The results presented here focus on the most common themes related to the acceptability and appropriateness of the MB content and group format (see Table 3). Although other themes emerged from the dataset, this manuscript focuses on the specific study aim related to client and facilitator perceptions of the acceptability and appropriateness of the MB intervention when delivered by paraprofessional HV staff and MHPs.
Table 3. Frequency of Themes by Facilitators and Clients
Theme
|
Sub-Themes
|
Facilitator Frequency: n (%)
N=46
|
Client Frequency: n (%)
N=88
|
Clients and facilitators found the Mothers and Babies content acceptable and appropriate.
|
Facilitators played a valuable role in relaying the information.
|
3(6.5%)
|
22(25.0%)
|
Clients found the tools and vignettes especially useful.
|
20(43.5%)
|
17(19.3%)
|
There were barriers and motivators to attendance.
|
Barriers to attendance included challenges experienced during pregnancy, family crises, scheduling conflicts, and transportation.
|
13(28.3%)
|
32(36.4%)
|
Assistance and access to transportation and childcare played a key role in increasing client attendance.
|
4(8.7%)
|
13(14.8%)
|
Clients found the group format acceptable.
|
Clients found the group size just right.
|
N/A
|
44(50.0%)
|
Being in a group of other pregnant women helped to normalize thoughts and feelings.
|
29(63.0%)
|
20(22.7%)
|
There were feelings of sadness at the completion of group.
|
2(4.3%)
|
6(6.8%)
|
Facilitators raised concerns with the appropriateness of the group format for certain populations.
|
Facilitators found it challenging to engage women who were experiencing crises, housing instability, and/or trauma.
|
11(23.9%)
|
N/A
|
Facilitators found it difficult to implement with clients who were illiterate, had literacy challenges, or learning disabilities.
|
6(13.0%)
|
Facilitators found it challenging to manage discussions during group.
|
21(45.7%)
|
Mothers and Babies Content
Clients and Facilitators Found the Mothers and Babies Content Acceptable and Appropriate
Overall, facilitators and clients described the content of MB as easy to understand, useful, relatable, and universal.
“Yeah, it wasn’t hard to read at all…there was other examples and there was activities that you can do as well, so it’s not like you’re just left there like, ‘I don’t know how to do this,’ or, ‘I really didn’t understand the activity for today or the session for today or the activity that you would have to do at home,’ and that was very helpful as well, actually paying attention to your days and how everything goes.” [Client]
Clients reported consistent understanding and satisfaction with the content of all three MB modules (pleasant activities, thoughts, and social support). The vast majority of the clients discussed using skills from one or more of the modules in their daily lives.
“I try to look back on the pleasant activities and then also feel like moods and outer reality, I try to keep it not so negative inside. I mean I don't know when I first started out, I had like 13 negative thoughts. Then I got it down to like six or five I remember.”[Client]
Clients denoted the valuable role that their facilitator played in the acceptability of the content. Although the content was described as straightforward by clients and facilitators alike, clients repeatedly highlighted how their facilitator provided both meaning and context as needed during the group sessions.
“I think the reason why—I know me in particular—received the information so well is because the facilitator was very engaging. You can have facilitators who make the content dry, drab—you know, it feels like our facilitator actually kept it interesting...We read, just it didn’t feel like we were just going through the motions. There was always an opportunity for feedback and insight and things of that nature that made us able to apply the content to our own lives a little bit more. We always were able to place things into perspective.” [Client]
Clients brought up specific tools from the curriculum they found most helpful; specifically the QMS and vignettes used to introduce each CBT module (see Additional files 1 & 2 for reference). Clients noted that the experience of tracking their moods daily helped them draw connections between their thoughts, activities, and/or social supports and their moods. A client described the impact the QMS had on her mood:
“...it helped me monitor my moods and my activities. I noticed when I wasn’t doing activities that my mood was a little low. If I kept busy, my mood was a little better.” [Client]
The vignettes were referred to repeatedly in a very favorable light by both clients and facilitators. The vignettes helped clients identify thought patterns and behaviors, and also helped clients draw connections between actions and their moods.
