A Community-Based Podcast Approach to Promoting Population Health Awareness of Perinatal Mood and Anxiety Disorder Education, Resources, and Support

Utah's postpartum depression rate is 14.8%, higher than the national average (12.5%). Individuals with perinatal mood and anxiety disorders (PMADs) often remain untreated, primarily due to barriers to accessing maternal mental health resources. This project aimed to develop and implement an accessible, supportive, educational podcast highlighting local resources for individuals experiencing PMADs. Despite existing maternal mental health resources available throughout the Salt Lake Region of Utah, the perinatal population experiences multiple barriers to accessing PMAD information essential to supporting positive health outcomes. Anonymous pre- and post-intervention surveys were disseminated to perinatal individuals through a social media platform and QR-coded flyers strategically placed in community areas frequented by perinatal individuals. Chi-squared tests applied to survey data identified changes in respondents' knowledge acquisition pre- and post-intervention. Podcast analytics were used to gauge listenership and assess the efficacy of the two dissemination strategies. The project lead developed eight episodes of a PMAD podcast to educate perinatal individuals about PMADs and how to access local PMAD resources, specifically. The dissemination of the podcast utilized two strategies: social media posts and QR-code flyers. Listeners downloaded the podcast episodes 1,800 times, with 61.8% of the downloads within Utah. Utah perinatal mothers reported benefits, including zero cost, stigma reduction, increased knowledge, and accessibility to existing local PMAD resources. Of those who responded to the post-intervention survey, 39% used one of the resources discussed in a podcast episode (n = 14). Data showed a statistically significant (p < .001) increase in awareness of perinatal therapists and Postpartum Support International within the population. This project demonstrates the feasibility and effectiveness of using a podcast to provide accessible, supportive, and educational maternal health resources to perinatal individuals. Future practice may benefit from utilizing social media platforms to effectively reach and engage perinatal individuals with PMADs while incorporating podcasts to provide validation and education.

1 A Community-Based Podcast Approach to Promoting Population Health Awareness of Perinatal Mood and Anxiety Disorder Education, Resources, and Support Joni S. Lybbert, Jamie Hales, Caroline Stephens College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III May 7, 2023 2 Abstract Background: Utah's postpartum depression rate is 14.8%, higher than the national average (12.5%). Individuals with perinatal mood and anxiety disorders (PMADs) often remain untreated, primarily due to barriers to accessing maternal mental health resources. This project aimed to develop and implement an accessible, supportive, educational podcast highlighting local resources for individuals experiencing PMADs. Local Problem: Despite existing maternal mental health resources available throughout the Salt Lake Region of Utah, the perinatal population experiences multiple barriers to accessing PMAD information essential to supporting positive health outcomes. Methods: Anonymous pre- and post-intervention surveys were disseminated to perinatal individuals through a social media platform and QR-coded flyers strategically placed in community areas frequented by perinatal individuals. Chi-squared tests applied to survey data identified changes in respondents' knowledge acquisition pre- and post-intervention. Podcast analytics were used to gauge listenership and assess the efficacy of the two dissemination strategies. Intervention: The project lead developed eight episodes of a PMAD podcast to educate perinatal individuals about PMADs and how to access local PMAD resources, specifically. The dissemination of the podcast utilized two strategies: social media posts and QR-code flyers. Results: Listeners downloaded the podcast episodes 1,800 times, with 61.8% of the downloads within Utah. Utah perinatal mothers reported benefits, including zero cost, stigma reduction, increased knowledge, and accessibility to existing local PMAD resources. Of those who responded to the post-intervention survey, 39% used one of the resources discussed in a podcast 3 episode (n = 14). Data showed a statistically significant (p < .001) increase in awareness of perinatal therapists and Postpartum Support International within the population. Conclusions: This project demonstrates the feasibility and effectiveness of using a podcast to provide accessible, supportive, and educational maternal health resources to perinatal individuals. Future practice may benefit from utilizing social media platforms to effectively reach and engage perinatal individuals with PMADs while incorporating podcasts to provide validation and education. Keywords: perinatal mood and anxiety disorders, postpartum depression, podcasts, social media, barriers to care 4 A Community-Based Podcast Approach to Promoting Population Health Awareness of Perinatal Mood and Anxiety Disorder Education, Resources, and Support Problem Description Perinatal mood and anxiety disorders (PMADs) are among the most common pregnancy and postpartum complications (US Preventative Task Force, 2019). As of 2020, the rate of postpartum depression in Utah is 14.8%, higher than the national average of 12.5% (Utah's Public Health Data Resource, 2020; Centers for Disease Control and Prevention [CDC], 2022a). These statistics do not account for other perinatal mood and anxiety disorders such as postpartum anxiety, postpartum obsessive-compulsive disorder, postpartum posttraumatic stress disorder, or postpartum psychosis. Furthermore, the Utah average underrepresents minorities: in 2019, 16% of Hispanic and 21% of Black, indigenous, and people of color (BIPOC) individuals in Utah reported having postpartum depression (Office of Health Disparities, 2021). Multiple risks are associated with untreated PMADs for the mother and the child. Most notably, untreated PMADs can lead to suicide, infanticide, and child maltreatment (Choi & Sikkema, 2016; Kendig et al., 2017). Other risks include loss of relationships, loss of financial resources, increase in substance use, poor compliance with medical recommendations, and exacerbation of medical diseases (Kendig et al., 2017). Available Knowledge Risk factors for developing a PMAD include: prenatal depression or anxiety, marital or partner dissatisfaction, current or past abuse, high life stress, a lack of social support, unplanned pregnancy, and pregnancy or birth complication (American College of Obstetricians and Gynecologists [ACOG], 2018; Hutchens & Kearney, 2020). Individuals who have more risk factors and are more likely to score higher on the Edinburgh Postnatal Depression Scale (EPDS) 5 are less likely to be able to access care (Coffman et al., 2020). Regardless of risk factors, ACOG recommends universal screening of all pregnant and postpartum individuals (2018). Though screening alone has some benefits, best practice is referral to a mental health care provider or starting medication treatment (ACOG, 2018). Unfortunately, individuals with PMADs often remain