Exploring the Experiences of Peer Counsellors Providing Remote Behavioural Activation Therapy for Antenatal Depression: A Qualitative Study

Exploring the Experiences of Peer Counsellors Providing Remote Behavioural Activation Therapy for Antenatal Depression: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the Experiences of Peer Counsellors Providing Remote Behavioural Activation Therapy for Antenatal Depression: A Qualitative Study Taryn Lambert, Christine Callaghan, James Wonkyu Jung, Janice Skiffington, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8800739/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Purpose Growing evidence shows that peer-support and peer-led counselling is beneficial for people with antenatal depression, however, little is known about the experiences of peer counsellors (PCs) in providing support. Understanding PCs’ experiences is essential for determining whether a peer-led model of care is appropriate for improving access to mental health support in pregnancy. This qualitative research aimed to capture the personal impact and experiences of PCs while offering peer support in a randomized trial of remote peer-delivered Behavioral Activation Therapy for Antenatal Depression, the P3 PAAD Trial. Methods Data were collected through qualitative semi-structured interviews with PCs involved in the P3 PAAD Trial. Guided by an experience-based framework, inductive thematic analysis was employed to explore the perceptions and experiences of peer counsellors with training and delivering peer counselling to pregnant Albertans. Results Five themes emerged, 1. Positive Fulfillment 2. Personal Growth and Learning, 3. Fostering Dialogue on Maternal Mental Health, 4. Connection and 5. Support. PCs found fulfillment in providing support, witnessing personal growth in mentees, and expressing a desire to continue their involvement. PCs experienced mutual learning with mentees, benefitted from applying learned skills to their own daily lives, and in some cases, recognized a need to further their own treatment. PCs confronted stigma and facilitated open discussions about maternal mental health while finding solidarity and support through meaningful connections with mentees and fellow counsellors. PCs felt emotionally supported, with resources and guidance readily available. Conclusions Providing peer-led counselling was perceived as largely beneficial, and the results indicate that peer-led antenatal mental health support can be beneficial to those providing the support in addition to those receiving it. These findings also support further exploration of a peer-led model of care as a potential approach for improving access to antenatal mental health support. Antenatal Depression Peer-Counselling Behavioral Activation Therapy Qualitative Research Perinatal Mental Health BACKGROUND Pregnancy is a life stage marked by substantial physiological and psychological change and is associated with an increased risk of depression 1 , 2 . Antenatal depression (AD) is a common psychiatric condition with severe implications for maternal and infant well-being, including associations with substance misuse, preeclampsia, postpartum depression, premature rupture of membranes, preterm birth, low birthweight, and lasting adverse child neurological, behavioral, and emotional development 1 – 9 . There is a need for accessible, affordable and effective interventions to treat AD within the short window of pregnancy to mitigate adverse impacts on maternal and child health. In recent years, para-professional and peer-administered (peers being those in recovery from past perinatal depression) counselling interventions have increasingly been explored as cost-effective and accessible option for AD treatment, that aligns with the preferences of the perinatal population for non-pharmaceutical treatment 2 , 3 , 8 – 14 . Peer support interventions for depression have shown significantly higher improvements in depression symptoms compared to standard of care and can potentially deliver comparable effectiveness to group cognitive behavioral therapy 15 , 16 . Both peer-support and more structured peer-administered counselling interventions offer significant benefits for patients with depression through sharing of common experiences, fostering empathy and support, and providing an environment for open discussion and connection, shown to promote active recovery 17–21 17, 18 , 20 , 21 . However, the appropriateness of engaging peers as care-providers for AD has been the subject of recent academic debate 21 , 22 . While some evidence suggests that those engaged in less formal peer-support report positive impacts on their well-being, 17, 23 , others suggest that engaging in peer-support may be associated with distress 24 Overall, little is known about the nuanced experiences of the peers delivering counselling interventions, and whether they perceive any benefits or harms from the training and/or their counselling role An improved understanding of peer-experiences of delivering para-professional counselling interventions for perinatal depression can enhance our understanding of ethical principles surrounding this promising avenue of treatment. Our qualitative study aimed to capture the firsthand experiences of non-professional volunteers with lived experience of perinatal depression in providing a remote behavioural activation (BA) counselling and peer support intervention for AD. METHODS We conducted a qualitative inductive thematic analysis study of the lived experiences of peer counsellors (PCs) involved in delivering remote BA therapy for AD. In accordance with this approach, we allowed themes to emerge organically from participant narratives, to prioritize participant voice and perspective 25 , 26 . Our study was approved by the Conjoint Health Research Ethics Board at the University of Calgary, Canada (REB21-1162) and was conducted in compliance with the Helsinki Declaration ( https://www.wma.net/policies-post/wma-declaration-of-helsinki/ ). We published the PAAD Trial protocol 23 and registered the trial in the ISRCTN registry (51098220). We recruited PCs involved in the Peer-Administered Support for Antenatal Depression (PAAD) Trial 23 , which investigated the effectiveness of a peer-led, BA and peer-support intervention for AD, administered via video chat or phone in 2022–2023, in Calgary, Canada. The PAAD trial used social media platforms and university-campus advertisements to recruit peers, defined as individuals with prior lived experience of AD or postpartum depression, who had achieved recovery from depressive symptoms, had completed some postsecondary education, demonstrated an understanding of mental health, and a willingness to engage in evidence-based treatments for depression 23 . All PCs completed four training sessions and certification, prior to administering the intervention, and attended weekly supervision meetings with a certified clinical psychologist 23 , 27 . All participants recruited for this qualitative analysis were already familiar with the research team from their initial recruitment, training and involvement for the PAAD trial 23 , . Twelve individuals provided written, informed consent to being a PC, but three withdrew prior to starting the training and another one withdrew before completing the training. Our female research coordinator (CC) invited the 8 PCs who completed the training via email, to participate in a qualitative interview between November 2023 and February 2024. We aimed to recruit PCs at different stages of the counselling process to capture diverse viewpoints and experiences across different levels of involvement in the intervention. Our female undergraduate practicum student researcher with training in qualitative methods (TL) conducted semi-structured interviews using out original pilot-tested interview guide, exploring PC perceptions of, and experiences, with delivering the intervention for AD (Supplementary File 1). Interviews were conducted via Zoom, Facetime and over the phone according to PC preference between December 2023 and March 2024. The interviewer (T.L.) introduced herself to participants as an undergraduate practicum student working with the PAAD team. She emphasized her research interest in maternal and child health, while also noting that she had no personal experience with pregnancy or motherhood. Interviews were approximately 30 minutes in duration and were audio recorded and de-identified. We assigned each PC a pseudonym (in place of study ID#), and had interviews transcribed verbatim by a certified online transcription service (Rev.com). The semi-structured interviews elicited insights and discussion about training and certification, providing BA and peer support, the perceived impact of participation on their well-being, and the identification of strengths and weaknesses of the intervention. The semi-structured interviews utilized nine guiding prompts to initiate discussions across various dimensions aligned with our research objectives (Supplementary File 1). These prompts