“There are examples on some of them [vignettes], where they showed an example of one person and the other person. One person was negative about their day and just didn’t want to do anything and the other one started off negative and then they try to get their day better by doing things. And well sometimes I feel like that. Sometimes I just don’t want to get up. It just takes me a while to figure out how to get myself to feel better.” [Client]
A significant portion of facilitators felt that the majority of MB content was appropriate, irrespective of client demographics, with some facilitators and clients noting MB was relevant to other family and community members as well as to their own personal lives.
“...So the fact that it can relate to anybody—it doesn’t matter what your race, gender, age, sexual orientation is—it pertains to everybody that’s going through this new chapter of their life. Whether it’s having their first child, or having a second or a third child, everybody goes through the change in life and I just thought it helped us come together. Just because we’re all different doesn’t mean that we don’t have some common similarities and Mothers and Babies I think really pulled out the similarities in the groups." [Facilitator]
Group Format and Implementation
Attendance Barriers and Motivators
There were several challenges reported by clients and facilitators related to attendance. Some facilitators shared frustrations with cohorts or individual sessions that were unable to get started due to low attendance. Facilitators and clients noted that the very characteristics of the population that was recruited for groups created challenges in attendance. For example, challenges during pregnancy, such as fatigue and medical complications, impacted the women’s ability to attend groups.
“I just was not feeling well. Sometimes I would come to class and not feel my best, but I would still stick it out. But, it was kind of like a struggle to drag myself there only because I was not feeling well...” [Client]
Despite efforts to schedule cohorts at the most convenient times for clients, there were multiple factors that affected their availability to attend groups. The most prevalent factors that impacted attendance, mentioned by clients and facilitators, were family crises and scheduling conflicts with work and school. Clients also noted having to skip sessions to take care of family members or sick children.
“I also feel like that’s another deterrent for other people because of the time because if you’re working full-time and things like that, and you don’t have a flexible schedule, it’s kind of hard to get that two to two and a half hours once a week in the middle of the day.” [Client]
Additionally, challenges related to transportation to and from groups were identified, including access to reliable transportation, having to travel long distances, and having to travel during rush hour traffic in urban areas.
“You know, the challenges, transportation. You know, getting there. Because sometimes I do—I live far from the office [HV Program] but that part is challenging living far out from the office. And ya’ll have it the people come get us back and forth. That’s—I know it’s challenging for me and them because they gotta worry about gas and we gotta worry about our safety.” [Client]
Assistance and access to transportation and child care services played a key role in client attendance. Free child care, which was provided at the majority of the sites, was helpful even for first time mothers who were taking care of younger siblings or other young family members. This was deemed valuable by all clients, yet facilitators noted the increased time needed to coordinate this service and transition the children to child care, in order for groups to start on time.
“I thought the child care was perfect because sometimes we have two or three children that we can’t leave unsupervised or that we don’t have someone who can take care of them. I thought that was perfect.” [Client]
Clients Found the Group Format Acceptable
The group environment played a key role in encouraging women to engage in intervention activities. Clients noted that an intimate, welcoming, and confidential space impacted their decisions to stay and share during group sessions.
“At first, I was kind of skeptical because I am kind of a quieter person, so I was kind of skeptical about opening up and just revealing personal information about myself, but I knew that the group was confidential, and it was told to us that the group was confidential and nothing that we said was going to be used outside or anything, so that kind of made me open up." [Client]
The majority of the clients felt their cohort size fit in a “Goldilocks band” where the group had been large enough to learn from peers, yet small enough to share freely without feeling rushed. Some clients voiced a desire to have additional women in group, yet others voiced that they would not have felt as comfortable if there had been more women in the session. No clients expressed concern with the group size being too large.
"It was good at four because we could all share a little bit here and there. If it was more than six, then it would take too long because it’s six people trying to say something. And you don’t know how long you would have. And you don’t want to rush certain things." [Client]
Clients emphasized the important role that their peers played in the group experience. Having a space to meet other women who were pregnant and experiencing similar challenges was very meaningful. Additionally, meeting women outside of their home helped address feelings of isolation and loneliness. The experiences shared in group helped clients form friendships and valuable social support networks with peers. Clients and facilitators noted that the creation of social support amongst peers was one of the most significant outcomes of the groups.