untreated because they are not always connected to the local maternal mental health resources available (Bina, 2019; Grissette et al., 2018). Even when they are referred to appropriate resources, they experience multiple barriers to entry, such as financial barriers, time constraints, social stigma, and difficulty navigating the healthcare system (Bina, 2019; Canty et al., 2019; Grissette et al., 2018; Hansotte et al., 2017). Individuals who are BIPOC or have low incomes experience the aforementioned barriers to a greater degree and are less likely to seek help (Dagher et al., 2021; Hansotte et al., 2017; Office of Health Disparities, 2021). Many individuals within the perinatal population want to take their health into their own hands, but they require direction (Baggett et al., 2020; Hadfield & Wittkowski, 2017). One study found that mothers self-referred to a clinical trial involving a digital intervention at more than 3.5 times the rate of professional referrals (Baggett et al., 2020). Another systematic review and thematic analysis found that individuals preferred agency in their treatment decisions and felt increased distress when they perceived healthcare providers were making decisions for them (Hadfield & Wittkowski, 2017). Podcasts are one way the perinatal population can guide their own healthcare decisions by learning evidence-based information and how to access PMAD resources. Though there is currently no research on podcast use in the perinatal population, overall podcast use in the United States continues to rise, with 50% and 43% of people ages 12-34 and 6 ages 35-54 listening to podcasts monthly, respectively (Edison Research, 2022). Moreover, research supports the use of podcasts in other populations, such as physicians, English as a Foreign Language learners, and undergraduate students (Andersen & Dau, 2021; Kelly et al., 2022; Moryl, 2013; Şendağa et al., 2018). Systematic reviews show podcasts offer portability, flexibility, efficiency, and the ability to educate and entertain simultaneously (Andersen & Dau, 2021; Kelly et al., 2022). Additionally, there is evidence that learners change their behavior because of the education received through podcasts (Kelly et al., 2022; Şendağa et al., 2018). An integrative review found that effective modalities for improving maternal mental health have common throughlines: participants learn new coping mechanisms, their thought patterns and behaviors change, and new social supports are formed (Lavender et al., 2015). These can be achieved through a virtual platform, such as a podcast for perinatal mothers. Rationale The overarching goal of this project was to reach the target population—perinatal individuals who live in Utah—to help them more effectively access maternal mental health resources. As such, this perinatal population health project was guided by the ReachEffectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework, a popular framework used in the implementation sciences (Glasgow et al., 2019). RE-AIM was initially developed to address the problem of translating evidence into practice, especially regarding public health. The framework has five components: reach, effectiveness, adoption, implementation, and maintenance (Glasgow et al., 2019). This project utilizes the first three REAIM components (reach, effectiveness, and adoption) to describe the development, implementation, and evaluation of a population health PMAD podcast. 7 Based on experience with the perinatal population and familiarity with the research, the project lead selected the podcast format as the ideal approach for reaching and effectively meeting the population health needs of perinatal individuals in Utah, specifically minority and low income groups. Given that many perinatal individuals struggle to prioritize their needs (Barkin & Wisner, 2013), creating a podcast with local resources considers mothers' current prioritization. Podcasts can address some of the typical barriers perinatal individuals face while disseminating evidence-based information. They are entirely free, easily accessible, require no referral, can be listened to privately, and allow for multitasking (Perks & Turner, 2020). Thus, podcasts are an underutilized medium to reach and effectively engage perinatal mothers and offer them an easily adoptable mode for receiving evidence-based medical information (Lee et al., 2022). The RE-AIM model, therefore, provides an ideal iterative process evaluation framework for guiding optimal strategies to enhance the reach, effectiveness, and adoption of a podcast for perinatal individuals in Utah. Specific Aims This project aimed to develop and implement a free educational podcast series to improve perinatal individuals' knowledge about access to and engagement with PMAD interventions and resources. Methods Context and Target Population This quality improvement project occurred in the context of the Utah social media community and places where perinatal mothers commonly frequent in the Salt Lake and St. George region of Utah. Utah is unique because it has one of the highest fertility rates in the United States. The CDC has reported Utah's fertility rate in the country's top five every year 8 between 2014 and 2020 (2022b). Given this context, the target population for this project was Utah individuals in the perinatal period or within the time frame from conception through the first year after giving birth (Postpartum Support International, 2021). Population Health Podcast Intervention Phases The population health podcast intervention had four phases: (a) assessment of Utah perinatal mothers' awareness, use, and barriers to use of local PMAD resources and their preferences for a local resource PMADs podcast; (b) development of the PMADs podcast as well as a virtual and physical dissemination strategy for the podcast; (c) implementation of the virtual and physical dissemination strategy; and (d) evaluation of podcast listenership and population usability, feasibility, and satisfaction. First Phase Collaborating with content experts and guided by the literature, the project lead developed an anonymous web-based survey to assess Utah perinatal mothers' awareness, use, and barriers to use—including social determinants of health—of local PMAD resources (See Measures below). The survey also assessed the current scope of podcast use and preferences for a local resource PMADs podcast. The project lead distributed the survey via the social media community, including Instagram and Facebook, and posted flyers with QR codes linking to the survey at ten community health clinics that work with underserved populations, as well as the Individuals, Infants, and Children (WIC) offices in the Salt Lake Region. Second Phase During the project's second phase, the project lead created a list of maternal mental health resources in the area and contacted key providers and resources for an interview. Thirty-minute intake meetings were held before the podcast recording to set expectations for the podcast and 9 become familiar with the resource. Interviewees included multiple licensed clinical social workers, a marriage and family therapist, a physician assistant, an obstetrician, and a psychiatrist. Each podcast episode was then recorded and included: psychoeducation or a specific evidencedbased skill to improve mood, education on