedback to improve our intervention. In addition, we hypothesized that (1) participants would report a perceived increase in knowledge about anxiety and panic attacks and (2) participants would rate all session activities and skills as helpful in reducing anxiety. 3 Table 1.  Participant demographic information (N = 80). Measure Item N (%)a Trimester First Second Third Postpartum 1 person 2 people 3 people 4 people 5 people 6 people 7 people 8 people 9 people Data unavailable 0 1 2 3 4 5 6 8 Data unavailable US$25,0000 Data unavailable Uninsured Public Private Data unavailable 11 (13.8) 31 (38.8) 34 (42.5) 4 (5) 10 (12.5) 11 (13.8) 10 (12.5) 9 (11.3) 8 (10) 4 (5) 0 1 (1.3) 1 (1.3) 26 (32.5) 14 (17.5) 20 (25) 6 (7.5) 4 (5) 9 (1.3) 2 (2.5) 1 (1.3) 1 (1.3) 30 (37.5) 42 (52.5) 17 (21.3) 0 (0) 12 (15) 9 (11.3) 1 (1.3) 63 (78.8) 7 (8.8) 9 (11.3) Household size Number of children Household income Insurance a Method Note percentages may not equal 100% due to rounded decimals. Participants Measures Our convenience sample consisted of 80 Black pregnant and postpartum women from an urban city in the Midwest. The average participant was 26.72 (SD = 6.51) years old. Participants were recruited from our community partners. Our partners are a perinatal support program that was developed to aid communities at risk for maternal and infant mortality. Women enrolled in the perinatal support program were invited by their doulas face to face and via a call to participate in the in-person BBB SOS sister circle. Our study and recruitment occurred pre-pandemic, between 2017 and 2019. During this time, approximately 203 women received perinatal support services from our community partner and were offered participation in the study. One hundred and twenty-three (60.59%) did not enroll in our study. Reasons for declining participation were not recorded. Table 1 displays the complete demographic information of this sample. Demographic survey. Demographic questionnaires were used to collect information on participants’ self-identified race, age, pregnancy status, number of children, and type of insurance to describe the sample. The following three measures of worry, stress, and pregnancy-related anxiety were utilized only to confirm that our sample was our target population and that we could appropriately ask about their perceptions of the feasibility and acceptability of our sister circle anxiety intervention. Penn State Worry Questionnaire–Abbreviated.  The Penn State Worry Questionnaire–Abbreviated (PSWQ-A)50 is an 8-item scale designed to measure worry severity. Given that the present study’s sample is composed of Black women, an additional item was added to assess participants’ level of worry about racism. Each item was scored 4 on a scale from 0 (not at all typical of me) to 5 (very typical of me), which yielded composite scores ranging from 0 to 45. DeLapp et al.51 found the PSWQ-A to be a psychometrically sound brief measure of worry in Black Americans. Kessler Psychological Distress Scale. The Kessler Psychological Distress Scale (K10)52 is a 10-item measure of global distress experienced within a 4-week period. Specific items include questions about symptoms of anxiety and depression. The items were rated on a scale from 1 (none of the time) to 5 (all of the time). Composite scores can range from 10 to 50 and are derived from summing item responses. Krieger et al.53 found the K10 to be a reliable and valid measure of distress in Black American men and women. Pregnancy-Related Anxiety Scale. The Pregnancy-Related Anxiety Scale54 is a 10-item measure for expectant mothers that determines the severity of their worries about the various aspects of pregnancy, labor, and delivery, and then caring for a child. Items were scored on a scale from 1 (not at all) to 4 (very much). Composite scores were calculated by summing and then dividing the items’ responses by 10, yielding a possible range from 1 to 4. This questionnaire demonstrated high reliability and validity in a sample of Black pregnant women.54 Focus group booklet.  A focus group booklet was created and piloted for this study. It contained questions assessing participants’ understanding of panic attacks and stress before and after the intervention on a scale from 0 (nothing at all) to 10 (a great deal). Items that measured participants’ perceived effectiveness of exercises and strategies covered in each session were also included. Participants were asked to rate their overall experience participating in the sister circle on a scale from 0 (very negative) to 10 (very positive) and comfortability with sharing with others within the sister circle on a scale from 0 (not so much) to 10 (very much so). The final question asked participants if they would participate in a BBB SOS sister circle in the future. Focus group discussion. An academic and community research team formulated 10 focus group discussion questions. Questions centered on participants’ initial thoughts when asked to participate in BBB SOS, experiences and thoughts about exercises and activities utilized in the group, the timing of sessions, comfortability with doulas, identification in personal development, their experiences versus expectations, any ideas for improvement, and initial thoughts when asked to participate in BBB SOS. Procedure All study procedures were approved by the Kent State University Institutional Review Board. As noted above, Women’s Health recruitment procedures were completed by our community partner, a perinatal support program. BBB SOS sister circle Intervention training.  Two Black female perinatal doulas received in-person training from a licensed clinical psychologist to facilitate the BBB SOS intervention. They were provided with a manual that contained all intervention materials and instructions to use as a training guide. The training covered intervention goals and objectives, data measures, and data collection procedures. The BBB SOS curriculum was presented in detail. The clinical psychologist taught the intervention session by session, thoroughly covering session-specific content and materials, including psychoeducational and activity components. Prior to study implementation and independent of our study specifications, our BBB SOS doula facilitators possessed mental health certifications (e.g. Qualified Mental Health Professional and Community Health Worker) and were up-to-date with their continuing education courses as a part of their professional development. Therefore, we determined an extensive CBT training was not needed. Instead, the training included a brief CBT review and emphasized administering CBT-based activities to our target population. Finally, our BBB SOS doulas practiced administration with the staff multiple times before study implementation. Training took place over 3 months. Intervention overview.  BBB SOS was initially administered as an 11-week intervention. Staff and participants gathered weekly for 2-h sessions in a local community center. After two iterations, participant feedback led us to condense the 11-week intervention to 7 weeks. Review exercises and casual group discussions were shortened. However, no exercises were removed in their entirety. The remaining manuscript will focus mainly on our procedures and data on the 7-week intervention. Descriptive data from the 11-week intervention will be briefly discussed. In the first session, doulas explained the general goals of the research project. Then, written consent and participants’ demographic information (e.g. age, pregnancy status, and household income) were obtained during sign-in by a Black female undergraduate or graduate research assistant. Participants received a binder with the BBB SOS group mission statement that read: This is a place to speak your truth, to be heard, embraced, and received in a loving, relatable way that supports, encourages, and empowers Black women. and a covenant we adapted from the Women of Color Foundation with permission, that read: I see your beauty I sense your power Somerville et al. I celebrate your potential I support your prerogative to sing your own song. Participants were also given a copy of Soothe Your Nerves: The Black Woman’s Guide to Understanding and Overcoming Anxiety, Panic, and Fear55 as a complementary text to multiple intervention components. This text uses anecdotes to discuss Black women’s experiences with stress, anxiety, and panic attacks. These firsthand accounts include Black women who are childless, pregnant, postpartum, and mothers, highlighting that the stressors of Black women magnify during pregnancy and motherhood. It also promotes a sense of “sisterhood” by normalizing familiar and novel experiences. This is particularly helpful for BBB SOS groups with few or shy