Abstract
Rural Americans experience higher rates of perinatal depression (PND) compared to non-rural Americans yet have decreased access to treatment. To address treatment access disparities, we must build capacity for care within non-mental health settings and leverage technology. This study uses a phenomenological approach, exploring treatment experiences of rural perinatal people with PND who participated in a technology-assisted cognitive behavioral-based treatment program. Participants who completed at least one program session were invited to participate in a qualitative interview about their experience. Four core themes emerged: (1) educational value, (2) factors impacting program engagement, (3) accessibility, and (4) suggested improvements. The program offers a treatment option for rural perinatal people and presents a model for increasing access to care in rural areas.
Keywords
Background
Half a million pregnant and postpartum people each year experience perinatal depression (PND) (Horowitz & Goodman, 2005; Wisner et al., 2002). This high prevalence of PND is a public health concern, as PND has negative consequences for individuals experiencing symptoms and their family system (Jahan et al., 2021; Kingston et al., 2012; Muzik & Borovska, 2010). Untreated PND is associated with weight problems, alcohol use, drug use, socioemotional issues, and difficulty bonding/breastfeeding among birthing people (Chapman & Wu, 2013; Slomian et al., 2019; Wouk et al., 2017). It is also associated with poor cognitive functioning, developmental delay, behavioral inhibition, emotional maladjustment, violent behavior, and psychiatric disorders among children (Slomian et al., 2019). Individuals with untreated PND are less likely to follow recommended safety practices, take infants to well child visits, or get infants immunized (Balbierz et al., 2015; Minkovitz et al., 2005). Of particular concern, 25% of maternal mortality cases are attributed to mental health problems (Chin et al., 2022; Gimbel et al., 2024; Jahan et al., 2021; Lindahl et al., 2005), and high prevalence of PND with increased severity of symptoms exacerbates suicidality among pregnant and postpartum people (Chin et al., 2022; Gimbel et al., 2024; Lee et al., 2022; Yu et al., 2024).
Despite research demonstrating that PND poses significant risk to perinatal people and their children, it often goes untreated (Bonari et al., 2004; Jahan et al., 2021). Perinatal people who live in rural areas and experience economic disadvantage have higher rates of PND compared with non-rural and higher resourced peers; yet are less likely to receive mental health treatment (Mollard et al., 2016; O’Hara & McCabe, 2013; Villegas et al., 2011). Perinatal people in rural areas experience substantial barriers to mental health treatment access, including persistent mental health provider shortages, hospital closures and decreased availability of maternity services, and accessibility challenges related to cost, insurance status, transportation, and internet access (Gjesfjeld et al., 2015; Sawyer et al., 2006; Thomas et al., 2009). Even when mental health care is available and accessible, rural residents often find mental health treatment unacceptable due to stigma, lack of anonymity, and preference for informal providers (Cheesmond et al., 2019; Crumb et al., 2019). In addition to the stigma associated with mental health services, perinatal people often fear that seeking mental health treatment or obtaining a mental health diagnosis may lead to child welfare system involvement and to them being viewed as an unfit parent (Fong, 2019). To address treatment access disparities, we must build capacity to provide PND treatment within non-mental health community settings and leverage technology-assisted approaches.
Cognitive behavioral therapy (CBT) is an evidence-supported psychosocial depression treatment found effective when delivered individually, in groups, and via technology (Andrews et al., 2010; Butler et al., 2006; Hofmann et al., 2012). CBT has demonstrated effectiveness across diverse populations and contexts, including in non-mental health settings and with support from non-mental health providers (Himle et al., 2014; Wilson & Cottone, 2013). Technology-assisted CBT (t-CBT) offers potential to increase accessibility to mental health treatment, which may be especially relevant for rural and economically disadvantaged communities given long-standing treatment access barriers (Andrews et al., 2010; Stuhlmiller & Tolchard, 2009).
Increased access to internet and smartphones in rural areas further bolsters the potential for t-CBT programs in these communities. Although disparities remain, 73% of rural adults report having home broadband internet, compared with 76% of urban adults and 85% of suburban adults (Atske et al., 2024a). Similarly, 88% of rural adults report having a smartphone, compared with 91% of urban adults and 93% of suburban adults (Atske et al., 2024b). As policies continue to enhance rural infrastructure for broadband and provide subsidies for the cost of internet, t-CBTs are emerging as a critical treatment option for rural residents.