were piloted with researchers and colleagues to ensure their effectiveness. The interview questions were continuously reviewed after each session to ensure their effectiveness in eliciting relevant and meaningful responses. Two qualitative researchers (TL, KC) analyzed interview transcripts using inductive thematic analysis, which included a systematic examination of the text to identify recurring patterns, themes, and insights that emerged organically from the data. Both analysts read each manuscript multiple times to ensure a comprehensive understanding of the content, then coded salient phrases, concepts, and insights, within PC narratives. Codes were organized and grouped into broader themes and subthemes, capturing the essence of PC experiences and perceptions. We conducted member-checking for credibility, by inviting participants to verify that our interpretations and findings aligned with their experiences 28 . Two independent qualitative researchers (JH, KC) then audited our research process, by examining interview guides, coding processes, final themes and interpretations, to ensure dependability, and that personal biases had not overshadowed participant voices. RESULTS Seven PCs who trained and received certification completed interviews, including four who delivered the intervention to trial participants, one who partially completed the intervention, and two who did not deliver the intervention. The one PC who completed training and did not complete an interview, delivered one session of the intervention before the mentee withdrew from the trial. All participants resided in the Calgary Zone of Alberta Health Services, in Alberta Canada, in postal codes with average annual household incomes between $ 40,400 and $ 92,500. One participant had a Master’s degree, three had bachelor’s degrees, and three had completed some post-secondary training. PCs ranged in age from 29 to 45 years, and had between 1 and 2 children who ranged between 1 and 19 years of age at the time of participation. The majority were married, two were single, and one was widowed. The length of time elapsed since PCs first experience with perinatal depression ranged from < 1 year, to 15 years. Participants included those on maternity leave, those who worked outside of the home, and those who stayed at home to raise their children. Five themes emerged from the data: 1. “Positive Fulfillment” 2. “Personal Growth and Learning”, 3. “Fostering Dialogue on Maternal Mental Health”, 4.“Connection”, and 5. “Support”. These themes reveal the overall positive experience providing support as PCs. Theme 1: Positive Fulfillment Positive Fulfillment encapsulates the sense of purpose, satisfaction, and enrichment experienced by PCs in their counselling roles. Subtheme 1.1: Self-Fulfillment PCs expressed a sense of self-fulfillment, and noted how counseling provided them with a meaningful sense of purpose, particularly during transitional periods such as maternity leave and early motherhood. "It was nice for me. I think it was nice to be involved in something." (Beth) “I was on maternity leave at the time… it gave me some purpose through my maternity leave” (Lucy) Many PCs described feeling fulfillment while taking on a meaningful and helpful role. They expressed satisfaction in knowing that they were making a tangible difference to participants, and expressed pride in being able to offer guidance and assistance to others struggling with AD. “It made me feel like I was giving back to people who I could really relate to.” (Charlotte) “I just thought it was really rewarding helping people and then seeing value and coming back week after week.” (Emma) Subtheme 1.2: Counseling Fulfillment PCs found peer-led counseling rewarding, expressing satisfaction in seeing mentees' positive transformation and new coping skills. PCs mentioned feeling impressed by the mentee's growth, such as finding their voice and developing effective coping mechanisms. Witnessing this personal development brought a sense of fulfillment to the councilors, knowing they had played a role in supporting these women through their journey. “I loved seeing the metamorphosis of the ladies. From week one to week eight, there was a huge difference in their demeanour and their attitude, and I felt like it was a privilege to sit back and watch their personal growth through the whole program.” (Charlotte) “It felt good to know that you can be that ear for somebody.” 29 “This program…had such good tools and I saw the fruits of that in my mentees, like their relationships with their husbands and with their parents even. I saw things change there so much for the better. I felt like some of these skills helped my mentees find a voice to be like, ‘Oh, I am allowed to ask for what I need. Oh, I can talk about it.’" (Lucy) Subtheme 1.3: Desire to Continue PCs expressed their desire to continue participating in the intervention, emphasizing the fulfillment experienced through their involvement. Many expressed sadness at the thought of counselling only two to three people through the trial, and mild disappointment at the conclusion of the trial itself. “I sadly only got to mentor two people. And so that's one thing I was kind of sad about. I wanted to do that some more.” (Charlotte) “I just think that it could have been very good for a lot of women if it didn't end.” (Lucy) Many PCs expressed interest in future opportunities to support mothers with depression, highlighting the value they placed on their role for both themselves and their mentees. Many PCs saw their participation as not only personally fulfilling but also a valuable community service. “Because I'm definitely interested in if it ever comes back…So if it starts back up again or you want to change programs, you can always contact me.” 30 Theme 2 - Personal Growth and Learning PCs’ stories captured transformative journeys of reflection, acquisition of skills, knowledge building, self-discovery, and emotional growth during their roles. PCs expressed mutual learning between themselves and their mentees, and discussed how sharing experiences and emotions benefited both parties, highlighting the therapeutic value of their role. Engaging in mental health discussions proved cathartic and rewarding, fostering self-reflection and personal growth during counseling sessions. “I would explain to them that it felt more like a mutual benefit because you're giving them advice, but you're also listening to what you're telling them.” (Emma) PCs stressed that they were not merely imparting knowledge and support to the mentees but were also acquiring valuable skills themselves. Witnessing the resilience and strength of the mentees inspired many PCs to continue their own journeys of personal development. “I felt like they taught me how to be more patient, more loving, because they are both more compassionate people than I am. So it was really inspiring to listen to them .” 30 Further, PCs saw peer counselling as a chance to gain deeper insights into their own experiences with depression, actively pursuing self-discovery and learning through interactions with mentees, enhancing their understanding of themselves and their mental health experiences. “So, I found out [the mentees] help me at the same time. So, help[ing] people, try[ing] to teach people skills, at the same time, I was learning myself.” (Amy) Subtheme 2.1: Application of Learned Skills to Everyday Life PCs spoke about applying the resources, teachings, and skills they acquired and discussed with mentees during counseling sessions to their own lives. They highlighted a commitment to "practicing what they preached," meaning the lessons learned were not limited to the therapeutic setting but were actively incorporated into their own daily lives and interactions, furthering their own mental health journeys. "I found that whatever I was sharing with them, I was also thinking about myself, and making sure I am not saying one thing, and then doing something differently. I felt like whatever I was trying to preach, I was practicing myself. " (Emma) Many PCs discussed the transformative impact they experienced from integrating the skills learned in training and counselling, such as mindfulness, effective communication and pattern recognition. These novel practices became integral to their routines, leading to tangible benefits like improved interpersonal communication and emotional regulation. “I think there was skills that I learned that you can certainly apply to your own life that I wasn't really doing in the first place.” (Amy) “It [being a PC] absolutely helped just realizing my own patterns and how I can help myself avoid the downward spiral from my own mental health moving forward” (Beth) Sub-Theme2.3: Recognizing the Benefit of Continuing their Own Treatment Journey Some PCs faced emotionally challenging moments during counselling and training, which brought up unresolved past feelings or stirred present emotions. As a result, one counsellor withdrew from training in recognition that they needed to pursue additional