The Acceptability and Appropriateness of Delivering Postnatal Mental Health Support at Community Health Centers

ABSTRACT

Mental health symptoms are common among caregivers of young children in low‐resource settings, yet access to psychological care remains limited due to shortages of specialists, low awareness, and stigma. This qualitative study explored the acceptability and appropriateness of delivering a postnatal mental health intervention for mothers through community and township health centers (CTHCs) in Shanghai, China. We conducted in‐depth interviews with 50 mothers of children under 3 years of age, recruited from nine CTHCs and one parenting center, including both those with and without depressive symptoms. Data were analyzed using a rapid analysis approach to identify themes related to perceived values, burdens, motivations, and barriers to participation. Mothers valued interventions that aligned with their personal needs, addressed both parenting knowledge and mental health, offered emotional and social support, and involved family members. Key barriers included time constraints, childcare responsibilities, stigma toward mental health, and accessibility of the location of the intervention. Flexible delivery formats and modes, integration with routine child health services, and nonstigmatizing framing were identified as potential strategies to enhance engagement.

Mental health symptoms are common among caregivers of young children in low‐resource settings, yet access to psychological care remains limited due to shortages of specialists, low awareness, and stigma. This qualitative study explored the acceptability and appropriateness of delivering a postnatal mental health intervention for mothers through community and township health centers in Shanghai, China.

1. Introduction

Mental health symptoms are highly prevalent among caregivers of young children in low‐resource regions. In World Bank categorized low‐ and middle‐income countries (LMICs), approximately one in four women experiences perinatal depressive symptoms; one in five experiences postnatal depressive symptoms [1, 2]; and 22% are affected by generalized anxiety disorder in the perinatal period [3]. In rural China, nearly 39% of the caregivers of young children reported some symptoms of depression, anxiety, or stress [4]. Research has linked parental depression and anxiety symptoms to reduced responsiveness to children [5, 6], diminished mother–child interactions [7], fewer stimulating play materials at home, and increases in coercive parenting behaviors [8]. Moreover, children of caregivers with mental health symptoms are at elevated risks of cognitive and language developmental delays, attachment insecurity, problematic temperament, and poor health and growth trajectories [9, 10].

Psychotherapy interventions are effective for treating mental health problems, but they remain highly inaccessible in low‐resource communities. This is primarily due to a lack of specialists to deliver treatment, low awareness of mental problems by those with mental disorders, and widespread stigma toward mental illness [11, 12, 13]. Studies show that over 90% of the caregivers in low‐resource regions that experience mental health problems do not have access to treatment [1, 14]. Training nonspecialists to provide mental healthcare can address the shortage of mental health resources in low‐income settings [15]. A meta‐analysis of 13 perinatal depression interventions delivered by nonspecialists found an overall effect size of 0.38 on reducing depressive symptoms [16].

One of the most empirically tested interventions targeting perinatal mental health at scale in low‐resource communities is the Thinking Healthy Programme (THP) [17]. THP simplifies cognitive‐behavioral therapy techniques and provides step‐by‐step facilitation guidance, enabling delivery by paraprofessionals like community health workers without formal psychology training. Due to its proven effectiveness on maternal depression, it has become the flagship of the Mental Health Gap Initiative of the World Health Organization and has been widely adopted in many LMICs [18].

Although the effectiveness of THP is well established, little research has examined whether it could be implemented through primary healthcare providers at community and township health centers (CTHCs). In China, for example, CTHCs form the backbone of the primary healthcare system and serve as the first point of contact for essential health services, including maternal and child healthcare, for over 90% of the population [19]. However, the two previous pilots of THP were implemented through secondary and tertiary hospitals [20, 21], while delivery through the more accessible primary healthcare facilities remains unexplored. To improve the accessibility and coverage of THP, it is crucial to examine whether caregivers are willing and able to receive interventions similar to THP through CTHCs.

This study seeks to explore the appropriateness and acceptability of delivering postnatal mental health interventions by nonspecialists through CTHCs in Shanghai, China. We aim to answer three research questions: (1) What are the perceived values and burden of participation? (2) What are the motivations for mothers participating in such interventions? And (3) what are the enablers and barriers that affect the feasibility of the intervention implementation and delivery?

2. Method

2.1. Study Setting

The study was conducted in Shanghai, China. In 2024, Shanghai recorded the highest gross domestic product among all cities in China [22]. However, the incidence of postpartum depressive symptoms in Shanghai was 8.9%, with the rate rising over time [23].