Despite its promise, currently available t-CBTs for depression present challenges related to user engagement that are particularly relevant to rural residents. Given that most t-CBTs are developed and tested in academic research contexts with predominately white, higher resourced populations, rural residents often feel that existing t-CBTs do not reflect their lived experiences. For example, currently available t-CBTs are typically academic in nature, text heavy, and use jargon to present intervention content, which can make them difficult to follow (Etzelmueller et al., 2020; Farvolden et al., 2005; Richards & Richardson, 2012; van Ballegooijen et al., 2014). This academic, text heavy approach may be off-putting to rural residents who often have limited local resources and opportunities to access higher education, and subsequently, lower educational attainment levels compared with non-rural peers (Sanders, 2023).
Furthermore, most existing t-CBTs offer a one-size-fits-all approach, which can limit applicability and relatability of the treatment. This one-size-fits-all approach is typically normed to experiences and treatment preferences of higher resourced, white, non-rural populations. Although literature consistently demonstrates that treatment tailoring is imperative to increase engagement, accessibility, and acceptability of care (Krebs et al., 2010; Noar et al., 2007; O’Mahen et al., 2012, 2013), t-CBTs are not developed to support tailoring for specific client groups, settings, or contexts. In fact, there are no identified existing t-CBTs specifically tailored for rural perinatal people, further demonstrating that the experiences and perspectives of perinatal people living in rural areas are missing from currently available t-CBTs.
Despite the overall promise of t-CBTs for improving access to mental health treatment, studies show that individuals who begin using t-CBT for depression complete an average of 65% of sessions, limiting potential for symptom and functional improvement (Etzelmueller et al., 2020; van Ballegooijen et al., 2014). When t-CBT includes human support, treatment engagement, adherence, and outcomes improve (Andersson & Cuijpers, 2009; Richards & Richardson, 2012). To address current t-CBT engagement challenges, it is therefore essential to develop t-CBTs that are engaging and straightforward, designed to support treatment tailoring, and can be used independently or with human support.
We created Entertain Me Well (EMW), a t-CBT platform that delivers treatment for depression in an entertaining, flexible way, to address current engagement barriers associated with most t-CBT programs. EMW was intentionally designed to introduce CBT core concepts using a straightforward, accessible approach with all content at a fifth-grade reading level (Weaver, Zhang, et al., 2023). Concepts are presented via a multi-channel (i.e., video-based education, video-based animated story, text and image-based educational content) approach to support a variety of learning preferences and needs (Weaver et al., 2022; Weaver, Zhang, et al., 2023). One of EMW’s key innovations is utilization of entertainment, via an animated, character driven storyline, to present and model CBT concepts, skills, and tools. Using entertainment represents a strategy for increasing engagement and encouraging application and practice of knowledge (Weaver et al., 2022; Weaver, Zhang, et al., 2023).
Another key innovation of the EMW platform is the built-in flexibility that supports quick, easy, and low-cost treatment tailoring while maintaining core evidence-supported CBT concepts (Felsman et al., 2024; Weaver et al., 2024; Weaver, Zhang, et al., 2023). EMW was designed to allow tailoring of text, quotes, images, examples, and vignettes, and can be customized to reflect preferences and maximize relevance to client groups and settings. The EMW program delivers eight sessions of CBT for depression, following evidence-supported treatment models. The program has an accompanying workbook that provides an overview of session content and includes in-session and between session activities.
Tailoring treatment to be effective, accessible, and acceptable for rural perinatal people experiencing economic disadvantage is imperative and requires direct input from community partners who will be using and/or supporting treatment (Ward et al., 2018; Weaver, Zhang, et al., 2023). Our work with rural communities identified the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) as a promising setting to tailor and deliver t-CBT interventions for PND (Weaver, Landry, et al., 2023). WIC programs serve low-income perinatal people and their children between 0 and 5 years. They provide nutrition education and health food vouchers as well as infant formula. The WIC setting also assesses additional needs of their clients, such as physical and mental health concerns and offer referrals appropriately (Pooler et al., 2013; Weaver, Landry, et al., 2023).