support for their own mental health needs. The peer training encouraged reflection and self-awareness, empowering them to prioritize their mental health, demonstrating that the training enabled some PCs to recognize and seek out continued healing. “I wasn't in the right headspace to be participating because I needed to deal with my own [mental health]…before you're like, hey, let me try to help you out, when I know that I would very easily be sucked into [emotionally triggering conversations]” 29 Theme 3 - Fostering Dialogue on Maternal Mental Health Through their role in the intervention, PCs found themselves challenging stigma, normalizing conversations about AD, and establishing a supportive environment for women facing maternal mental health challenges. Subtheme 3.1: Confronting Stigma and Normalizing Maternal Mental Health Challenges PCs shared their experience with the stigma surrounding AD, particularly when discussing AD with others. Many described how stigma served as a barrier to seeking help for their own AD symptoms, fearing judgment or societal repercussions. Additionally, many revealed having experienced feelings of isolation due to the lack of open dialogue surrounding maternal mental health. “During my own periods of being pregnant and postpartum, I really struggled with depression, postpartum depression, and depression during pregnancy. And I felt very alone.” (Emma) “I never got support around [my depression]…mental health was always... It was just something that I was never fully super comfortable or confident talking to people about” (Lucy) “When I was pregnant, I felt like I didn't know how to react to my emotions or what I was feeling , and I feel like I was trying to manage everything myself." (Emma) A common sentiment among PCs was the normalization of AD symptoms within the context of pregnancy. Some explained how societal expectations and misconceptions led them to believe that experiencing AD symptoms was a typical aspect of pregnancy, downplaying the severity of their challenges. “Being pregnant, everyone makes the joke about pregnancy-brain, and even after the fact, it's mom-brain, but it always just felt like it was more than that. There's something else that just wasn't quite right, but I also didn't necessarily feel like it was worth bringing up to a doctor at the time. It just felt like, because it's such a joke almost, that this is a thing that everyone goes through it, so what's the big deal?” 29 Reflecting on their own past unmet needs, PCs acknowledged the importance of therapy interventions, emphasizing the crucial need for support for women facing AD. Many highlighted how their role facilitated open discussions, challenged stigma, and normalized conversations about maternal mental health. “Actually understanding [my mental health] was a legitimate struggle for me and I probably should have sought help for it in the moment, and how beneficial it probably would've been for me at the time to have had the opportunity to speak to another mother who could share, … ‘We can help you with some of these things.’" (Lucy) Subtheme 3.2: Gateway to Discussion Many PCs emphasized that their role served as a gateway to conversations about mental health struggles, offering an approachable avenue for dialogue about their own past experiences with mental health. “It maybe helped me secondhand [to] tell people about my own struggle, if that makes sense” (Charlotte) “Sometimes it's hard or there are certain people that don't really understand that that [AD] can happen. And so it was just nice for me to just also feel like I could get it out in the world.” (Beth) Theme 4 - Connection PCs described the connection, solidarity, and bonding they experienced through their relationships with mentees and other PCs. Many expressed gratitude for the opportunity to connect with others who shared similar experiences, and the bond they formed over shared struggles. These connections provided validation, a sense of belonging, and the reassurance they were not alone in their experiences. "So it was really nice because…it felt like we could bond over very similar experiences." (Beth) “I felt a really great connection. It was really nice to connect with women who I could relate to.” (Charlotte) "I felt like I could relate to them, and make them feel like it was easy to talk about it, and it's not always so easy to put it in action, and we could share those similar experiences." (Emma) “Feeling like I could relate to the fact that they were struggling was … It felt good to know that you can be that ear for somebody.” 29 Theme 5 - Support PCs consistently felt emotionally supported, stressing the importance of having their boundaries respected and no pressure to exceed their capabilities. They emphasized the availability of resources and guidance through supervision for addressing concerns ranging from counselling techniques to managing stress and balancing their responsibilities. Supervisory sessions alleviated anxiety and uncertainty, empowering PCs to fulfill their roles effectively without compromising their own well-being or work-life balance outside the trial. "If I ever needed anyone to talk to, they were there" (Amy) "And it never really seemed like there was too much pressure or responsibility on me for things that maybe I didn't have capacity for." (Beth) “I always felt supported. I never felt like I was in deep waters alone trying to navigate complex mental health issues or anything,” (Lucy) DISCUSSION The findings of this study capture the personal impact on and experiences of PCs in a randomized trial of BA and peer-support for AD. These insights are particularly significant within the context of the existing literature, which underscores the pressing need for effective interventions to address AD and the lack of evidence surrounding the PC experience and potential impacts on emotional well-being 3 , 14 , 21 – 23 . While some academic debate has arisen over concerns about the ethical implications and effectiveness of a peer-delivered model for addressing AD, our findings endorse this approach from the PC perspective 21 , 22 . Our findings illuminate that the counselling experience of PCs with lived experience of depression was unanimously positive, even in cases where peers realized they had not yet recovered adequately to provide support to another person with AD, as the experience revealed their own needs and empowered them to seek further treatment. Our findings are congruent with previous studies examining the experiences of those providing peer support for perinatal depression, adding credibility to the qualitative evidence supporting peer-led perinatal mental health interventions 25 , 26 . Our themes of Positive Fulfillment, and Personal Growth and Learning correspond with previous research findings, indicating that engaging in interventions to support individuals with AD can be personally fulfilling for PCs 17 . Our findings also align with existing literature highlighting the potential for peer-led interventions to positively impact the mental health and well-being of PCs themselves 17 . Themes of self-fulfillment, counselling fulfillment, and the desire to continue participating underscore the importance of recognizing the reciprocal benefits of peer-led interventions, for PCs as well as mentees 17 . Further, the theme of Fostering Dialogue on Maternal Mental Health highlighted that taking on a PC role acted to facilitate conversations about one’s own past mental health experiences, enabling PCs to challenge stigma and normalize conversations about maternal mental health. This indicates that PC roles might have the potential to improve mental health awareness beyond the PC-mentee dyad and reduce barriers to seeking help 20 , 23 , 31 . The themes of Connection and Support underscore the significance of meaningful relationships built by PCs during their training and PC experiences, both with mentees, and with other PCs. These experiences indicate that the role of PC not only allowed them to provide peer-support to those in need, but also enhanced their own peer support network with other PCs. The PCs in this study felt that they received adequate support in the context of providing a mental health intervention. This supports that the model of training and supervision used in the PAAD Trial was successful in ensuring a perception of safety and proficiency among PCs, which is a crucial aspect of creating supportive environments that prioritize the well-being of PCs 15 , 17 . Our findings additionally emphasize the power of peer connections in providing validation, reassurance, and a sense of belonging, which are essential elements in combating the isolation and stigma often associated with perinatal mental health struggles 15 , 17 . This finding is congruent with a previous systematic review of studies examining the acceptability and feasibility of peer-led mental health care in low- and middle-income countries, where it was found that adequate training, supervision, and opportunity to network with other PCs was crucial to overcoming difficulties and meeting patient needs. 