Overcoming training bottlenecks: mixed-methods evaluation of digital training for non-specialists in postnatal depression self-help treatment

ABSTRACT

Objectives

This mixed-methods study evaluated the feasibility, acceptability and preliminary effectiveness of an interactive digital training programme for non-specialist supporters providing a guided self-help intervention for postnatal depression (PND).

Methods

A total of 49 non-specialist trainees participated. Six digital training modules were flexibly delivered over a 5-week period. Training included a chatroom, moderated by a supervised assistant psychologist. Quantitatively, feasibility was assessed via participation and retention levels; acceptability was examined using course evaluation questionnaires; and effectiveness was measured pre-test-post-test quantitatively using a self-report questionnaire and pre-post using scenario questions. Participant focus groups explored feasibility, acceptability and effectiveness.

Results

The training was feasible; 41 completed the course and 42 were assessed at follow-up. Quantitative course evaluation and thematic analysis of focus group feedback demonstrated high training acceptability. RANOVAs indicated training significantly improved knowledge and confidence pre- to post-test. There were demonstrable increases in specific skills at post-test as assessed via clinical scenarios.

Conclusion

This training is a feasible, acceptable and effective way to upskill non-specialists in supporting treatment for PND, however supervised practice is recommended to ensure participants embed knowledge competently into practice. The training offers an effective first step in upskilling non-specialist supporters to support women with PND treatment at scale.

KEYWORDS:

• Postnatal depression
• digital
• training
• scalable
• behavioural activation

Introduction

Postnatal depression (PND) is a public health problem, affecting 10% to 25% of women postnatally (Howard et al., 2014; Noonan et al., 2017). Left untreated, PND can be highly distressing and disabling, with risks of both negatively impacting parenting (O’Hara & McCabe, 2013), and increasing potential cognitive and socioemotional problems across the child’s lifespan (Viveiros & Darling, 2019). Together with other perinatal mental health problems, PND is costly. In England, estimated costs are £8.1 billion/year (Bauer et al., 2014); in the United States they are $14 billion/year (Luca et al., 2020).

Whilst there are effective treatments for PND, access to perinatal-specific support varies within different healthcare systems based on symptom severity, healthcare insurance accessibility or healthcare provider availability. As early identification and intervention are associated with better treatment outcomes and relapse reduction (Hetrick et al., 2008), it is critical that women have prompt access to psychological treatment; akin to international calls for individuals to get ‘the right treatment at the right time’ (Kilbourne et al., 2018). Provider availability is a key barrier. Trained, competent licenced providers are a costly and often scarce resource amongst both high- (Singla et al., 2021) and low-income country healthcare systems (Clarke et al., 2013; Hoeft et al., 2017). A recent emphasis on the need to expand the reach of psychological support to a broader group of potential providers (Singla et al., 2018) led to England’s £301.75 million investment in ‘Start for Life’ family hubs (HM Government, 2022) or community centres. These provide early (0–2) parenting support, social care, health and mental health provision, with family support workers offering targeted support to families with parenting struggles and mental health problems, including depression. This workforce, however, lack training in delivering practical, accessible, effective and perinatally-tailored treatments.

The World Health Organization (WHO) proposed to increase the reach and scale of effective mental health provision through self-help and guided self-help interventions supported by non-specialists (World Health Organization, 2017). However, there is a lack of evidence about what level of training and skills are necessary for non-specialist providers to effectively support guided self-help interventions (Lund et al., 2020). This is critical, as recent large-scale trials of non-specialist led interventions with minimal supporter training and supervision have failed to find significant treatment effects (Caulfield et al., 2019). In contrast, where non-specialists are appropriately upskilled, implementation outcomes are positive (Atif et al., 2019; Lund et al., 2020). Further, with digital training approaches’ recent expansion, especially since COVID, there is a lack of evidence about the feasibility, acceptability and efficacy of these approaches in training the treatment delivery skills in non-specialist mental health supporters (Naslund et al., 2019; Rahman et al., 2019).

Therefore, this project aimed to test the feasibility, acceptability, and preliminary effectiveness of an online training programme for non-specialists to deliver a PND-specific guided self-help programme. This 6-week behavioural activation (BA) programme, the ‘Netmums guided self-help PND programme’ has been shown in trials to effectively reduce PND symptoms relative to a control group (O’Mahen et al., 2013, 2014) and helped form the basis for guided self-help for PND in the 2014 NICE Antenatal and Postnatal Mental Health Guidelines (National Institute for Health and Care Excellence, 2014). The training course, offered via FutureLearn, and accredited by the British Psychological Society has previously had wide uptake; since 2019 over 13,000 individuals joined, with 83% of supporters planning to use it.

In this study, we aimed to answer the following questions. For charitable sector providers:

Is the course feasible to deliver?

Is the course acceptable?

Does the course improve the knowledge, skills and competence in guided self-help for PND?