Our collaboration with rural WIC programs in Michigan revealed that although WIC providers identified PND treatment as a need commonly experienced by their perinatal clients, they shared that the lack of mental health treatment available in their communities presented a barrier to providing appropriate referrals. Our preliminary work with rural WIC clinics led to a community-university partnership focused on initiating a formal screening process for PND and building capacity to offer t-CBT for PND to clients who screened positive (Weaver, Landry, et al., 2023; Weaver et al., 2024). Through this partnership, we engaged in a participatory, iterative approach to tailoring EMW for rural WIC clients experiencing PND. The tailoring process resulted in the development of the Moms & Babies Feeling Better Together (MBFBT) program. MBFBT includes tailored text, quotes, images, and examples that reflect the realities and experiences of perinatal WIC clients in this rural community.
Although our tailoring process centered voices and experiences of rural WIC clients and providers, it is critical to explore the perspectives of rural perinatal WIC clients who use the MBFBT program. This qualitative study, conducted as part of an open pilot study of the MBFBT program (Weaver et al., 2024), explores the treatment experiences of rural WIC clients with PND who were offered and participated in the MBFBT program. Understanding WIC clients’ perceptions of MBFBT informs additional modifications and refinements that are needed to enhance engagement, relevance, and acceptability of the program as well as factors that may influence intervention implementation within additional rural WIC settings.
Method
This phenomenological, inductive qualitative study explores the research question:
Clients who engaged with at least one MBFBT session were invited to share their perceptions of and feelings about the program. This study utilizes participants’ lived experiences and perspectives to identify patterns and themes, contributing to development of a framework that identifies elements related to participant engagement and intervention acceptability. All study procedures were approved by the University of Michigan Institutional Review Board.
Participants and Setting
Perinatal clients at one rural Michigan WIC clinic who screened positive for depression, were invited to participate in a pilot study of MBFBT between March 2021 and September 2022 (Weaver et al., 2024). Clients who screened positive for depression during routine WIC appointments were given information about the pilot study and asked to complete a contact form if they were interested in learning more. Research assistants followed up with interested clients to provide study information. If clients remained interested, research assistants met with them to review consent, and clients had the opportunity to ask questions about the study and participation.
Pilot study participants completed a quantitative assessment at pre-treatment to confirm study eligibility. Participants were eligible for the study if they: (a) screened positive for at least mild depressive symptoms (EPDS> = 7), (b) did not currently receive psychosocial treatment, (c) had internet access, and (d) spoke English. Individuals were not eligible for the study if they: (a) previously completed a course of CBT (> = 8 sessions), (b) met criteria for a psychotic disorder or depression with psychotic features, or (c) presented with suicidal ideation with imminent risk. If individuals did not meet eligibility criteria, they received resources and referrals including local services and online support.
Eligible participants were provided access to MBFBT. Research assistants held a pre-intervention virtual meeting with participants to introduce the program and provide technical support. Participants were encouraged to complete one session per week; however, there were no requirements for completing the program within a standard amount of time. Research assistants scheduled brief virtual check-ins with participants after each session, at participants’ preferred day and time, to answer any questions they may have, and provide support for between session activities.
Participants were also invited to complete post-treatment, and 3-month follow-up assessments. At the post-treatment assessment, all participants who completed at least one MBFBT session were invited to participate in semi-structured, qualitative interviews about their treatment experience. The qualitative aspect of the pilot study, and the focus of the current study, was designed to explore perinatal WIC clients’ perceptions of the MBFBT program, with attention to understanding the feasibility and acceptability of the intervention model. Twenty-four perinatal WIC clients enrolled in the pilot study and 19 participants completed at least one MBFBT session. Twelve of the 19 participants were retained for post-treatment assessment (63.2%) and seven participants (58.3%) completed semi-structured qualitative interviews. Interviews were monitored for saturation.
Moms & Babies Feeling Better Together
MBFBT is housed on the EMW online platform and delivers CBT via a multi-channel approach, utilizing a character-driven storyline, video-based educational content, and text-based content (text, images, quotes, examples). EMW also intentionally presents CBT content in a simple, straightforward manner that appeals to multiple learning preferences (Weaver et al., 2022; Weaver, Zhang, et al., 2023). People using the program receive an accompanying workbook with in-session and between-session exercises.
MBFBT is eight-sessions and tailored for perinatal people and the rural WIC setting. Utilizing a community-engaged, iterative process, our research team collaborated with multiple community partners to tailor EMW’s t-CBT treatment for perinatal people and the rural WIC setting. WIC staff, peers, and researchers engaged in a series of interactive meetings to review EMW content and identify modifications and changes necessary to ensure content relevance and relatability for perinatal clients receiving WIC services. The tailoring process resulted in the MBFBT program which includes tailored images, text, quotes, and examples in each session as well as core, evidence-supported, CBT content (i.e., behavioral activation, cognitive restructuring, problem solving).