24 Importantly, the remote nature of counselling sessions over platforms like Zoom, PCs reported no negative impact on their ability to connect effectively. The improved understanding of PCs’ experiences of training for and delivering perinatal mental health interventions is key to supporting further exploration and implementation of peer-led interventions, which can help with overcoming existing barriers to care for those with AD 20, 23, 31 . Strengths and Limitations The richness of data provided by the seven participants is a strength of this study. However, the authors acknowledge that these experiences are drawn specifically from the PAAD Trial and may not be completely transferable to other counselling contexts. We were limited by a convenience sample for this study, as we had a limited number of PCs in the main trial from which to draw our sample for the current study, which may have limited the perspectives represented. However, we had high thematic saturation after seven interviews, and no new concepts or themes were emerging. However, we were unable to interview any PCs who did not complete the training which may have deprived the study of potentially contrasting perspectives, and it is unknown if their experiences were as positive as those who participated. The principal analyst had no direct lived-experience with pregnancy or depression, therefore personal experiences, or lack thereof may have influenced data interpretation. However, an external audit of the analysis and interpretation, along with member-checking supports strong confirmability and trustworthiness of our findings. Future Research While our study and the congruent findings of other qualitative studies support that peer-led perinatal mental health interventions can be beneficial to PCs as well as mentees 15 , 17 , 18 , 20 , 31 , quantitative investigation of the mental health impacts of the PC experience, as well as measures of stigma reduction could provide valuable insights into the safety, sustainability, and potential broader benefits of peer-delivered interventions for addressing AD. Further, assessing the transferability and credibility of our findings across diverse populations and various interventions will enhance their relevance and applicability. CONCLUSIONS Our study captures the positive impact of peer-led interventions on PCs engaged in delivering remote BA therapy alongside peer support for AD. Addressing AD during pregnancy is crucial for promoting positive birth outcomes, maternal mental well-being, and infant development. Peer-led interventions present an ethical and promising approach that fosters fulfillment, personal growth, connection, and support for PCs while mitigating stigma and empowering individuals to address mental health concerns. Abbreviations Peer Counsellors (PCs) Antenatal depression (AD) Declarations Ethics approval This study was approved by the Conjoint Health Research Ethics Board at the University of Calgary, Canada (REB21-1162). We published the PAAD Trial protocol 23 and registered the trial in the ISRCTN registry (51098220). Respondents gave written consent for review and signature before starting interviews./ All participants provided written informed consent prior to enrolment in the study. Consent to participate All participants provided written informed consent prior to enrolling in the study. Additionally, verbal consent was obtained from each participant before beginning the interviews Consent for publication Not applicable Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to our ethics agreement but are available from the corresponding author on reasonable request. Competing interests No authors have any competing interests to declare. Funding The PAAD trial was funded by the Calgary Health Foundation and the Alberta Children's Hospital Foundation. Author contributions KC and LT were the primary investigators of the trial and responsible for the concept and design of the study, J.J, C.C and JS were active in recruitment and data collection, TL was the primary data collector and analyzed the data. TL and KC authored the manuscript, and all authors provided substantive review and feedback of the manuscript and approved it for submission. 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Body-Anchored Qualitative Research Interviewing. Qual Health Res. 2010;20:859–67. 10.1177/1049732310364624 . Institute RCW, Alma. Moms Supporting Moms. Peer Mentor Manual. 2022. Sale JE, Brazil K. A Strategy to Identify Critical Appraisal Criteria for Primary Mixed-Method Studies. Qual Quant. 2004;38:351–65. 10.1023/b:ququ.0000043126.25329.85 . Byatt N, Xiao RS, Dinh KH, et al. Mental health care use in relation to depressive symptoms among pregnant women in the USA. Arch Women Ment Health. 2015;19:187–91. 10.1007/s00737-015-0524-1 . Grace B, Shawe J, Johnson S, et al. You did not turn up… I did not realise I was invited…: understanding male attitudes towards engagement in fertility and reproductive health discussions. Human Reproduction Open 2019; 2019: hoz014. DOI: 10.1093/hropen/hoz014. Lingley-Pottie P, McGrath PJ. Distance therapeutic alliance: the participant's experience. ANS Adv Nurs Sci. 2007;30:353–66. 10.1097/01.Ans.0000300184.94595.25 . Additional Declarations No competing interests reported. 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Antenatal depression (AD) is a common psychiatric condition with severe implications for maternal and infant well-being, including associations with substance misuse, preeclampsia, postpartum depression, premature rupture of membranes, preterm birth, low birthweight, and lasting adverse child neurological, behavioral, and emotional development \u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. There is a need for accessible, affordable and effective interventions to treat AD within the short window of pregnancy to mitigate adverse impacts on maternal and child health. In recent years, para-professional and peer-administered (peers being those in recovery from past perinatal depression) counselling interventions have increasingly been explored as cost-effective and accessible option for AD treatment, that aligns with the preferences of the perinatal population for non-pharmaceutical treatment \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePeer support interventions for depression have shown significantly higher improvements in depression symptoms compared to standard of care and can potentially deliver comparable effectiveness to group cognitive behavioral therapy \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Both peer-support and more structured peer-administered counselling interventions offer significant benefits for patients with depression through sharing of common experiences, fostering empathy and support, and providing an environment for open discussion and connection, shown to promote active recovery \u003csup\u003e17\u0026ndash;21 17, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. However, the appropriateness of engaging peers as care-providers for AD has been the subject of recent academic debate \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. While some evidence suggests that those engaged in less formal peer-support report positive impacts on their well-being, \u003csup\u003e17, 23\u003c/sup\u003e, others suggest that engaging in peer-support may be associated with distress \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Overall, little is known about the nuanced experiences of the peers delivering counselling interventions, and whether they perceive any benefits or harms from the training and/or their counselling role\u003c/p\u003e \u003cp\u003e An improved understanding of peer-experiences of delivering para-professional counselling interventions for perinatal depression can enhance our understanding of ethical principles surrounding this promising avenue of treatment. Our qualitative study aimed to capture the firsthand experiences of non-professional volunteers with lived experience of perinatal depression in providing a remote behavioural activation (BA) counselling and peer support intervention for AD.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe conducted a qualitative inductive thematic analysis study of the lived experiences of peer counsellors (PCs) involved in delivering remote BA therapy for AD. In accordance with this approach, we allowed themes to emerge organically from participant narratives, to prioritize participant voice and perspective \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Our study was approved by the Conjoint Health Research Ethics Board at the University of Calgary, Canada (REB21-1162) and was conducted in compliance with the Helsinki Declaration (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wma.net/policies-post/wma-declaration-of-helsinki/\u003c/span\u003e\u003cspan address=\"https://www.wma.net/policies-post/wma-declaration-of-helsinki/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). We published the PAAD Trial protocol \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and registered the trial in the ISRCTN registry (51098220).