Participants were recruited from nine CTHCs, each selected from one district based on accessibility to the research team. Among these centers, four were community health centers located in urban subdistricts, and five were township health centers, which serve as the parallel primary health institutions in rural, periurban, or recently urbanized areas of the city. To ensure representation of the vast migrant population in Shanghai, the largest in China [24], we also recruited participants from an early childhood parenting center serving migrant communities. The center is funded and operated by a local nonprofit organization that promotes stimulating parenting practices in the surrounding communities, which have a high proportion of migrant households. Most mothers that visited the center had migrated from other provinces.

2.2. Participants

Participants were mothers of children under 3 years of age that either visited the selected CTHCs for well‐child check‐ups or registered with the early childhood parenting center during the study period. Mothers were eligible regardless of whether they experienced depressive symptoms or whether they were the primary caregiver of their child. However, those with critically ill children were excluded from the study.

2.3. Procedures

The study was conducted in two periods, June 1–7 and August 25–30, 2024. Participants were recruited from CTHCs during their well‐child visits, the routine check‐ups to monitor children's overall health, and to administer mandatory vaccinations. These visits are scheduled once every 2 or 3 months until 1 year after childbirth and once every 6 months thereafter. During each visit, the mother typically meets with a pediatrician for a health assessment and then accompanies the child for their vaccination. During the study periods, the pediatricians introduced the study during the health assessment and informed mothers that they can choose to participate in it at the end of their visit, after the child receives vaccination.

While the mothers were waiting during the postvaccination observation period, research staff provided a detailed explanation of the study and obtained oral consent. The mothers that agreed to participate completed a brief screening survey that collected demographic information and screened for depressive symptoms using the 10‐item Center of Epidemiologic Studies Depression Scale (CESD‐10) [25]. All mothers whose scores above 8 were invited to participate in an in‐depth interview. Although the manual recommended a cutoff score of 10 for being at risk of depressive symptoms [26], we used a threshold of 8 to avoid insufficient recruitment. To gain a more comprehensive understanding of the experience of mothers, we also invited mothers that did not exhibit depressive symptoms for interviews on a first‐screened, first‐invited basis until information saturation was reached.

To recruit participants from the early childhood parenting center, we distributed a digital version of the same screening survey via WeChat to all the households that registered in the center. All mothers whose scores on the CESD‐10 were above 8 were invited to participate in the in‐depth interviews, along with a randomly selected sample of mothers without depressive symptoms. All mothers from both the CTHCs and the parenting center that completed the short survey received a small gift worth approximately 5 USD. Those that also completed the in‐depth interviews received an additional gift worth approximately 15 USD.

Four trained interviewers from the research team conducted semistructured, one‐on‐one interviews with the selected mothers in private rooms provided by either the CTHCs or the parenting center. The interviewers were blinded to participants’ CESD‐10 results to limit personal bias. The interview guide was developed to assess the appropriateness and acceptability of a proposed postnatal mental health intervention adapted from THP. Following Proctor et al., acceptability and appropriateness were treated as two key prerequisites for successful implementation [27]. In this study, acceptability is measured by the mother's motivations to participate in the proposed intervention, their perceived gains from participation, and perceived burdens associated with participation. Appropriateness is measured by whether the proposed delivery model would enable the mothers to participate considering the constraints they face. In this study, acceptability refers to mothers’ motivations to participate, perceived benefits, and perceived burdens associated with participation. Appropriateness refers to whether the proposed delivery model would enable mothers to participate despite the constraints they face.

Interviewers described the intervention to each participant using the following script: The intervention consists of group sessions, with three to five mothers of infants or toddlers in each session. The sessions take place in a private room at a community or township health center, last approximately 1 h each, and are delivered by trained social workers from that health center. The sessions are a space for mothers to share challenges related to childrearing and to learn evidence‐based psychological and behavioral techniques to help them navigate those challenges. The intervention also includes structured activities through which mothers can gain knowledge about self‐care and children's well‐being.

2.4. Analysis

Interviews were audio‐recorded, transcribed verbatim, translated from Chinese to English, and analyzed using a rapid analysis approach [28]. A summary template was initially developed based on the interview guide and refined during the first few interviews. Interviewers completed the template for each participant shortly after their interview and cross‐checked it against the corresponding transcript to ensure clarity, completeness, and accuracy. At the end of each day, the research team held debriefing sessions to review the interviews and discuss potential modifications to the interview guide or areas of focus for subsequent interviews.

