Our results describe the qualitative data collected from perinatal participants participating in the larger SUMMIT trial (n = 23), providers delivering BA in the trial (n = 28), and a range of stakeholders (n = 18), across Canada and the United States (see Table 1 for participant characteristics).
Table 1
Participant demographic characteristics
Perinatal participants (n = 23)
|
Frequency (%) unless otherwise indicated
|
Age
|
|
Mean and range
|
32.0 (20–40)
|
Location
|
|
Canada
|
14 (60.9)
|
United States
|
9 (39.1)
|
Race/ethnicity
|
|
White
|
12 (52.2)
|
Other
|
9 (39.1)
|
Prefer not to answer
|
2 (8.7)
|
Marital Status
|
|
Married or stable relationship
|
19 (82.6)
|
Single or dating
|
5 (21.7)
|
Prefer not to answer
|
2 (8.7)
|
Employment
|
|
Maternity Leave
|
8 (34.8)
|
Full-time employment
|
6 (26.1)
|
Part-time employment
|
3 (13.0)
|
Unemployed
|
3 (13.0)
|
Other
|
3 (13.0)
|
Highest Level of Education
|
|
High School or College/Trade School
|
5 (21.7)
|
University (undergraduate degree)
|
8 (34.8)
|
University (graduate degree)
|
10 (43.5)
|
Household income
|
|
$0 - $39,999
|
4 (1)
|
$40,000 - $79,999
|
4 (17.4)
|
$80,000 or more
|
13 (56.5)
|
Prefer not to answer
|
2 (8.7)
|
Number of children
|
|
No children, pregnant
|
8 (34.8)
|
1 child
|
3 (13.0)
|
2 children
|
4 (17.4)
|
Providers (n = 28)
|
Frequency (%) unless otherwise indicated
|
Age
|
|
Mean and range
|
44 (41.3 to 46.6)
|
Location
|
|
Canada
|
12 (42.9)
|
United States
|
16 (57.1)
|
Provider Type
|
|
Specialists providers (SP)
|
13 (46.4)
|
Non-specialists providers (NSP)
|
15 (53.6)
|
Gender
|
|
Female
|
26 (92.9)
|
Male
|
2 (7.1)
|
Stakeholders (n = 18)
|
Frequency (%) unless otherwise indicated
|
Location
|
|
Canada
|
9 (50.0)
|
United States
|
9 (50.0)
|
Stakeholder Type
|
|
Community-based (patient advocates, clinicians, community partners)
|
9 (50.0)
|
Hospital-based (psychiatrists, hospital administrators, and clinicians)
|
9 (50.0)
|
Objective 1. Accessing healthcare during COVID-19
When asked whether COVID-19 impacted perinatal participants’ access or decisions to access their regular healthcare (such as going to their family doctor), the majority of perinatal participants (n = 16 of 23, 69.6%) stated that COVID-19 had impacted their access. This finding was affirmed by a majority of providers (n = 16 of 28, 57.1%), who stated that they were aware that their SUMMIT patients experienced barriers to accessing their regular healthcare through their discussions of their patients’ health, wellbeing, and anxieties during the BA sessions. Thus, they had relevant insights about the impacts of COVID-19 on their participants’ access to healthcare.
Of the 16 perinatal participants and 16 providers who reported that COVID-19 impacted their or their SUMMIT patients’ access to healthcare respectively, two types of barriers emerged (see Table 2 for an overview of the barriers): (1) external barriers, which referred to institutional or government regulations that impacted healthcare service delivery (perinatal participants: n = 16 of 16, 100%; providers: n = 11 of 16, 68.8%); and (2) internal barriers, which referred to barriers derived from personal choices, anxieties, or fears over the potential for virus exposure (perinatal participants: n = 12 of 16, 75.0%; providers: n = 9 of 16, 56.3%).
Table 2
Reported barriers to accessing healthcare during COVID-19, n (%)
Key Themes
|
Perinatal participants (n = 23)
|
Provider
Participants (n = 28)
|
Yes, barriers were experienced
|
16 (69.6)
|
16 (57.1)
|
Of the participants who said “yes”, the barriers addressed were “external barriers” (e.g., institutional or governmental regulations)
|
16 (100.0)
|
11 of 16 (68.8)
|
Of the participants who said “yes”, the barriers addressed were “internal barriers” (e.g., personal choices, anxieties, or fears over the potential for virus exposure)
|
12 (75.0)
|
9 of 16 (56.3)
|
No Barriers
|
6 (26.1)
|
8 (28.6)
|
Unsure/No response
|
1 (4.3)
|
4 (14.3)
|
External barriers to accessing healthcare during COVID-19
Of the 16 perinatal participants who stated that COVID-19 impacted their access to healthcare, all 16 (100.0%) reported experiencing external barriers. Similarly, 11 (68.8%) providers reported that external barriers impacted their BA patients’ access to care, with one who expressed that:
“I see messages all the time… [about] what [patients’] visits are going to look like [due to COVID-19 related guidelines]… I think it's been hard for patients to figure out” (SP_04_US).
