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Acceptability of the Family & Pregnancy Pop-Up Village model, a cross-sector community-engaged care model to address birth inequities in San Francisco: A mixed-methods study 

Abstract

Background: 

Racial inequities in perinatal care outcomes in the U.S., including maternal morbidity and mortality, are exacerbated by systemic and institutional racism. The “Family & Pregnancy Pop-Up Village” (PV) is a community-institutional collaboration that provides a one-stop-shop for clinical, city and wraparound services at a convenient time and location in an uplifting environment for Black, Indigenous, and pregnant people of color (BIPOC) and their families. This study aims to examine the acceptability and accessibility of PV for pregnant people and their families. 

  

Methods: 

We used a convergent mixed-methods design. Survey data were obtained from 116 PV participants (n=58 pregnant/postpartum recipients; n=58 family recipients) followed by semi-structured in-depth interviews with 13 pregnant and postpartum people and 5 family members between July 2021 and June 2022. Surveys and interviews were conducted in English or Spanish. Surveys were self-administered and data entered directly by respondents in REDCap. Interviews conducted by a team member were audio-recorded and transcribed. Acceptability was assessed using the Theoretical Framework of Acceptability domains. We conducted descriptive, bivariate, and multivariate analyses of the quantitative data and framework analysis of the qualitative data. 

  

Results: 

The average acceptability score for the full quantitative sample was 91.9 (SD = 14.4) out of 100. Controlling for other factors, respondents who reported experiencing some discrimination during prenatal care encounters had significantly lower acceptability scores than those who reported never experiencing discrimination. From the qualitative data, most respondents held positive attitudes toward PV, citing its welcoming, supportive, and vibrant atmosphere. The mean accessibility score was 76.0 (SD = 21.0) out of 100. The burden of participation was mixed, with some respondents noting the difficulty in timely access to services at PV and making recommendations for reducing this burden. Respondents had high perceived efficacy of PV in being linked to services, attributed to providers’ effective communication with respondents.

  

Conclusions: 

BIPOC pregnant people and their families found the PV model as an acceptable and accessible option for receiving perinatal care services. Continued community-institutional co-creation of this model will ensure integration of community priorities and long-term sustainability. 



Journals: 

NPJ Women’s Health 

BMC Women’s Health 


Introduction 


The U.S. has the highest maternal mortality rate among high income countries, with stark inequities in critical perinatal outcomes including severe maternal morbidity, preterm birth, and infant death (1). Black women are about three times more likely than White women to die from pregnancy-related complications and their infants twice as likely to die before the age of one (2,3)  Even in states like California, where maternal mortality rates have been on the decline and are lower than the national average, these disparities persist (4). 


The factors driving inequities in maternal and neonatal health are complex, but there is clear evidence that a key driver is racism, which manifests as inequities in access to and experience of care (6,11,12). For instance, Black people and other racial and ethnic minority groups are more likely to live  on low incomes and face barriers to receiving high quality care (3,6). Even if public insurance, such as Medicaid, bridges the financial gap, barriers such as lack of transportation, childcare and other factors create difficulty with accessing care. Several studies also highlight discrimination and lack of person-centered care (i.e. care that is responsive to and respectful of individual’s needs, preferences, and values) (13) experienced by Black women and birthing people during care encounters, including disrespect, not being listened to, and not being believed when reporting concerns, which reflect interpersonally mediated racism (12,14,15). These experiences affect receipt of timely care even where geographic access is not a barrier (5,16). Inequitable experiences in accessing and receiving healthcare compound the pervasive stress of everyday discrimination, reducing the health and wellbeing of Black people. Thus, to improve birth outcomes, interventions that address equitable access to care and eliminate experiences of racism and discrimination in care settings are needed.  

Members of our team embarked on a one year Human-Centered Design (HCD) process in 2017 to better understand and inform intervention development around the experiences of San Francisco (SF) residents who face the most severe inequities in pregnancy care and outcomes: individuals insured by Medicaid and particularly those who identify as Black (17). Despite being a progressive city with many equity-focused pregnancy care programs, participants described excessive practical barriers to care and rampant experiences of interpersonal racism, ranging from overt to more subtle discrimination (such as not making eye contact, leaving someone waiting while attending to others, etc.). Referrals between agencies were also a source of stress because services were fragmented and disconnected. Our results  confirmed extensive evidence demonstrating that current U.S. care delivery structures, built within a culture of white supremacy, have resulted in care that is difficult to access (18–20), does not meet the stated needs of individuals, and does not support autonomy and dignity of Black pregnant people (11,19,21–24). This informed the development of the Family & Pregnancy Pop-Up Village (PV): a one-stop-shop for comprehensive services (clinical, city/government, and wraparound) based on the stated needs of community, in a safe, healing, and empowering environment, with a focus on improving the comprehensive health and wellness of individuals, families and communities. Key components of the model include co-locating multiple organizations to provide easier “one-stop-shop” access to comprehensive services organized within five distinct areas (Health & Wellness; Food & Agriculture; Youth Zone; Local Economy; and Arts & Culture); using anti-racism principles in all aspects of model design and service delivery; and leveraging community-institutional partnership to ensure an effective and sustainable model (Figure 2). In addition, creating an environment that felt safe and uplifting was a priority, given our findings that women of color in particular feel that their pregnancies are often pathologized rather than being celebrated.