Once all interviews were completed, the research team constructed a matrix using Microsoft Excel to organize the responses by participant and domain. Themes were identified via an iterative process where two researchers independently coded the summaries before comparing their codes to ensure intercoder reliability. Quotes were selected to characterize each theme. All researchers involved in the analysis were masked to participants CESD‐10 depression status until the themes were developed and finalized.

3. Results

We enrolled a total of 42 mothers from CTHCs (17 with and 25 without depressive symptoms) and eight mothers from the parenting center (one with and three without depressive symptoms; four missing data). Table 1 presents the demographic characteristics of the 50 mothers and their children. Over half (26, or 52.0%) of the children were under 12 months of age. Most mothers were between 30 and 35 years old (21, or 42.0%), with 22.0% (11) aged 30 or below. Of the mothers, 34.0% (17) completed an associate degree or below, 44.0% (22) had a bachelor's degree, and 14.0% (7) held a master's degree or above. A majority of the mothers (27, or 54.0%) had only given birth to one child. Regarding occupation, 54.0% (27) were employees, followed by 14.0% (7) that were self‐employed and 12.0% (6) that were unemployed. Nearly half of the participants were local residents (48.0%), and most lived in urban communities (52.0%). Information was partially missing for four mothers.

TABLE 1.

Characteristics of all the participants.

Variables	Total (N = 50)
Child age range (months)
<12	26 (52.0%)
12–24	11 (22.0%)
24–36	9 (18.0%)
Mother age range (years)
≤30	11 (22.0%)
30–35	21 (42.0%)
35–40	10 (20.0%)
>40	4 (8.0%)
Education
Master's degree and above	7 (14.0%)
Bachelor's degree	22 (44.0%)
Junior college and below	17 (34.0%)
Number of births
One	27 (54.0%)
Two	19 (38.0%)
Occupation
Employee	27 (54.0%)
Self‐employed	7 (14.0%)
Temporary worker	1 (2.0%)
Unemployed	6 (12.0%)
Other	5 (10.0%)
Place of origin
Local	24 (48.0%)
Nonlocal	26 (52.0%)
Type of residence
Urban community	26 (52.0%)
Township	24 (48.0%)

Data analysis generated three themes describing its acceptability and two describing the appropriateness of its delivery, with two to four subthemes grouped under each theme (see Table 2).

TABLE 2.

Themes and subthemes generated through the data analysis.

Domain	Theme	Subtheme
Acceptability of the intervention	Perceived participation value	Alignment between intervention content and personal needs
		Format of the intervention
		Mode of content delivery
	Perceived participation burden	Frequency and duration of the intervention sessions
		Participation fee
	Motivations for participating in the intervention	Emotional and social support needs
		Interest in parenting and postpartum knowledge
Appropriateness to intervention delivery	Personal constraint	Availability of time to participate
		Acceptance of mental health‐related topics
		Willingness to communicate and engage with others
		Availability of childcare support or the ability to attend with the child
	Environmental constraint	Suitability of the activity environment
		Accessibility of the intervention location

3.1. Domain 1: Acceptability of the Intervention

3.1.1. Perceived Participation Value and Burden

Mothers’ acceptance of mental health interventions was influenced by a trade‐off between two key factors: the perceived value of participating in the intervention and the perceived burden associated with participation.

A central concern for mothers was whether the content of the intervention could address their specific questions or meet their individual needs. As one mother expressed, “I'm definitely interested in this program, but we don't have that much time. Everyone faces different issues and has different concerns. I think you could share each topic separately in a group chat, and moms who are interested could choose to attend a corresponding offline session based on the topic” (115FX, 30 years old, with a 1‐month‐old, nondepressed). When mothers subjectively believe they do not have mental health concerns or lack a perceived need to improve their mental well‐being, their acceptance of the program also decreases. As one put it, “For me, it's not really necessary. I think I'm in a pretty good mental state” (201CM, 40 years old, with an 8‐month‐old, nondepressed).

In addition to meeting individualized needs, the timing of the intervention was also an important acceptability factor. A mother of a 2‐year‐old noted, “I feel like by this stage, I've figured things out on my own. I've already passed the phase where I needed someone to tell me what to do or what to watch out for” (009HL, 30 years old, with a 26‐month‐old, nondepressed). Similar views were echoed by other participants: “I'm not particularly interested now. I used to need it more—especially before my child turned two. Before my child was 2 years old, I was much more inclined to attend such activities” (215CM, 31 years old, with a 29‐month‐old, nondepressed).