Perinatal participants also described these new regulations during COVID-19 could be stressful and challenging:
“I can never get [a hold of my family doctor]… So that’s been [difficult]… My first appointment [during COVID] took a few weeks [to get] and it was really anxiety inducing because it's my first pregnancy… All aspects from my home doctor, to midwifery, to my OB; COVID definitely impacted me.” (Perinatal_16_ Canada)
“Breastfeeding clinics were closed so that was hard…I know they were offering things online, but I actually had trouble breastfeeding and didn’t access [help] because [finding an online service was] tough. I needed hands-on help, and I thought: 'no way I could get enough support online'.” (Perinatal_24_ Canada)
Internal barriers in accessing healthcare during COVID-19
Of the 16 perinatal participants who stated that they had experienced barriers to their usual healthcare, three-quarters (12 of 16; 75.0%) explained that internal barriers impacted their decisions to access healthcare. Likewise, of the 16 providers who stated that their participants reported experiencing barriers to their usual healthcare, 9 (56.3%) stated that their SUMMIT patients experienced internal barriers to accessing healthcare. A participant explained that:
“In my first trimester, I was very sick, very dehydrated. I needed fluids, probably pretty bad where I should have gone to the ER but I chose not to because I didn’t want to get exposed during COVID.” (Perinatal_05_US)
Similarly, a provider said that: “I have noticed that [my patients in BA] are generally more nervous about coming in for their appointments…I mean, I don’t disagree with them. I’m nervous to go in, too” (NSP_05_US).
Objective 2. Perceived barriers to resuming in-person sessions during COVID-19
All participant groups reported three key barriers to resuming in-person psychotherapy sessions in the future that were specific to the COVID-19 pandemic: (1) concerns about virus exposure in a hospital setting; (2) concerns about virus exposure while taking public transportation; and (3) concerns about having to wear a mask during psychotherapy sessions (see Table 3).
Table 3
Reported barriers and facilitator to resuming in-person psychotherapy sessions during COVID-19, n (%)
Key Themes
|
Perinatal participants
n = 23
|
Provider
Participants
n = 28
|
Stakeholder
Participants
n = 18
|
Barriers to resuming in-person psychotherapy sessions
|
|
|
|
Concerns about safety/virus exposure at the hospital
|
17 (73.9)
|
20 (71.4)
|
14 (77.8)
|
Concerns about safety/virus exposure while taking public transit
|
6 (26.1)
|
7 (25.0)
|
9 (50.0)
|
Needing to wear a mask during psychotherapy sessions
|
3 (13.0)
|
7 (25.0)
|
9 (50.0)
|
Facilitators to resuming in-person psychotherapy sessions
|
|
|
|
Implementing and communicating robust safety protocols to patients
|
11 (47.8)
|
11 (39.3)
|
13 (72.2)
|
Seeking alternative location to increase safety e.g. offsite, not so deep in the hospital, or in a larger room
|
4 (17.4)
|
9 (32.1)
|
8 (44.4)
|
Concerns about safety and virus exposure while in the hospital
The majority of perinatal participants (n = 17 of 23, 73.9%), providers (n = 20 of 28, 71.4%), and stakeholders (n = 14 of 18, 77.8%) expressed that future participants may be reluctant to attend in-person BA sessions due to concerns about virus exposure in a hospital setting. These participants described that pregnant and postpartum women might be particularly fearful of potentially contracting COVID-19 and transmitting it to their newborn and their families, especially at a hospital:
“If you have a new baby or are pregnant, you won’t want to expose yourself [at the hospital to COVID-19] or expose your new baby. [In the SUMMIT trial women will], all be pregnant or have babies. So, it won't just be us being at risk, we'll probably have to bring our infant with us too.” (Perinatal_02_ US)
“Now that we’re in COVID, there’s going to be a lot of anxiety… Even [if they do not bring their] kids, my general sense is that there’s a fear of a hospital setting. I think that’s going to be a barrier... These waiting rooms are huge, packed, full of people, [which may be a deterrent for future participants].” (NSP_06_Canada)
Some perinatal participants expressed that if they were randomized to receive in-person sessions; they would be concerned about their safety at the hospital and choose to opt-out:
“I would be worried about COVID transmission, especially postpartum… I don’t think [future participants] would be very comfortable….I would not be very comfortable bringing my child into a session… So, if I had to go to the hospital in-person [for BA sessions], I would have chosen not to.” (Perinatal_12_ Canada)
Taking public transportation
Perinatal participants (n = 6 of 23, 26.1%), providers (n = 7 of 28, 25.0%), and stakeholders (n = 9 of 18, 50.0%) described that future patients may be reluctant to attend in-person sessions because of the potential virus exposure while taking public transportation. One perinatal woman explained that:
“I'm very risk-averse…I’m not sure at what point I would feel comfortable taking the subway to come to [Canadian hospital], which is what I did before [the pandemic]... I don't know when I would feel comfortable doing that, to be honest.” (Perinatal_15_ Canada)
Likewise, a U.S. provider stated that: “Transportation [would be a barrier] for clients who don’t have a car… [and] having to risk exposure on the bus or the train to get to the appointment” (SP_07_US). One Canadian stakeholder highlighted that this would be a barrier especially in the winter: "We have to think about our winters [since more people take transit in the winter] and the risk of being on a very crowded transit" (Stakeholder_03_Canada).