local PMAD resources, and validation of the PMAD experience. Data collected from the anonymous survey was reviewed and integrated into the post-production of the podcast episodes. Concurrently, a physical and virtual dissemination strategy was developed and implemented. The project leader created a virtual dissemination strategy using Instagram, Facebook groups, local social media influencers, and local providers. The project lead created flyers with a QR code linking to the podcast and a list of dissemination locations, specifically high-traffic areas where mothers spend time in Utah. There were two different QR codes: one given to state community health centers and Federally Qualified Health Centers (FQHC) and another for public places throughout the state, such as libraries, coffee shops, and indoor playgrounds. Additionally, the project leader discussed with community partners (i.e., WIC, local Boys & Girls Clubs, People Helping People, and Utah Community Action) optimal virtual settings and physical locations to disseminate the podcast to reach individuals who have low incomes or identify as BIPOC. Third Phase The project lead released podcast episodes weekly and implemented the dissemination plan over eight weeks. Implementation included: posting regularly on various social media platforms; teaching virtually about the purpose of a local resource PMADs podcast and the barriers it addresses; and reaching out to podcast guests, local providers, and community partners to post about the podcast on their personal social media pages. Furthermore, the project lead and 10 research assistants disseminated hundreds of QR code flyers to several FQHCs and high-traffic locations where Utah mothers frequent. Finally, organizations with a social media presence, such as Postpartum Support International Utah Chapter, Utah's Planned Parenthood, and Maternal Mental Health of Utah, shared the podcast on their virtual platforms. Final Phase The project's final phase was the evaluation of the podcast listenership and population usability, feasibility, and satisfaction. The evaluation was achieved by administering an anonymous post-implementation survey to podcast listeners via the Show Notes and other virtual platforms eight weeks after the first episode's release. The survey inquired about suggested future topics for and needed changes to the podcast. Additionally, the podcast hosting site provided a summary of podcast engagement statistics. Overview of Study of the Intervention Surveys were administered before and after the implementation of the PMADs podcast to assess for reach and effectiveness, namely improvement in awareness, use, and barriers to use. The podcast hosting website and Instagram page monitored implementation. The postimplementation survey collected information about reach, effectiveness, adoption, usability, feasibility, and satisfaction. Given the anonymity of the surveys, the number of participants who responded to both surveys is unknown. No efforts were made to reach out to the same participants from the initial survey; however, Instagram was used to disseminate both surveys. Measures Pre-implementation Data were collected and managed using research electronic data capture (REDCap) tools hosted at the University of Utah (Harris et al., 2009; Harris et al., 2019). An anonymous 63-item 11 REDCap survey was developed and implemented to assess current awareness, use, and barriers to use—including social determinants of health—of local PMADs resources (see Appendix A). The survey also assessed the current scope of podcast use and preferences for a local resource PMADs podcast. Specifically, this survey included questions in five domains: (a) sociodemographics; (b) podcast preferences; (c) current awareness of PMADs; (d) barriers faced when accessing maternal mental health resources; and (e) suggestions on how to share resources with other perinatal individuals. Sociodemographics. Sociodemographic questions included: Participant Location (first asked if they lived in Utah, and if answered yes, offered the 29 counties in Utah; if selected no, asked to write in which state they lived); Age (18-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-50, 51+); Sex (female, male, intersex, not listed, prefer not to respond); Gender (woman, man, nonbinary, transgender man/female-to-male, transgender woman/male-to-female, gender nonbinary/genderqueer/gender nonconforming, agender, bigender, none of these describe me, prefer not to say); Race (American Indian or Alaska Native, Asian, Black or African American, White, More than one race, Other Race, Prefer not to Answer, Unknown); Ethnicity (Hispanic or Latino, Not Hispanic or Latino); Income (less than $25,000, $25,000-$49,999, $50,000-$74,999, $75,000-$99,999, $100,000-$149,999, $150,000-$199,999, $200,000+); Highest Education Level Completed (elementary school to 8th grade; some high school; high school graduate; GED or equivalent; some college, no degree; occupational/technical/vocational program; associate's degree; bachelor's degree; master's degree; professional school degree (e.g., MD, DDS, DNP, DVM, JD); doctoral degree (e.g., PhD, EdD); unknown; none of these apply); Relationship (single, never married; married; living with partner; in a domestic partnership or civil union; widowed; divorced; separated); and Number of Children (continuous variable). No names or 12 contact information were requested, and the anonymity of the survey was expressly written in the introduction to the survey. Podcast Preferences. Questions about podcast preferences asked whether or not the participant listened to podcasts currently. If they did listen to podcasts, they were asked about preferences for podcast length and what they gain by listening to podcasts with predetermined answers (i.e., knowledge, entertainment, connection). There was also an option for participants to select "Other" and fill in the blank with their reasoning. Participants who did not listen to podcasts were asked the reasons they did not listen to podcasts with an alternative "Other" option as well. Current Awareness of PMADs. Current awareness of PMADs was determined by 9-12 True/False questions, one Yes/No question, and one fill-in-the-blank question (depending on how the participant answered questions). The questions asked about participants' awareness of various perinatal mood and anxiety disorders, maternal mental health providers, Postpartum Support International, and where they would go for help. Barriers to Accessing Maternal Mental Health Resources. In the barriers section, participants were asked two Yes/No questions: one regarding previous provider-led discussions about mental health and the other regarding previously accessed maternal mental health resources. Multiple "Select All That Apply" questions were asked next to determine the support a provider previously offered and the barriers the participant faced in accessing maternal mental health resources. The predetermined barriers listed were derived from the literature (Bina, 2019; Canty et al., 2019; Grissette et al., 2018; Hansotte et al., 2017) and divided into four groups: financial barriers, time barriers, stigma barriers, and health care structure barriers. Participants 13 were given an "Other" option in each category to provide additional information regarding their personal