Mothers weigh these perceived gains from the intervention against the time and money they are being asked to invest in it. The proposed intervention was expected to include 24 sessions, delivered biweekly as in‐person group activities, each lasting 45 min to 1 h. However, around one‐fifth of participants felt that a biweekly schedule was too frequent and might discourage mothers from participating from the outset. As one mother noted, “I think it's quite difficult, especially for working mothers. It's hard to find time during the weekday, and even on weekends, we just want to rest and still have to take care of the baby. Once every 2 weeks is actually a bit too frequent” (007XH, 37 years old, with a 6‐month‐old, depressed). Some mothers suggested that if the biweekly schedule is to be kept, it would be better to offer part of the sessions online, allowing for greater flexibility. Others proposed reducing the frequency to once a month: “Once a month might be better. Moms are really busy, and with the baby growing, families face different challenges each month. Honestly, every month brings new issues” (002XH, 37 years old, with a 13‐month‐old, nondepressed). Regarding the duration of each session, participants were generally satisfied with the 45‐min to 1‐h format and emphasized that sessions should end within 1 h. “It's better to keep it short—about an hour—because babies feed frequently, like every 3 h” (012XH, 34 years old, with a 6‐month‐old, depressed). In terms of cost, participants generally suggested a fee range of $5 to $15 per session. Most mothers felt that the quality of the program mattered more compared to cost. As one mother explained, “I think it really depends on the quality of the activity. If it's well‐designed, the cost is totally acceptable” (209CM, 35 years old, with a 6‐month‐old, depressed). Some mothers also recommended offering a few trial sessions before charging fees: “If I find it helpful, I'd probably be willing to pay” (214CM, 36 years old, with a 12‐month‐old, nondepressed). “It depends on whether I find it useful or effective after attending. If it really works for me, I'd be willing to come no matter the cost” (114FX, 34 years old, with a 2‐month‐old, nondepressed).

Interestingly, the mode of intervention delivery affected not only the mothers' perceived investment in the intervention but also their perceived gains. With the widespread use of mobile devices in China and their integration into many social services, mothers are increasingly open to online service models. As one mother shared, “I think the phone is a very convenient tool. Since mothers need to take care of their children, their time is very fragmented. It's actually more convenient to share parenting and mental health information in group chats” (002XH, 37 years old, with a 13‐month‐old, nondepressed). Some mothers expressed a preference for a hybrid model that combines online and offline formats. “If I were asked to come in and join a discussion, I probably wouldn't say much. I'm more comfortable chatting online. Face‐to‐face might be a bit awkward” (203CM, 34 years old, with a 18‐month‐old, nondepressed). “It might be better to start with a few sessions online and gradually transition to offline activities. At the beginning, not many people are willing to attend in person. For example, there were similar offline activities during my pregnancy at the hospital, but I never went once. I only joined online, mainly because I didn't know anyone, and it felt a bit awkward to go alone” (102FX, 33 years old, with a 2‐month‐old, depressed). However, some mothers insisted on the importance of in‐person interaction. “Nowadays, information is everywhere, but sometimes being a mom still feels lonely—especially for first‐time mothers. Compared to reading other people's posts online, if I can actually meet another mom in person and we go through things together, I think that sense of companionship is more valuable.” Additionally, some mothers pointed out that since there is already an abundance of information available online, if the intervention only provides generic knowledge, its appeal and effect may be greatly reduced. “I would prefer if you could share real clinical cases or personal experiences from other mothers. That would be much more engaging for me” (001XH, 33 years old, with a 19‐month‐old, depressed).

3.1.2. Motivations for Participating in the Intervention

The acceptability of the intervention activities to participants largely depends on the specific content included in the mental health program. In line with expectations, some mothers reported experiencing anxiety and depression postpartum and a need for techniques to regulate their emotions. In terms of coping with their own postpartum mental and physical health, some participants shared personal experiences. One mother recalled, “After giving birth, it was during a time when the overall environment was bad, and I couldn't get anything I needed. I was incredibly anxious. If there had been someone to help me deal with postpartum depression and anxiety back then, I think I would've felt much better” (003HL, some demographic data not reported). Another mother hoped to learn how to regulate her emotions in specific parenting situations: “I want to know how to manage my mindset—how to handle it when my baby is emotionally unstable, and how to calm myself down” (113FX, 29 years old, with a 13‐month‐old, depressed).

