According to national estimates, postpartum depression (PPD) affects up to 15% of new mothers in the United States, with long-term adverse effects for both mother and child if untreated (
Ko et al., 2017
). Women of color experience disproportionately higher rates of PPD (Scholle et al., 2003
); prevalence rates as high as 54% have been documented among Latina women (Lucero et al., 2012
). Latinas are also the least likely demographic group to seek mental health support for PPD due to a number of structural and sociocultural barriers (Abrams et al., 2009
). Meanwhile, the novel coronavirus disease-2019 (COVID-19) pandemic has shed light on longstanding racial health disparities in the United States. Latinos have been three times as likely to become infected with, and nearly twice as likely to die from, the virus as non-Hispanic White people (Oppel et al., 2020
). Racial health disparities in women's mental health will be compounded by the long-term effects of the COVID-19 pandemic, and this calls attention to the urgent need for mental health care that is not only culturally relevant, but also remotely accessible.- Oppel R.A.
- Gebeloff R.
- Lai K.K.R.
- Wright W.
- Smith M.
The fullest look yet at the racial inequity of coronavirus.
https://www.nytimes.com/interactive/2020/07/05/us/coronavirus-latinos-african-americans-cdc-data.html
Date: 2020
Date accessed: July 20, 2020
One of the most prominent risk factors for PPD is stressful life events (
Stone et al., 2015
; Qobadi et al., 2016
). In a sample of 900 perinatal women considered to be at low risk for developing PPD, Davenport et al., 2020
documented a more than 25% increase in women experiencing PPD symptoms since the start of the pandemic. A recent national survey found that 27% of U.S. residents are experiencing symptoms of depression—more than three times what is usually observed in the U.S. population (Ognyanova et al., 2020
). People of color in particular are reporting significantly higher rates of stress over fear of contracting the virus, meeting their basic life needs, and accessing health care (- Ognyanova K.
- Perlis R.H.
- Baum M.
- Lazer D.
- Druckman J.
- Santillana M.
- Della Volpe J.
The State of The Nation: A 50-state Covid-19 Survey Report# 4.
https://covidstates.net/COVID19%20CONSORTIUM%20REPORT%20JUNE%202020.pdf
Date: 2020
Date accessed: July 16, 2020
American Psychological Association (APA), 2020
). Large-scale disasters are commonly accompanied by increases in mental and behavioral disorders; health professionals are thus working to bolster mental health systems in preparation for long-term COVID-19 implications (American Psychological Association (APA)
Stress in the time of COVID-19 [Press release].
Stress in the time of COVID-19 [Press release].
https://www.apa.org/news/press/releases/stress/2020/stress-in-america-covid.pdf
Date: 2020
Date accessed: August 20, 2020
Galea et al., 2020
). Supporting the delivery of care through virtual platforms has become a priority for researchers, practitioners, and policymakers. Although health systems are responding to this need, exemplified by Medicare's recent expanded coverage of virtual visits with psychologists and social workers (Galea et al., 2020
), such changes can leave behind populations most impacted by health disparities because informatics interventions are not often designed for and with marginalized populations (Veinot et al., 2018
). In this commentary, we propose an intersectional and participatory research and policy agenda that leverages user-centered design and cultural tailoring to better serve the mental health needs of Latina mothers.Barriers to PPD Care for Latina Women
Cognitive-behavioral therapy and interpersonal psychotherapy have been found to be effective PPD interventions for Latina women (
Grote et al., 2015
; Muñoz et al., 2007
). Although effective, these evidence-based psychosocial interventions require consistent participation and engagement, with benefits emerging after 12 to 16 weekly individual or group sessions (Dennis and Hodnett, 2007
). For new Latina mothers, a host of sociocultural and structural barriers can make such PPD treatments inaccessible or ineffective during a critical postpartum period (Blackmore and Chaudron, 2014
; Callister et al., 2011
; Kozhimannil et al., 2011
).Extensive research has documented that Latinos have more difficulties obtaining quality mental health services compared with other ethnic groups (
López et al., 2012
; Shattell et al., 2008
). Sociocultural barriers such as stigma, language, and cultural beliefs regarding motherhood leave Latina women less likely to access postpartum mental health care and engage in follow-up treatment (Abrams et al., 2009
; Callister et al., 2011
; Kozhimannil et al., 2011