Methods

Participants

Three charitable sector organisations across the Southwest of England were invited to participate: Action for Children Exeter (Children’s Centre providing parenting support) (Action for Children, n.d.), FearLess (providing support services to people experiencing domestic and sexual violence) (FearLess, 2022) and 0–19 Torbay (a partnership of services supporting the health, development and well-being of children, young people and families (0 to 19 Torbay 0, n.d.) (see Table 1). Staff were eligible if they were currently working in one of these organisations and had professional contact with women who may be experiencing PND symptoms. Participants included Children’s Centre workers (providing parenting support), family support workers (supporting families at home) and health navigators (support workers providing practical and emotional support) working with the Splitz Promoting Choice project (an initiative collaborating organisations and community groups to reduce health inequalities and support marginalised women).

Table 1. Total number of participants from collaborating organisations.

Organisation	n	%
Action for Children	32	65.3
Splitz	7	14.3
Torbay 0–19	10	20.4

n = number of participants.

Procedure

This study was ethically approved by the University of Exeter’s Ethics Committee (eCLESPsy 514,190). Prior to recruitment, service leads from the collaborating organisations were briefed on the study, then liaised directly with potentially eligible staff and forwarded contact details to the research team. Individuals were approached via email and text message with study information and an invitation letter. Interested persons were sent an informed consent form to complete via Qualtrics (Qualtrics, 2005) (a secure and GDPR compliant data survey system) which included the option of participating in a focus group.

Consented individuals completed a baseline questionnaire assessing their skills, knowledge and confidence when working with women with PND symptoms. Once completed, the trainees were emailed registration information for the FutureLearn guided self-help PND course, entitled ‘Addressing Postnatal Depression as a Healthcare Professional’. The course consisted of 6 teaching modules: (1) recognising PND symptoms and helping women to focus on a key problem to address, (2) identifying and adapting patterns of avoidance (3) communication strategies, and (4) balancing motherhood expectations and behaviours, (5) helping mothers to stay well Trainees completed the training course flexibly over 3–5-weeks. The course included reading, videos and exercises/role play material to help participants think through how to support a woman working through the PND guided self-help treatment. A key component of the training course was an online chatroom whereby trainees discussed their learning, moderated by an assistant psychologist (SD) and supervised by a perinatal clinical psychologist (HOM).

Trainees then completed both a follow-up questionnaire 5 weeks after course registration assessing their skills, knowledge and confidence when working with women with PND symptoms and course evaluation questionnaire.

Consenting trainees were invited to participate in 90-minute focus groups that included questions about the feasibility, acceptability and effectiveness of the training programme. Ten participants participated in one of three focus groups conducted on Microsoft Teams (Microsoft Teams, 2023) by SD, assisted by CJ or AD. These were video recorded and audio transcribed verbatim.

Measures

Feasibility

Feasibility of the course was assessed against pre-determined criteria, defined in two ways: (1) the proportion of individuals approached who agreed to participate in the course (85%), and (2) the proportion of individuals (who agreed to participate) that completed the course (75%). Feasibility of undertaking the course and providing PND support was also explored in focus groups.

Acceptability

Acceptability of the course was assessed quantitatively by questionnaires developed for this evaluation (see Supplementary Figures S1 and S2 for full questionnaires) and qualitatively by focus groups. Following (Sekhon et al., 2017) recommendations, we assessed the participants’ intention, affective attitudes about the training and their experiences of learning. Acceptability was quantitatively defined as at least 70% of participants rating at least 4 out of 5 points (1 = strongly disagree, 5 = strongly agree) on scales assessing the training programme, content and structure, and at least a 7 out of possible 10 points (1 = poor, 10 = excellent) on a scale assessing the overall experience of the course. Participants’ reports of acceptability and potential areas for improvement were explored in focus groups (see Table 2).

Table 2. Focus group topic guide

Focus group guide
Tell us about your experiences working with parents with PND prior to this course. In family centres specifically In other settings prior to that
What training/skills did you have/use when you worked with parents with PND prior to this course? Parenting specific clinical skills (e.g. 0–2 work, VIG, etc) Parental mental health-specific skills
Did it meet your expectations? What were you expecting before you started the course – both on a PND course generally and then this course in particular? If no, what were you expecting?
Has the course provided you with anything to help you support working with parents with PND? (e.g. skills, workbook, knowledge, assessment, etc). Confidence- has your confidence changed? Competence Immediate toolkit to help women
If you’ve used the client workbook with parents with PND can you described how you have introduced it/used it? How did it go? How did the women respond? (eager, apprehensive, did they need persuading?) Any difficult situations you had to overcome? One to one setting Group setting to initially introduce workbook
How did you find taking part in the online training course? How was it for you? Initial registration onto course? Working through the modules? – how did you approach fitting this course in with your work commitments?
What was the moderated chat room/discussions like for you?
Are there any components of the course that you found really engaging? And were there any aspects that were less engaging?
Can you describe how completing the course has affected your professional work? Any skills enhanced/embedded? Job satisfaction – making a difference?
How would you improve this training? Content Technical issues
Would you recommend the course to colleagues?