barriers. Perinatal Resource Sharing Suggestions. Participants were asked to provide suggestions on how to share resources with other perinatal individuals, including the best avenues to reach mothers (word of mouth, social media, professionals, flyers, Google Searches, events, educational presentations, radio, TV, newspaper, blog posts, articles, farmer's markets, other) and what social media sites they use most often (Instagram, TikTok, Facebook, YouTube, Twitter, Snapchat, Reddit, Pinterest, LinkedIn, WhatsApp, Other, I don't use social media). Three open-ended questions asked participants for podcast dissemination suggestions related to their favorite Utah content creators and social media influencers, public locations mothers spend their time, and organizations participants felt may share the resource. Implementation Podcast platform statistics were monitored throughout implementation, including total episode downloads and download locations, to understand which topics were most interesting to listeners and the overall reach of the podcast. Instagram insights were also monitored throughout implementation to track followers and engagement with the content. The number of Instagram followers far outweighed the number of podcast listeners. While the podcast platform maintained listener anonymity, some Instagram followers chose to message the project lead about the helpfulness of the podcast, disclosing their own identity. Post-implementation Guided by the RE-AIM framework, content experts, and quality improvement measures, an 84-item anonymous post-implementation REDCap survey was developed and distributed to podcast listeners (See Appendix B). The survey evaluated reach, effectiveness, adoption, 14 usability, feasibility, and satisfaction of the PMADs local resource podcast. Additionally, statistics received from the podcast hosting website, QR code flyers, and the Instagram page were summarized. Reach. Analytics of the podcast hosting website, QR code flyers, and followers on the Instagram page measured reach of the local resource PMADs podcast. For example, the podcast streaming service allows the podcast host to see the number and location of the downloads. The podcast streaming service counts a download each time the audio file is requested from them (Buzzsprout, n.d.). The QR code analytics indicated the frequency the QR code was scanned to determine the reach of the perinatal population through this mechanism. Finally, the postimplementation survey asked how participants found the podcast and whether or not they followed the Instagram page. Effectiveness. Effectiveness was evaluated by asking the same questions in the Current Awareness of PMADs section of the pre-implementation survey to see if there was a change. Six True/False questions were asked to determine if participants gained knowledge from the podcast and if they considered using a resource discussed within the podcast. Additionally, participants were asked to answer "True" or "False" to the following statement: "The podcast helped me overcome barriers to accessing maternal mental health care." They were then asked which barriers they have experienced in the past (Financial Barriers, Time Constraints, Concerns about Stigma, The Structure of the Healthcare System, Other, I face no barriers to accessing maternal mental health resources); how the podcast helped them overcome those barriers with predetermined answers; and what barriers they continue to face. Adoption. Adoption was determined by asking how many episodes participants listened to (1, 2, 3, 4, 5, 6, 7, 8+); on average, how much of each episode they completed (10%, 20%, 15 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%); the reasons that kept them coming back to listen to other episodes; and whether or not they shared an episode with a friend. Finally, they were asked to respond using a five-point Likert scale (Strongly Disagree, Disagree, Neither Agree or Disagree, Agree, Strongly Agree) to the statement: "I will continue to listen to the podcast." Usability. To assess usability, the post-implementation survey asked the participant to evaluate the statement: "The podcast is easy to use" using a five-point Likert Scale with five options (Strongly Disagree, Disagree, Neither Agree or Disagree, Agree, Strongly Agree). Feasibility. Feasibility has many areas of focus, including acceptability, demand, implementation, practicality, and adaptation (Bowen et al., 2009). Because feasibility significantly overlaps with the RE-AIM framework, many of the previously mentioned questions address the project's feasibility. In addition, the post-implementation survey asked the participant to evaluate the statement: "The podcast is helpful to me" with a five-point Likert Scale (Strongly Disagree, Disagree, Neither Agree or Disagree, Agree, Strongly Agree). They were further asked to evaluate the statements: "The podcast fits my needs" and "The podcast is applicable to me," using the same Likert scale to assess the practicality of the intervention for this population. Satisfaction. To assess satisfaction, the post-implementation survey asked participants to evaluate three statements using a five-point Likert Scale (Strongly Disagree, Disagree, Neither Agree or Disagree, Agree, Strongly Agree): "I like the podcast," and "I am satisfied with the podcast," and "The podcast fits my needs." Analysis Descriptive statistics depicted and compared sociodemographic data, awareness, use, and barriers to use of local PMADs resources collected in the pre- and post-implementation surveys. Furthermore, descriptive statistics described reach, effectiveness, adoption, usability, feasibility, 16 and satisfaction. Findings were presented as frequencies and percentages. A chi-square test of independence compared responses to knowledge questions before and after the podcast implementation using a p-value of <.01. Additionally, a chi-squared test of independence was used to detect differences between the two population samples. Qualitative data from open-ended questionnaire items were analyzed via content analysis (Vaismoradi et al., 2013). The words were read verbatim and then coded. Coded data were then categorized, organized, and summarized. Ethical Considerations This project was quality improvement in nature and not subject to University of Utah institutional review board oversight. This project took a population health approach to improve the quality disbursement of maternal mental health resources. Though podcast listeners could disclose their identities by following along on the social media page and messaging the project lead, no disclosure was required for the pre-survey nor the post-survey. Therefore, the final data were not paired. At the end of each survey, resource information was provided so mothers could seek support if needed (e.g., Postpartum Support International Support line, link to Utah Maternal Mental Health resource website). There were no conflicts of interest concerning this study. Results Pre-implementation Perinatal Population Survey Two-hundred-six Utah perinatal individuals completed the pre-implementation population survey (Table 1). The majority of the respondents were between the ages of 25-34 (85%, n = 175), white (94.2%, n = 194), non-Hispanic or Latino (94.7%, n = 195) individuals 17 with annual incomes between $50,000 and $149,999 (71.7%, n = 147) and a bachelor's degreelevel of education (53.4%, n = 110). Podcast Use Over three-quarters of perinatal mothers (76.7%, n = 158) reported listening to podcasts, and over half reported listening to them at least weekly (60.0%, n = 90). An additional 27.7% (n = 47) of podcast listeners reported listening to podcasts monthly. Most podcast listeners (81.7%, n = 129) preferred episode durations of 20-60 minutes, with a third of whom (32.9%, n = 52) preferred episode durations of 30-45 minutes. Only 5.1% (n = 8) preferred episodes under 10 minutes. The top five reasons respondents listened to podcasts were: knowledge (86.7%, n = 137); entertainment (76.6%, n = 121); laughter (67.7%, n = 107); a break (57.0%, n = 90); and inspiration (56.3%, n = 89). Nearly one-quarter of Utah perinatal mother respondents (23.3%, n = 48) indicated they do not listen to podcasts. The two primary reasons for not listening to podcasts were lack of time (45.8%, n = 22) and being too tired to focus (27.1%, n = 13). Other reasons included a preference for other forms of media (such as audiobooks, music, and visual media); lack of podcast knowledge; and not having a podcast they currently enjoy. Barriers to Use Seventy percent of respondents (70.4%, n = 145) felt they knew whom to talk to if they experienced a PMAD. Respondents then wrote in the specific person they would go to for help. Of the 145 individuals who knew where to seek help, over half (53.8%, n = 78) wrote they would solely go to their obstetrician, midwife, or primary care provider (PCP). An additional quarter (24.1%, n = 35) of individuals listed their obstetrician, PCP, or midwife as one of the resources 18 they would go to, along with a therapist or a family member. Eight individuals wrote that they would contact a maternal mental health specialty clinic or PSI (5.5%). Figure 1 shows the different ways providers supported mothers during the perinatal period. The majority of mothers (85.4%, n = 176) experienced a provider discussion about their mental health. The most frequent way providers offered support included using a screening tool (68.8%, n = 121); having a supportive conversation (57.4%, n = 101); having a medication discussion (42%, n = 74); and writing a medication prescription (29.5%, n = 52). Less frequent forms of support included therapy recommendations or referral (21.6%, n = 38); suggesting local support groups (8.5%, n = 15); suggesting online support groups (5.1%, n = 9); and books (1.7%, n = 3). Figure 2 and Figure 3 show the different barriers perinatal mothers reported in accessing maternal mental health resources. In order of frequency, the four main categories of barriers included: healthcare structure barriers (79.6%, n =164), time constraints (75.7%, n = 156), and financial and stigma barriers (both at 68.4%, n = 141). The three most common financial barriers were lack of knowledge about insurance coverage (40.3%, n = 83); high cost (38.3%, n = 79); and an inability to pay for childcare (25.7%, n = 53). A third of respondents (31.6%, n = 65) did not face any of the listed financial barriers. The three most common time constraints were other tasks taking priority (46.6%, n = 96); feeling at max capacity (40.8%, n = 84); and feeling too busy for therapy (28.6%, n = 59). Approximately a fourth (24.3%, n = 50) of individuals found that none of the time constraints listed applied. The three most common stigma barriers were feeling like they should be able to fix it (56.3%, n = 116); worrying about what others will think (27.7%, n = 57); and fear of being a bad mother (25.5%, n = 52). Approximately a third (31.6%, n = 65) of respondents did not face any listed stigma barriers. 19 Finally, the most common healthcare structure barriers were lack of knowledge about the maternal mental health specialty (36.9%, n = 76); worry about being "pushed" to take medication (35%, n = 72); and expecting a referral from a provider if mental health was "bad enough" (18%, n = 37). Approximately one-fifth of respondents (20.4%, n = 42) did not face any of the listed healthcare structure barriers. Post-implementation Podcast Listener Survey Thirty-nine Utah perinatal females completed the post-implementation population survey (Table 1). The majority of the respondents were between the ages of 25-34 (79.5%, n = 31), white (97.4%, n = 38), non-Hispanic or Latino (94.9%, n = 37) individuals with annual incomes between $50,000 and $149,999 (71.8%, n = 28) and a bachelor's degree-level of education (41%, n = 16). A chi-square test of independence shows that the pre-implementation and postimplementation samples of the population are similar except for education (p = .01), which differs significantly. Reach Between November 9, 2022, and February 1, 2023, there were 1,800 podcast downloads from various podcast platforms, 1,112 of which were within Utah (61.8%). Downloads occurred in 53 different Utah cities. The top cities were Salt Lake City with 332 downloads, Lehi with 97 downloads, Provo with 56 downloads, Ogden with 54 downloads, and South Jordan with 51 downloads. Figure 4 shows the distribution of podcast downloads. Due to the logistics of finding research assistants, the QR code flyers were available throughout the state from December 15, 2022, to February 1, 2023. Over the six weeks, community health centers and public places QR code flyers were scanned 33 and 74 times, respectively. 20 The majority of podcast listeners found the resource through social media (74.4%, n = 29), and some others found it because they knew the host personally (23.1%, n = 9). The primary social media platform used was Instagram, and as of February 1, 2023, there were 1,545 followers on the podcast's dedicated Instagram page. Two people (5.1%) found the resource because a friend shared the podcast with them, and one person (2.6%) discovered it through a podcast platform recommendation. One person (2.6%) found the podcast from the flyers distributed throughout the state. Specifically, the respondent saw the flyer at an indoor playground and family recreation center. Effectiveness Knowledge Changes Table 2 describes knowledge changes. Perinatal individuals who listened to the podcast reported the following: 100% (n = 39) learned new information about maternal mental health, 84.6% (n = 33) learned new vocabulary from the podcast, 97.4% (n = 38) learned a new coping skill, 100% (n = 39) learned about new resources, and 89.7% (n = 35) considered using one of the resources shared. Additionally, 35.9% (n = 14) of podcast listeners used one of the resources shared in an episode. Resources accessed include PSI support groups (n = 2), "PSI Utah" (n = 1), Utah's maternal mental health website (n = 1), therapy with an interviewed therapist (n = 1), the PSI Support Line (n = 1), a TED Talk (n = 1), and "self-care strategies" (n = 1). A chi-square test of independence showed that when comparing nine knowledge questions before and after the intervention, seven questions did not show significant improvement, and two did show significant improvement. The two knowledge improvements in the population following the intervention were awareness of maternal mental health therapists X2 (1, N = 245) = 15.4, p = .00009 and awareness of the organization Postpartum Support International X2 (1, N = 245) = 12.0, p = .0005. 