\u003c/p\u003e \u003cp\u003eWe recruited PCs involved in the Peer-Administered Support for Antenatal Depression (PAAD) Trial \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, which investigated the effectiveness of a peer-led, BA and peer-support intervention for AD, administered via video chat or phone in 2022\u0026ndash;2023, in Calgary, Canada. The PAAD trial used social media platforms and university-campus advertisements to recruit peers, defined as individuals with prior lived experience of AD or postpartum depression, who had achieved recovery from depressive symptoms, had completed some postsecondary education, demonstrated an understanding of mental health, and a willingness to engage in evidence-based treatments for depression \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. All PCs completed four training sessions and certification, prior to administering the intervention, and attended weekly supervision meetings with a certified clinical psychologist \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. All participants recruited for this qualitative analysis were already familiar with the research team from their initial recruitment, training and involvement for the PAAD trial\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTwelve individuals provided written, informed consent to being a PC, but three withdrew prior to starting the training and another one withdrew before completing the training. Our female research coordinator (CC) invited the 8 PCs who completed the training via email, to participate in a qualitative interview between November 2023 and February 2024. We aimed to recruit PCs at different stages of the counselling process to capture diverse viewpoints and experiences across different levels of involvement in the intervention. Our female undergraduate practicum student researcher with training in qualitative methods (TL) conducted semi-structured interviews using out original pilot-tested interview guide, exploring PC perceptions of, and experiences, with delivering the intervention for AD (Supplementary File 1). Interviews were conducted via Zoom, Facetime and over the phone according to PC preference between December 2023 and March 2024. The interviewer (T.L.) introduced herself to participants as an undergraduate practicum student working with the PAAD team. She emphasized her research interest in maternal and child health, while also noting that she had no personal experience with pregnancy or motherhood. Interviews were approximately 30 minutes in duration and were audio recorded and de-identified. We assigned each PC a pseudonym (in place of study ID#), and had interviews transcribed verbatim by a certified online transcription service (Rev.com). The semi-structured interviews elicited insights and discussion about training and certification, providing BA and peer support, the perceived impact of participation on their well-being, and the identification of strengths and weaknesses of the intervention. The semi-structured interviews utilized nine guiding prompts to initiate discussions across various dimensions aligned with our research objectives (Supplementary File 1). These prompts were piloted with researchers and colleagues to ensure their effectiveness. The interview questions were continuously reviewed after each session to ensure their effectiveness in eliciting relevant and meaningful responses.\u003c/p\u003e \u003cp\u003eTwo qualitative researchers (TL, KC) analyzed interview transcripts using inductive thematic analysis, which included a systematic examination of the text to identify recurring patterns, themes, and insights that emerged organically from the data. Both analysts read each manuscript multiple times to ensure a comprehensive understanding of the content, then coded salient phrases, concepts, and insights, within PC narratives. Codes were organized and grouped into broader themes and subthemes, capturing the essence of PC experiences and perceptions. We conducted member-checking for credibility, by inviting participants to verify that our interpretations and findings aligned with their experiences \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Two independent qualitative researchers (JH, KC) then audited our research process, by examining interview guides, coding processes, final themes and interpretations, to ensure dependability, and that personal biases had not overshadowed participant voices.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eSeven PCs who trained and received certification completed interviews, including four who delivered the intervention to trial participants, one who partially completed the intervention, and two who did not deliver the intervention. The one PC who completed training and did not complete an interview, delivered one session of the intervention before the mentee withdrew from the trial. All participants resided in the Calgary Zone of Alberta Health Services, in Alberta Canada, in postal codes with average annual household incomes between \u003cspan\u003e$\u003c/span\u003e40,400 and \u003cspan\u003e$\u003c/span\u003e92,500. One participant had a Master\u0026rsquo;s degree, three had bachelor\u0026rsquo;s degrees, and three had completed some post-secondary training. PCs ranged in age from 29 to 45 years, and had between 1 and 2 children who ranged between 1 and 19 years of age at the time of participation. The majority were married, two were single, and one was widowed. The length of time elapsed since PCs first experience with perinatal depression ranged from \u0026lt;\u0026thinsp;1 year, to 15 years. Participants included those on maternity leave, those who worked outside of the home, and those who stayed at home to raise their children.\u003c/p\u003e \u003cp\u003eFive themes emerged from the data: 1. \u0026ldquo;Positive Fulfillment\u0026rdquo; 2. \u0026ldquo;Personal Growth and Learning\u0026rdquo;, 3. \u0026ldquo;Fostering Dialogue on Maternal Mental Health\u0026rdquo;, 4.\u0026ldquo;Connection\u0026rdquo;, and 5. \u0026ldquo;Support\u0026rdquo;. These themes reveal the overall positive experience providing support as PCs.\u003c/p\u003e\n\u003ch3\u003eTheme 1: Positive Fulfillment\u003c/h3\u003e\n\u003cp\u003ePositive Fulfillment encapsulates the sense of purpose, satisfaction, and enrichment experienced by PCs in their counselling roles.\u003c/p\u003e\n\u003ch3\u003eSubtheme 1.1: Self-Fulfillment\u003c/h3\u003e\n\u003cp\u003ePCs expressed a sense of self-fulfillment, and noted how counseling provided them with a meaningful sense of purpose, particularly during transitional periods such as maternity leave and early motherhood.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"It was nice for me. I think it was nice to be involved in something.\" (Beth)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was on maternity leave at the time\u0026hellip; it gave me some purpose through my maternity leave\u0026rdquo; (Lucy)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany PCs described feeling fulfillment while taking on a meaningful and helpful role. They expressed satisfaction in knowing that they were making a tangible difference to participants, and expressed pride in being able to offer guidance and assistance to others struggling with AD.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It made me feel like I was giving back to people who I could really relate to.\u0026rdquo; (Charlotte)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I just thought it was really rewarding helping people and then seeing value and coming back week after week.\u0026rdquo; (Emma)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eSubtheme 1.2: Counseling Fulfillment\u003c/h3\u003e\n\u003cp\u003ePCs found peer-led counseling rewarding, expressing satisfaction in seeing mentees' positive transformation and new coping skills. PCs mentioned feeling impressed by the mentee's growth, such as finding their voice and developing effective coping mechanisms. Witnessing this personal development brought a sense of fulfillment to the councilors, knowing they had played a role in supporting these women through their journey.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I loved seeing the metamorphosis of the ladies. From week one to week eight, there was a huge difference in their demeanour and their attitude, and I felt like it was a privilege to sit back and watch their personal growth through the whole program.\u0026rdquo; (Charlotte)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It felt good to know that you can be that ear for somebody.\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cem\u003e29\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;This program\u0026hellip;had such good tools and I saw the fruits of that in my mentees, like their relationships with their husbands and with their parents even. I saw things change there so much for the better. I felt like some of these skills helped my mentees find a voice to be like, \u0026lsquo;Oh, I am allowed to ask for what I need. Oh, I can talk about it.