Patient engagement to examine perceptions of perinatal depression screening with the capabilities, opportunities, motivation, and behaviors (COM-B) model

{"Background": "Perinatal depression affects 1 in 8 women in the United States and is one of the most common medical complications of pregnancy. Untreated perinatal depression can lead to adverse outcomes for both mothers and infants, including low birth weight, preterm birth, postpartum depression, suicidal ideation, and maternal suicide, which is a leading cause of maternal mortality in the U.S. Universal depression screening using validated instruments like the Edinburgh Postnatal Depression Scale (EPDS) is recommended by the U.S. Preventative Services Task Force, the American College of Obstetrics and Gynecology, and the Canadian Task Force on Preventive Health Care. However, it remains unclear whether screening leads to better health outcomes, how patients perceive screening, and whether screening results in behavioral changes. Few studies have involved patients with lived experience in the design or delivery of research. This study applied the Capability, Opportunity, Motivation \u2013 Behavior (COM-B) framework to explore facilitators and barriers in depression screening and post-screening stages for perinatal women.", "Methods": "Between June 2019 and August 2019, semi-structured in-depth interviews were conducted with 29 perinatal women recruited from two clinic locations (one rural, one suburban) within a county public health district in Central Illinois. Inclusion criteria were: currently pregnant or within 12 months postpartum, self-reported perinatal depression screening experience, age 18 or older, English-speaking, and residing in the public health district's county. The average age of participants was 29.5 years (SD=6.05). The sample was 51.7% Black (n=15), 37.9% White (n=11), 6.9% Asian (n=2), and 3.4% multiracial (n=1); 55.2% had more than 12 years of formal education; average number of children was 2.21 (SD=1.34). Six trained patient-researchers (women with lived experience of perinatal mental health problems) conducted the interviews alongside a research assistant. Interviews averaged 40 minutes and were conducted face-to-face at participants' preferred locations. All interviews were audio recorded and transcribed verbatim. Data were analyzed using directed content analysis with the COM-B framework in Nvivo12. An intercoder reliability test was conducted after 50% of the data, yielding Cohen's kappa values of 1.0 and 0.8 for two selected transcripts, indicating perfect agreement.", "Key Results": "The analysis identified themes within the COM-B framework divided into two stages: the depression screening stage and the post-screening stage. In the screening stage, the most prominent factor was reflective motivation (201 coded instances), including perceptions that screening questions were too general or broad, that results/feedback were not delivered to patients, and that screening sometimes led or did not lead to resources. Automatic motivation (79 instances) included feeling judged or blamed by providers and fear about consequences of answering truthfully. Physical opportunity (82 instances) included concerns about screening timing (e.g., screening too soon after birth when women were in pain or exhausted), doctor-patient relationship/communication quality, and perceptions that screening was treated as a routine checklist. Social opportunity (31 instances) included lack of privacy and stigma. Psychological capability (23 instances) involved comprehension of the screening and knowledge about depression screening. Physical capability (8 instances) included inability to focus on screening due to medical circumstances. In the post-screening stage, physical opportunity was the most prominent factor (92 instances), including lack of resources for fathers, lack of affordability (finance, insurance, citizenship issues), lack of transportation, unwanted medication/treatment, and providers taking initiative to make linkages. Physical capability (18 instances) included inability to take psychiatric medication during pregnancy/breastfeeding and logistical barriers like finding childcare or taking time off work. Automatic motivation (16 instances) included preferring to ask trusted friends rather than seeking professional help. Psychological capability (9 instances) included being too depressed to reach out, stress/inability to process information, and suicidal ideation. Reflective motivation (7 instances) included lack of mother-centric services and resources not being helpful. Social opportunity (5 instances) included stigma about perinatal depression and experiences of racism at the hospital.", "Clinical Implications": "The findings provide actionable insights for healthcare providers and facilities to improve perinatal depression screening processes. Key recommendations include: (1) providing patients with prior training or information about prenatal depression before screening to improve comprehension and reduce psychological barriers; (2) ensuring that screening results, scores, and resource information are delivered to patients on the screening day as part of mandatory protocols; (3) improving provider-patient communication to prevent patients from feeling disconnected or that screening is merely a checklist item; (4) optimizing screening timing\u2014avoiding screening immediately after birth when women are recovering and instead screening later in pregnancy and allowing recovery time postpartum; (5) addressing systemic barriers such as loss of Medicaid insurance coverage at 60 days postpartum, lack of affordable childcare, and lack of transportation; (6) offering mother-centric services and alternatives to medication-only approaches; and (7) recognizing that patients with prior depression experience may need more proactive provider-initiated linkage to services, as they may be too depressed to reach out on their own. These findings are essential for designing comprehensive patient-centered screening protocols given the increase in state and federal policies urging universal depression screening."}