Effectiveness

Effectiveness of the course was measured in three ways. First, baseline and post-training 16-item questionnaires assessed participant knowledge and skills on a 5-point Likert scale (1 = poor, 5 = excellent) and confidence on a 6-point Likert (1 = very confident, 6 = no confidence). Second, participants read a clinical scenario about PND and then used free-text to respond as to which model(s) and tools they might use to address the problem. Two different, but conceptually similar, scenarios were used at baseline and at post-training to avoid testing effects. They were matched on length, type of clinical problems and participant characteristics. Responses were coded and compared pre- and post-training. Finally, the effectiveness of the course was explored qualitatively in focus groups.

Analysis

Quantitative

Responses were analysed using SPSS 28 (IBM Corp, 2017). Descriptive statistics and frequencies were calculated for knowledge/skills and confidence measures at baseline and post-training. The post-training scores were then compared to the baseline measures using repeated-measures Analysis of Variance (RANOVA).

Qualitative

Content analysis of free-text scenario questions was conducted by SD and CJ, who immersed themselves in the data. Using a deductive approach, themes were decided upon as the unit of assessment. An analysis matrix was then devised and checked by HOM. Data was then coded according to categories, and SD and CJ compared codes to ensure reliability. Codes were compared with hypotheses about expected change i.e. improved knowledge about perinatally adapted BA (Elo & Kyngäs, 2008).

Thematic analysis (Braun & Clarke, 2006) was employed to analyse focus group data. SD became immersed in the transcripts, reading them multiple times and generating initial codes. These codes were iteratively discussed with CJ and a coding system was finalised with HOM. Themes were then created by SD in discussion with HOM and CJ.

Results

Feasibility

As depicted in the CONSORT diagram (Figure 1), the high rates of individuals who were approached and subsequently agreed to participate (92%), completed the course (82%), and assessed at follow-up (84%) surpassed feasibility criteria. The moderated chatroom was also deemed feasible, with 39/48 (81.25%) trainees utilising it and an average of 19 comments per trainee.

Figure 1. CONSORT flow diagram showing participant flow through the study.

A flow diagram showing the number of participants at each stage of the study, with arrows denoting the direction of participant flow.

Read the detailed description of this figure

long description: A flow diagram showing the number of participants who were at each stage of the study, with four stages including enrollment, allocation, follow-up and analysis. The diagram has vertical arrows between each stage of the study to show the number of participants included in all aspects of the study and horizontal arrows going off to the right of the diagram to show the number of participants who withdrew and optional aspects of the study.

Focus groups: feasibility

The following content pertains to themes derived from the focus groups including the current landscape of perinatal mental health support within the third sector and how that informed the need for and feasibility of the programme (see Table 3).

Table 3. ‘Context’ themes from focus groups highlighting the feasibility of undertaking the course in third sector organisations – with quotes to demonstrate.

Current mental health support offered
Link between providers (incl. signposting)	We’re trying to be a bit of a link between the midwives and the health visitors. P1 We work closely with the perinatal mental health team, with mum’s consent, we liaise with them and support mum to attend appointments and things. P7 Sometimes we can be one of the first people because health visitors nowadays have much less hands-on to do with families. P7
Dynamic of support − 1-2-1 vs group	There are some that we worked with one-to-one, it’s less now that we used to but sometimes after a child’s story, it becomes evident that that family needs a one-to-one because then they wouldn’t be able to access a group. P1 I hold a caseload, I work one-to-one with families out in the community, in their homes. P7
Mother-baby attachment work/groups (incl. baby massage)	At the moment we do video interaction guidance, we do Here’s Looking at you Baby … which is a lovely, very informal, attachment based group. P1 We also do baby massage, that’s really good to watch those parent/child interactions and pick up on a parent’s mood. P10
Universal support (incl. building relationships and safe spaces)	I think sometimes it’s just holding the space for them to tell their story. P8 Building that relationship with them is so rewarding and important. P2 It’s quite low-level stuff. We’re just looking out for parents, see how their attachment bonding is with their babies and how they’re presenting each week. Just building up those relationships and having conversations. P9
PND in antenatal sessions	In our antenatal sessions … we do a whole section on postnatal depression, how it’s okay to come forward and sort of explaining about how many women actually do struggle with depression after having a baby. P10
Inundated referrals	We are inundated with referrals at the moment. I think there is a bit more pressure now to do a course and then close them but that isn’t at the heart of what we’re offering. P1
Health visiting team stretched	The health visiting team in Devon are very stretched. It’s only one. Each health visitor would have one of those cases. It is a very limited number but it is intensive health visiting which most pregnant women are not getting hardly anything at the moment. P1 Helping Us Grow Supported. It’s in Devon. It’s an intervention where the children’s centre are linking with the health visiting team. For a very, very, very limited number of parents who’ve got identifiable, who meet the criteria first-time parent, usually, a young parent … mental health is one of them. The midwifery team are encouraged to refer and then their health visiting team will allocate a health visitor and the children’s centre will allocate a practitioner. They will then have that set theoretically, that same-named health visitor and children’s centre practitioner for two and a half years. P1
Falling through the gaps – when clients are not unwell enough for psychiatry/psychology but too complex for primary care (IAPT)	They’re just not getting the help that they need because they are considered a bit too complex for Talkworks and they are not reaching the threshold for mental health assessment and NHS-funded counselling. P1 I can identify signs of postnatal depression … They haven’t been referred to perinatal mental health services only because they’re not ‘too bad’ … Only if you are really complex and vulnerable you will be able to access appropriate support. P5
Fragmented/sporadic support	These sorts of groups and that the children’s centres etc. that’s all lacking now. It’s very fragmented and sporadic the things that are set up. P6
Lack of training support for PND
Lack of PND-specific training	I think this is the proper in-depth one. We’ve had brief stuff before, just for what to look out for. That’s about it. P9
Stigma of mental health
PND	You wouldn’t necessarily have mums come to you and go ‘Hi. I’ve been diagnosed with postnatal depression, can you keep an eye on my little one for me?’ because obviously the shame about it, the embarrassment. P6 You almost feel rude to presume that someone might have symptoms of postnatal depression because unfairly there is such a stigma. P3 There’s a pressure to be a perfect mum and admitting that you’ve got low mood and speaking to someone about that would be really hard for some women. P3