MBFBT is self-paced and completed independently. People using the program are asked to complete one session per week. Each session takes between 25 and 30 minutes. Research assistants provide brief (5–10 minutes.) check-ins with participants after each session to answer questions and offer between session activity support.
Data Collection
Semi-structured qualitative interviews were conducted with seven participants. Master’s and doctoral level research staff, trained on qualitative interviewing and study procedures, conducted all interviews. Questions focused on understanding participants’ experiences using the program and had three sections: overall experience in the program, perceptions of program content, and the check-in process. Interviews were completed virtually via zoom, scheduled at participants’ convenience, and ranged from 20 to 60 minutes in length. They were recorded with participants’ permission, and transcribed verbatim.
Analysis Plan
Thematic analysis was used to analyze transcribed interview data after transcripts were assessed for accuracy. Five independent coders followed Strauss and Corbin’s (1990) procedures for thematic analysis of interview data. Our analysis began with in-vivo or line by line coding that focused on identifying minute aspects of responses using participants’ own language and meaning (Strauss & Corbin, 1990). The research team, including all five independent coders, met regularly to connect open coded passages to broader patterns and themes representing axial codes. The research team engaged in dialogue to interpret the axial codes and discuss and resolve any inconsistencies. Axial codes were further collapsed into core categories that represented the most variation in participants’ experiences with and perceptions of MBFBT (Strauss, 1987).
Throughout our thematic analysis process, we followed Strauss and Corbin’s model for resolving inconsistencies in qualitative coding. We utilized an iterative process, where the independent coders and research team met regularly to revisit codes as we analyzed the data. In addition, coders engaged in memoing, keeping detailed notes of their thought processes and interpretations as well as questions and inconsistencies that came up during the coding process. Finally, the research team engaged in theoretical sampling, in which data either supporting or challenging existing codes were identified and discussed. Taken together, these processes were used to identify, analyze, and resolve inconsistencies in qualitative coding.
Results
Our analysis resulted in four core categories relevant to client’s experience with MBFBT: (1) educational value, (2) factors impacting program engagement, (3) accessibility, and (4) suggested improvements.
Educational Value
Participants consistently described their experience with MBFBT as having educational value. Participants shared that their experience with the program increased self-awareness of their mental health needs and ways in which their behaviors and thoughts may impact their overall well-being. In addition, participants identified the straightforward, easily digestible way content was presented as a strength that contributed to their ability to understand and apply skills and knowledge from the program. Finally, participants felt receiving education about PND normalized their own experiences with PND.
Increased Self-Awareness
A key takeaway from participants related to their feelings of increased self-awareness of their mental health needs after utilizing MBFBT. Participants shared that engaging with the program enabled them to recognize and understand their depressive symptoms, improving their ability to apply skills to change behavior and decrease emotional dysregulation.
When discussing their increased self-awareness, one participant explained, “I like the activities and the different ways for you to recognize when your depression hits. . .different steps on recognizing it and how to sort, for lack of a better term, combat it (3).” Participants emphasized ways their increased self-awareness supported their ability to better understand how depression impacted their actions and thinking. As this participant shared:
I liked how it helped me with my problems, too. I don’t know, I never thought about doing stuff like that, like going back and. . .what’s it called, thinking about my problems and what I could do and to not always be thinking so negative. . .It helped me learn a lot. (11)
Support to Apply Skills and Knowledge
Participants identified MBFBT as providing content that directly supported their ability to apply CBT skills and knowledge to their own lives. They attributed the support in applying skills and knowledge to the straight-forward and easily digestible content delivery. Participants indicated that presenting content in this straight-forward, easily digestible way enhanced their ability to apply the skills and strategies introduced in the program.
Applying strategies to support taking action was identified by participants as critical to experiences with MBFBT. Participants shared that the program not only emphasized the importance of taking action, but also provided concrete ways to practice the skill, even when it seemed difficult for them. Speaking to this, one participant noted, “. . .I feel like [with] the depression, [taking action] that’s the number one hardest thing to do. But once you overcome that, you can definitely do all the other things for sure (74).” Participants shared that using the concrete, straightforward strategies offered by the program helped them to understand the connection between their actions and their mood, and to start doing more even when it was challenging for them. When talking about the importance of applying strategies to take action, one participant noted, “. . .and having goals to meet. . .not every week I met my goal, but still I had those goals written down to try to accomplish (28).”