21 The majority of individuals (82.1%, n = 32) felt they knew whom to talk to if they experienced a PMAD. Respondents then wrote in the specific person or resource they would go to for help. Of the 32 individuals who knew where to go for help, a third (30.8%, n = 12) wrote they would solely go to their obstetrician, midwife, or PCP, and an additional 18.8% (n = 6) of individuals listed their obstetrician, PCP, or midwife as one of the resources they would go to for help in addition to a therapist, psychiatrist, friend or another resource. One-quarter of the individuals (25%, n = 8) listed a PMAD clinic, a therapist specializing in PMADs, PSI, or the state government maternal mental health website as one of the resources. Overcoming Barriers and Continued Barriers The majority of podcast listeners (87.2%, n = 34) reported experiencing some kind of barrier to accessing maternal mental health resources in the past. Such barriers included: time constraints (69.2%, n = 27), financial barriers (61.5%, n = 24), the structure of the healthcare system reported (30.8%, n = 12), concerns about stigma (28.2%, n = 11), and other (15.4%, n = 6). The "other barriers" included: childcare (n = 3) and knowledge about resources and how to find them (n = 3). Podcast listeners then responded to how the podcast helped them overcome the barriers they individually specified (see Figure 5). One respondent who selected "Other" under financial barriers stated, "I haven't listened to an episode about this yet." The respondent who selected "Other" under healthcare structure barriers wrote, "Unsure." Because the intervention did not erase all barriers, respondents described barriers they continue to face. Four podcast listeners said that despite the podcast, they continue to struggle with time constraints. One mother wrote, "Having 3 kids I'm not sure how I'll have time to do therapy." Two mothers wrote that childcare continues to be a concern, and three other individuals wrote about financial concerns. One woman specified, "Still financial, but I now 22 know you can go to groups for free which is awesome." Another wrote, "I wish it was more affordable. Having kids is expensive and seeking help for myself is often one more thing to pay for. I feel like my focus financially is on the betterment of my children and not myself." One woman wrote a specific stigma concern, "My own pride in thinking I can handle it or that the hard time will pass on its own." Finally, one woman wrote that she did not know where to go, and another felt like she was not listened to by providers. She wrote, "After trying a few different providers (therapist not included - I have a great therapist!), I have yet to find someone who will consider my story personally and look at me individually in regards to treatment, rather than a blanket approach and immediately pushing medication. I prefer non-medicated options first but have yet to find true support for that." Adoption Survey respondents listened to an average of 2.8 (SD = 1.7) episodes, and 71.8% (n = 28) of them listened to 100% of the episode. An additional 20.5% (n = 8) completed 70-90% of each episode. The eight episodes released at the time of the survey ranged in duration from 33 minutes to 54 minutes, and the majority of podcast listeners (84.6%, n = 33) liked the current length of the podcast episodes. Additionally, 10.3% (n = 4) preferred longer episodes, while 5.1% (n = 2) preferred shorter episodes. Podcast listeners continued to return to the podcast because they felt validated in their experience (79.5%, n = 31) and appreciated the knowledge gained (71.8%, n = 28). Finally, two-thirds of respondents (66.7%, n =26) enjoyed the podcast segment where the podcast host reviewed journal articles, and the other third (33.3%, n = 13) were neutral. All survey respondents (100%, n = 39) agreed or strongly agreed that they would continue to listen to the podcast. Feasibility, Usability, and Satisfaction 23 The vast majority of the podcast listeners (97.4%, n = 38) were satisfied with the podcast, and all (100%, n = 39) agreed or strongly agreed that the podcast was easy to use, applicable to them, fit their needs, they liked it, and they found it helpful (Table 3). Discussion Summary Guided by the RE-AIM framework, this project developed and implemented a free localresource PMADs podcast to improve population awareness, access to, and use of local PMADs resources. Consistent with studies conducted in other regions of the United States, this project found that perinatal individuals in Utah face similar financial barriers, time constraints, stigma barriers, and healthcare structure barriers (Bina, 2019; Canty et al., 2019; Grissette et al., 2018; Hansotte et al., 2017). In addition, findings suggest that a free local-resource PMADs podcast is a useful, feasible, acceptable, and effective way to engage and reach this population of perinatal mothers and overcome barriers to care. Perinatal individuals who listened to the local-resource PMAD podcast felt validated in their experience as a mother; learned new information about maternal mental health; and, in some cases, went on to use resources discussed in the podcast. Interpretation There is a paucity of research on perinatal individuals's podcast use. However, research in other populations suggests podcasts are valuable for their portability, flexibility, efficiency, and ability to educate and entertain simultaneously (Andersen & Dau, 2021; Kelly et al., 2022). Findings from this project suggest that podcasts are valuable to the perinatal population for similar reasons. The portability, flexibility, and efficiency inherent to podcasts helped individuals overcome some barriers to accessing care. For example, a common theme throughout the literature and this project is that individuals experience a scarcity of time (Bina, 2019; Canty et 24 al., 2019; Grissette et al., 2018; Hansotte et al., 2017); however, most individuals in this project found ways to listen to long-form podcast episodes in their daily lives through multitasking. Additionally, perinatal individuals who listened to the podcast felt validated in their experience and learned new information, resources, vocabulary, and coping skills. The podcast format overcame other common barriers to accessing care like reduction of stigma, increasing knowledge of healthcare options, cost-free information, and no need for childcare. Finally, the project's findings align with the evidence that some podcast learners change their behavior because of information gained from the podcast (Kelly et al., 2022; Şendağa et al., 2018). Of the 39 individuals who completed the post-survey, over a third (35.9%, n = 14) used one of the resources discussed in an episode. This project suggests that podcasts can be a useful, feasible, acceptable, and effective medium for reaching perinatal individuals. Some barriers continued despite efforts to overcome them: finding time to attend therapy or a support group and cost of using resources. Perhaps these continued barriers are due in part to a systemic issue where individuals more frequently take parental leave due to a new child and receive less pay during their leave, while men are often given less time for leave but are paid more during it (Herr et al., 2020). Unequal parental leave sets up families for inequality in childcare tasks. Societal pressures may