participants. Second, this text discusses and dispels harmful myths and stereotypes, such as the “Strong Black Woman” trope. Next, it breaks down the stigma of therapy within the Black community and introduces the basic tenets of CBT. Finally, CBT components and related strategies are explained and recommended to promote healthy emotional functioning. Doulas encouraged participants to read specific chapters of Soothe Your Nerves for assigned homework related to specific BBB SOS sessions. Doulas also provide verbal summaries of the text at the beginning of sessions so that participants who did not have time to read or do not enjoy reading can follow group discussions. After participants were settled, the doulas checked in with participants, completed introductions, and then introduced the BBB SOS guiding principles and group mission statements. Later, they instructed participants to develop their personal mission statement that allowed them to establish their goals for participating in the sister circle. Doulas ended session one by leading the group in reciting the BBB SOS covenant, reinforcing the sisterhood dynamic of the sister circle. Sessions 2 through 5 began similarly: check-in and review of Soothe Your Nerve text and review of group guidelines and mission statement. During these check-ins, doulas would discuss previous exercises, homework completion, and participation in BBB SOS strategies outside of the intervention. Afterward, participants were provided with detailed psychoeducation about the emotional, cognitive, and biological consequences of stress, anxiety, and panic attacks. Some education on postpartum depression was also discussed with participants, given its prevalence in this population.56 During these sessions, doulas led discussions about the psychological impact of images and stereotypes of Black women in the media. They encouraged the participants to share their experiences with anxiety, racism, and racial stress. In addition, doulas introduced and led evidencebased strategies to reduce anxiety, including goal setting, progressive muscle relaxation, and visualization. Partici­ pants also learned how to engage in cognitive restructuring through a Build Your Own Theme Song (BYOTS) activity 5 that helped them use music to replace negative thoughts with positive thoughts. Participants also received hair consultations, information about hair care needs during pregnancy, and a hair scarf wrapping demonstration. In the latter half of sessions five and six, participants participated in pregnancy yoga led by a certified instructor. Session six was also devoted to educating participants about nutrition using the U.S. Department of Agriculture’s recommendations.57 Focus group.  During the final session, participants celebrated their completion of the BBB SOS with a graduation party. A focus group discussion also occurred and lasted approximately 2 h. It was led and audio recorded by either a trained Black female graduate student (MA) or a project coordinator (MA). Both women have previous work experience related to mental health concerns in Black communities in the sampled area. These women did not participate in any of the other BBB SOS sessions and are not authors on this article. Their focus group training was conducted by a licensed clinical psychologist (PhD). The focus group interviewer took observational notes. In addition to the focus group discussion, participants also answered questions in paper focus group booklets. All data were collected at the local community center, where the BBB SOS sessions occurred. No other individuals were present besides doula facilitators, undergraduate or graduate students, and project coordinator, all of whom were Black females. Participants received a certificate, a US$50 Walmart gift card, a yoga mat, and food storage containers for their participation in the study. We also provided transportation and onsite childcare to participants in need for all our sessions to reduce additional attendance barriers for pregnant mothers. See the Online Appendix for a flowchart of the BBB SOS Curriculum (Figure 1). Supervision. We conducted fidelity checks weekly to assess the doula-led intervention implementation. Checks were completed live during the sessions by a Black female undergraduate or graduate research assistant. A standard CBT checklist was modified to assess group interventionspecific components such as guiding principles, facilitators’ knowledge, and group participation questions. Doulas were provided a completed fidelity checklist and weekly observational report. See Online Appendix for our fidelity checklist. A licensed clinical psychologist also provided weekly group supervision, which BBB SOS doula facilitators, doulas on separate projects, research assistants, and project coordinators attended. Statistical analysis We conducted power analyses to determine an appropriate sample size for our study. 6 Women’s Health Recruitment by Doulas Decision Enrolled into BBB SOS Session 1 Session 2 Check-in Team & Group Introductions Introduce Sister Circles, Guiding Principles, & Group Mission Statement Discuss Curriculum Develop Mission Statement Receive Soothe Your Nerves Text Recite Sister Circle Covenant Check-in Review of Soothe Your Nerves Text Review Guidelines & Group Mission Statement Hair Struggles, Hair Care, & Head Wrapping Demonstration Recite Sister Circle Covenant Session 3 Check-in Review Guidelines & Group Mission Statement Review of Soothe Your Nerves Text Psychoeducation of Stress, Anxiety, & Panic Attacks Telling My Stress Story Progressive Muscle Relaxation Recite Sister Circle Covenant Session 4 Session 5 Session 6 Check-in Review of Soothe Your Nerves Text Review Guidelines & Group Mission Statement Psychoeducation Review Images of Black Women Discussion Recite Sister Circle Covenant Check-in Review of Soothe Your Nerves Text Review Guidelines & Group Mission Statement Review Images Visualization Exercise Progressive Muscle Relaxation Prenatal Yoga Recite Sister Circle Covenant Check-in Review of Soothe Your Nerves Text Review Guidelines & Group Mission Statement Visualization Action Planning Prenatal Yoga Recite Sister Circle Covenant Develop Mission Session 7Statement Receive Soothe Your Nerves text Recite Sister Circle Covenant Check-in Session Evaluation Graduation Focus Group Booklet Focus Group Discussion Recite Sister Circle Covenant Figure 1.  BBB SOS intervention flowchart. BBB SOS, Birthing Beautiful Babies Sisters Offering Support. According to G*Power, approximately 34 study participants were required to detect an effect for our study-­ specific hypotheses.58 Specifically, we evaluated a priori power analyses for our paired t-tests, with an alpha of 0.05, a power of 0.80, and a medium effect size. Quantitative.  Quantitative data analyses were conducted using SPSS 25.0. Skewness and kurtosis data were reviewed to assess normality according to Kline’s59 recommendation. Descriptive data analyses of participant baseline worry, distress, and pregnancy-related anxiety were analyzed. Participants’ baseline and post-knowledge about panic attacks and stress were collected via the focus group booklets and evaluated using paired samples t-tests. Qualitative.  Qualitative data analysis procedures were rooted in Grounded Theory60,61 and were led by the first author on this manuscript, a Black female doctoral student. Audio transcripts of the BBB SOS focus groups were reviewed by all authors on the paper. Then, they conducted an organizational meeting to discuss and create coding guidelines. The data was open-coded by four undergraduate research assistants (two Black females, one Black male, and one White female) for general themes. Coders were instructed to read the transcripts and identify any general themes they felt represented many participants’ responses. In addition, coders were asked to highlight and note any specific examples on the transcript indicative of such Somerville et al. themes on a coding form. They were not given any specific themes to identify in the transcripts. Once coders completed and submitted their initial open coding, they met with the lead author, who provided them with selective coding procedures. Coders were asked to re-read the transcripts and identify quotes that represented or related to learning and feasibility. These themes were selected by authors on this article during the organizational meeting as they related to our research question: will Black pregnant and postpartum women perceive the BBB SOS sister circle anxiety intervention to be helpful? More specifically, the theme “Learning/Valuable” was defined as experiences that represented, but were not limited to, successful or useful skills, beneficial takeaways, or additive value. Coders