The idea of connection was the centralized theme in both the primary and secondary analyses, tying the core themes of community with women experiencing PD, normalization of depression, and reduced stigma of depression together. Feedback provided by the participants elucidated whether the use of technology helped to maintain the sense of community and connection or detracted from the program.
Feedback from participants was overwhelmingly positive, with many women expressing hope that the program would continue in the future. All of the participants across the three groups described the VC UPLIFT as helpful in reducing feelings of isolation and increasing a sense of having a common experience. This is important because isolation is a common experience among peripartum women with PD in both urban and rural settings. Urban pregnant women with depression report feelings of intense isolation and loneliness [32]. Similarly, rural pregnant women report that transportation and isolation/loneliness are predominant stressors for them [27].
Women described the intervention using videoconference system as convenient, as they did not have to find childcare or transportation, despite minor technical difficulties at times. This provided women with the opportunity to participate in a group intervention in which they would not otherwise have had the ability or motivation to participate. This indicates that interventions delivered via telehealth may address gaps in access to care for such women. Additionally, telehealth may be the only option available where there is limited access to mental health providers. In at least one study, nearly 36% of rural pregnant women met criteria for depression, yet approximately 92% were not receiving any type of mental health services [33]. This is more than double the approximate 15% of pregnant women overall who experience depressive symptoms, where 50% do not receive mental health services. These statistics are in alignment with common barriers to mental health services, such as isolation, transportation, and shortage of mental health providers reported in rural communities [13, 15, 16]. Based on the results of our qualitative study, a group telehealth intervention is a promising platform for addressing isolation and reducing barriers to accessing mental health services for childbearing women in both urban and rural communities.
In contrast to the isolation often felt among depressed pregnant women, the VCI provided participants with a sense of universality, normalization of their experiences, and reduced stigma of mental health issues. As technology-mediated support groups increase in number, it is necessary to explore whether therapeutic factors found in face-to-face group settings may or may not be present in digital forums and/or how these might be better integrated into telehealth. For example, universality is known as a common curative factor of groups and is highly correlated with participants’ perceived helpfulness of a group [34]. Universality appears to be present in both online and in-person group sessions. However, technology may not be an ideal platform for establishing deeper connections with others, in comparison to in-person groups. Fostering interactions between and after VCI sessions might mitigate this perception.
Opportunities for deeper connections with peers outside the group setting are more limited and future interventions should explore this telehealth limitation to enhance connection within group care. This study provides data supporting universality through a telehealth intervention. This matches other research findings that therapeutic factors, such as universality and shared common experiences among group members, are present in telehealth support groups [35].
Based on participant suggestions, future programs could include a structure or means for patients to interact outside of weekly group meetings. Participants recommended platforms to support this such as a private social media group, email lists, or instant messaging/group texting. Participants also recommended extending sessions well into the postpartum period (beyond 8 weeks) as a means to provide continued support to women transitioning into motherhood and to protect against postpartum depression. Some participants also recommended in-person sessions or meet-ups beyond the VCI, although many expressed that they would likely not attend. However, some viewed in-person sessions as a means to establish greater trust among group attendees and offer peer support, should the need arise. Also, the likely geographic distance between participants would not be conducive to in-person interactions.
The greatest drawbacks to the VCI were related to the occurrences of VC instability and difficulty communicating when technological problems arose. The most common technical difficulties for some women were directly related to internet resources, such as weak wireless connections and insufficient bandwidth for video conferencing. These challenges may be more prevalent in rural areas. Prior to attending the VCI, each participant met with a study team member to test the individual’s technology, practice connecting and using the platform, and to troubleshoot any difficulties. This process significantly reduced the occurrence of technical problems, but did not eliminate them, particularly for those participants with inadequate internet connections. Provision of direct technology support and timely troubleshooting of technical issues can lead to more positive experiences.
Other approaches to offset difficulties could include arranging for adequate internet bandwidth in women’s homes, or collaborating with local community facilities, such as libraries or public health clinics to provide adequate internet connections and private settings for women to participate. Ideally, rapid access to a technical support person who could assist with troubleshooting is important, as well as encouragement to use telephone connection during the session, as a quick alternative to videoconferencing. Furthermore, it is important to explore how telehealth environments can better support personal connections amongst individuals similar to in-person interactions. Addressing the suggestions that women made during the focus groups should be integrated in order to maximize the effectiveness of this and other telehealth intervention programs.
Limitations
The study had a limited number of participants and only 17 out of 47 (36%) participated in a focus group. This could potentially bias results, as those who participated in a focus group may be different than those who did not; those who were less satisfied may have been less likely to participate, and conversely, those who were more satisfied may have been more likely. To address this potential bias and to effectively identify barriers and solutions to successful telehealth group mental health programs, future research should focus on individuals who decline or discontinue participation in telehealth programs, or those who do not reap benefits.
The inclusion of a limited number of Hispanic women (reflecting Utah’s population at large) and other women of color in the study limits the generalizability of findings to those that participated in the study (Table 2). The two women of color in the group vocalized the need for prenatal providers to initiate conversations about mental health, and about the stigma of mental health. However, because there were only two participants of color, it is unclear if this emphasis was related to ethnic identity. Follow-up is needed to understand varying racial/ethnic experiences.
Finally, as the women did not engage with one another outside of the VCI sessions, it is unknown whether creating intentional connections outside of the group may enhance the positive outcomes of the intervention; further study is needed.