“I think a lot of it was just being an intimate group of women...Even though we all come from completely different backgrounds, me being a first-time mom who works full-time and one having four kids and then the other one being a stay-at-home mom but yet we all shared a lot of the same day-to-day struggles." [Client]
“Even though we didn’t know each other you could—they showed care. And that was the biggest thing for me...It’s just nice to have—that you still have people out there that is concerned of your wellbeing...They would just say, ‘Happy you came. Good seeing you.’ That was another thing that kept me coming by, getting the little support from them, of keeping yourself encouraged to keep coming." [Client]
Numerous women noted that their main motivation in attending MB groups was to become “better mothers.” They emphasized the value of pregnancy and parenting experiences shared by peers during group. The conversations during sessions helped normalize thoughts and information for clients. Facilitators noted that the normalization of certain feelings also helped decrease feelings of isolation, assuring mothers that they are not alone. It was noted that the normalization of specific feelings was a byproduct of a group environment and would have been difficult to address in a one-on-one setting.
“And one of the moms, her eyes lit up, and she was like, ‘...I thought I was the only one, and I felt like I was a horrible mother because I wasn’t initially just ecstatic.’ So, then we went into those kinds of conversations, and just having them realize that they’re not the only ones experiencing whatever it is they’re experiencing, I think that was just wonderful for them.” [Facilitator]
Numerous clients voiced that the cohort went by “fast.” Various clients noted feeling sad with the completion of their cohort. The majority of clients voiced that the length of the sessions was ideal, with some mothers voicing that the sessions could have gone on a bit longer. Only one client noted that a cohort could have been shorter than six sessions.
"And I know that a lot of people were upset when the classes came to an end because we had all felt such a bond together—that we didn’t know what to do with our Wednesdays after the class ended." [Client]
Challenges Related to the Appropriateness of the Mothers and Babies Program Group Intervention and Suggestions for Improvement
Facilitators voiced challenges with the implementation of the group modality with clients who were experiencing crises, housing instability (including homelessness, couch surfing, and precarious living situations), and/or trauma. Several facilitators suggested the program incorporate examples that discussed these challenges into the examples and vignettes found in the manuals to help facilitators address them. A couple of facilitators also suggested incorporating more resources for facilitators to give to clients in the program.
“I found a lot of the moms were homeless, and I didn’t realize before this group...I didn’t realize that so many moms were homeless. For some reason, they opened up more in the Mothers and Babies group and told me that they were homeless, a lot of them living in shelters and pregnant, or living in a car, or they were squatters living in homes, and just to be able to address those issues...Well, I think each group facilitator should at least be aware that those stressors are real and that they should have a resource to refer to because it will come up. It came up in every group I had...So, basically, there is a need that’s a great stressor because if a mom has the stress she’s homeless, it’s hard for her to focus on a group if she has the other stressors.” [Facilitator]
A second challenge commonly identified by group facilitators was implementing materials with clients who were either illiterate, had literacy challenges, or learning disabilities. Some facilitators noted the need to accommodate for different reading levels by completing activity sheets out loud instead of having clients write out their responses. Facilitators suggested for future groups to provide more opportunities for clients to complete materials out loud to not single out clients who are uncomfortable with writing.
“So, with the manual we did have one participant in one cohort that did have difficulty with reading and writing...I didn't want that to become something that made her uncomfortable in the group and that she felt other people were aware of that...I just basically tried to read as much as I possibly could from each of the, you know, from the participant's manual, specifically, because of that reason. And I also, of course, the personal projects [QMS] I went over that.” [Facilitator]
One of the main challenges highlighted by facilitators was managing discussions during group. Facilitators aimed to create an environment where clients felt comfortable sharing, listening to their peers, and reviewing the information presented in group. Some facilitators felt this balance was harder to achieve their first time facilitating as they were becoming acquainted with the curriculum. Challenges that impacted finding a healthy equilibrium during group implementation included: side conversations between clients, family crises shared during groups, and clients who required additional time due to disabilities, learning, or English as a Second Language challenges.
"…if someone is wanting to share something that is really personal or really intense or difficult, that if you were delivering this one-on-one, you could really spend some time focusing and really talking about that. But in a group setting, you might be able to spend some time talking about that to acknowledge and validate and to recognize just the importance of what someone shared, but you just can’t spend the whole time talking about that. And so, I think that inherently can feel really difficult as a facilitator to move on from that, and also being respectful to the other group members, and also knowing that we have material to cover.” [Facilitator]