Context: Current mental health support offered

Participants emphasised that mental health and parenting support for perinatal women was fragmented and sporadic, describing their services as inundated with referrals. These services primarily provide universal and non-targeted support. Pre-training, participants reported they referred women to other services, such as secondary perinatal mental health services, midwifery and health visitors. Furthermore, women often fell through gaps in these services, as their symptoms were either not severe enough for secondary care or too complex for primary care.

Participants reported a significant in-service need for programmes that increased their knowledge and skills in supporting PND. Many reported this programme was their first in-depth training in parental mental health support. A minority had completed Health Education England funded courses in Children’s and Young People’s interventions, including CBT and attachment-based interventions for parenting.

Participants liked how the BA focus of the course complemented their organisations’ strengths-based approach.

Feasibility

All participants completed the course within the 5-week period, though many completed in 2–3 weeks. The course was reported as easy to understand, user-friendly and flexible; the flexibility enabled participants to fit it into their schedules easily.

Participants also found the moderated chat function helpful to their learning, with some describing how they made comments, while others simply enjoyed reading their peers’ comments.

Impact of stigma of mental health on course implementation

Most participants reflected on the shame associated with mental health. Pre-course they were fearful to talk about PND with colleagues and clients, reporting that this stigma may hinder the feasibility of implementing the intervention, expressing a desire for further training on talking about PND with parents.

Acceptability

Participant course evaluation

All aspects of the course met the acceptability criteria. ‘Training programme’ and ‘content and structure’ sub-measures were rated at least 4 out of a possible 5 points by at least 70% of participants and all ‘overall experience’ sub-measures were rated at least 7 out of a possible 10 points by at least 70% of participants (see Supplementary Table S1).

Areas recommended for additional training

In the course evaluation questionnaire, participants suggested topics for further training: time to consolidate learning, knowledge of recommended general support and self-help systems, dual diagnosis and PND, the impact of unhealthy relationships on PND, and conducting risk assessments.

Focus groups: acceptability

Predominant themes regarding acceptability of the course arose from focus groups describing participants’ experience of learning (see Table 4).

Table 4. ‘Experience of learning’ themes from focus groups highlighting the acceptability of the training – with quotes to demonstrate.

Expectations
Meeting expectations	I think it met my expectations. It was really clear. I think the examples were really good. P1 I had enough of theories and models … I’ve studied a lot. What I was looking is to find practical things how to apply and how to deal with. Some tools let’s say practical tools to help me in my work and this is what you provided. I will say, you responded to my level of expectations very well. P5
More accessible than expected	I don’t know what to expect, but I think when it was much more accessible and easy to manage than I may thought it was going to be
High expectations as interested in PND	I had high expectations because I have an interest in PND and it did meet those expectations. P4
Level of complexity
Content too in-depth	It sounded like, from the comments that quite a lot of the other people were quite clinical-based and from what they were writing, it sounded like they had quite a lot experience with postnatal depression already. Yes, it was quite in-depth. I wasn’t sure if it was a little too in-depth for the line of work where I am, at work and how much of it I would actually use within the work setting. That was just my personal opinion, but it’s useful to have that and to be able to refer back to it. I think week one, I found a little bit heavy going, but the other two weeks were fine. P9
Confusion over use of material – they are not psychotherapists	Wondering about that myself because we haven’t actually had a discussion about whether we could actually use those client workbooks … because we’re not trained psychotherapists. P6 From the position of our role as health navigator, I’m supposed to signposting, to help, let’s say for a short period of time to mental health workers. I don’t know, even if I feel confident to use it I don’t know if legally use these booklets. P5
Areas less engaged
Some of the videos	Some of the videos were really good and some I wasn’t as engaged with I guess. P2
Areas didn’t learn anything from having done similar course prior	There was areas that I didn’t learn anything from. However I always think the day I stop wanting to refresh is the day I need to give up my job. P10

Expectations

The course surpassed participants’ high expectations and was more accessible than anticipated.