Surprisingly, however, techniques to support mental health were only one among many types of knowledge mothers hoped to learn from the intervention. Other key motivations for participation included the wish to gain knowledge related to parenting and postpartum health. Although mothers were aware that the core focus of the intervention was on their own mental health, their eagerness to learn parenting knowledge and skills remained one of the primary reasons they chose to attend the in‐person sessions. As one mother shared, “I hope the doctor can tell us the average developmental milestones for babies at this stage, including height, weight, activity levels, what they should be playing with, eating, learning, and what we should be preparing for in the next stage. I'd prefer to hear it from a professional doctor—it would feel more reliable. When I search online, everyone seems to have a different opinion” (104FX, 35 years old, with a 2‐month‐old, depressed).

In addition to acquiring new knowledge, the mother's need for emotional and social support emerged as an even stronger motivation to participate in the center‐based intervention. Many emphasized that participating in such group activities within the community health center helped meet their strong emotional and social support needs during the postpartum period. One mother shared, “The format of this activity is quite appealing. In the environment I live in, I don't have other moms around me to talk to. If there were such a program, I would be very willing to join” (207CM, 35 years old, with a 5‐month‐old, nondepressed).

Another participant noted, “What I'm really looking forward to is meeting other moms with children around the similar age. During or even after the sessions, I'd be able to talk with them, maybe even support each other. I think that's something very valuable for a mother” (003XH, 35 years old, with a 6‐month‐old, nondepressed).

For some mothers that had migrated from other regions, these regularly held mental health group sessions served as an important way to become familiar with the new area and build new social connections. One nonlocal mother explained, “I moved here from my hometown and don't have any friends here. Sometimes I feel quite isolated and helpless. I think this program is really beneficial for mothers like me” (209CM, 35 years old, with a 6‐month‐old, depressed).

Mothers also expressed a desire for the program to provide a safe space for emotional expression. One participant remarked, “In this kind of activity, we can vent about things happening at home. That's really needed, because sometimes there are things you just can't talk about with your husband or family. But here, you can talk to other moms, and they might share their experiences, offer comfort or advice. That can really change how I feel—like things aren't so bad after all” (011XH, 33 years old, with a 2‐month‐old, depressed).

Besides seeking support from fellow caregivers, mothers also viewed the intervention as an opportunity for their family to learn about and be involved in parenting. It could encourage husbands or other family members to take a more active role in childcare, while also providing support for the mothers themselves, as one mother explains: “Personally, I think it would be great to invite fathers to join as well. I believe fathers may also face similar challenges. If moms and dads could bring their children and join the sessions together—maybe three to five families at a time—it might be even better. Fathers could talk to each other, and mothers could also connect with one another” (001XH, 33 years old, with a 19‐month‐old, depressed).

One mother further explained the reason she hoped fathers could participate: “Many men don't know how to take care of the family, which is actually a reflection of the traditional division of labor in Chinese households. They focus too much on their work and think, ‘You don't understand the pressure I face at work, and all you do is take care of the child at home—how can you still have so many complaints?’ But that's not right, because both sides are working to support the family. I think these activities can encourage fathers to get involved so they can better understand what mothers are going through” (003HL, some demographic data not reported).

Some mothers expressed a strong desire for the grandparents at home to receive parenting knowledge as well. “It's not just us who need to learn—especially the grandparents who are helping with childcare, they need to learn too. If the knowledge is shared by someone they perceive as professional, they're more likely to accept it than if it's just coming from me” (007HL, 35 years old, with a 4‐month‐old, nondepressed).

3.2. Domain 2: Appropriateness of Intervention Delivery

3.2.1. Personal and Environmental Constraints

The appropriateness of participating in mental health interventions is shaped by a range of personal and environmental constraints. On the personal level, key barriers include the availability of time, as many mothers, particularly working mothers, struggle to balance childcare responsibilities with other commitments. One mother noted, “Especially when the baby is very young, feedings are so frequent. It's basically feeding, diaper change, feeding, diaper change. You can hardly get away for 2 or 3 h” (002XH, 37 years old, with a 13‐month‐old, nondepressed). Another shared, “Working mothers already have limited time for themselves, both at work and at home. Attending an additional activity feels like an extra burden—mentally and physically, there's no spare capacity” (003HL, some demographic data not reported).