were given the following examples to guide their selective coding further: “Because of SOS, I take deep breaths when I am stressed,” “Gained friendships,” and “I enjoyed talking about my issues.” The theme “Feasibility” was defined as comments that represented sister circles being practical, achievable, reasonable, or workable (e.g. “the sessions occurred regularly,” “doulas handed out materials,” “the members worked together as a team”). Coders were also asked to identify noteworthy themes. They were instructed to note such themes as “Other” and provide a descriptor that appropriately categorized the statement and/or theme. Coders documented their selective codings on a separate coding form and submitted it to the lead author. She combined all coding forms into a single composite summarizing all coders’ responses on an Excel spreadsheet. Afterward, a consensus meeting was held with the coders and the first author to discuss the composite. The first author shared identified discrepancies among the coders in open and selective codings. Then, she led the coders to discuss among themselves to reach resolutions. At the beginning of the meeting, the coders were in 86% agreement. At the end of the meeting, the coders were in 100% agreement. The first author prepared a summary of the coders’ themes, which was shared with the four coders for final confirmation. Our results in this manuscript will include both the open and selective coding findings. Some open coding findings were also identified during the selective coding process. These findings will be summarized once in our “Results” section under the subsection selective coding for brevity. Finally, we believe that saturation was achieved in our study. After multiple focus group discussions were coded, the codes derived in later focus group sessions were redundant with earlier sessions. No new themes appeared to emerge from coders in the last five focus groups. Therefore, after coding eleven focus groups, the authors on this article and coders collectively decided that (1) we received sufficient data to address our research questions and (2) further data collection would likely not yield additional insights. 7 Descriptive analyses Demographic.  Data were normally distributed. Participants reported having an average of 1.83 (SD = 1.31) children. The average household size was 3.31 (SD = 1.86) and the majority of participants (52%) had a household income of below US$10,000 annually. Seven (8.75%) of participants reported being privately insured; 63 (78.75%) were publicly insured; 1 (1.25%) was not insured; and 9 (11.25%) data were unavailable. Table 1 displays the number of children, household size, income levels, and health insurance data. Additional demographic data on the sample was obtained via city records. Data highlight that the neighborhoods from which the sample was drawn are racially homogeneous. Ninety-five percent of residents in these neighborhoods identify as Black and 11% identify as Hispanic or Latino.62 Twenty-five percent of residents are college-educated.63 The sampled neighborhoods are also considered high-crime areas by national standards, as one out of 14 neighborhood resident reports being a victim of a crime annually.64 Results Anxiety symptomology Data indicate that participants were experiencing mode­ rate levels of worry (M = 25.32, SD = 11.38) and distress (M = 21.86, SD = 7.14) and low levels of pregnancy-related anxiety (M = 1.90, SD = .60) prior to the start of the BBB SOS intervention (Table 2). Participants also reported experiencing race-related worries, ranging from low (0) to high frequencies (5). Eleven participants (13.75%) indicated that it was “very typical of [them],” a 5, to worry they may be treated or viewed unfairly to because of their race; 8(10%) reported a 4 rating; 12 (15%) reported 3, 9 (11.25%) reported 2, 11(13.75%) reported 1; 26 (32.50) reported it was “not at all typical of [them]” 0. Data of 3 participants were unavailable. BBB SOS intervention completion Eleven cohorts (N = 80) of BBB SOS were conducted between 2017 and 2019. Of the 80 participants in this study, 24 participated in the 11-week intervention, and 56 participated in the 7-week intervention. On average, participants attended four sessions. Thirty-six participants completed the focus group session. Forty participants (50%) were considered treatment completers, as they attended 50% or more BBB SOS sessions, which was pre-determined by our grant project objectives. Table 3 displays a summary of participants that completed approximately 25%, 50%, and 75% of the BBB SOS Intervention. 8 Women’s Health Table 2.  Summary of descriptive analyses. Measure N Minimum Maximum Mean SD PSWQ-A K10 Pregnancy-Related Anxiety 77 59 66 0 10 1 45 40 3.3 25.32 21.86 1.896 11.380 7.143 .603 PSWQ-A, Penn State Worry Questionnaire–Abbreviated; K-10, Kessler Psychological Distress Scale. Table 3.  Summary of participant BBB SOS intervention completion. Intervention Completion (N = 80) N (%) <25%–49% Completion 50%–74% Completion ⩾75% Completion 40 (50) 13 (16.25) 27 (33.75) BBB SOS Intervention Completion Cuttoffs by Group. Participants who were in the 7-week BBB SOS group: <25%–49% completion is approximately one to two sessions completed; 50%–74% completion is approximately three to four sessions completed; ⩾75% completion is approximately at least five sessions completed. Participants who were in the 11-week BBB SOS group: 25%–49% completion is approximately two to four sessions completed; 50%–74% completion is approximately five to seven sessions completed; ⩾75% completion is approximately at least eight sessions completed. Table 4.  Comparisons of pre- and post-knowledge about panic attacks and stress. M SD   Pre Knowledge about Panic Attacks Post Knowledge about Panic Attacks Pre Knowledge about Stress Post Knowledge about Stress 4.63 8.49 6.29 8.97 3.011 2.536 3.006 2.189 Focus group booklet responses A paired sample t-test revealed an increase in knowledge about panic attacks (t(34) = 9.09, p < .001, d = 1.54) and stress (t(1, 34) = 6.12, p < .001, d = 1.03) after completing the sister circle (Table 4). In addition, participants’ responses suggested that they found all activities completed and skills learned in the sessions to be quite effective. Specifically, they reported high ratings for the development of a personal mission statement (M = 8.24, SD = 2.57), visualization exercise (M = 8.80, SD = 1.53), progressive muscle relaxation (M = 9.12, SD = 1.24), pregnancy yoga (M = 9.03, SD = 2.04), nutrition instruction (M = 8.70, SD = 2.14), cognitive restructuring (M = 8.19, SD = 1.81), and action planning (M = 9.12, SD = 1.41). The mean rating for participants’ overall experience was 9.60 (SD = 1.09), and the mean rating for comfortability with sharing was 9.69 (SD = .80). Finally, most participants (94.30%) indicated that they would be interested in participating in a sister circle in the future. Open coding themes Supportive environment. Open coding analysis of focus group responses indicated that the BBB SOS provided a Paired Samples Test p d 1.538   1.034   t df 9.090 34 <.001 6.115 34 <.001 supportive and non-judgmental environment. For example, one participant stated, “I can speak freely now. You know what I mean. Without fear of being judged.” Another woman expressed similar sentiments, “It brought a lot out of me . . . So it’s like I was comfortable in this setting to speak how I feel without being judged to get what I needed to get out.” Many participants attributed their comfortability in the group setting to the efforts of the facilitators. For example, participants commented, “I think the doulas made it very comfortable .  .  . to come and talk” and “In there, you’re not being judged. Like they don’t want nothing from you. Like they trying help you as much as you can and your situation that you’re about to go through.” Openness.  Another woman compared this group to ones that she participated in the past stating, “They went over and beyonder [sic] . . . this group made us feel, or made me feel more comfortable.” Others highlighted how the openness of the facilitators impacted their experience and encouraged them to be vulnerable and transparent. For example, one woman discussed a facilitator’s approach, In this field they want to hear your story, but they’ll never tell you theirs and that’s where a connection is lost. But the minute Somerville et al. she started talking, she shared her whole life story and that instantly got a connection. Another woman shared a similar viewpoint and added that the facilitators normalized her experience: “I’m not the only one who goes through A, B, and C. Hearing different ways that they handle these situations . . . it gives me a whole new insight on things.” Building a sisterhood.  