Level of complexity

For most, the complexity level was appropriate and acceptable. A small minority with less exposure to previous mental health training and experience found the content occasionally too in-depth (week one was a particularly steep learning curve).

Confidence change

Participants felt more confident using the CBT model and talking about PND with staff and clients.

Areas less engaged

Two participants, qualified in the CBT-based CYP-IAPT Postgraduate Diploma training (Children and Young People) with subsequent supervision training, were already familiar with the core CBT models in the course. However, they explained ‘the day I stop wanting to refresh is the day I need to give up my job’.

Effectiveness

Knowledge and skills

Knowledge scores increased significantly from baseline (M = 39.63, SD = 11.59) to post-training (M = 61.22, SD = 7.30), F(1,40) = 189.61, p = >.001, ηp2 = .83. The effect size was large, with a Cohen’s d of 1.58. The baseline (α = .94) and post-training (α = .96) scales were highly reliable.

Confidence

Confidence scores also increased significantly from baseline (M = 54.78, SD = 14.74) to post-training (M = 32.80, SD = 8.10), where lower scores indicated higher confidence level, F(1,40) = 112.71, p = >.001, ηp2 = .74. The effect size was large, with a Cohen’s d of 1.31.The baseline (α = .97) and post-training (α = .96) scales were highly reliable.

Scenario question assessing knowledge and skills in the questionnaire

Content analysis of scenario questions assessing knowledge and skills used to address clinical PND situations (see Tables 5–7) indicated an increase in CBT skills from baseline to post-training. Further, the way participants would work with parenting and the parent–infant relationship notably changed; using support that directly intervenes with the parent–infant relationship pre-training, to understanding maternal triggers and reactions post-training.

Table 5. Model used to address clinical situation scenario question at baseline and post-training.

Baseline (n = 49)			Post (n = 42)
	N	%		n	%
Models/strategies	8	16.3	Models/strategies	39	92.6
Genogram	2		TRAP/TRAC model	23
Internal working model	1		The Cycle of Depression	8
Drama triangle	1		Talking therapy	1
Cycle of abuse	1		CBT (hot cross bun/thoughts, feelings, behavioural model)	3
CBT (Hot cross bun/ Thoughts, feelings, behavioural model)	5		PND in the community (the course)	4
Family therapy model	1
Motivational Interviewing	1
Client-practitioner work	21	42.9	Client-practitioner work	12	33.3
VIG/observe child play	3		Mood diary	5
1:1 meeting	1		Problem statement	1
Full assessment	2		Plan conversation with partner	2
Home visit	2		Building relationship/talk through problems/person-centred approach	2
Building relationships/ talk through problems/ person centred approach	15		Goal setting	1
Goal making	1		Discussing the positives	1
Moving forward action	1
Strengths-based approach	1
ROMs	17	34.7
MIRI	4
MORS	10
GAD7	2
PHQ9	1
EPDS	1
Antenatal efficacy scale	1
SDQ	1
Child/family-oriented strategies	16	32.7
Child’s story	4
Family star/outcome star	7
Baby massage	3
Here’s Looking at you, Baby	4
Thrive training	1
Mother/baby session	5
Referrals/signposting	6	12.2
Contact HV/PMHT/GP	5
Peer Support	1
Don’t know/don’t use models/don’t work clinically	5	10.2	Don’t know/don’t use models/don’t work clinically	0
No answer	6	12.2	No answer	4

Questions allowed for open responses, i.e. participants could respond with more than one answer.

Percentages refer to the percentage of participants who mentioned these topics out of the total number of respondents.

n = Number of people who responded and below are areas they mentioned.

CBT = Cognitive Behavioural Therapy; VIG =Video Interactive Guidance; ROM = Routine Outcome Measurements; MIRI = Maternal Infant Responsiveness Instrument; MORS = Mothers Object Relations Scales; GAD7 = General Anxiety Disorder-7; PHQ9 = Patient Health Questionnaire-9; EPDS = Edinburgh Postnatal Depression Scale; SDQ = Strengths and Difficulties Questionnaire; TRAP/TRAC = Trigger, Response, Avoidance Pattern/Trigger, Response, Alternate Coping response; HV = Health Visitor; PMHT = Perinatal Mental Health Team; GP = General Practitioner.

Table 6. Therapeutic task used to address clinical situation scenario question at baseline and post-training.