). Sociocultural barriers combined with limited access to health insurance, lack of affordable childcare, transportation challenges, and rigid employment circumstances make PPD treatments such as cognitive-behavioral therapy and interpersonal psychotherapy less accessible for Latina women (Blackmore and Chaudron, 2014
; Callister et al., 2011
). For those patients who do seek help, language barriers might make finding a provider a daunting task—only 5.5% of all psychologists in the United States are qualified to provide services in Spanish (Hamp et al., 2016
).The Promises and Challenges of Telemedicine
Telemedicine has the potential to address the sociocultural and structural barriers to PPD treatment affecting Latina women. First, by enabling Latina women to seek treatment from the privacy and comfort of their own homes, virtual care can address the challenges of perceived stigma associated with mental health treatment (
Baker-Ericzén et al., 2012
). Second, bilingual and bicultural mental health professionals could treat Latina women living in a different geographic region that otherwise would not offer access to these providers (Mashima, 2012
). This would help to alleviate the widespread shortage of bicultural and bilingual mental health professionals who understand how cultural values affect help-seeking behavior (Sánchez et al., 2015
). Third, the convenience of accessing mental health services remotely is particularly advantageous for Latina mothers, who might face time constraints, transportation barriers, and inadequate childcare. Finally, from the perspective of mental health providers, there is evidence that telemedicine improves quality of care and reduces health care costs (Kvedar et al., 2014
).Recent research on virtual psychotherapy and behavioral health mobile applications suggests that patients are open to trying novel treatment options, albeit with reasonable concerns about quality of care, privacy, and sustainability (
Renn et al., 2019
). Several of these applications have been self-directed, often in the form of online modules that must be completed by patients on strict timelines with little to no assistance from a licensed provider. As a result, these applications have seen high attrition and low participation rates (Haga et al., 2019
). Many of the clinical trials have consisted of predominately non-Hispanic groups (mostly White women) and were deemed ineffective (Barrera et al., 2015
; Le et al., 2011
). In studies investigating patient feedback, women reported not seeing the relevance of each module's content to their own lives, and ultimately desiring more personalized treatment plans and increased contact with a mental healthcare provider (Baker-Ericzén et al., 2012
; Pugh et al., 2015
; O’Mahen et al., 2015
).- O’Mahen H.
- Grieve H.
- Jones J.
- Mcginley J.
- Woodford J.
- Wilkinson E.
Women's experiences of factors affecting treatment engagement and adherence in internet delivered Behavioural Activation for Postnatal Depression.
Internet Interventions - The Application of Information Technology in Mental and Behavioural. 2015; 2: 84-90
As virtual mental health platforms continue to enter the market it will become increasingly important to incorporate evidence-based practices and consumer preferences in their design (
Carlo et al., 2019
). Veinot et al., 2018
remind us, however, that if informatics interventions do not meaningfully engage underserved populations in the design process, the interventions themselves are at risk of reinforcing existing health inequalities.A Participatory and Intersectional Research Agenda
Racial discrimination and the magnification of preexisting health disparities increase the risk for traumatic stress among communities of color (
Lund, 2020
). Public health scholars and practitioners are calling for an intersectional research agenda that examines the impact of the COVID-19 pandemic on marginalized populations, often focusing on the mental health impact on women as they balance caretaking and paid work responsibilities (Bowleg, 2020
; Kantamneni, 2020
; Laurencin and McClinton, 2020
; Tai et al., 2020
). To address the mental health needs of Latina mothers during and beyond COVID-19, we propose a participatory research agenda that leverages human-centered design principles. Human-centered design centers the experience of the end-user when developing and testing products and tools; qualitative methods and hands-on design activities help to capture firsthand experiences to best match innovations with user needs (Harte et al., 2017
). The Discover, Design, Build and Test model is useful in this context, as it can guide the iterative redesign of psychosocial interventions by engaging stakeholders (e.g., patients, clinicians, developers) to ensure feasibility and usability (Lyon et al., 2019
).- Lyon A.R.