contribute as well: the majority of the mental load and domestic tasks of running a home default to the woman in a heterosexual relationship, and therefore, individuals feel they do not have mental real estate available to dedicate to personal needs (Ciciolla & Luther, 2019). Perinatal individuals in Utah may also face significant cultural influences due to the state's large population of members of The Church of Jesus Christ of Latter-day Saints. The most recent statistical report from the organization reports that 66% of Utah's population, or 2.16 million Utahns (2021), are members of the religion. Traditional gender 25 roles are part of the religion's doctrine: individuals are encouraged to stay home to nurture their children, while men are encouraged to leave home to provide (The Church Education System, 2001; The Church of Jesus Christ of Latter-day Saints, 1995). Changes to systems as well as contextual discussions with individuals challenging gender roles, may help mothers overcome these continuous barriers. Consistent with other studies (Bina, 2019; Canty et al., 2019; Grissette et al., 2018; Hansotte et al., 2017), this project found that individuals largely turn to their obstetrician, midwife, or PCP when seeking help with perinatal mental health concerns. When individuals discussed their mental health with providers, it typically involved taking the EPDS, discussing medication, and having a supportive conversation. Far fewer providers offered information about local resources and support groups suggesting that Utah providers who frequently work with perinatal individuals often do not refer them to local maternal mental health resources. While this project did not survey providers to learn what prevented them from discussing resources with patients, prior research suggests several reasons, including low reimbursement for consultations, limited time, limited knowledge about the resources, overburdened staff, and difficulty discerning between the process of matrescence and a psychiatric disorder (Bina, 2019). Future research should seek to find efficient and productive methods to support frontline providers in overcoming these barriers. Despite distributing hundreds of flyers throughout the Salt Lake and St. George regions of Utah, the flyers were far less effective at reaching perinatal individuals than the virtual dissemination strategy. Most perinatal mothers in this study found the podcast resource through Instagram, suggesting that social media may be a preferred way to reach this target population, consistent with a previous study (Baggett et al., 2020). However, it is important to note that 26 despite efforts to reach individuals who are minoritized through the use of funds to pay for social media advertisements and flyers posted in community health centers, the demographics of the respondents did not fully reflect those efforts. It is possible that using social media strategies in healthcare may inadvertently reinforce systemic racism and miss those impacted by social determinants of health. Though this theory has been proposed previously (Matamoros-Fernández & Farkas, 2021), research is scarce on it. Future research should examine multiple social media communities to see how systemic racism may be intrinsic to the algorithms that guide the user experience. Within the context of this project, the lack of heterogeneity may be rectified by having exploratory conversations with community partners from local organizations to receive input on how best to reach minoritized groups. One benefit of a virtual approach is its ability to reach perinatal individuals in rural areas with fewer resources. Within Utah, maternal mental health resources primarily exist in the Wasatch Front, the most populated area in Utah, leaving individuals in rural areas to rely on local physicians. However, because of the COVID-19 pandemic, many local maternal mental health resources now offer virtual appointments. Both the wide availability of the podcast and the virtual dissemination plan helped individuals who live in rural areas learn about the resources within the state and their accessibility. Podcasts may be one way to meet the needs of perinatal mothers in rural areas moving forward. Limitations Several project limitations may impact the generalizability of findings. First, the sampled portion of the perinatal population was predominantly White, educated, affluent individuals. Despite the specific efforts to reach individuals who are BIPOC or low-income, more research and input from community partners may help the podcast reach more individuals in these 27 minoritized groups. Second, most of the virtual podcast dissemination was via Instagram, potentially leaving out a portion of the population not active on that social media platform. Though we tried to mitigate this by posting QR code flyers throughout the community, they generated little engagement. Third, there was a significant drop in sample size from the initial population survey (n = 206) and the post-survey after the intervention (n = 39). The decrease in sample size may be due to the timing of project implementation during the Thanksgiving, Christmas, and New Year's holidays, impacting engagement with the resource. Nevertheless, sensitivity analyses suggest these two groups were similar across all demographics except education level. Conclusions A local resource PMADs podcast is a useful, feasible, acceptable, and effective way to engage and reach perinatal mothers and teach them how to access maternal mental health resources in the state. DNP-prepared APRNs are uniquely positioned to facilitate collaboration between specialties to creatively address population health problems through the assessment, development, implementation, and evaluation of interventions (McCauley et al., 2020; Rocafort, 2019). Implications for future practice include: using social media to find perinatal individuals who may be struggling; using podcasts to educate perinatal individuals; informing providers, such as PCPs and obstetricians, about the resource; and connecting with more local organizations who work with individuals who are BIPOC or have low-incomes. From a sustainability perspective, the podcast is partially sustainable because it will remain online once published. However, continuing to produce the podcast takes time and dedication to the cause. Fortunately, the PSI Utah chapter asked the project lead to join the board 28 as the Chair of Community Outreach, which will help with the continued production of the podcast. Moving forward, the ideal goal is for a future DNP student to distribute the podcast to primary care offices, obstetrician clinics, and pediatrician offices to help inform these providers about the PMAD resources available in the state. Providers in the maternal mental health community in Utah enthusiastically assisted with the project, and organizations willingly promoted the resource. Though providers were not surveyed, there was a general willingness to collaborate to connect individuals to local resources. Future quality improvement projects could focus on surveying local PCPs, certified nurse midwives, obstetricians, and pediatricians to improve understanding of barriers to referral and help them overcome those barriers. DNP students and DNP clinicians are prepared to be influential community leaders. 