Baseline (n = 49)			Post (n = 42)
	n	%		n	%
CBT/BA-focused tasks	4	8.2	CBT/BA-focused tasks	34	80.6
Mood/thoughts diary	4		Problem statement	8
CBT/Cognitive techniques	1		Depression cycle	5
			Mood diary	16
			TRAP/TRAC model	4
			Circle of relationships	1
			Workbook	3
			Planning conversations with partner	4
Identify problems	17	34.7	Identify problems	9	25
Share feelings/worries	9		Assessment	2
Assess with ROMs	3		Listen/talk to mother	6
Child’s story	1		Family history	1
Meet at home	1		Traumatic delivery	1
Reflect on birth/pregnancy/family relations	2		Identify/name low mood	1
Client focused tasks	15	30.6	Client focused tasks	5	13.9
Task/goal setting	6		Speak to partner about feelings	3
Attend support group	2		Me time/self-care activities	2
Breathing/relaxation exercises/self-care	3		Attend support group/network	1
Look at support network	4
Baby interventions	16	32.6	Baby interventions	1	2.8
Baby massage	10		Baby massage	1
Here’s Looking at You Baby	2
VIG	2
Baby groups	2
Signposting/referral	8	16.3	Signposting/referral	1	2.8
PMHT referral	3		PTSD referral	1
Talkworks	1
Contact GP/HV	4
Don’t know/Not clinical	2	4.1	Don’t know/Not clinical	0	0
No answer	4	8.2	No answer	4	11.1

Questions allowed for open responses, i.e. participants could respond with more than one answer.

Percentages refer to the percentage of participants who mentioned these topics out of the total number of respondents.

n = Number of people who responded and below are areas they mentioned.

CBT = Cognitive Behavioural Therapy; BA = Behavioural Activation; TRAP/TRAC = Trigger, Response, Avoidance Pattern/Trigger, Response, Alternate Coping response; ROM = Routine Outcome Measurements; VIG = Video Interactive Guidance; GP = General Practitioner; HV = Health Visitor; PTSD = Post Traumatic Stress Disorder.

Table 7. Reason provided for therapeutic task used to address clinical situation scenario question at baseline and post-training.

Baseline (n = 49)			Post (n = 42)
	n	%		n	%
Help improve mother-baby relationship/attachment	12	24.5	Help improve mother-baby relationship/attachment	26	61.9
Validate feelings/feel important/heard/encourage self-awareness	6	12.2	Self-awareness/knowledge	6	14.3
			Triggers/pattern of low mood/unhelpful behaviour	11
Assess/see progress	7	14.3	Depression knowledge	3
Reduce isolation	1	2	Recognise positives	2
Get support/referrals/safety	1	2	Identify challenges	4
			Identify goals	2
Don’t know	2	4.1	Identify coping strategies	4
No reason provided	10	20.4	Self-beliefs/Beliefs of good mother	2
			Help improve relationship	5	13.9
No answer	6	12.2	With partner	2
			With baby	1
			Support network	3
			Don’t know	0	0
			No reason provided	14	38.9
			No answer	4	11.1

Questions allowed for open responses, i.e. participants could respond with more than one answer.

Percentages refer to the percentage of participants who mentioned these topics out of the total number of respondents.

n = Number of people who responded and below are areas they mentioned.

Focus groups: effectiveness/impact of the training programme on learning and skills

Themes from focus groups surrounding the effectiveness of the training course on trainees’ learning (see Table 8) confirmed findings from the quantitative data and qualitative scenario questions.

Table 8. ‘Learning’ themes from focus groups highlighting the effectiveness of the course on participants’ learning – with quotes to demonstrate.

Specific strategies/tools
Mood diary	The mood diaries and the way of reframing things can be really useful for many of the mums. P2
Planning conversations	The fact that it’s really broken down into the absolute tiny detail of how to go about it. Thinking about it in advance, what would be barriers to communication? P6
Ideal mum	Really liked the bit about the ‘ideal mum’ … Asking those questions about why do you think that makes the ideal mum? Isn’t something I would’ve ever necessarily thought to, I’ve tried to avoid that subject completely if I thought they wanted to bring it up but it makes sense to bring it up and challenge it. P3
TRAP/TRAC model/Inside out and Outside In thinking	The outside-in thinking was quite good to think of examples and yes, the TRAPs and TRACs. They’re the things that stand out. P1 It’s also it’s that targeted support so there’s those TRACs and TRAPs to follow and you’ve got that target of, ‘Let’s look at this’. P4 I loved the whole TRAC thing. There were points in there that really got me thinking. P10
Non-specific strategies
Helping clients to overcome barriers	It’s about how you get engagement, how you activate a client to keep going, to persevere and to actually do stuff when there are barriers. P1
Repeat back what client says	I think when I was doing the training I found it really interesting how there was obviously that technique to repeat back essentially exactly what they’d said, but to make them listen to it themselves. You’d say, ‘so you don’t tend to do the things you used to do anymore’. Then they would explain more and it helps a woman to accept that they do have low mood without you persuading them to, just by their own words. P3
Clarity around mental health definitions/symptoms
Labelling PND symptoms	It is actually a symptom and it can be this and something can be done about it and these are the tools you can use. P6 We could just identify these are symptoms and work with the workbook with them just to improve those symptoms. P3

Specific strategies/tools

Specific tools learned from the course was a prominent theme, based on CBT and BA models, including the mood diary, Inside-Out and Outside-In, the TRAP/TRAC model, planning conversations and what it means to be an ‘ideal mum’.