- Munson S.A.
- Renn B.N.
- Atkins D.C.
- Pullmann M.D.
- Friedman E.
- Areán P.A.
Use of human-centered design to improve implementation of evidence-based psychotherapies in low-resource communities: Protocol for studies applying a framework to assess usability.
JMIR Research Protocols. 2019; 8: e14990
Designing virtual PPD interventions and tools with Latina mothers would help to make postpartum care more effective and accessible in a number of ways. First, human-centered design principles can guide the development of culturally tailored self-guided mental health care tools that often act as a pathway toward clinical PPD interventions. Self-help content can unpack cultural stigma surrounding motherhood and misconceptions about mental health by highlighting the lived experiences of Latina mothers. Visual and narrative representation of women of color in the branding of these tools can encourage Latina women to address their mental health in a more familiar and welcoming setting. Second, usability testing with Latina mothers can improve the effectiveness of video teleconferencing and text-based coaching options to make clinical experiences less intimidating. Culturally tailored onboarding, for example, can describe how a virtual session with a provider offers privacy, flexibility, and personalized care. Direct participation by Latina mothers in the research and design process can thus expand the reach of virtual PPD interventions and improve retention by targeting culturally specific barriers.
Translating Participatory Research into Policy
At the policy level, structural barriers must be addressed to expand virtual mental health care options for patients in general, but for high-risk groups such as postpartum Latina women more critically. Telemedicine regulations vary by state and have been changing rapidly during the COVID-19 pandemic, with no clear indication of how virtual mental health care will fare. Although insurance providers are expanding coverage to support virtual therapy options, many services are still out of reach. To date, nearly 50 million Americans have filed for first-time unemployment benefits over the course of 16 weeks (
Kelly, 2020
); many of these workers are left uninsured and scrambling to maintain coverage (- Kelly J.
Nearly 50 million Americans have filed for unemployment—Here’s what’s really happening. Forbes.
https://www.forbes.com/sites/jackkelly/2020/07/09/nearly-50-million-americans-have-filed-for-unemployment-heres-whats-really-happening/#2f4b251127d3
Date: 2020
Date accessed: August 8, 2020
Collins, 2020
). Subscription-based online therapy platforms can provide clinical care for those uninsured or underinsured, but with monthly fees at $200 to $300, cost will remain a critical barrier. Public and private insurance coverage should be expanded to include subscriptions to commercial behavioral health platforms that offer a range of clinical and non-clinical support. The Centers for Medicare & Medicaid Services, for example, have expanded access to telehealth visits and virtual check-ins on a temporary basis under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act (H.R.6074). Although temporary, the telemedicine policy changes under H.R.6074 must continue beyond the COVID-19 pandemic to meet the preexisting and forthcoming mental health needs of high-risk populations. The user-centered design of virtual mental health interventions can help to identify which care models and payment structures are most effective for particular populations, thus translating participatory research into actionable policy.- Collins S.R.