Due to differences in household composition, family structure, daily routines, and the level of support available, there was significant variation in when parents were willing or able to participate in activities at the CTHCs. One mother with multiple children explained, “On weekends, their dad can take care of the two kids, so I usually take that time to do part‐time work, and I don't have time to attend. During the week, I'm with them, and when the older one goes to school, I have a bit more flexibility” (002HL, 44 years old, with a 24‐month‐old, nondepressed).

Another mother that had returned to work commented, “From Monday to Friday, I definitely don't have time. Weekends are the only option. I think this is the case for most dual‐income households” (004XH, 39 years old, with a 20‐month‐old, depressed). One participant suggested offering multiple time slots throughout the day: “I recommend that you divide the day into several options, because children's schedules are sometimes unpredictable. It would be helpful to give moms more flexibility. Every child seems to have a different routine” (012XH, 34 years old, with a 6‐month‐old, depressed). The presence or absence of childcare support, or the ability to bring a child along to sessions, also plays a crucial role in determining whether mothers can attend.

The attitude of mothers toward mental health‐related topics and their willingness to engage in open communication with others significantly influence the feasibility of participating. During the interviews, one mother shared her perspective on mental health interventions: “Many mothers, myself included, are reluctant to participate in this kind of session—mainly because it involves psychological issues and problems with our children. There's this belief that ‘family shame should not be made public’” (003HL, some demographic data not reported). In addition to the stigma surrounding mental health, this mother also believed that “I don't think psychological issues require intervention. Once my child grows up, I'll naturally feel better” (003HL, some demographic data not reported).

Similar attitudes were observed among other participants. Many mothers tend to focus intensely on their children's well‐being while overlooking their own mental health. As one mother explained, “When we come to something like this, I think most people are here to learn about things related to their babies. Whenever a problem arises, adults will prioritize the child. As for our own emotions, we just find ways to cope by ourselves. And honestly, it's really hard to talk about your feelings with strangers. But if it's about baby‐related issues, it's much easier to reach a shared understanding and emotional connection” (007XH, 37 years old, with a 6‐month‐old, depressed).

Safety and accessibility concerns further impact participation. Mothers reported that these challenges include the suitability of the activity environment, such as whether it is safe, comfortable, and child‐friendly. Another factor is the accessibility of the intervention location, particularly in terms of distance and transportation convenience. Together, these factors form the practical conditions under which mothers can realistically engage with mental health support services.

4. Discussion

Our study suggests that delivering mental health interventions through community‐based services is appropriate for mothers of children aged 0–3 years in Shanghai; However, the acceptability of the interventions are contingent upon the fulfillment of several key participation prerequisites. Participants emphasized that the intervention content should align with their actual needs. Key considerations include accessible locations, compatibility with parenting responsibilities, and appropriate frequency and duration to accommodate the diverse needs of participants that are often busy with work and home duties. The findings in this paper highlight key barriers to implementing mental health interventions and contribute to the growing literature on adapting psychosocial interventions to target populations. We also found that mental health issues remain stigmatized, suggesting that efforts to promote engagement must start by addressing the concerns and attending to the priorities identified by participants. Focusing on topics that are of particular concern to mothers, such as parenting knowledge and skills, involvement of family members in caregiving, and peer support, may help enhance their willingness to adopt and stay engaged with mental health interventions.

Our interviews revealed that only a few mothers would participate in the program with the sole intention of improving their mental health. The majority indicated that their primary motivation was to gain parenting knowledge and skills. Previous research indicated that such patterns may be rooted in cultural norms that emphasize maternal sacrifice and selflessness [29]. Many mothers in China are influenced by societal expectations to prioritize their child's well‐being over their own and neglect their mental health [30]. Mothers experiencing psychological distress often face stigma and fear being perceived as inadequate, which discourages them from seeking help [31]. Additionally, limited awareness and understanding of mental health may further prevent mothers from seeking help. Some mothers may not recognize their emotional struggles as mental health problems, instead attributing their depressed mood to being “exhausted from parenting” or believing that they simply need to “push through” [32]. For these mothers, we propose integrating elements of motivational enhancement therapy (MET) into the initial orientation sessions. MET plays a critical role in mental health treatment by helping individuals resolve ambivalence and strengthen their commitment to change [33]. Techniques, such as motivational interviewing, can support mothers in expressing their desire for improvement and should increase their engagement and adherence to the intervention [34]. The interview findings further highlight the need to integrate parenting knowledge and skills into mental health interventions, not only to meet the expressed interests of mothers but also to enhance overall engagement. A successful example of this approach is the Thinking Healthy Programme—Peer delivered (THPP), an adaptation of the original THP model that incorporates components, such as nutrition, child health, and early development from existing maternal and child health education programs [35]. This integrated model has been shown to effectively address the urgent informational and support needs of mothers during the perinatal period [36].