Many participants explained that the skills and knowledge they gained around taking action helped them continue applying strategies for moving forward despite challenges. One participant commented:
Through this program, I was motivated to join a play group that we go to twice a week. I’ve started to try to reach out, to connect with some of the moms in the playgroup. . .so far it hasn’t been super successful with the ones I’ve connected with. We don’t have a lot in common, but I’m looking, I’m still looking. There’s other moms. I also joined a book club for myself so once a month I get to go to this thing. And it just pushed me to really look for a lot of the things that I needed, the socialization. (40)
Participants also described ways the program supported their ability to apply skills and knowledge around identifying unhelpful, negative thoughts and replacing them with more helpful ones. The between session activities provided by the program were identified as particularly helpful supports for applying cognitive restructuring skills. One participant explained:
On the worksheet, I got to write down my own problems or even think about them and then just write ‘em down and put it into more positive stuff instead of, you know, thinking, oh, I’m never gonna be good enough. . .I don’t know. . .everything just helped me realize, it’s not always good to be thinking negative. (11)
Another participant noted, “I thought it was helpful and I still have those worksheets to look back on (35).”
Normalization of PND
Finally, when discussing the educational value of the MBFBT program, participants often shared the belief that the program normalized their experiences with PND. Given the high stigmatization of PND is this rural community, this was particularly important. A participant saliently shared this sentiment, explaining:
. . .having the videos and having something that you can relate to. I definitely liked cuz it’s like, okay, that’s not just me. Obviously, they got this from other moms, women out there. So that was nice that you can kind of have a relation to like, okay, it’s not just me. I don’t feel crazy or anything like that. (28)
Factors Impacting Program Engagement
Program engagement, and the specific factors that facilitated engagement, was identified as a key element of participants’ experience with MBFBT. Participants consistently described the program as reducing typical barriers to treatment engagement and specifically noted that the character-driven storyline and brief human support after each session enhanced their engagement and commitment to the program overall.
Flexibility
Participants discussed the flexibility of MBFBT and how that flexibility enabled them to use the program in a meaningful way. Many participants noted that they were the primary caregivers for their children and that they had very little time to address their own needs. Most participants shared that MBFBT fit into their schedules as new parents who were balancing a lot and appreciated the flexibility to complete sessions and progress through the program on their own time. One participant spoke to this, noting that the program, “was around, um, our time, especially moms having busy schedules (28).” Another participant noted that the self-paced nature of the program provided flexibility, explaining, “I did like that. . .it didn’t take a lot of time. It was like, you know, kind of self-paced and I could just go through it real quick without my son even realizing that I was doing something on the computer (40).”
Relatability of Character Driven Storyline
All participants identified the animated, character-driven storyline featuring Billi the balloon and its relatability as a core factor that supported their program engagement and contributed to meaningful use. Participants shared that Billi’s story helped keep them engaged and moving through the program. In addition, participants shared that the use of animation and Billi’s characterization as a balloon kept them entertained, contributing to high engagement levels. Furthermore, participants found Billi’s story highly relatable and could see themselves in Billi. They shared that this supported their engagement as they saw Billi and how she navigated depression as a model they could follow. When describing their experience, one participant explained:
Definitely the storyline of Billi, the balloon. I liked how it wasn’t a person or anything like that. It was just a balloon. It wasn’t pinpointed to anything. It was how she reacted, how she felt, how she went about going about her depression, anxiety, things that she felt worked and didn’t work. I really liked that. (28)
This participant agreed, sharing, “. . .oh my gosh me and Billi are literally the same person but she’s a balloon. . .I think that was really nice to have. . .and not like you know. . .like a real person like acting it out or anything like that because that’s kind of harder to connect to (74).” Participants also noted that one reason Billi’s story was relatable was because everything didn’t always turn out perfectly for her. As this participant commented:
I don’t think there’s anything you could have done to make Billi more perfect. I think that Billi being a balloon was perfect. All of the little nuances with that. . .she was extremely relatable. The way she talked, it felt like I was saying these things. . .I liked that she was going through the journey and I feel like everything she experienced was so realistic. At one point I told [the researcher], I’m glad that she showed up at the restaurant and nobody was there. That’s the thing that happens. . .it didn’t feel like it was like, this is how it’s gonna work out for you. And it’s gonna be great every time. (40)
The same participant also noted:
It just all seemed very realistic and that’s good because especially someone who is suffering from a depressive episode doesn’t want to see something where everything works out fine. It’s great cause that’s not what it feels like. So, I really like that. And I really appreciated that she was a balloon therefore, relatable to everybody. And, you know, just her experiences were just very realistic. (40)
Participants also found it relatable and engaging to see Billi use the skills and strategies she learned in therapy. Two participants clearly described this, with one explaining, “She knew how to handle it well. . .cause she went to therapy so she could learn. . . And seeing the way she handled it. . .it did help me the way she explained it (11).” And another stating, “She overcame her depression. She pushed herself to be more motivated to do things and once she did get going, things got easier for her (10).” Finally, one participant exemplified the overarching sentiment that Billi helped them learn, sharing, “When you listen to her, it’s like one of those, like, yeah! Like, oh, you know, I completely get that (3).”