\u0026rsquo;\" (Lucy)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eSubtheme 1.3: Desire to Continue\u003c/h3\u003e\n\u003cp\u003ePCs expressed their desire to continue participating in the intervention, emphasizing the fulfillment experienced through their involvement. Many expressed sadness at the thought of counselling only two to three people through the trial, and mild disappointment at the conclusion of the trial itself.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I sadly only got to mentor two people. And so that's one thing I was kind of sad about. I wanted to do that some more.\u0026rdquo; (Charlotte)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I just think that it could have been very good for a lot of women if it didn't end.\u0026rdquo; (Lucy)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany PCs expressed interest in future opportunities to support mothers with depression, highlighting the value they placed on their role for both themselves and their mentees. Many PCs saw their participation as not only personally fulfilling but also a valuable community service.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Because I'm definitely interested in if it ever comes back\u0026hellip;So if it starts back up again or you want to change programs, you can always contact me.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003e30\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2 - Personal Growth and Learning\u003c/h2\u003e \u003cp\u003ePCs\u0026rsquo; stories captured transformative journeys of reflection, acquisition of skills, knowledge building, self-discovery, and emotional growth during their roles. PCs expressed mutual learning between themselves and their mentees, and discussed how sharing experiences and emotions benefited both parties, highlighting the therapeutic value of their role. Engaging in mental health discussions proved cathartic and rewarding, fostering self-reflection and personal growth during counseling sessions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I would explain to them that it felt more like a mutual benefit because you're giving them advice, but you're also listening to what you're telling them.\u0026rdquo; (Emma)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePCs stressed that they were not merely imparting knowledge and support to the mentees but were also acquiring valuable skills themselves. Witnessing the resilience and strength of the mentees inspired many PCs to continue their own journeys of personal development.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I felt like they taught me how to be more patient, more loving, because they are both more compassionate people than I am. So it was really inspiring to listen to them\u003c/em\u003e.\u0026rdquo; \u003csup\u003e\u003cem\u003e30\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurther, PCs saw peer counselling as a chance to gain deeper insights into their own experiences with depression, actively pursuing self-discovery and learning through interactions with mentees, enhancing their understanding of themselves and their mental health experiences.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So, I found out [the mentees] help me at the same time. So, help[ing] people, try[ing] to teach people skills, at the same time, I was learning myself.\u0026rdquo; (Amy)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSubtheme 2.1: Application of Learned Skills to Everyday Life\u003c/h3\u003e\n\u003cp\u003ePCs spoke about applying the resources, teachings, and skills they acquired and discussed with mentees during counseling sessions to their own lives. They highlighted a commitment to \"practicing what they preached,\" meaning the lessons learned were not limited to the therapeutic setting but were actively incorporated into their own daily lives and interactions, furthering their own mental health journeys.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I found that whatever I was sharing with them, I was also thinking about myself, and making sure I am not saying one thing, and then doing something differently. I felt like whatever I was trying to preach, I was practicing myself. \" (Emma)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany PCs discussed the transformative impact they experienced from integrating the skills learned in training and counselling, such as mindfulness, effective communication and pattern recognition. These novel practices became integral to their routines, leading to tangible benefits like improved interpersonal communication and emotional regulation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think there was skills that I learned that you can certainly apply to your own life that I wasn't really doing in the first place.\u0026rdquo; (Amy)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It [being a PC] absolutely helped just realizing my own patterns and how I can help myself avoid the downward spiral from my own mental health moving forward\u0026rdquo; (Beth)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eSub-Theme2.3: Recognizing the Benefit of Continuing their Own Treatment Journey\u003c/h3\u003e\n\u003cp\u003eSome PCs faced emotionally challenging moments during counselling and training, which brought up unresolved past feelings or stirred present emotions. As a result, one counsellor withdrew from training in recognition that they needed to pursue additional support for their own mental health needs. The peer training encouraged reflection and self-awareness, empowering them to prioritize their mental health, demonstrating that the training enabled some PCs to recognize and seek out continued healing.\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I wasn't in the right headspace to be participating because I needed to deal with my own [mental health]\u0026hellip;before you're like, hey, let me try to help you out, when I know that I would very easily be sucked into [emotionally triggering conversations]\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cem\u003e29\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3 - Fostering Dialogue on Maternal Mental Health\u003c/h2\u003e \u003cp\u003eThrough their role in the intervention, PCs found themselves challenging stigma, normalizing conversations about AD, and establishing a supportive environment for women facing maternal mental health challenges.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3.1: Confronting Stigma and Normalizing Maternal Mental Health Challenges\u003c/h2\u003e \u003cp\u003ePCs shared their experience with the stigma surrounding AD, particularly when discussing AD with others. Many described how stigma served as a barrier to seeking help for their own AD symptoms, fearing judgment or societal repercussions. Additionally, many revealed having experienced feelings of isolation due to the lack of open dialogue surrounding maternal mental health.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;During my own periods of being pregnant and postpartum, I really struggled with depression, postpartum depression, and depression during pregnancy. And I felt very alone.\u0026rdquo; (Emma)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I never got support around [my depression]\u0026hellip;mental health was always... It was just something that I was never fully super comfortable or confident talking to people about\u0026rdquo; (Lucy)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When I was pregnant, I felt like I didn't know how to react to my emotions or what I was feeling\u003c/em\u003e,\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eand I feel like I was trying to manage everything myself.\" (Emma)\u003c/h2\u003e \u003cp\u003eA common sentiment among PCs was the normalization of AD symptoms within the context of pregnancy. Some explained how societal expectations and misconceptions led them to believe that experiencing AD symptoms was a typical aspect of pregnancy, downplaying the severity of their challenges.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Being pregnant, everyone makes the joke about pregnancy-brain, and even after the fact, it's mom-brain, but it always just felt like it was more than that. There's something else that just wasn't quite right, but I also didn't necessarily feel like it was worth bringing up to a doctor at the time. It just felt like, because it's such a joke almost, that this is a thing that everyone goes through it, so what's the big deal?\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003e29\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eReflecting on their own past unmet needs, PCs acknowledged the importance of therapy interventions, emphasizing the crucial need for support for women facing AD. Many highlighted how their role facilitated open discussions, challenged stigma, and normalized conversations about maternal mental health.