Internet-based behavioural activation to improve depressive symptoms and prevent child abuse in postnatal women (SmartMama): a protocol for a pragmatic randomized controlled trial

Child abuse is a challenging issue in public health as it affects the physical, psychological, and social health outcomes of individuals for a lifetime [1‐9]. From a societal perspective, child abuse imposes a substantial financial burden on societies as it creates high direct and indirect costs in low, middle, and high-income countries [10‐12]. Existing research has identified the following characteristics as being associated with a higher risk for child abuse: parental depression, anxiety and anger-hyperactivity, parent stress, poor parent–child interactions, and low social support [13]. However, there is presently no solution for how to prevent child abuse right after birth.

Postnatal depression is another critical problem closely related to child abuse [14, 15]. Depression is the leading cause of disease-related disabilities among women [16, 17]. Previous studies indicated that women with postpartum depression were at higher risk for lower physical and psychological health, substance abuse, and suicidal behaviours [18‐22]. Child abuse and postnatal depression often co-occur, and the rate of childhood maltreatment is highest during the first year of life [23, 24]. Children born to depressed mothers were at higher risk for prematurity, delayed physical, motor, and cognitive development [22]. Moreover, postnatal depression among mothers was associated with a significantly increased risk for harsh parenting, physical and psychological abuse [14, 15, 25‐27].

Previous evidence has demonstrated that cognitive behavioural therapy (CBT) is effective for improving depressive symptoms among postnatal women [28‐33], and emerging evidence has shown that it also reduces maternal stress [34, 35]. Behavioural activation (BA) is a simple but effective psychotherapy that follows the basic CBT principles but does not include cognitive restructuring. The practical principles of BA may be of particular use for postnatal women, who face multiple competing demands on their time and attention. Further, the parsimonious, simple nature of BA supports its straightforward application with a wide range of mental health providers, contributing to its promise as a highly scalable intervention [13]. Moreover, as BA facilitates participants to engage in positive behaviours and works on problem-solving strategies when barriers to implementation of these behaviours are encountered, it may increase positive parent–child interactions, possibly enhancing the bonding relationship between mothers and children and improving child outcomes. In a large study of BA in postnatally depressed mothers who were also randomly assigned to receive either relaxation or a video-feedback parent–child intervention, both conditions resulted in improved cognitive, behavioural and attachment outcomes for the child at 2 years of age [36]. These results suggest that BA may help to support the parent–child relationship underpinning attachment, possibly preventing parental abusive behaviours toward their children.

Internet-based psychotherapy has become an alternative approach to face-to-face psychotherapy or other interventions due to its strengths in accessibility, reach, and cost effectiveness [28, 32, 37‐41]. These approaches have gained widespread application during the COVID-19 pandemic. Users can choose their device, time, and place to receive the program depending on their needs. Providers of the program, on the other hand, can deliver the application to the mass target population with fewer human resources and lower cost. A number of studies have now demonstrated that internet-based cognitive behavioural therapy (iCBT) [38, 42], which contains internet-based behavioural activation (iBA) is an effective treatment for prenatal depression, and that iBA itself is an effective treatment for postnatal depression [31, 32].

Internet-based psychotherapy not only reduces practical barriers to access for users but may also reduce psychological barriers. Previous evidence has shown that many women with postnatal depression struggle with stigmatization, and this can be an obstacle for health care providers attempting to connect depressed mothers with medical care [43, 44]. In qualitative studies of iBA for postnatal depression, mothers who reported struggling with stigma stated that they found internet intervention more acceptable than face-to-face intervention [45]. We expect that internet-based interventions including smartphones, which have become such standard communication tools, would make it easier for mothers in need to seek care for their mental health. Internet-based psychotherapy, however, has its own challenges. Many studies have described the high attrition rate of internet-based psychotherapy, ranging from 9.7 to 78.9% of the participants, as a weakness of web-based interventions [40, 46]. Internet-based interventions demonstrated improved retention rates with human support [28, 32, 41, 47‐49]; however, the adequate intensity of support needed to achieve the goal is still unknown. As the implementation of the program involves not only the users but also medical providers and hospital managers, it is essential to understand how the program is perceived in terms of acceptability, appropriateness, feasibility, and potential harm perceived by these stakeholders.

The strength of the study is that it evaluates the effectiveness of the iBA program for maternal depressive symptoms and psychological aggression toward children in a randomized-controlled trial. The study also intends to examine the implementation outcomes of the iBA program, which is essential in delivering the program to the population in need. The limitation of the study is that all the outcomes are measured by the self-report scales. Although all the postnatal mothers are recruited in the postnatal check-up at one month after delivery, the time that they complete the baseline online survey and finish enrolment may differ. This may influence the baseline EPDS scores. Moreover, the participants are to be recruited in relatively large hospitals, and the finding of the study may not be generalizable to the postnatal women having deliveries at smaller hospitals and clinics.

The results of the study may be relevant and beneficial to the health care needs of postnatal women and their children, as well as in providing future directions to health policy for postnatal care and child abuse prevention.