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Nursing & Health Sciences, 15(3), 398–405. https://doi.org/10.1111/nhs.12048 37 Tables and Figures Table 1 a Characteristics of Utah Perinatal Women Who Responded to the Pre-implementation and Post-implementation Surveys Pre-Survey (n = 206) n (%) Post-Survey (n = 39) n (%) Age 20-24 10 (4.9) 4 (10.3) 25-29 85 (41.3) 17 (43.6) 30-34 90 (43.7) 14 (35.9) 35-39 19 (9.2) 3 (7.7) 40-44 2 (1.0) 1 (2.6) Sex Female 206 (100) 39 (100) Gender Woman 206 (100) 39 (100) Perinatal Status Pregnant 59 (28.6) 7 (17.9) Postpartum (≤1 year) 147 (71.4%) 32 (82.1) Race (Mark all that apply) White 194 (94.2) 38 (97.4) More than one race 5 (2.4) 1 (2.6) Asian 2 (1.0) 1 (2.6) Other Race 2 (1.0) 0 (0) Native Hawaiian or Other Pacific Islander 1 (0.5) 0 (0) Prefer not to Answer 4 (1.9) 0 (0) Ethnicity Not Hispanic or Latino 195 (94.7) 37 (94.9) Hispanic or Latino 11 (5.3) 2 (5.1) b Household Income Less than $25,000 4 (1.9) 3 (7.7) $25,000-$49,999 24 (11.7) 3 (7.7) $50,000-$74,999 37 (18.0) 8 (20.5) $75,000-$99,999 52 (25.5) 8 (20.5) $100,000-$149,999 58 (28.2) 12 (30.8) $150,000-$199,999 15 (7.3) 3 (7.7) $200,000+ 16 (7.8) 2 (5.1) Education Elementary school to 8th grade 1 (0.5) 0 (0) High School graduate 5 (2.4) 4 (10.3) Some college 25 (12.1) 6 (15.4) Occupational/technical/vocational program 11 (5.3) 0 (0) Associate's degree 17 (8.3) 2 (5.1) Bachelor's degree 110 (53.4) 16 (41.0) Master's degree 32 (15.5) 7 (17.9) Professional degree 4 (1.9) 1 (2.6) Doctoral degree 1 (0.5) 3 (7.7) a Perinatal: the time frame from conception through the first year after giving birth. b Income based in US dollars. c Sensitivity analysis using a chi-squared test of independence *p < .05, chi-squared test of independence. P-Values c p = .57 p = 1.0 p = 1.0 p = .17 p = .85 p = .96 p = .53 p = .01* 38 Table 2 Utah Perinatal a Women Awareness of PMADs b and PMAD Local Resources Before and After Podcast Implementation Perinatal Mothers’ Awareness of: Pre-Survey Post-Survey n (%) n (%) Postpartum depression 206 (100) Postpartum anxiety 198 (96.1) Postpartum obsessive-compulsive disorder 116 (56.3) Postpartum psychosis 141 (68.4) PMADs are the most common complication of pregnancy 114 (55.3) Where to get help 145 (70.4) Perinatal therapists 137 (66.5) Website maternalmentalhealth.utah.gov 14 (6.8) Postpartum Support International (PSI) 24 (11.7) a Perinatal: the time frame from conception through the first year after giving birth b PMAD = perinatal mood and anxiety disorder *chi-squared test of independence, p < .001 38 (97.4) 39 (100) 22 (56.4) 29 (74.4) 24 (61.5) 32 (82.1) 38 (97.4)* 4 (10.3) 13 (33.3)* 39 Table 3 Podcast Listeners Pespectives on Feasbility, Usability, and Satisfaction (n = 39) Strongly Agree or Agree Neither Agree or Disagree Strongly Disagree or Disagree n (%) n (%) n (%) The podcast is easy to use. 39 (100) 0 (0) 0 (0) I like the podcast. 39 (100) 0 (0) 0 (0) The podcast is applicable to me. 39 (100) 0 (0) 0 (0) The podcast fits my needs. 39 (100) 0 (0) 0 (0) I am satisfied with the podcast. 38 (97.4) 1 (2.6) 0 (0) The podcast is helpful to me. 39 (100) 0 (0) 0 (0) I will continue to listen to the podcast. 39 (100) 0 (0) 0 (0) 40 Figure 1 Forms of Help Providers Offered Perinatal Individuals n = 176 80% % OF PERINATAL INDIVIDUALS 70% 68.8% 60% 57.4% 50% 40% 42.0% 30% 29.5% 20% 21.6% 10% 8.5% 0% Ed inb urg Me Po st Scr naata een l D ing epr es dic a tio n dis cus s ion 5.1% Th e rec rapy om refe me rra nda l o tio r n sio n FORMS OF HELP OFFERED BY PROVIDER On 0.0% 1.7% lin es upp ort Po gro dca ups sts 41 Figure 2 Financial Barriers and Time Constraints Utah Perinatal Individuals Face in Accessing Maternal Mental Health Resources Financial Barriers I don't know if my insurance will cover mental health. It costs too much. I cannot afford to pay someone for childcare. I was not offered paid maternity leave. My insurance does not cover mental health. I cannot afford to take time off of work. I don't have insurance. I am not allowed to take time off of work. Other. Time Constraints Other tasks take priority. I am at max capacity. I am too busy to do therapy. I don't have time to find a therapist. I cannot take time off of work. Other. 0% 5% 10% 15% 20% 25% 30% 35% Percentage of Individuals Facing The Barrier 40% 45% 50% 42 Figure 3 Stigma and Healthcare Structure Barriers Utah Perinatal Individuals Face in Accessing Maternal Mental Health Resources Stigma Barriers I feel like I should be able to fix it myself. I am worried about what people will think if they know I am struggling. I'm afraid of being seen as a bad mother. I don’t want to be seen as "crazy." People in my life have dismissed the way I feel. "Good" mothers don't get depressed. I don't know anyone else who feels the way I do. My family doesn't believe in mental illness. My culture doesn't support mental health. Other. Healthcare Structure Barriers I didn't know people specialized in maternal mental health. I don't want to be pushed to take medication. I thought my provider would make a referral if my anxiety/depression... I would prefer to talk to my support system before a professional. I brought up my mental health concerns and a provider downplayed my... I didn't know there were resources for maternal mental health. I don't know if medication is safe while pregnant and/or breastfeeding. I had a bad experience in therapy before. My provider did not bring it up. I had a bad experience with the medical system before. Other. 0% 10% 20% 30% 40% Percentage of Individuals Facing the Barrier 50% 60% 43 Figure 4 Podcast Downloads Density Chart in Utah by County 100 downloads 50-99 downloads 25-49 downloads 10-24 downloads 1-9 downloads 0 downloads 44 Figure 5 Number of Perinatal Individuals who Overcame Barriers Through The Use of The PMADs Podcast (n = 39) Financial Barriers, n = 24 I did not have to take time off work to learn. I did not have to worry about transportation. I did not have to pay someone for childcare to listen to it. I did not have to worry about insurance to get the information. I did not have to worry about the cost because it is free. Other Time Constraints, n = 27 I did not have to take time off work to receive the information. I did not have to spend my time searching for resources. I could complete other tasks while listening to the podcast. I was able to find time for a podcast in my daily life. Stigma Barriers, n = 11 I now know others who feel the way I do. I now know that many "good" mothers get depressed. I worry less about being seen as "crazy." I feel less like I should be able to fix it myself. I am less worried about what people will think if they know I am... I am less afraid of being seen as a bad mother. Healthcare Structure Barriers, n = 12 I feel more empowered to ask my provider for a referral I feel more empowered to bring up my mental health with a provider. I better understand that many medications are safe while pregnant... I now know medication is not the only option. I know where to start when searching for a provider. I now know there are resources for maternal mental health. I now know providers can specialize in maternal mental health. I now trust healthcare providers more. Other. 0 5 10 15 Number of Perinatal Individuals 20 25 45 Appendix A 46 › 47 48 49 50 51 52 53 54 55 56 Appendix B 57 58 59 60 61 62 63 64 65 66 67 68