Focus group participants viewed the BBB SOS as a sisterhood. They reported, “We got our little bond together” and “You gain additional family . . . you create a definite bond with them. Everybody here that works here really been helpful and understanding.” Some expressed their appreciation for the support and their lack of that in prior experiences. For example, “It’s nice. It’s kind of building that community . . . I have a lot of strong Black women friends, but all of us live very far apart now, so I don’t have that.” Others discussed their admiration for being connected to women with similar experiences and challenges: “I’m the only one of my friends who has a child or who’s pregnant, so it was nice to be able to talk to other people who are pregnant like on a regular basis” and “I don’t have a whole bunch of moms. So I be in here trying to soak it up okay.” Sharing experiences with others. Many focus group participants reported that they enjoyed their experience and would recommend BBB SOS to others in need. For example, “I would tell people about the sister circles and stuff because it’s like a support .  .  . we come here, and we know that we gonna be able to express ourselves . . . Gonna get to learn something. We gonna be getting some feedback.” Other participants agreed and added, “Whether you’re a single mother or not, I mean everybody can get something from it,” and “Yeah, same here. I just be like ‘Girl you better get over there. Get those problems out. Girl they talk to you. You just get in the class, get with the program honey like. Just let them know.’” In addition to discussing the benefits of the group with close friends and family, one woman recommended it to her young pregnant clientele: “I think that they could use the information and use the support since they are so young. If they could get the skills now or at least get introduced to different components.” Additional findings related to positive experiences not only appeared in the open coding analysis but also reappeared in the selective coding analysis. These results will be outlined in the section below for brevity. Selective coding Learning/valuable Psychoeducational.  Sixty-six statements were related to identified benefits and valuable takeaways. Specifically, focus group participants reported enhanced knowledge 9 about various psychoeducational topics after their participation in the BBB SOS. For example, they reported, “I could identify a panic attack from a mile away” and “I think I learned a lot more about stress and anxiety.” Another expressed that she valued the information she received about nutrition during pregnancy and postpartum: “When you’re pregnant, a lot of things change and what you can and cannot eat is one of them. So getting that professional opinion on what is good for us.” Applying coping skills.  In addition, focus group participants reported that BBB SOS sessions facilitated their identification of emotions and triggers and implementation of adaptive coping skills. For example, I was able to let go in the beginning when we talked about stress, family, and things like that. I was able to let go of some of the stresses and let go of a couple more stresses so now I feel like I’m carefree and I have a lot more freedom. Similarly, one woman explained that she was able to manage her emotions in an effective manner and “stop [the anger] before it gets too bad.” In regard to identifying triggers, one woman stated, “It was an eye opener because it’s one thing to feel stressed. It’s another thing to be able to express why you feel stressed .  .  . When you’re able to kind of pinpoint what’s triggering your stress, you’re able to then find coping skills to match your stressors.” Finally, another woman stated that visualization exercises “recentered” her and assisted her ability to manage parental stress. Instructional materials and activities Text. Many focus group participants commented on specific activities and the related impact on their learning or skill development. One woman explained that the Soothe Your Nerves text aided in her understanding of stress and offered normalization. She stated, “It defines [stress] in a way that is unique, and it doesn’t make it seem to be like this outcasted feeling.” Build Your Own Theme Song.  The focus group participants also reported favorable opinions about the BYOTS activity improving their ability to reframe their negative beliefs. Specifically, some participants alluded that their theme song helped them remain hopeful during times of adversity. For example, “I think everyone having an individual theme song . . . is very helpful because it gives you assurance and it gives you that boost of self-confidence that everybody needs.” Another woman added, “The theme song, I personally had one gospel song . . . I think it is very helpful.” Yoga.  Multiple participants reported that the pregnancy yoga activity alleviated stress. One woman stated, “I think that yoga is a really good stress reliever for me personally. I like to stretch, and I’ve always found it to kind of be really relaxing.” 10 Action planning. Focus group participants found the action plan activity to be a simple and effective tool for setting goals and increasing adaptive and decreasing maladaptive behaviors. One woman explained that the activity helped her “break things down” to the point that it made tasks “seem less severe.” Another woman added, “[Action planning] would help somebody who never set a goal before . . . so they could just go back and make a plan.” Some focus group participants attributed the action plan to increasing their motivation and commitment to goal directed behavior. For example, “It gave me a vision. It helped me see something to look forward to ‘cause I didn’t. It gave me another goal to see that.” Others commented in agreement: That’s like my biggest thing is, like I could set a goal, but I’ll never stick to it so being in this class kinda taught me how to stick to my goals and make a game plan and plan of management. Improved mood. Findings showcased that the focus group participants reported participation in BBB SOS increased behavioral activation, mood, and functioning and facilitated personal growth and self-empowerment. For example, one woman stated, “Having a sister circle that you like dedicated to every week, it make you feel better leaving the house every week, especially being a stay-at-home mom and everything.” In addition, one woman verbalized her increased ability to effectively process her anger: “Just like knowing what triggers is and how to refrain from just cussing people out . . . I think that’s just pretty much where I came from.” Another woman stated that she can now manage her internalizing symptoms: “I’m in a better place . . . becoming a better person,” and “Us talking about depression and things we’ve been through. It definitely helped out in those areas.” Empowerment. The focus group participants underscored that their participation helped change their perspectives on their circumstances, others, and the environment. For example, one woman stated, I have more knowledge of my situation and I have more information as far as what I’m going through that can take me in my day-to-day life with my child. I’m fully aware of things that I wasn’t. I have a little bit more confidence .  .  . this situation helped me a lot me ‘cause I stay by myself. It helped a lot with that and to better open up myself up a little bit more so I wouldn’t be so closed minded to things that I was before. Another woman shared a similar realization about how the sister circle influenced interactions with her mother. For example, [My mom] has panic attacks and anxiety so . . . I told her about the book. It helped with our relationship and our Women’s Health bonding because . . . this is what we needed our whole life. It made a difference in my life because it was something I didn’t see that needed more focus. In addition to changing perspectives, some participants specifically noted an increase in positive thinking: I just really like the feeling. It was just really nice, and it gave us a different view of ourselves and everything. How to make ourselves more positive and not think of the negative in every situation. It made us more confident. Family and community impact. One woman concluded that her participation in BBB SOS helped her and others in her family: “I actually helped a lot of people now. Like my sisters and them. They know how to open up and how to talk about things.” Another woman shared her beliefs about the impact BBB SOS could have on the Black community and family unit: I think that they could use the information and use the support since they are so young. If they could get the skills now, or at least get introduced to different components, read the book, come to class, or see an environment where black women aren’t just fighting each other . . . they would set a good tone for their family that they’re making. Feasibility.  