Non-specific strategies

Non-specific strategies including helping clients to overcome barriers and repeating back what a client says were discussed.

Clarity around mental health definitions/symptoms

Participants now reported clarity around mental health symptoms and stated they were able to label PND symptoms, and that once identified, symptoms could then be targeted for improvement.

Impact on practice

Themes arose on the impact on participants’ practice (see Table 9), which was the final assessment of the course effectiveness.

Table 9. ‘Impact on practice’ themes from focus groups highlighting the effectiveness of the course on participants’ work – with quotes to demonstrate.

Confidence change
Confidence with CBT model	I’ve studied the CBT model … it’s just really useful tools that have come out of it. I think I definitely feel more confident thinking about it and describing it to others. P2
Confidence to talk about PND	There’s changing point, isn’t there, to where it becomes a problem. I feel a lot more confident now identifying that and trying to put some support in place for women. P3
Use of tools
Incorporated in conversations with staff and clients	It’s slipping into our everyday language, isn’t it? The more familiar we’ve got with the FutureLearn booklet, that just in general conversations perhaps about their thoughts and how that’s impacting on their feelings and behaviours and being able to just have those sitting alongside somebody in a group or just having those conversations. P1 I think definitely the training has been very helpful in even if we are not delivering it as it would be planned to be delivered, but by having taken those opportunities to have those conversations that are based on that learning. P1
Not used tools yet	I haven’t put it into practice with any of my clients but since doing that training, I’ve really thought about certain things and how I’m going to approach them and how I’m going to talk to them and it’s really helpful. P3
Embedding it in the service	We’d love to be able to actually do it and embed that. I think that we have got the flexibility to enable that. P1
Incorporating tools with their resources	In terms of the actual exercises within, it’d be really interesting to try to incorporate a few of those into our usual well-being handbooks. P3
Reduces anxiety	I think the booklet gives us a lot of support doesn’t it? As practitioners that it takes away a lot of that anxiety because you’ve got that structure to work from. P1
Knock on effect	I started reflecting on it kind of with my own practice as well. I know it’s not meant to be for us, but I think it was quite interesting to do that as well. P2
Approach to client-work
One-to-one or group setting	You’ve got some tools in there that are good for those one-to-one conversations or like those general conversations, if they’re just bringing something up in a group. P7 I would actually do it one-to-one. I don’t think that would actually work within a group necessarily. P10 Once you build that relationship and they start disclosing how they’re really feeling and that would be the case of then getting them in one-to-one. P9
Frequency of meeting with clients to do the workbook	With this kind of work, it’d be really lovely if it was the same person, wouldn’t it? Who’ve got to know them and got that therapeutic alliance with them … it doesn’t always work like that … You build up the relationship and then somebody new has to start it. I think that might be something we have to think about a little bit. P1 You would probably have to do this fairly regularly in order for it to actually start because I think one of the things that is most useful about it is that you can literally monitor progression. P6
Identification of women to work with	I’m almost thinking it might be a mother that’s missed the perinatal support, but that we identify as still struggling perhaps post one of our groups. P1 Only for the clients that are not already engaging with perinatal mental health services, because otherwise, we’ll duplicate services I guess. P5
Applicability of content	Something that could be tweaked for paternal postnatal depression as well or even, maternal postnatal depression if it’s the non-birthing parent as well – or folks in a same-sex relationship? P8
Not scary for clients	It didn’t feel scary and if you were that person following it, you wouldn’t feel pressure. P3
Barriers
Lack of engagement	The resistance to maybe some of the meetings or not putting in place some of the strategies. P2 Maybe they do recognise, but they don’t want to engage because they worry about what that means for them, their family, their baby. P8
Practicalities	I think for her to have time to do the homework would be really tricky. P4
Overcoming barriers	That’s where our persistence and creativeness would come in … I guess that’s where the practitioner skill comes in. P1

Use of tools

Many participants reported incorporating learning in conversations with staff and clients, with a cultural shift within organisations of how PND was discussed. There was scope to integrate the course tools within existing resources.

Approach to client-work

Participants believed the workbook would be more effective with clients one-to-one, however, group settings provide better opportunities to initially broach PND. Participants wanted to meet clients regularly, with practitioner consistency to build therapeutic relationships.

Barriers

Barriers highlighted included lack of client engagement and time for homework (self-help material), which practitioners’ skill, flexibility, and creativity could overcome.