PV was launched, through a collaborative institutional-community partnership process, in San Francisco’s Bayview district in July 2021.  PV events have been held monthly since the July 2021 launch through the writing of this paper, apart from annual scheduled breaks for strategic planning and two cancelled events due to safety concerns (large Covid exposure in August 2021 and unsafe weather conditions March 2023).

 


Orientation to acceptability and accessibility and paper objectives

     

The sustainability of any health intervention is predicated on its acceptability and accessibility.  We utilize the theoretical framework of acceptability (TFA) to guide our understanding of both the acceptability and accessibility of PV (5). We examined the acceptability of PV by exploring pregnant and postpartum patients and their families’ perceived affective attitude towards the intervention, the effort required to engage with the Village (accessibility and burden), their perceptions of the intervention's effectiveness, and their confidence in seeking out resources outside of the Village (self-efficacy). This work is situated within our team’s broader mission of continually engaging community members in model iteration to ensure responsiveness to their needs; the current analysis focuses on nine monthly events of PV implementation, which we consider to be a formative phase (From July 2021 to June 2022).      

The primary aim of this study is to assess participant perspectives of the acceptability and accessibility of the Family & Pregnancy Pop-Up Village. The secondary aim is to examine the relationship between sociodemographic characteristics, experiences of discrimination, and pregnancy and obstetric factors with participants’ perceptions of acceptability and accessibility. 

                      

METHODS 


Setting

San Francisco’s Bayview district was chosen as the PV site as it is home to 19% of all birthing SF residents who are Medicaid-insured and 36% of birthing residents who identify as Black (6). In addition, 61% of all birthing people in Bayview are Medicaid insured and 93% identify as members of a racial or ethnic minority group (7). Furthermore, Bayview residents have significantly lower rates of timely prenatal care (inequities in access) and higher rates of preterm birth (inequities in outcomes) than residents of other neighborhoods, even when limited to within Medicaid-insured individuals only(6)


Study design 

During nine months of Pregnancy Village Pop-Up intervention events between July 2021 and June 2022, we conducted a mixed-methods, community engaged process evaluation involving triangulation of qualitative and quantitative data to assess: 1) the feasibility and fidelity of the PV model; 2) acceptability of PV among recipients and factors affecting the sustainability of provider participation; and 3) the preliminary impact of PV, such as perceptions of provider person-centeredness, accessibility, trust, comfort, and trust in the healthcare system. This paper focuses on the findings related to acceptability and accessibility.


Study participants and data collection

PV recipients were recruited at nine monthly events between July 2021 and June 2022. The target demographic for the recruitment effort was pregnant BIPOC people and their families who were receiving services at PV. Inclusion criteria for the present study were: (1) being at least 15 years old, or 18 years old, if not pregnant or postpartum; (2) being a pregnant or postpartum person who participated in at least one PV event; or a family member of a pregnant or postpartum person who participated in a PV event; and (3) able to speak English or Spanish. The goal was to recruit 120 individuals who identified as BIPOC (based on feasibility of recruiting about 10-15 people during each event), with a 70-30 split between pregnant and postpartum people and family members. We enrolled 120 participants but determined four to be ineligible after demographic data review, leaving 116 study participants.


We used a convenient but purposive sampling approach where potentially eligible participants were asked while checking in for PV events if they will be interested in learning more about a study to assess their experience at PV. Those who indicated interest were then approached by the research team, who confirmed eligibility, told them about the study and obtained consent. Participants who agreed to participate in the study were then invited to complete a survey about their experience at PV with the option to complete it on site using a PV tablet or receive a QR code with a link to complete it later online on their own device (most participants completed it on site). All participants provided verbal informed consent and were compensated with a $20 gift card for participating in the survey. Participants were able to take the survey more than once. If they attended multiple PV events, and fifteen individuals did so.  


The survey evaluated various domains of the PV experience. The questionnaire included questions adopted or adapted from multiple validated scales, as well as new items developed by the team incorporating feedback from our community advisory board (CAB) and from cognitive interviews with three pregnant and postpartum people from the Bayview and the neighboring San Francisco Bay Area. 


A subset of participants who agreed to participate in the in-depth interviews were scheduled for one-on-one, semi-structured interviews using Zoom Web Conferencing within four weeks of attending a PV event.  The interview guide was developed using the Theoretical Framework of Acceptability (TFA) to assess acceptability, as well as other questions to assess perceptions of accessibility, person-centered care, community engagement, and trust in the healthcare system. In-depth interviews were recorded, with participant permission, and transcribed for analysis by a third-party transcriptionist. Transcripts were checked for accuracy and clarity by members of the research team. Field notes were also recorded throughout the interviews, and a templated summary outline was created afterwards, which facilitated rapid analysis for model iteration.  Interviews lasted between 30 to 60 minutes and participants were compensated an additional $20 for participation in the in-depth interview. 