Accountability
Participants identified the accountability of the weekly check-in model as a factor that impacted program engagement and follow-through. The brief, flexible way of receiving human support helped participants move through the program, gain clarification around concepts that were difficult to understand, and have support for between session activities. Participants consistently discussed that the weekly check-ins motivated them to complete their session for the week and to work on their homework. This was perceived as important for accountability. One participant shared: “I liked having to talk to someone each week, each session, cause then it holds me accountable. I need assistance when I’m doing that stuff, so it made me make sure I would do it (35).” This participant offered a similar sentiment, explaining: “I knew I had to talk with her a certain day, so I had to make sure I was going to do it and like really do my homework and apply the worksheets and stuff. And if I needed clarification, I knew she would be able to help me (35).”
Participants also discussed how the weekly check-ins motivated them. Participants appreciated the connection with a support person and wanted to make progress and share their accomplishments. A participant stated:
[Check-ins] not only kept me motivated to want to keep doing these things every week and pushing myself, but it made me proud and excited. And I would look forward to talking to her to tell her about all the things that I accomplished or was doing. And to get that encouragement was always good. (40)
Another participant commented:
Everyday, after we met on Monday, I was okay like, let’s get to it you know? So it was really nice and it felt like I accomplished something because I feel like during pregnancy the term lazy is easily thrown around. So that was something that I was able to do, and I felt accomplished doing it and it was beneficial for me for sure. (74)
Participants also noted that having a designated touch point with a support person who was solely focused on their needs enhanced their program engagement. As this participant described:
Someone to talk to besides your child. It was just like to being able to talk with another adult, that was nice. I don’t get that often. . .the check-ins, I felt like, you know, it gives me time to focus on what I’m feeling instead of, you know, other people, like what, you know, my kids are going through, it gives me a moment to myself to get away from my children. I love ‘em but I need a break once in a while. (10)
Accessibility
Finally, participants expressed that the accessibility of the program helped to reduce barriers to seeking mental health care.
Reduced Practical Barriers
Participants reported that the MBFBT model reduced practical barriers to mental health treatment. Many participants described their busy lifestyles, often balancing caregiving responsibilities with work outside of the home, as a key barrier to accessing mental health treatment. Participants viewed MBFBT as reducing those barriers and allowing them to access the treatment on their own time and at their own pace, without leaving their homes. One participant explained their ability to complete the program stating, “Especially with me being a single mom, getting to be able to do the courses, working full-time, even when I was pregnant, I was working full-time and, and trying to get the time to do the courses and do the meetings while having my job (3).”