Discussion

PND is prevalent in the community but access to support is limited, highlighting health inequalities that remain unaddressed. This mixed-methods study demonstrated that the training was: feasible to deliver to non-specialist practitioners in the charitable sector, highly acceptable, and effective at increasing participants’ knowledge, skills and confidence in managing PND symptoms. These effects, produced in a relatively short period of time, were consistent with a nascent literature examining the effectiveness of digital training programmes in upskilling non-specialist providers of mental health interventions, in high, middle and low-income countries (Clarke et al., 2013; Hoeft et al., 2017; Singla et al., 2021). As the first formal evaluation for this online course, the findings support the role of the voluntary sector in providing timely, accessible support for women experiencing mild to moderate PND symptoms.

Feasibility

Our findings confirmed the course was feasible to deliver to charitable sector providers. Nearly all invited individuals consented to participate, exceeding the recruitment target by 10. Course completion rates were very high (82%), exceeding the feasibility threshold, and comparable to other mental health training evaluation retention levels (e.g. 75% retention (Rahman et al., 2019); 94.3% (Armstrong et al., 2011). The moderated chatroom was also feasible, with high engagement.

The flexible training structure was a key factor to participants feasibly completing the course alongside their busy workloads.

Acceptability

The course content and structure were highly acceptable to participants. Quantitative measures (training programme, content and structure and overall experience) exceeded our acceptability thresholds. Overwhelmingly positive focus group feedback was provided by 10 participants.

The course’s range of didactic and interactive activities were rated positively. Content was delivered didactically in reading, videos and audio clips and interactively in a moderated online chat function, allowing for active learning and reflection. This approach builds on literature demonstrating that didactic strategies alone, although effective for disseminating information and increasing provider knowledge (Fixsen et al., 2005), produce limited sustained behaviour change.

Effectiveness

The course effectively improved participants’ knowledge, skills and competence in PND guided self-help. Knowledge/skills scores increased pre-post course and these quantitative findings were strongly corroborated with the skills-based scenario questions and focus group themes. Participants’ knowledge of PND improved from being vague and abstract to focused and CBT- and BA-based.

At baseline, participants responded to a PND clinical scenario with parenting and baby-focused activities to address mood difficulties. Post-training, most participants reported they would use CBT and BA strategies, particularly the TRAP/TRAC model and ‘Inside-Out Outside-In thinking’. Future training may benefit from helping practitioners trained in parenting approaches to apply their skills to behavioural models for PND, for example, additional procedural practice through role plays, but most importantly, supervised feedback on actual case content. This is consistent with research demonstrating that treatment comprising PND-tailored CBT and additional strategies that target parenting are associated with both improved PND and child outcomes (Stein et al., 2018).

The course effectively improved practitioner confidence in supporting women with PND symptoms, as suggested by pre-post quantitative improvements in confidence scores and focus group feedback. Pre-course, many trainees lacked confidence to initiate conversations with women about PND, due to awareness of parent’s self-stigma and the trainee’s lack of PND-specific training and awareness of available support. Confidence increased significantly post-training such that participants could now discuss PND with colleagues and service users, though not to fully deliver the intervention. These findings suggest this level of training effectively imparted foundational awareness skills of PND support, but further supervision was needed to embed skills in practice (Beidas & Kendall, 2010; Henggeler et al., 2002; Herschell et al., 2010; Schoenwald et al., 2009).

Consistent with many non-specialist mental health training evaluations (Armstrong et al., 2011; Rahman et al., 2019), this study utilised a pre-post-test design, lacking a control group. Confounding factors therefore cannot be ruled out; social desirability may have produced biased responses, although the quantitative responses were online and anonymous, and the scenario-based questions assessed specific skills based on free-recall and the ability to appropriately apply the correct skills. This study did not utilise case-based competence assessments (e.g. videos of participants using the workbook with clients), as the pragmatic and short-term nature of this study lacked the resources to assess competency skills both at immediate post-training or following implementation of the intervention, thus limiting our ability to determine participants’ true increase in competency over time. Indirectly however, the clinical scenarios provided a feasible mechanism to assess whether the content of their knowledge changed.

Conclusion

The online course is a feasible, acceptable and effective way to upskill charitable sector healthcare professionals working with women with mild to moderate PND symptoms. For non-specialist providers, this training serves to effectively impart important foundational PND support skills, though supervised practice would be fundamental for delivery of the intervention. This study offers a promising first step forward in extending accessible evidence-based training to non-specialists who have direct access to women in the community experiencing mild to moderate PND symptoms. This training would enable third-sector organisations staff to reach these women confidently and effectively in non-stigmatising ways and could expand access to support.

Acknowledgments

Thank you to South West Academic Health Science Network for our funding, Steph Comley for creating the FutureLearn course, Latika Ahuja and Samantha Eden for helping create the course content, and our participants.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/02646838.2023.2280714

Additional information

Funding

This work was supported by the South West Academic Health Science Network (company number 08495463).