Did you lose your health insurance because of the coronavirus pandemic? Coverage options for laid-off workers and others. The Commonwealth Fund.
https://www.commonwealthfund.org/blog/2020/coverage-options-laid-off-workers
Date: 2020
Date accessed: August 24, 2020
Our policy recommendations mirror those currently promoted in response to the COVID-19 pandemic and pre-existing racial women's health disparities. A United Nations policy brief on mental health during COVID-19 calls for investment in mental health interventions that can be delivered remotely, with an increased focus on digital self-help and digital mental health services and parenting programs (
United Nations, 2020
). Strengthening mental health services during the pandemic is seen as a critical step toward preventing a rise in ill mental health, and an opportunity to improve the cost-effectiveness of mental health interventions. Similarly, the Black Maternal Health Momnibus Act of 2020 addresses racial disparities in maternal mortality and calls for investment in digital tools for telehealth to improve health outcomes in underserved areas. The Tech to Save Moms Act specifically proposes a grant program to promote digital tools designed to improve maternal health outcomes for minoritized women (United Nations
Policy brief: COVID-19 and the need for action on mental health.
Policy brief: COVID-19 and the need for action on mental health.
www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf
Date: 2020
Date accessed: May 25, 2020
Black Maternal Health Caucus. (2020).
).Black Maternal Health Caucus
United States House of Representatives.
United States House of Representatives.
https://blackmaternalhealthcaucus-underwood.house.gov/Momnibus
Date: 2020
Date accessed: November 16, 2020
Structurally, these proposals have the potential to be more easily adopted alongside the
Helping MOMS Act of 2019, 2019
which increases Medicaid coverage from the currently required 60 days to up to 12 months postpartum. At the state level, the urgency to treat PPD is also gaining traction; several states have passed or proposed policies that address maternal mental health care. In Illinois, House Bill 2438 requires insurers to cover maternal mental health care during the pregnancy and postpartum periods. In Texas, House Bill 253 requires the state's Health and Human Services Commission to undertake efforts to increase awareness and reduce stigma surrounding PPD.Helping MOMS Act of 2019
H.R.4996, 116th Cong., 1st Sess United States Congress.
H.R.4996, 116th Cong., 1st Sess United States Congress.
2019
https://www.congress.gov/bill/116th-congress/house-bill/4996
Date accessed: August 20, 2020
As the COVID-19 pandemic compounds a preexisting need for accessible and effective maternal mental health care, such policies should be implemented nationally while prioritizing remote treatment options. Because we are only beginning to witness how communities of color will be impacted by the far-reaching effects of the COVID-19 pandemic, it is important to produce research and scholarship that speaks to the specific needs of populations most impacted by health disparities. Disproportionally high rates of PPD and growing access to information and communication technologies among Latina women signal a promising starting point to examine and leverage the potential of virtual mental health care. An intersectional and participatory research agenda that expands access to virtual postpartum care for Latina women can contribute to existing policy work in the areas of mental health, telemedicine, racial health disparities, and women's health.
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Biography
Carmen Gonzalez, PhD, is an assistant professor in the Department of Communication at the University of Washington. Her community-based research on health communication is focused on digital and health equity, addressing the information and health needs of marginalized communities.
Biography
Magaly Ramirez, PhD, MS, MS, is an Assistant Professor in the Department of Health Services at the University of Washington School of Public Health. Dr. Ramirez’s research focuses on designing and testing technology-enabled interventions to reduce disparities impacting Latino populations.
Biography
Autumn Diaz, BA, is a graduate student in the Department of Communication at the University of Washington. Her research utilizes socioecological frameworks to study health communication, difference, and equity.
Biography
Miriana Duran, MD, MPH, is a Research Coordinator in the Department of Health Services at the University of Washington. She is an International Medical Graduate from Mexico, her research focuses on qualitative methods and human-centered design to address health disparities in the Latino population.
Biography
Patricia Areán, PhD is a professor in the University of Washington’s Department of Psychiatry and Behavioral Sciences. Her research focuses on the treatment of mental disorders in minority populations, and the use of technology for improving access to psychosocial treatments.
Article info
Publication history
Published online: November 26, 2020
Accepted:
October 15,
2020
Received in revised form:
October 15,
2020
Received:
August 3,
2020
Footnotes
The authors would like to acknowledge the UW ALACRITY Center (NIMH grant number P50 MH115837) for support of this work. There are no conflicts of interest to disclose.
Identification
Copyright
Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health.