Content relevance emerged as a critical dimension shaping participants’ evaluation of the intervention. Considering this, the next phase of intervention development should systematically align the content of the THP with the sociocultural context of urban Chinese households. This process should be informed by in‐depth qualitative interviews with mothers of children aged 0–3 years across different child age groups, mental health profiles, and family structures, with the aim of identifying specific concerns related to postnatal mental health, individual well‐being, family dynamics, and parenting challenges. For example, cognitive‐behavioral guidance for mothers should also incorporate training on how to communicate mental health issues to partners and other family members. Additionally, developing cognitive‐behavioral therapy training specifically for fathers and other caregivers may enhance the overall effect of the intervention. Ensuring that intervention materials are responsive to these locally grounded priorities and sociocultural contexts is a necessary precondition for effective implementation.

In addition, our findings suggest that the timing, frequency, and associated costs of the intervention play an important role in the acceptance of mothers of the program. Regarding frequency and duration, most mothers indicated a preference for monthly sessions throughout the course of 1 year, which is less frequent than the original THP model which suggests running biweekly sessions throughout a year. In practice, adaptations to THP have already been made across countries to accommodate local needs. For instance, in India, the number of sessions was reduced to between 6 and 14 per year, with content and delivery adjusted based on the caregiver needs, circumstances, and capacity to participate, including offering individual sessions when necessary [37]. In Pakistan, the program was shortened to a maximum of 10 sessions per year [38]. Research also indicates that adaptations must be made systematically to preserve the core components of the intervention, ensure implementation fidelity, and maintain the required dosage of the intervention [36]. The final schedule and frequency of the intervention will be refined following the pilot phase to identify a model that is both acceptable and feasible for mothers of children aged 0–3 years to receive mental health support. However, our interviews revealed a consistent view among mothers that the child health clinics within community health service centers are viewed as a promising platform for implementation, though further alignment between the intervention schedule and the existing care‐seeking routines of mothers may be needed. Cost was also identified as an important consideration in a mother's decision to participate, and supportive measures may help mitigate its impact. Previous studies have shown that practical support measures, such as travel reimbursements [39], expedited medical check‐ups, and flexible appointment scheduling, can significantly improve parental adherence and engagement [40].

The most prevalent barrier to participation in our sample is stigma around mental health issues. Mental health stigma, consistently reported in similar studies conducted in LMICs, often leads women to decline participation in mental health programs either due to fear of being stigmatized or because their family members refuse to acknowledge the existence of any psychological issues [40]. Women in need of support often feel compelled to conceal their participation, for example, by telling their families they are attending medical appointments, in order to continue with the intervention [40]. Addressing stigma around mental health issues requires changing perceptions among not only the intervention participants, but also their family members, the wider community, and society as a whole. While stigma reduction is still a long‐term goal, integrating mental health support into commonly used perinatal and early childhood healthcare services may help normalize mental healthcare and reduce stigma [36]. In addition, the use of nonstigmatizing language has been demonstrated to be effective in addressing this barrier [41]. Researchers emphasize that mental health interventions within child health systems should be framed around a more holistic and family‐oriented message, such as positioning the initiative as “empowering new mothers for the healthy development of their children” rather than focusing solely on reducing mental illness, in order to foster greater acceptance of psychosocial support among mothers and their families [42]. With regard to the scope of intervention, preventive or universal strategies have been shown to enhance acceptance of mental health support and promote more robust psychological well‐being among target populations [43].

