Interpretation of the findings
In general, the finding that parents face a large number and variety of barriers to participating in a prevention programme for their children is consistent with previous studies of parents with depression (Festen et al., 2014; Pihkala & Johansson, 2008; Solantaus et al., 2009).
Regarding overburden, many parents indicated that they were discouraged from participating in GuG-Auf-Online due to the stresses of the covid-19 pandemic. This was initially surprising, since during the period of the survey children’s leisure activities were generally available in Germany, schools were closed less often, psychotherapy sessions no longer had to take place online, and parents worked less from home than at the height of the covid-19 pandemic. However, the results of a representative cross-sectional study by Calvano, Engelke, Holl-Etten, Renneberg, and Winter (2023) from December 2021 also show that in Germany, parents had poorer mental health during the period when data collection for the online survey began than during the first months of the covid-19 pandemic. These results support the finding from the online survey that parents were still feeling stressed by the covid-19 pandemic at the time of data collection.
The finding regarding the role of shame has been demonstrated elsewhere in regards to depression broadly (summarized by Kim, Thibodeau, & Jorgensen, 2011) as well as specifically in the context of barriers to seeking prevention services for parents with depression (Festen et al., 2014; Pihkala & Johansson, 2008). Shame thus seems to be a relevant issue for parents with depression seeking preventive support for their children and should therefore be carefully considered during recruitment and intervention efforts.
Regarding avoidance (not wanting to be reminded of the depression), previous literature has shown that the desire to avoid confrontation with one’s depression concerned parents whose depression was in remission (Festen et al., 2014; Solantaus et al., 2009). Our study extends these findings by showing that avoidance can also characterise parents who currently feel depressed. Furthermore, avoidance was the one barrier that correlated most highly with current symptoms of depression, suggesting that particularly parents who currently feel depressed may avoid participating in a programme like GuG-Auf-Online.
In addition to the three main themes described above, one additional barrier seems to be that parents did not see the connection between their own mental health and that of their children. This is consistent with one previous study (Festen et al., 2014). In our sample, the lack of understanding about the connection between parental depression and the health of the children seems to be experienced as a barrier. Since a high proportion of participating parents in our sample felt depressed, it is conceivable that this finding (lack of understanding) could be related to the self-focused that often characterises people with depression. However, it is questionable as to what extent this finding can be generalised to all parents with depression because another interview study found that the majority of parents (with different diagnoses, but also depression) notice that their children are affected by parental illness (Stallard, Norman, Huline-Dickens, Salter, & Cribb, 2004).
Overall, many individual barriers seem to interact and contribute to parents not participating in GuG-Auf-Online.
Implications for the implementation of GuG-Auf-Online
There are some implications that can be derived from the results of the online survey and experiences with recruitment for GuG-Auf-Online and the online survey.
To improve advertising for GuG-Auf-Online and enhance the number of parents who participate in the programme, information available online about GuG-Auf-Online could be expanded. For example, it could be helpful to point out directly that many parents are reluctant to participate in such a prevention programme because of feelings of shame. It could help to signal to parents that we take these feelings seriously and that at the same time there is no reason to let these feelings hinder them. Furthermore, there are plans to discuss with experts the extent to which potential participants can and should be given tools for dealing with shame in advance. Regarding the overburden of parents, it would be helpful to point out in advance that whilst regular participation is a requirement of the programme, group leaders understand if participants need to skip individual sessions. Even though some parents have criticised the amount of time required to participate in GuG-Auf-Online, the authors are of the opinion that the current scope of the programme should be retained. Shortening the programme further may result in important content being removed and there may be too little time for exchange within one's own family and between families. An alternative might be to explicitly state that participation in the programme may reduce the levels of stress within the family in the long-term.
Implications for other prevention programmes for parents
In general, when recruiting for similar prevention programmes, it might be helpful to focus on social networks and groups for parents. It might also be helpful to ask concerned parents to help with recruitment (e.g., forward flyers to other parents). The results of the survey indicate that the online setting is not necessarily a barrier to participation in prevention programmes. Especially for programmes where recruitment is difficult, it would be conceivable to increase the number of participants through an online setting. Regarding the barriers of potential participating parents, it is advisable to address feelings of shame (e.g., in the information material) and that there is no reason to let these feelings hinder parents. In this context, it would be helpful to draw potential participants' attention to the qualitative evaluation of GuG-Auf (Claus et al., 2019): There, former participants reported that speaking publicly about their own depression was not as bad as they had feared. Furthermore, it might be helpful to offer opportunities for parents to talk with the study team about their personal barriers and to check whether their concerns really apply to the prevention programme.
Strengths and limitations
The online survey conducted has some strengths and weaknesses. One clear strength is that the findings have important clinical implications not just for the implementation of Gug-Auf-Online specifically but also for family- and group-based prevention more generally. Not only did the findings replicate previous studies but the impact of novel barriers was also addressed. For example, to our knowledge it is the first study to show that the online setting is not an important barrier to participate in an prevention programme for parents with depression.
A second strength is the inclusion of a relatively large and young, not highly educated sample of participants personally affected by depression. This group (young and not highly educated people) is often underrepresented in studies of prevention programs. Focusing on their views/attitudes could be helpful in attracting more families from this underrepresented group to prevention programmes. Statistical comparisons of the sample to those who ultimately participated in the GuG-Auf-Online prevention programme are limited due to the relatively small sample (September 2022: N = 21 parents). However, there was a trend for survey participants to be younger with a somewhat lower level of education (see Figs. 1 and 2 as well as the description of the sample) and a higher proportion exhibited depressive symptoms (64% in the online survey, assessed via a self-administered questionnaire with cut-off, versus 35% in GuG-Auf-Online, assessed via a diagnostic interview). An additional methodological strength was the inclusion not only of fixed-choice a-priori items but also open-ended questions in order to uncover additional barriers that were had not foreseen. In the open responses, only a few new aspects were mentioned, but predominantly those that had already been considered in the items with a closed response format. This indicates that the state of research is approaching theoretical saturation. What is still missing to reach theoretical saturation (that means a further data collection is no longer necessary as all relevant aspects have been collected), however, is the questioning of parents who fundamentally refuse to participate in prevention programmes that are tied into a research context. In the data available (in the open responses), there is no indication that such parents were included in our sample.
A category system with anchor examples was developed for the evaluation of the open response formats. The inter-coder reliability was very good and represents another strength of the study conducted.
Some weaknesses of the study are nonetheless worth mentioning. Firstly, it is unclear whether the negative wording of the items provoked negative response behaviour (in the sense of high item responses). This was not controlled for in the study. Secondly, it was difficult to understand the true meaning of some open-ended responses because they were very short. Future studies using interview or focus-group methodology may be better placed to extend our qualitative findings. Furthermore, unfortunately the cultural diversity of the sample is unclear. Although 28% of participants indicated that members of their cultural group would not participate in GuG-Auf-Online, it is not clear from the data which cultural groups these answers refer to. Finally, in hindsight, when constructing the items it would have been possible to use the Perceived Barriers to Psychological Treatment Scale (PBPT; Mohr et al., 2010) as a guide. Although the scale measures barriers to treatment, there are overlaps in content with barriers to participation in prevention programmes.