Forty-two statements were related to feasibility aspects, specifically the structure and flow intervention and format of sessions. Participants varied in their opinions about the length and timing of the sessions. Many reported enjoying the incorporation of various materials and activities to increase their skill building and understanding of anxiety or panic. Some participants wanted a wider range of discussion topics: We always talked about how we done broke up, and that we may be mad at each other. So how are we going to coparent? See I came in and I was like, ‘That’s not my life. That’s not my reality. In addition, some commented on the varying levels of participation from participants: “I guess the participation kinda dwindled as we progressed in the program,” and “See some people kind of get bored. And them younger girls, y’all have to try to find a way to draw those younger girls in and keep them here.” Discussion The present study utilized a mixed-methods framework to evaluate the feasibility and acceptability of BBB SOS, a manualized culturally relevant stress and anxiety inter­ vention, for pregnant and postpartum Black women. To the best of our knowledge, we are the first to utilize a sister-circle intervention with a Black perinatal sample. Somerville et al. Quantitative and qualitative study findings supported our hypotheses. Data showcased that participants reported increased perceived knowledge about stress, anxiety, panic attacks, and emotional triggers and their ability to identify such feelings and events and manage them effectively using CBT coping strategies. Focus group participants described their overall BBB SOS experience as positive, empowering, and enriching. They found the environment and group dynamic supportive and enjoyed connecting with individuals experiencing similar milestones and adversities. This finding is consistent with other studies that employed sister circle frameworks.20,26–28,65 Focus groups reported that session activities increased their motivation for behavior change, encouraged planning and goal setting, and increased support and behavioral activation, ultimately contributing to their reported improved mood. This aligns closely with well-documented evidence of the effectiveness of CBT approaches in treating anxiety and depression.33,66 Participants also reported mixed feelings about session length and group-member participation, which have been common critiques made by individuals participating in group-based interventions.67 The present study revealed several noteworthy findings. First, our study had a 39.4% enrollment rate. Evidence shows that community participatory-based research studies that utilize samples of low-income individuals, racial minorities, or perinatal women traditionally face significant recruitment and enrollment barriers.68,69 There were limited data on the enrollment rates of low-income Black perinatal samples. However, multiple marginalized samplespecific factors would likely contribute to lower enrollment rates. We attribute our enrollment success to participants’ established relationships with doulas prior to study enrollment. Participants were familiar with receiving resources from their doulas and valued their referrals and recommendations. In addition, cumulatively, our doula facilitators have over 35 years of experience working with this population. This likely was beneficial to our study as they were the first point of contact for participants and could communicate project objectives in a culturally-receptive manner. Also, we believe our study compensation was viewed favorably by prospective participants. Our study compensations included Walmart gift cards, yoga mats, and food storage containers. These were not miscellaneous incentives but were linked to population-specific needs and/or topics and activities discussed in BBB SOS. They showcased that our team cares about participants’ experiences during pregnancy and motherhood and wants to aid in reducing their financial and health burdens. Second, multiple participants reported that they held the research team and facilitators in high regard, which is uncommon among Black research participants. Despite previous study findings of cultural mistrust of healthcare 11 workers and researchers due to historical injustices70 even when staff included racial minorities or Black women,71 our focus groups commented that the BBB SOS facilitators’ transparency and authenticity created a safe space and atmosphere of trust. This development may be due to our facilitators’ willingness to use selfdisclosure. Some clinicians strongly discourage the use of self-discourse of personal details in attempts to uphold concrete professional boundaries between the therapist and the client.72,73 However, this can have an adverse effect. By continually prompting clients to be vulnerable, without sharing on the therapist’s part, clients may become disconnected and frustrated by the overt power differential. We believe our facilitators’ use of self-disclosure followed by modeling techniques of identifying and labeling emotions, quickly set the therapeutic framework for our participants. Our data suggest that self-disclosure may be particularly helpful when working with Black women, as they report feeling alienated, dismissed, and ignored in their health encounters. In addition, Black women are aware of their marginalized and often powerless disposition, which is only amplified in a therapeutic setting. Self-disclosure may help create authentic conversations, resulting in careful attentiveness from staff and active participation from Black women. In addition, we believe our facilitator-led discussions that utilized storytelling to self-disclose, a common cultural practice among Black individuals,74,75 promoted group connectedness and shaped a sister-like dynamic. Collectively, these factors helped increase participants’ confidence in the facilitators and their instruction. Third, the group dynamic of Black female facilitators and peer support sharply contrasts with participants’ frequent experiences of marginalization and rejection linked to racism and sexism in modern-day society.76 BBB SOS likely fosters feelings of belonging, security, and safety, as all staff members and group participants identify as Black and female. These racial and social components embedded in the structure of BBB SOS potentially decrease participant anxiety and stress intuitively. Research indicates that Black individuals in predominately White spaces experience increased stress and anxiety.77,78 Some of these responses may be linked to anticipating and experiencing frequent microaggressions in these spaces.79 However, others may be related to the fear of being a victim of a hate crime, such as physical or sexual violence that could be potentially life-threatening or fatal.80–82 Experiences of stress and anxiety are also likely to present among groups of other races or ethnicities, given the pervasiveness of anti-Black racism.83 Similarly, studies of Black women report within racial group conflict and tensions due to gender-based stereotypes, suggesting that all-female support groups may be preferred.84,85 Fourth, participants perceived the culturally-tailored and traditional CBT-based activities to be effective in 12 managing stress and anxiety. Multiple participants reported enjoying the BYOTS Song musical cognitive restructuring activity. Some explained that they chose familiar gospel songs with uplifting and encouraging lyrics, prompting them to decrease their overall negative thinking. Prior research supports this finding, as music and spirituality often promote resiliency and serve as protective factors for Black individuals against poor mental health outcomes.20,75,86,87 Participants also expressed appreciation for a traditional CBT action plan worksheet activity that utilized a step-by-step outline approach. They noted that it reduced their hopelessness and helped them identify a path to change. Previous studies highlight mixed findings regarding individuals’ receptiveness to using worksheetbased activities in therapy.88,89 Finally, participants reported that they believed the assigned psychoeducational text, Soothe Your Nerves, enhanced their understanding of topics and the development of CBT skills. In contrast to our findings, previous studies revealed that participants often do not complete their assigned homework or complain about having additional work outside of the group.90,91 An