Wearing a mask during psychotherapy sessions
Needing to wear masks during BA sessions was identified as a potential barrier by all three groups to varying degrees (perinatal participants n = 3 of 23, 13.0%; providers n = 7 of 28, 25.0%; and stakeholders n = 9 of 18, 50.0%). Overall, participants expressed concern that wearing masks might impact the quality and experience of the BA sessions:
“[An] obstacle [is] that it’s hard to imagine doing therapy in masks. It’s probably going to make it so impersonal. I would not want to do that.” (Perinatal_04_ Canada)
“I can’t really see us doing in person care until we don’t have to wear masks. I don’t know if [perinatal women] will feel comfortable…especially having if they have to bring their baby with them. [Providers] are used wearing [masks] all the time [but perinatal women aren’t].” (NSP_04_US)
"If [the patient] is required to wear a mask in the common areas or even throughout the entire therapy, how does that feel to her? Is she okay with wearing a mask? Does that induce her anxiety?" (Stakeholder_05_Canada)
Objective 3. Perceived facilitators to resuming in-person sessions during COVID-19
Across all participant groups, the most common suggested facilitators to resuming in-person psychotherapy sessions were: (1) implementing and communicating robust safety protocols and (2) having sessions at an offsite location, not so deep within the hospital, or in larger rooms (see Table 3). The stakeholder group also suggested that when the SUMMIT trial intends to resume in-person sessions, recruiters for the trial should emphasize the possible benefits of in-person psychotherapy to potential participants (n = 5, 27.8%) and collect further data from potential participants about their attitudes towards returning to in-person psychotherapy (n = 4, 22.2%) (see Table 3).
Implementing and communicating robust safety protocols
Implementing and effectively communicating robust safety protocols was a facilitator suggested by 11 (47.8%) perinatal participants, 11 (39.3%) providers, and 13 (72.2%) stakeholders. Participants suggested that information could be disseminated to patients to address patients’ anxiety about coming to the hospital:
“Definitely let the patient know [what] the plans [is for] cleanliness, ‘this is what we do, this is our procedure, you don’t have to see anyone, you just come in, you don’t have to touch anything, we’re going to be 6 feet apart, there is a partition [or] Plexiglas.’ Just reassuring them on that end.” (Perinatal_01_US)
“We’d have to be able to provide some kind of assurance of safety in educational materials that were provided to the patients along with their SUMMIT orientation, explaining why in-person was a safe option...” (NSP_01_US)
“A way to decrease the fear and anxiety is to create a little info booklet or package that we can give to people that are consenting to in-person…. [on] the use of masks and all of the stuff…to help reduce any of those issues.” (Stakeholder_07_Canada)
Conducting sessions at offsite locations, not so deep within the hospital, or in larger rooms
Another facilitator suggested by 4 (17.4%) perinatal participants, 9 (32.1%) providers, and 8 (44.4%) stakeholders was to provider alternative locations to where sessions are delivered, such as rooms that are not so deep inside the hospitals or in larger rooms where participants can socially distance or be separated by plexiglass. For instance, participants suggested that holding sessions in a larger room could address barriers to attending in-person psychotherapy, such as concerns about having to wear masks: “Maybe [have sessions] in a larger room where you can distance even more than six feet apart” (Stakeholder_17_Canada).
Participants also suggested that conducting the BA sessions on the first floor of the hospital, or even offsite at a non-clinical location may be a facilitator for resuming in-person psychotherapy sessions:
“Instead of walking through a busy lobby, taking the elevator up, [I’d prefer] a room on the first floor as close to the door as possible [and] one person [goes in] at a time. That would be great... Walk[ing] through a healthcare facility… would be super nerve-wracking…I had to take an elevator [to see my doctor], and I was panicked for three days after.” (Perinatal_23_ Canada)
“I think patients would be more interested in coming to some sort of outpatient facility or not the hospital, like a private office somewhere … Of course, there’s cost implications and cleaning and all these things.” (SP_07_US)