Another participant similarly addressed the importance of accessing the program on their own time and at their own pace, commenting, “I liked that it was weekly and that it was around our time, especially moms having busy schedules. I did it with having two kids and tons of doctor’s appointments with my son. So that was very beneficial (28).” Finally, this participant described the program as allowing them to focus on their mental health needs in a way that works for them, sharing:
. . .it was something beneficial for me that I was taking time out of my day to actually focus on me. . .I just like that it was kind of my own kind of therapy session. I didn’t have to go to somebody and have them hear me out or anything like that. I kind of just adapted to it on my own. (74)
Easily Digestible, Accessible Content
When reflecting on presentation of content, participants reported that content was accessible and presented in easily digestible, straightforward language. They commented on the mixed media presentation approach to materials which provided a vehicle for the content without requiring significant amounts of reading. Participants reported that this approach enhanced their understanding of the material and their ability to effectively apply skills and strategies in their own lives. One participant described the importance of content that supported a variety of learning styles, commenting:
I liked how, instead of having to thoroughly read something to learn, it was more visual and, you know, I had to use my ears. . .I didn’t have to read it myself all the time. A lot of it was, you know, it spoke to you instead of you having to read a book. (10)
Another participant offered a concurrent sentiment, explaining:
The videos weren’t too long or too short, they were well explained. Same with the pamphlet of reading it over. . .I am not a big fan of reading over paperwork. And I didn’t feel like. . .Wow, I’m really tired of reading this. . .I think it was really perfect on how that was presented and written out. (28)
Participants also shared that they appreciated the worksheets presenting the in-session and between-session activities, noting that the worksheets also included a mix of visual and written content. Participants viewed the design of the worksheets as low-burden and helpful to their follow-through. As one participant stated, “I like the worksheets and everything. And I like how, you know, it gave us some graphics of, kinda like a calendar. . .for writing things down and planning stuff and all that (3).”
Suggested Improvements
Although participants shared many aspects of MBFBT that they viewed as impactful and helpful, participants also identified several elements that would improve the program. There were common improvements noted across participants, including using a transdiagnostic intervention approach, having a more advanced level of the program for individuals with prior treatment experiences, optimizing the platform for mobile users, and integrating the experience of pregnancy and postpartum into the character-driven story.
Some participants shared that the program’s focus on depression was helpful and also that they experienced anxiety. They indicated that a focus on both depression and anxiety would have been helpful, as one participant noted, “My experience was really severe postpartum anxiety. And so, if there was a little bit more about those experiences, those feelings too. . .that would be nice (40).”
In addition, one participant shared that they had prior experience in therapy and recommended having a second level or more advanced program option. This participant indicated that a more advanced level would allow individuals who already knew the basics about depression and treatment the opportunity to delve deeper into intervention content. The participant explained, “. . . I think that a good idea would be to maybe have two levels of like, you know, have you already learned some stuff through therapy and, tailoring it a little bit to a different level (40).”
Participants also commented that the program was optimized for desktop computers and was harder to navigate on mobile devices. As all participants reported using their smartphones to access the program, this is a critical issue and emerged as a common suggested improvement. As one participant commented:
. . .especially when it comes to people who have to use mobile like I do, cuz my laptop is broken, it’s just a bit more difficult to navigate on it. Some of the words will kind of be cut off, and whatnot, especially towards the end when it’s moving on to another section or another activity. (3)
Finally, although participants found Billi and the character-driven storyline relatable, they also shared the desire to see Billi experience pregnancy or navigate the postpartum period. Participants believed a story featuring Billi during pregnancy or the postpartum period would be more relatable and engaging. One participant explained, “Maybe if Billi had children. . .I mean, you can’t really avoid your children. . .Maybe some different experiences like a person with children. . . that way, some of the moms can relate more to her with what’s going on (10).” Another participant echoed this sentiment, noting, “I think it would be great to see Billi explore those awkward mom moments of showing up at the playgroup and trying to connect with someone and not being able to really make that connection (40).”
Discussion and Implications for Practice
Perinatal mental health is a critical public health concern. Findings from this study suggest that WIC clients found the MBFBT program feasible and acceptable. Given the need for innovative, accessible approaches of bridging mental health treatment access gaps experienced by perinatal people living in rural communities, our findings indicate that offering MBFBT in WIC settings may be a promising service delivery model.
Qualitative findings from this study further support our quantitative pilot findings showing high levels of treatment engagement among participants (Weaver et al., 2024). Our quantitative pilot study found that participants attended an average of 5.8 of eight MBFBT sessions, with 58% of participants attending all eight sessions (Weaver et al., 2024). Qualitative findings provide insight to the specific factors facilitating treatment engagement, including the relatability of the character-driven story and the flexibility of the program. Participants’ receptivity to the character-driven story, as both an engaging and educational treatment element, indicates the value of integrating entertainment with mental health treatment. MBFBT’s entertaining approach, utilizing a character-driven storyline to introduce and model core intervention concepts, represents a contrast from most existing t-CBTs for depression that are text heavy and academic in nature. Findings suggests that integrating entertaining narrative content with psychoeducation, skills, and tools, represents a promising approach for enhancing treatment engagement, and subsequently treatment outcomes.