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Actually understanding [my mental health] was a legitimate struggle for me and I probably should have sought help for it in the moment, and how beneficial it probably would've been for me at the time to have had the opportunity to speak to another mother who could share, \u0026hellip; \u0026lsquo;We can help you with some of these things.\u0026rsquo;\" (Lucy)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3.2: Gateway to Discussion\u003c/h2\u003e \u003cp\u003eMany PCs emphasized that their role served as a gateway to conversations about mental health struggles, offering an approachable avenue for dialogue about their own past experiences with mental health.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It maybe helped me secondhand [to] tell people about my own struggle, if that makes sense\u0026rdquo; (Charlotte)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes it's hard or there are certain people that don't really understand that that [AD] can happen. And so it was just nice for me to just also feel like I could get it out in the world.\u0026rdquo; (Beth)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4 - Connection\u003c/h2\u003e \u003cp\u003ePCs described the connection, solidarity, and bonding they experienced through their relationships with mentees and other PCs. Many expressed gratitude for the opportunity to connect with others who shared similar experiences, and the bond they formed over shared struggles. These connections provided validation, a sense of belonging, and the reassurance they were not alone in their experiences.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"So it was really nice because\u0026hellip;it felt like we could bond over very similar experiences.\" (Beth)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I felt a really great connection. It was really nice to connect with women who I could relate to.\u0026rdquo; (Charlotte)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I felt like I could relate to them, and make them feel like it was easy to talk about it, and it's not always so easy to put it in action, and we could share those similar experiences.\" (Emma)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Feeling like I could relate to the fact that they were struggling was \u0026hellip; It felt good to know that you can be that ear for somebody.\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cem\u003e29\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5 - Support\u003c/h2\u003e \u003cp\u003ePCs consistently felt emotionally supported, stressing the importance of having their boundaries respected and no pressure to exceed their capabilities. They emphasized the availability of resources and guidance through supervision for addressing concerns ranging from counselling techniques to managing stress and balancing their responsibilities. Supervisory sessions alleviated anxiety and uncertainty, empowering PCs to fulfill their roles effectively without compromising their own well-being or work-life balance outside the trial.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"If I ever needed anyone to talk to, they were there\" (Amy)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"And it never really seemed like there was too much pressure or responsibility on me for things that maybe I didn't have capacity for.\" (Beth)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I always felt supported. I never felt like I was in deep waters alone trying to navigate complex mental health issues or anything,\u0026rdquo; (Lucy)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe findings of this study capture the personal impact on and experiences of PCs in a randomized trial of BA and peer-support for AD. These insights are particularly significant within the context of the existing literature, which underscores the pressing need for effective interventions to address AD and the lack of evidence surrounding the PC experience and potential impacts on emotional well-being \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. While some academic debate has arisen over concerns about the ethical implications and effectiveness of a peer-delivered model for addressing AD, our findings endorse this approach from the PC perspective \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Our findings illuminate that the counselling experience of PCs with lived experience of depression was unanimously positive, even in cases where peers realized they had not yet recovered adequately to provide support to another person with AD, as the experience revealed their own needs and empowered them to seek further treatment. Our findings are congruent with previous studies examining the experiences of those providing peer support for perinatal depression, adding credibility to the qualitative evidence supporting peer-led perinatal mental health interventions \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur themes of Positive Fulfillment, and Personal Growth and Learning correspond with previous research findings, indicating that engaging in interventions to support individuals with AD can be personally fulfilling for PCs \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Our findings also align with existing literature highlighting the potential for peer-led interventions to positively impact the mental health and well-being of PCs themselves \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Themes of self-fulfillment, counselling fulfillment, and the desire to continue participating underscore the importance of recognizing the reciprocal benefits of peer-led interventions, for PCs as well as mentees \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFurther, the theme of Fostering Dialogue on Maternal Mental Health highlighted that taking on a PC role acted to facilitate conversations about one\u0026rsquo;s own past mental health experiences, enabling PCs to challenge stigma and normalize conversations about maternal mental health. This indicates that PC roles might have the potential to improve mental health awareness beyond the PC-mentee dyad and reduce barriers to seeking help \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe themes of Connection and Support underscore the significance of meaningful relationships built by PCs during their training and PC experiences, both with mentees, and with other PCs. These experiences indicate that the role of PC not only allowed them to provide peer-support to those in need, but also enhanced their own peer support network with other PCs. The PCs in this study felt that they received adequate support in the context of providing a mental health intervention. This supports that the model of training and supervision used in the PAAD Trial was successful in ensuring a perception of safety and proficiency among PCs, which is a crucial aspect of creating supportive environments that prioritize the well-being of PCs \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Our findings additionally emphasize the power of peer connections in providing validation, reassurance, and a sense of belonging, which are essential elements in combating the isolation and stigma often associated with perinatal mental health struggles \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. This finding is congruent with a previous systematic review of studies examining the acceptability and feasibility of peer-led mental health care in low- and middle-income countries, where it was found that adequate training, supervision, and opportunity to network with other PCs was crucial to overcoming difficulties and meeting patient needs. \u003csup\u003e24\u003c/sup\u003e Importantly, the remote nature of counselling sessions over platforms like Zoom, PCs reported no negative impact on their ability to connect effectively.\u003c/p\u003e \u003cp\u003eThe improved understanding of PCs\u0026rsquo; experiences of training for and delivering perinatal mental health interventions is key to supporting further exploration and implementation of peer-led interventions, which can help with overcoming existing barriers to care for those with AD \u003csup\u003e20, 23, 31\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThe richness of data provided by the seven participants is a strength of this study. However, the authors acknowledge that these experiences are drawn specifically from the PAAD Trial and may not be completely transferable to other counselling contexts. We were limited by a convenience sample for this study, as we had a limited number of PCs in the main trial from which to draw our sample for the current study, which may have limited the perspectives represented. However, we had high thematic saturation after seven interviews, and no new concepts or themes were emerging. However, we were unable to interview any PCs who did not complete the training which may have deprived the study of potentially contrasting perspectives, and it is unknown if their experiences were as positive as those who participated. The principal analyst had no direct lived-experience with pregnancy or depression, therefore personal experiences, or lack thereof may have influenced data interpretation. However, an external audit of the analysis and interpretation, along with member-checking supports strong confirmability and trustworthiness of our findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eFuture Research\u003c/h2\u003e \u003cp\u003eWhile our study and the congruent findings of other qualitative studies support that peer-led perinatal mental health interventions can be beneficial to PCs as well as mentees \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e, quantitative investigation of the mental health impacts of the PC experience, as well as measures of stigma reduction could provide valuable insights into the safety, sustainability, and potential broader benefits of peer-delivered interventions for addressing AD. Further, assessing the transferability and credibility of our findings across diverse populations and various interventions will enhance their relevance and applicability.