explanation for our finding is that the utilized text readings were recommended, not mandatory. In discussion, facilitators asked people if they read the text, provided chapter summaries, and led discussions related to skill development and application. It’s possible that BBB SOS participants enjoyed group discussions and completed assigned readings to contribute actively and have enriching group discussions. Limitations The present study is not without limitations. We could not collect data from participants who stopped attending BBB SOS sessions, which may have highlighted additional treatment barriers and provided valuable recommendations for future interventions. A second limitation is that our BBB SOS doula facilitators served dual roles for participants. As part of their job with our community partners, they provided perinatal support. Methodologically, this limits the generalizability of our data to situations where this dual role is not present. Clinically, however, this decision likely increased participant trust and the development of positive rapport. This dual role likely has a similar clinical strength as when individual therapists encourage their clients to participate in group therapies that the therapist facilitates.92,93 Implications Despite these limitations, the clinical implications of this study’s findings are promising. For example, the BBB SOS culturally relevant framework may aid Black women in understanding and mastering CBT concepts and skills. Previous research outlines that Black individuals are likely to struggle to apply CBT skills despite being the leading Women’s Health modality in mental health treatment.94 Studies suggest that most intervention approaches fail to teach in a culturally sensitive manner.95 However, the BBB SOS intervention created a sense of sisterhood akin to those already present in the Black community, which likely made learning new CBT approaches and techniques less daunting for group members, given participants’ perceived helpfulness. Moreover, research shows that individuals are more likely to try new behaviors and take risks with family or friends in a supportive and nurturing environment.96 Future directions Future studies should document various maternal mental health outcomes of Black women before, during, and after the sister circle to thoroughly and comprehensively investigate the mental health impact of BBB SOS or other CBT interventions that utilize sister circles. Studies incorporating sister circles may also want facilitators to cover specific session topics that complicate pregnancy and postpartum, including domestic violence, custody issues, grief, and COVID-19-related stressors.97–99 Role-playing activities could help increase interpersonal effectiveness among participants, friends, and family and navigate racial mistreatment at doctor offices and hospital settings.100–102 Finally, incorporating journaling activities may help quieter and shyer participants engage in group activities and be motivated to share their experiences.103 Sustainability plan. As we continue to implement BBB SOS, we regularly invest in efforts that promote sustainability and meet the multitude of needs of our target population. Our project staff reviews data from each focus group discussion, paying particular attention to concrete critiques or suggestions noted by participants. We also request feedback from our facilitators. Then, we actively incorporate their feedback in our following BBB SOS groups as applicable. We polled participants for our most recent group to identify a convenient meeting time before finalizing a schedule. In addition, we prompted our independent reviewers to assess our facilitators’ efforts to be lively and maintain the group’s interest. This component was recently added to enhance our fidelity checks. We implement weekly group supervision throughout the intervention and provide training reviews upon request from doula facilitators or if our clinical psychologist identifies a need. We also conduct biannual meetings to review the cohesiveness and practicability of the BBB SOS curriculum, intervention materials, and staff resources. Finally, we regularly disseminate our BBB SOS development, experience, and findings. Our team presents at community events and regional, national, and international conferences featuring our community-based participatory research, which includes Black female lay individuals (e.g. perinatal doulas, cosmetologists) and researchers and clinicians (e.g. doctoral students and licensed Somerville et al. clinical psychologists). These efforts allow us to (1) educate audiences about the mental health and physical health risks and needs of Black pregnant women, (2) present our innovative efforts to address our population-­specific needs using cultural-infused strategies and components, (3) showcase our participants’ experiences, and (4) exchange information from other researchers. We have effectively utilized these exchanges to foster new collaborations and partnerships and obtain additional funding for our work. Conclusion Too often, Black women and their children suffer due to systemic racism, and their needs are not prioritized in mental health care settings. The present study aimed to address these problems by developing a culturally relevant stress and anxiety intervention for Black pregnant and postpartum women, prioritizing their needs and perceptions in our study design and objectives. Our findings highlight that doula-led peer-supported interventions are practical, feasible, and acceptable to Black perinatal women. We believe our existing community partnerships, use of lay Black female doula facilitators and peer supports, and interactive curriculum with comprehensive psychoeducation and concrete strategies to address general pregnancy-related anxieties and race-related worries contributed significantly to our enrollment success and overwhelmingly positive feedback from BBB SOS participants. We hope to see others invest in similar cultural considerations when developing public policy, designing research, and treating clients. More specifically, we challenge others to employ an iterative process of asking and listening to Black women. This validates their experience, gives them a voice and power, and creates a safe space to receive helpful mental health information and resources. Collectively, these actions work to combat the mental and physical health effects and realities of systemic racism for Black women. Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. All study procedures were approved by the Kent State University Institutional Review Board (IRB) (IRB LOG#: 17-517). Consent for publication We received written informed consent to publish from all individual participants included in the study in accordance with our institutional consent procedures. 13 Author contribution(s) Keaton Somerville: Conceptualization; Data curation; Formal analysis; Methodology; Writing—original draft; Writing— review & editing. Tiffany Rowell: Conceptualization; Data curation; Formal analysis; Methodology; Writing—original draft. Robert Stadulis: Conceptualization; Methodology; Writing— review & editing. Debra Bell: Methodology; Project administration; Resources; Writing—review & editing. Angela Neal-Barnett: Conceptualization; Funding acquisition; Project administration; Supervision; Writing—review & editing. Acknowledgements We acknowledge the perinatal women who participated in the sister circles. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Ohio Commission on Minority Health and First Year Cleveland (OCMH) (Grant/Award Number: 413356), Sisters of Charity (Grant/Award Number: 413364), Akron Community Foundation (Grant/Award Number: N/A), and Mount Sinai Health Care Foundation (Grant/Award Number: N/A). These funding sources had no other involvement other than financial support. Competing interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K.S., T.R., R.S., and D.B. declare that they have no conflict of interest. A.N.-B. is the Vice President for Healthy Corporations, Companies, and Communities of A3B, LLC. Availability of data and materials This is not applicable as we do not wish to upload our study data file to protect the confidentiality and anonymity of participants. ORCID iD Keaton Somerville https://orcid.org/0000-0003-3844-9172 Supplemental material Supplemental material for this article is available online. References 1. Krishnamoorthi M, Balbierz A, Lbaraque-Arena D, et al. Addressing the national crisis facing Black and Latina women, birthing people, and infants: the maternal and child health equity summit. Obstet Gynecol 2023; 141(3): 467–472. 2. MacDorman MF, Thoma M, Declcerq E, et al. Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016–2017. Am J Public Health 2021; 111(9): 1673–1681. 14 3. Kothari CL, Paul R, Dormitorio B, et al. The interplay of race, socioeconomic status and neighborhood residence upon birth outcomes in a high Black infant mortality community. SSM Popul Health 2016; 2: 859–867. 4. Hernandez ND, Francis S, Allen M, et al. Prevalence and predictors of symptoms of perinatal mood and anxiety disorders among a sample of urban Black women in the South. Matern Child Health J 2022; 26(4): 770–777. 5. Borda JL. The embodied maternal rhetorics of Serena Williams. Comm Crit Cult Stud 2021; 18(4): 349–368. 6. Campbell K. The minds of Black women—impacts on mental health and well-being across collective identities and experience. Doctoral Dissertation, The Ohio State University, Columbus, OH, 2020. 7. Bond RM, Gaither K, Nasser SA, et al. Working agenda for Black mothers: a position paper from the association of Black cardiologists on solutions to improving Black maternal health. Circ Cardiovasc Qual Outcomes 2021; 14(2): e007643. 8. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015; 105(12): e60–e76. 9. Villarosa L. Why America’s Black mothers and babies are in a life-or-death crisis. The New York Times Magazine, 11 April 2018, p. 11. 10. McMaster KJ, Peeples AD, Schaffner RM, et al. Mental healthcare provider perceptions of race and racial disparity in the care of Black and White clients. J Behav Health Serv Res 2021; 48(4): 501–516. 11. Saluja B and Bryant Z. How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States. J Womens Health 2021; 30(2): 270–273. 12. Dominguez TP, Dunkel-Schetter C, Glynn LM, et al. Racial differences in birth outcomes: the role of general, pregnancy, and racism stress. Health Psychol 2008; 27(2): 194–203. 13. McLemore MR, Altman MR, Cooper N, et al. Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth. Soc Sci Med 2018; 201: 127–135. 14. Salm Ward TC, Mazul M, Ngui EM, et al. “You learn to go last”: perceptions of prenatal care experiences among African-American women with limited incomes. Matern Child Health J 2013; 17(10): 1753–1759. 15. Carter SE, Walker RL, Cutrona CE, et al. Anxiety mediates perceived discrimination and health in African-American women. Am J Health Behav 2016; 40(6): 697–704. 16. Donovan RA, Galban DJ, Grace RK, et al. Impact of racial macro-and microaggressions in Black women’s lives: a preliminary analysis. J Black Psychol 2013; 39(2): 185–196. 17. Gibbons FX, Kingsbury JH, Weng CY, et al. Effects of perceived racial discrimination on health status and health behavior: a differential mediation hypothesis. Health Psychol 2014; 33(1): 11–19. 18. Gur RE, White LK, Waller R, et al. The disproportionate burden of the COVID-19 pandemic among pregnant Black women. Psychiatry Res 2020; 293: 113475. 19. Kim HG, Kuendig J, Prasad K, et al. Exposure to racism and other adverse childhood experiences among perinatal Women’s Health women with moderate to severe mental illness. Commun Ment Health J 2020; 56(5): 867–874. 20. Neal-Barnett A, Stadulis R, Murray M, et al. Sister circles as a culturally relevant intervention for anxious Black women. Clin Psychol Sci Pract 2011; 18(3): 266–273. 21. Neal-Barnett A, Stadulis R, Ellzey D, et al. Evaluation of the effectiveness of a musical cognitive restructuring app for Black inner-city girls: survey, usage, and focus group evaluation. JMIR mHealth uHealth 2019; 7(6): e11310. 22. Belgrave FZ, Reed MC, Plybon LE, et al. An evaluation of sisters of Nia: a cultural program for African American girls. J Black Psychol 2004; 30(3): 329–343. 23. McDaniel B. An examination of an intervention program: the Sister Circle. Doctoral Dissertation, Pepperdine University, Malibu, CA, 2012. 24. Thomas O, Davidson W and McAdoo H. An evaluation study of the Young Empowered Sisters (YES!) program: promoting cultural assets among African American adolescent girls through a culturally relevant school-based intervention. J Black Psychol 2008; 34(3): 281–308. 25. Allen C. Calling all the sisters: the impact of sister circles on the retention and experiences of Black womyn collegians at predominately white institutions. Doctoral Dissertation, Clemson University, Clemson, SC, 2019. 26. Benoit-Wilson M. Sidebar: how our sister-circle of six Black female physicians fought health care inequities to deliver a dose of hope. N C Med J 2021; 82(5): 351–352. 27. Croom NN, Beatty CC, Acker LD, et al. Exploring undergraduate Black women’s motivations for engaging in “sister circle” organizations. J Women High Educ 2017; 10(2): 216–228. 28. Elfman L. Black Athlete Sister Circle provides support, mentorship, opportunities. Stud Affairs Today 2021; 24(2): 12. 29. Teasdell A, Lee SJ, Calloway AM, et al. Commitment, community and consciousness: a collaborative autoethnography of a doctoral sister circle. J Afr Am Women Educ 2021; 1(1): 30. 30. West NM. In the company of my sister-colleagues: professional counterspaces for African American women student affairs administrators. Gend Educ 2019; 31(4): 543–559. 31. Gaston MH, Porter GK and Thomas VG. Prime time sister circles: evaluating a gender-specific, culturally relevant health intervention to decrease major risk factors in mid-life African-American women. J Natl Med Assoc 2007; 99(4): 428–438. 32. Thomas VG, Gaston MH, Porter GK, et al. Prime time sister circles® II: evaluating a culturally relevant intervention to decrease psychological and physical risk factors for chronic disease in mid-life African American women. J Natl Med Assoc 2016; 108(1): 6–18. 33. Bandelow B, Michaelis S and Wedekind D. Treatment of anxiety disorders. Dialog Clin Neurosci 2017; 19(2): 93–107. 34. Chand SP, Kuckel DP and Huecker MR. Cognitive behavior therapy. Treasure Island, FL: StatPearls Publishing, 2022. 35. Carter MM, Sbrocco T, Gore KL, et al. Cognitive-behavioral group therapy versus a wait-list control in the treatment of African American women with panic disorder. Cognit Ther Res 2003; 27: 505–518. 36. Feske U. Treating low-income and minority women with posttraumatic stress disorder: a pilot study comparing Somerville et al. prolonged exposure and treatment as usual conducted by community therapists. J Interpers Violence 2008; 23(8): 1027–1040. 37. Abrams JA, Hill A and Maxwell M. Underneath the mask of the strong Black woman schema: disentangling influences of strength and self-silencing on depressive symptoms among US Black women. Sex Roles 2019; 80: 517–526. 38. Jean EA, Neal-Barnett A and Stadulis R. How we see us: an examination of factors shaping the appraisal of stereotypical media images of Black women among Black adolescent girls. Sex Roles 2022; 86(5–6): 334–345. 39. Hall JC, Conner KO and Jones K. The strong Black woman versus mental health utilization: a qualitative study. Health Soc Work 2021; 46(1): 33–41. 40. Agyemang P and Powell-Wiley TM. Obesity and Black women: special considerations related to genesis and therapeutic approaches. Curr Cardiovasc Risk Rep 2013; 7(5): 378–386. 41. Tenfelde SM, Hatchett L and Saban KL. “Maybe Black girls do yoga”: a focus group study with predominantly lowincome African-American women. Complement Ther Med 2018; 40: 230–235. 42. Woodyard C. Exploring the therapeutic effects of yoga and its ability to increase quality of life. Int J Yoga 2011; 4(2): 49–54. 43. Bryant AS, Seely EW, Cohen A, et al. Patterns of pregnancy-related hypertension in Black and White women. Hypertens Pregnancy 2005; 24(3): 281–290. 44. Roberts JM, Bodnar LM, Patrick TE, et al. The role of obesity in preeclampsia. Pregnancy Hypertens Int J Women Cardiovasc Health 2011; 1(1): 6–16. 45. Rosenberg L, Wise LA and Palmer JR. Hair-relaxer use and risk of preterm birth among African-American women. Ethn Dis 2005; 15(4): 768–772. 46. Byrd A and Tharps L. Hair story: untangling the roots of Black hair in America. New York: Macmillan Publishers, 2014. 47. Manns-James L and Neal-Barnett A. Development of a culturally informed protocol for hair cortisol sampling in Black women. Public Health Nurs 2019; 36(6): 872–879. 48. Somerville K, Neal-Barnett A, Stadulis R, et al. Hair cortisol concentration and perceived chronic stress in low-income urban pregnant and postpartum Black women. J Racial Ethn Health Disparities 2021; 8(2): 519–531. 49. Donahoo S and Smith AD. Controlling the crown: legal efforts to professionalize Black hair. Race Justice 2022; 12(1): 182–203. 50. Crittendon J and Hopko DR. Assessing worry in older and younger adults: psychometric properties of an abbreviated Penn State Worry Questionnaire (PSWQ-A). J Anxiety Disord 2006; 20(8): 1036–1054. 51. DeLapp RC, Chapman LK and Williams MT. Psychometric properties of a brief version of the Penn State Worry Ques­ tionnaire in African Americans and European Americans. Psychol Assess 2016; 28(5): 499–508. 52. Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in nonspecific psychological distress. Psychol Med 2002; 32(6): 959–976. 53. Krieger N, Smith K, Naishadham D, et al. Experiences of discrimination: validity and reliability of a self-report measure 15 for population health research on racism and health. Soc Sci Med 2005; 61(7): 1576–1596. 54. Rini CK, Dunkel-Schetter C, Wadhwa PD, et al. Psycho­ logical adaptation and birth outcomes: the role of personal resources, stress, and sociocultural context in pregnancy. Health Psychol 1999; 18(4): 333–345. 55. Dowse E, Chan S, Ebert L, et al. Impact of perinatal depression and anxiety on birth outcomes: a retrospective data analysis. Matern Child Health J 2020; 24(6): 718–726. 56. Guintivano J, Sullivan PF, Stuebe AM, et al. Adverse life events, psychiatric history, and biological predictors of postpartum depression in an ethnically diverse sample of postpartum women. Psychol Med 2018; 48(7): 1190–1200. 57. Uruakpa FO, Moeckly BG, Fulford LD, et al. Awareness and use of MyPlate guidelines in making food choices. Proced Food Sci 2013; 2: 180–186. 58. Erdfelder E, Faul F and Buchner A. GPOWER: a general power analysis program. Behav Res Methods Instrum Comput 1996; 28: 1–11. 59. Kline RB. Convergence of structural equation modeling and multilevel modeling, https://methods.sagepub.com/book/ sage-hdbk-innovation-in-social-research-methods/n31.xml 60. Chun Tie Y, Birks M and Francis K. Grounded theory research: a design framework for novice researchers. SAGE Open Med 2019; 7: 8822927. 61. Foley G and Timonen V. Using grounded theory method to capture and analyze health care experiences. Health Serv Res 2015; 50(4): 1195–1210. 62. United States Census Bureau. American community survey: demographics data. Cleveland OH: United States Census Bureau, 2016. 63. United States Census Bureau. American community survey. Suitland, MD: United States Census Bureau, 2020. 64. Federal Bureau of Investigation. Crime reports: crime data. Cleveland, OH: Federal Bureau of Investigation, 2020. 65. Chilton JA, Downing C, Lofton M, et al. Circle of Sisters: raising awareness of Native American women to breast cancer. J Health Care Poor Underserved 2013; 24(3): 1167–1179. 66. Hofmann SG, Asnaani A, Vonk IJ, et al. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res 2012; 36: 427–440. 67. Ezhumalai S, Muralidhar D, Dhanasekarapandian R, et al. Group interventions. Indian J Psychiatry 2018; 60(Suppl. 4): S514–S521. 68. Chang MW, Nitzke S, Brown R, et al. Recruitment challenges and enrollment observations from a community-based intervention (mothers in motion) for low-income overweight and obese women. Contemp Clin Trials Commun 2017; 5: 26–33. 69. Tchouankam T, Estabrooks P, Cloyd A, et al. Recruiting low-income African American men in mental health research: a community-based participatory research feasibility study. Am J Mens Health 2021; 15(3): 1018418. 70. Arnett MJ, Thorpe RJ Jr, Gaskin DJ, et al. Race, medical mistrust, and segregation in primary care as usual source of care: findings from the exploring health disparities in integrated communities study. J Urban Health 2016; 93(3): 456–467. 71. George S, Duran N and Norris K. A systematic review of barriers and facilitators to minority research participation 16 among African Americans, Latinos, Asian Americans, and Pacific Islanders. Am J Public Health 2014; 104(2): e16–e31. 72. Henretty JR and Levitt HM. The role of therapist self-disclosure in psychotherapy: a qualitative review. Clin Psychol Rev 2010; 30(1): 63–77. 73. Arroll B and Allen EC. To self-disclose or not self-disclose? A systematic review of clinical self-disclosure in primary care. Br J Gen Pract 2015; 65(638): e609–e616. 74. Hamilton JB. Storytelling: a cultural determinant of health among African American cancer patients. J Cancer Educ 2021; 36(2): 211–213. 75. Lee H, Fawcett J and DeMarco R. Storytelling/narrative theory to address health communication with minority populations. Appl Nurs Res 2016; 30: 58–60. 76. Hodson G, Ganesh N and Race T. Double-pronged bias against Black women: sexism and racism (but not rightwing ideology) as unique predictors. Can J Behav Sci 2021; 53(4): 507–513. 77. Triana MD, Jayasinghe M and Pieper JR. Perceived workplace racial discrimination and its correlates: a meta-analysis. J Organ Behav 2015; 36(4): 491–513. 78. Williams MD. HBCU vs. PWI: institutional integration at PWIs and Black doctoral student depression, anxiety, and stress. Doctoral Dissertation, University of Minnesota, Minneapolis, MN, 2014. 79. DeLapp RC and Williams MT. Preparing for racial microaggressions: the role of cognition and emotion in the proactive coping process of African American college students. New Ideas Psychol 2021; 63: 100897. 80. Wang LI. Hate crime and everyday discrimination: influences of and on the social context. Rutgers Race Rev 2002; 4: 1–31. 81. Craig KM. Retaliation, fear, or rage: an investigation of African American and White reactions to racist hate crimes. J Interpers Violence 1999; 14(2): 138–151. 82. Lyons CJ. Defending turf: racial demographics and hate crime against Blacks and Whites. Soc Forces 2008; 87(1): 357–385. 83. Bell P. Anti-blackness, surface-level diversity continues to matter: what must we do? Equal Divers Incl 2020; 39(7): 749–759. 84. Watson NN and Hunter CD. “I had to be strong”: tensions in the strong Black woman schema. J Black Psychol 2016; 42(5): 424–452. 85. Franklin CW. Black male-Black female conflict: individually caused and culturally nurtured. J Black Stud 1984; 15(2): 139–154. 86. McCrary JM, Altenmüller E, Kretschmer C, et al. Association of music interventions with health-related quality of life: a systematic review and meta-analysis. JAMA Netw Open 2022; 5(3): e223236. 87. Nguyen AW. Religion and mental health in racial and ethnic minority populations: a review of the literature. Innov Aging 2020; 4(5): igaa035. Women’s Health   88. Parsons MB, Rollyson JH and Reid DH. Evidence-based staff training: a guide for practitioners. Behav Anal Pract 2012; 5(2): 2–11.   89. Tallon D, McClay CA, Kessler D, et al. Materials used to support cognitive behavioural therapy for depression: a survey of therapists’ clinical practice and views. Cogn Behav Ther 2019; 48(6): 463–481.   90. Jungbluth NJ and Shirk SR. Promoting homework adherence in cognitive-behavioral therapy for adolescent depression. J Clin Child Adolesc Psychol 2013; 42(4): 545–553.   91. Tang W and Kreindler D. Supporting homework compliance in cognitive behavioural therapy: essential features of mobile apps. JMIR Ment Health 2017; 4(2): e5283.   92. Davenport DS. Ethical issues in the teaching of group counseling. J Spec Group Work 2004; 29(1): 43–49.   93. Zur O. Multiple relationships in psychotherapy and counseling: unavoidable, common, and mandatory dual relations in therapy. Abingdon: Taylor & Francis, 2016.   94. Jonassaint CR, Belnap BH, Huang Y, et al. Racial differences in the effectiveness of internet-delivered mental health care. J Gen Intern Med 2020; 35(2): 490–497.   95. Lawton L, McRae M and Gordon L. Frontline yet at the back of the queue–improving access and adaptations to CBT for Black African and Caribbean communities. Cogn Behav Ther 2021; 14: e30.   96. Greaney ML, Puleo E, Sprunck-Harrild K, et al. Social support for changing multiple behaviors: factors associated with seeking support and the impact of offered support. Health Educ Behav 2018; 45(2): 198–206.   97. King LS, Feddoes DE, Kirshenbaum JS, et al. Pregnancy during the pandemic: the impact of COVID-19-related stress on risk for prenatal depression. Psychol Med 2023; 53(1): 170–180.   98. James L, Brody D and Hamilton Z. Risk factors for domestic violence during pregnancy: a meta-analytic review. Violence Vict 2013; 28(3): 359–380.   99. Xiao X and Loke AY. The effects of co-parenting/intergenerational co-parenting interventions during the postpartum period: a systematic review. Int J Nurs Stud 2021; 119: 103951. 100. Hawkes-Robinson WA. Role-playing games used as educational and therapeutic tools for youth and adults. Tratto Acad 2011; 1: 38. 101. Westerman MA and Steen EM. Revisiting conflict and defense from an interpersonal perspective: using structured role plays to investigate the effects of conflict on defensive interpersonal behavior. Psychoanal Psychol 2009; 26(4): 379. 102. Rønning SB and Bjørkly S. The use of clinical role-play and reflection in learning therapeutic communication skills in mental health education: an integrative review. Adv Med Educ Pract 2019; 10: 415–425. 103. Haertl K. Journaling as an assessment tool in mental health. Assessments in occupational therapy mental health: an integrative approach. 2nd ed. San Francisco, CA: SLACK Incorporated, 2008, pp. 61–79.