Our results align with the Entertainment Overcoming Resistance Model (EORM). According to the EORM, narrative storytelling and character involvement aids individuals in reducing resistance to treatment and enhances inherent behavior change (Green & Brock, 2000; Moyer-Gusé, 2008). Individuals are invested in the story, a theory the EORM calls “transportation” and begin the process of “identification,” or aligning with the characters as the story progresses (Green & Brock, 2000; van Laer et al., 2014). These two concepts decrease individuals’ resistance to treatment because they are driven to believe them based on the story presented (Braddock & Dillard, 2016). With the MBFBT program, participants were driven by Billi’s story and her use of CBT concepts to change her behavior and reduce depressive symptoms. Participants were able to adopt these strategies into their own behavior change practices. In addition to this, narrative engagement enhances individuals’ reflective capacity as they apply concepts and skills to their own lives.
Furthermore, findings from this study support extant literature showing that treatment tailoring is associated with increased treatment engagement (Barrera et al., 2013; Krebs et al., 2010; Noar et al., 2007). MBFBT was specifically tailored for rural perinatal people and the WIC setting. Participants viewed MBFBT as being easily digestible and accessible, which likely connects to the intentional tailoring for this population and context. Specifically, participants commonly shared their appreciation for the straightforward language and mixed media used throughout the platform. As rural residents have been historically left out of mental health intervention research, their experiences and perspectives are often missing from t-CBTs. Our findings demonstrate the importance of designing tailorable programs and working collaboratively with community members who are experts of their own experiences. Although this study focuses on rural residents, it is likely that this approach would be impactful for increasing treatment engagement among many marginalized groups of perinatal people.
Results also align with research suggesting that t-CBTs with human support result in higher treatment engagement, compared with t-CBTs completed independently (Andersson & Cuijpers, 2009; Richards & Richardson, 2012). Participants commonly identified human support provided by brief weekly check-ins with research staff as important for their follow-through with MBFBT. For this pilot study, weekly check-ins were completed by research staff members. It is critical to explore the potential for WIC providers to support the brief check-ins for this service delivery model, with attention to alignment with standard WIC practice and potential training needs. WIC already employs peer support models in other areas of their practice (e.g., breastfeeding peer support) and peer support for MBFBT may seamlessly fit into their already existing support model. Further research assessing the implementation of the check-in model by WIC staff is needed.
Overall, our findings suggest the promise of delivering MBFBT in rural WIC clinics. Mental health treatment access disparities impacting rural communities have persisted for at least six decades, without substantial change. As rural residents often lack trust in outside, distant providers and resources, (Cheesmond et al., 2019; Crumb et al., 2019; Henderson et al., 2015) it is imperative to identify rural community settings with capacity for offering mental health treatment. This study suggests that offering MBFBT through WIC reduced practical barriers to care. It is likely that many of the perinatal clients served by MBFBT may not have had the time, financial resources, transportation access, or child care support to seek treatment. By offering the MBFBT program through WIC, an established and trusted resources in this rural community, acceptability-related barriers such as stigma are reduced as well. Offering MBFBT through WIC presents a meaningful service delivery model for addressing perinatal mental health that requires further attention from researchers, practitioners, and policymakers.
Limitations
This study has limitations that must be acknowledged. First, this study includes a small sample of perinatal people recruited from one rural WIC clinic. Second, not all participants who completed the program participated in qualitative interviews. This was due in part to retention challenges at different time points throughout the study and must be addressed in future research. Third, although technology access was not a barrier for this sample, not all rural populations are heterogeneous and other rural communities may face challenges related to device and/or internet access as well as differences in treatment preferences. Finally, although our team followed established processes outlined by Strauss and Corbin for resolving inconsistencies in qualitative coding, we did not assess inter-rater reliability.
These limitations notwithstanding, MBFBT offers a potentially acceptable treatment option for perinatal WIC clients and presents a promising model for increasing access to care in rural areas. Participants’ experiences indicate that MBFBT fit into their lifestyle, was relevant to personal experiences, and provided motivation to meet their goals. Further research assessing WIC client perceptions of MBFBT with larger, more diverse samples across multiple WIC clinic sites, as well as WIC provider perceptions of MBFBT implementation, is needed.
Footnotes
Disposition editor: Cristina Mogro-Wilson
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received financial support from the Eisenberg Family Depression Center at the University of Michigan and the Michigan Department of Health and Human Services for the research presented in this article.