The attitudes of family members toward mental health, as well as the level of family support, play a critical role in both the willingness of participants to engage in the intervention and their continued participation [44]. Previous experience shows that participants declined to enroll at the initial recruitment stage due to opposition from family members [45]. The study found that family involvement varied significantly. Some family members simply allowed participants to join the intervention, while others took on caregiving responsibilities during session times, accompanied participants to the hospital, attended sessions with them, or encouraged them to complete between‐session activities [40]. These findings highlight the importance of involving key family members—such as husbands or maternal grandmothers—in the initial orientation session and sessions that emphasize strengthening the participant's social support system. From the perspective of several mothers in this study, the active participation of family members was also an important motivator for joining the program. By leveraging the professional expertise offered by health service providers and incorporating shared experiences from other families with children of similar ages, the intervention can help family members better understand the perspectives of mothers, learn parenting skills together, and become more willing to share caregiving responsibilities, ultimately offering mothers greater support. As a step further, engaging family members in cognitive‐behavioral guidance and mental health education may also improve their parenting practices as they become increasingly involved in caregiving. The group‐based format of the healthy thinking intervention is well‐suited to both engaging mothers and promoting family involvement [37, 46]. Prior research has shown that family members who are motivated to support mothers during the intervention are more likely to remain engaged and provide consistent support throughout the perinatal period [36].

In this study, we recruited not only mothers with depressive symptoms, but also a subset of mothers without an identified risk of depression. Notably, we did not find significant differences between the two groups in terms of perceived acceptability and appropriateness of the mental health intervention delivered by community health centers. Some mothers without depressive symptoms also shared that they had experienced emotional fluctuations during the postpartum period. Based on our analysis of the reported barriers, motivations, and perceived benefits and burdens associated with the intervention, we conclude that postpartum mental health support delivered by community health centers may be acceptable and appropriate not only for mothers experiencing postpartum depression, but also for the broader population of postpartum mothers. In addition, although the proposed intervention was perceived as acceptable and appropriate by mothers of children aged 0–3 years, the perceived need varied by the children's age: Mothers with children under 12 months old often described stronger emotional distress and a more urgent need for support, whereas those with older children reported that their need for support decreased over time. These findings suggest that while postpartum mental health support may remain relevant beyond the 3 years after childbirth, earlier initiation of interventions may be particularly beneficial. In resource‐constrained settings, prioritizing early engagement in the first year postpartum may maximize the perceived value and potential impact of community‐based mental health services.

We acknowledge several limitations to this study. First, the qualitative interviews were conducted before the development of the intervention materials. While most mothers expressed a willingness to participate in mental health support activities organized by community health centers, the intervention had not yet been implemented at the time of the interviews. As a result, there may be a gap between participants’ stated intentions and their actual engagement once the program is in place. Second, the use of convenience sampling may have introduced bias toward more positive or motivated responses. Mothers who were open to participating in the interviews may reflect a subset of individuals who are also more inclined to engage in the intervention itself. Finally, all data were collected from mothers in Shanghai, resulting in a sample with relatively high socioeconomic status, educational attainment, and potentially greater mental health literacy than other regions in China. Additionally, stigmatization of mental illness, baseline acceptance of mental health services, and health‐seeking behavior may all differ in other communities in China. Considering this, although our sample includes caregivers with diverse backgrounds, the findings may have limited generalizability to lower resource regions. In these regions, achieving comparable acceptability may require more extensive, context‐specific adaptations of THP, including addressing structural barriers and sociocultural resistance. Future research could examine the feasibility and implementation of this intervention in low‐resource contexts and among populations with greater socioeconomic diversity.

Despite these limitations that need to be addressed by future trials, our study advances the understanding of how mental health interventions can be culturally adapted for implementation across diverse regions and populations. Exploring perspectives from a wider range of potential participants and identifying possible barriers can support more thoughtful planning before full‐scale implementation, helping to tailor the intervention to local contexts. Furthermore, examining the motivations behind participant engagement offers valuable insight for optimizing intervention design, reinforcing maternal motivation to improve mental well‐being, and promoting greater adherence to the program. Our findings indicate the importance to examine both personal (time, awareness, financial conditions) and sociocultural factors (stigma, family support), since that's one of the main takeaways from our study.

Author Contributions

Yuyin Xiao and Qi Jiang were responsible for conceptualization, methodology, data collection, formal analysis, writing – original draft, and writing – review and editing. Yiwei Qian and Jiaqi Shi were responsible for data collection and formal analysis. Hanwen Zhang and Christina Rose Kennedy was responsible for writing – review and editing. Guohong Li, Fan Jiang, and Scott Rozelle were responsible for conceptualization, methodology, supervision, and writing – review and editing.

Conflicts of Interest

The authors declare no conflicts of interest.