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eOur study captures the positive impact of peer-led interventions on PCs engaged in delivering remote BA therapy alongside peer support for AD. Addressing AD during pregnancy is crucial for promoting positive birth outcomes, maternal mental well-being, and infant development. Peer-led interventions present an ethical and promising approach that fosters fulfillment, personal growth, connection, and support for PCs while mitigating stigma and empowering individuals to address mental health concerns.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cspan lang=\"EN-US\"\u003ePeer Counsellors (PCs)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"EN-US\"\u003eAntenatal depression (AD)\u003c/span\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Conjoint Health Research Ethics Board at the University of Calgary, Canada (REB21-1162). We published the PAAD Trial protocol \u003csup\u003e23\u003c/sup\u003e and registered the trial in the ISRCTN registry (51098220).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRespondents gave written consent for review and signature before starting interviews./\u003c/em\u003e \u003cem\u003eAll participants provided written informed consent prior to enrolment in the study.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided written informed consent prior to enrolling in the study. Additionally, verbal consent was obtained from each participant before beginning the interviews\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to our ethics agreement but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo authors have any competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PAAD trial was funded by the Calgary Health Foundation and the Alberta Children\u0026apos;s Hospital Foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKC and LT were the primary investigators of the trial and responsible for the concept and design of the study, J.J, C.C and JS were active in recruitment and data collection, TL was the primary data collector and analyzed the data. TL and KC authored the manuscript, and all authors provided substantive review and feedback of the manuscript and approved it for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge Sona Dimidjian and Emily Cameron for their instrumental contributions to the conduct of the trial.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAyano G, Tesfaw G, Shumet S. Prevalence and determinants of antenatal depression in Ethiopia: A systematic review and meta-analysis. PLoS ONE. 2019;14:e0211764. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0211764\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0211764\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller ES, Saade GR, Simhan HN et al. 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You did not turn up\u0026hellip; I did not realise I was invited\u0026hellip;: understanding male attitudes towards engagement in fertility and reproductive health discussions. \u003cem\u003eHuman Reproduction Open\u003c/em\u003e 2019; 2019: hoz014. DOI: 10.1093/hropen/hoz014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLingley-Pottie P, McGrath PJ. Distance therapeutic alliance: the participant's experience. ANS Adv Nurs Sci. 2007;30:353\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.Ans.0000300184.94595.25\u003c/span\u003e\u003cspan address=\"10.1097/01.Ans.0000300184.94595.25\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antenatal Depression, Peer-Counselling, Behavioral Activation Therapy, Qualitative Research, Perinatal Mental Health","lastPublishedDoi":"10.21203/rs.3.rs-8800739/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8800739/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eGrowing evidence shows that peer-support and peer-led counselling is beneficial for people with antenatal depression, however, little is known about the experiences of peer counsellors (PCs) in providing support. Understanding PCs\u0026rsquo; experiences is essential for determining whether a peer-led model of care is appropriate for improving access to mental health support in pregnancy. This qualitative research aimed to capture the personal impact and experiences of PCs while offering peer support in a randomized trial of remote peer-delivered Behavioral Activation Therapy for Antenatal Depression, the P3 PAAD Trial.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were collected through qualitative semi-structured interviews with PCs involved in the P3 PAAD Trial. Guided by an experience-based framework, inductive thematic analysis was employed to explore the perceptions and experiences of peer counsellors with training and delivering peer counselling to pregnant Albertans.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFive themes emerged, 1. Positive Fulfillment 2. Personal Growth and Learning, 3. Fostering Dialogue on Maternal Mental Health, 4. Connection and 5. Support. PCs found fulfillment in providing support, witnessing personal growth in mentees, and expressing a desire to continue their involvement. PCs experienced mutual learning with mentees, benefitted from applying learned skills to their own daily lives, and in some cases, recognized a need to further their own treatment. PCs confronted stigma and facilitated open discussions about maternal mental health while finding solidarity and support through meaningful connections with mentees and fellow counsellors. PCs felt emotionally supported, with resources and guidance readily available.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eProviding peer-led counselling was perceived as largely beneficial, and the results indicate that peer-led antenatal mental health support can be beneficial to those providing the support in addition to those receiving it. These findings also support further exploration of a peer-led model of care as a potential approach for improving access to antenatal mental health support.\u003c/p\u003e","manuscriptTitle":"Exploring the Experiences of Peer Counsellors Providing Remote Behavioural Activation Therapy for Antenatal Depression: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 21:48:27","doi":"10.21203/rs.3.rs-8800739/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-09T06:49:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T05:21:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T13:45:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T15:58:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120667864117021467049132762093530506696","date":"2026-03-15T12:18:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T18:57:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162996845928900092896218390671680005641","date":"2026-03-14T13:02:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-13T13:03:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226072436721494564407568199831637540309","date":"2026-03-09T06:02:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198641985412729257882366272823998839918","date":"2026-03-08T10:07:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7916733654416373960238020876138315612","date":"2026-03-06T17:42:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T15:06:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-04T10:11:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-12T07:29:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-11T18:41:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2026-02-11T18:37:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"20ac6272-91ca-4481-82f5-332695bf571b","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T12:54:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 21:48:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8800739","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8800739","identity":"rs-8800739","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}