Barriers to Implementing a Group Treatment for Depression with Mothers of Head Start Children

Objective and Purpose: Addressing the mental health needs of low-income mothers with depression has been demonstrated to be an effective strategy for improving academic performance of their children. However, use of evidence-based treatments has not been widely used for this purpose. It is unclear whether this failure is due to characteristics of potential clients, interventions, or the systems of care in which services are delivered. This study explored potential barriers to implementing Interpersonal Psychotherapy, a group treatment for depression, with mothers of Head Start children in south Los Angeles, including possible differences in the level of consensus among various stakeholders regarding perceived barriers.

Methods: Semi-structured interviews were conducted with 27 family service workers, 10 early education teachers, and 10 therapists employed by a community-based agency offering Head Start. Interviews were recorded, transcribed, and coded by 3 independent coders using Dedoose. Interview questions were guided by the Exploration, Preparation, Implementation and Sustainment framework (Aarons, Hurlburt & Horwitz, 2011). Interview transcripts were analyzed using a methodology of “Coding Consensus, Co-occurrence, and Comparison” outlined by Willms et al. (1992). Degree of consensus of perceived barriers was assessed using criteria similar to those outlined by Romney et al. (1986). Issues raised by semistructured interview participants were placed in three categories: low consensus consisted of needs cited in ≤ 33% of all interviews, moderate consensus 34%–66%, and high consensus ≥ 67% of all interviews. Differences in perspectives among three stakeholder groups were assessed by comparing level of consensus across all groups.

Results: The barriers to implementation identified by stakeholders fell into four broad categories. Structural/resource barriers included scheduling difficulties, lack of appropriate space, childcare and transportation needs, therapist concerns, physical safety, and difficulty sustaining the intervention. Language and cultural differences included cultural beliefs about mental health, linguistic accessibility, and therapist-participant ethnic similarity. Participant concerns included skepticism about the efficacy of the intervention, lack of time to attend the group, having a partner who would not support attendance, and discomfort disclosing their depression due to stigma, pride, or fear of DCFS. The format of the intervention included concerns about group dynamics, the pacing of the model, and attrition. There was low to moderate consensus among the three stakeholder groups with regards to potential barriers, demonstrating significant differences. Teachers and FSWs were more likely to identify discomfort disclosing depression due to stigma, pride, or fear of DCFS, FSWs were more likely to identify barriers regarding the format of the intervention, including group dynamics, and therapists were more likely to identify resource barriers like transportation and childcare needs.

 Conclusions and Implications: Although some of the barriers identified are consistent with the inner setting of the organizations and providers, along with characteristics of clients and the intervention, the perceived mismatch between clients and providers emerged as a potential barrier not well described by the EPIS framework. Lack of consensus among different provider stakeholders is another potential barrier that may reflect an organizational culture lacking in shared understandings as to client receptivity, organizational capacity and familiarity with the intervention.