Measures

Acceptability


Acceptability was assessed using a 7-item scale adapted from the acceptability of health apps among adolescents (AHAA) scale for the acceptability of health interventions( (5,8). We assessed the following sub-domains of TFA: (1) affective attitude (i.e., how an individual feels about the intervention); (2) burden (i.e., the perceived amount of effort that is required to take part in the intervention; (3) intervention coherence (the extent to which the participant understands the intervention and how it works; (4) opportunity costs (i.e., the extent to which benefits, profits, or values must be given up to engage in the intervention); (5) perceived effectiveness (i.e., appropriateness or the extent to which the intervention is likely to achieve its purpose); and (6) self-efficacy (i.e., participants’ confidence that they can perform the behavior required to participate in the intervention) (2). Response options were structured using a 4-point Likert scale. Negatively-worded questions were reverse coded before generating summative scores and any missing data (6%) were imputed as the mean of other items in the measure. The scores were standardized to range from 0 to 100 to compare between scores. The scales’ psychometric properties within this sample were evaluated using factor analysis.


Accessibility

Respondents’ perceptions of PV accessibility were assessed through an accessibility scale composed of three questions based on investigators’ prior experience conducting research with this target population (Figure 1): (1) “How long did it take you to get to Pop-Up Village from where you typically stay?” (2)“How do you feel about the time it took you to get to PV?”. (3) “Compared to how you access your usual sources of care and resources, would you say the services at Pop-Up Village are…?”. The responses to the three items were summed and then standardized to range from 0 to 100 for comparison between scores, where a low accessibility score is indicative of poor accessibility. Any missing data were imputed as the mean of other items in the measure.


Predictor Variables

We examined associations between acceptability and accessibility and the following sociodemographic characteristics, experiences of discrimination, and pregnancy and obstetric factors: age, gender, race and ethnicity, education, residence, employment status, receipt of public income assistance, language, English proficiency, housing status, support, medical insurance status, food insecurity (9), relationship status, experience of everyday discrimination (10), experience of discrimination during prenatal care encounters (10), pregnancy status, parity, prenatal care attendance, number of preterm birth pregnancies, and pregnancy loss history.


Statistical Analyses 

We used descriptive statistics to examine the respondents' sociodemographic characteristics, acceptability scale and accessibility scores. Prior to bivariate analysis, missing responses to the experience of everyday discrimination and experience of discrimination during prenatal care encounters questions were recoded to “sometimes.” Response options to the housing status question were recoded accordingly as seen in Table 3.  Additionally, Response options to the accessibility items were recoded as seen in Figure 1. Bivariate analyses of the predictor variables – sociodemographic characteristics, experiences of discrimination, and pregnancy and obstetric factors – and outcome measures – acceptability and accessibility – were then evaluated using crosstabulations to express the bivariate clustering distribution of the predictor and outcome variables, as well as regression to examine statistically significant associations. Statistically significant predictors (p<0.05) were considered for inclusion in multivariate models. Multivariate models were refined through excluding closely related variables identified through collinearity tests and model fit assessment. To account for clustering given some respondents answered more than once, we estimated linear mixed effects models. We performed sensitivity analyses in which duplicate responses were excluded and “Not applicable” responses were recorded to missing and excluded from the analysis. STATA (version 14) was used to conduct all analyses and differences were considered statistically significant at p<0.05.

 

Qualitative Analysis

We used a framework analysis approach to analyze the data (11). The qualitative lead (OJO) developed an initial deductive codebook based on the interview guide (5). Six analysts (OJO, PD, KV, EK, HS, and KM) independently coded transcripts using Dedoose software, and two transcripts were reviewed collaboratively to ensure inter-rater reliability. We compared and discussed coding in detail, refining the codebook and adding inductive codes. The remaining transcripts were coded individually by balanced pairs of analysts, and the qualitative lead reviewed the coding to ensure consistency. Codes related to acceptability of the PV model and accessibility of PV services were then queried and evaluated. Analytic summaries for the codes were compiled in a framework table as follows: (1) anticipated affective attitude; (2) experienced affective attitude; (3) self-efficacy; (4) perceived effectiveness; (5) usefulness of PV services; (6) appropriateness of PV services; (7) barriers to access; (8) facilitators of access; and (9) service recommendations and suggestions for improvement. 


Results 

Quantitative 

Participant Characteristics     

Respondent’s sociodemographic and reproductive health characteristics are summarized in Table 2. Half (50%) of respondents were currently or recently pregnant (within the past year). Nearly half of participants were between 25-34 years of age (27%) or 35-44 years of age (22%). Forty-one percent of respondents identified as Black or African American, and 36% identified as Latine. Forty-five percent had an educational level beyond high school, and 18% had not completed high school. About two-thirds (64%) of respondents reported being unemployed, and close to half (47%) on income assistance. Two-thirds (66%) of respondents had public health insurance. Forty-two percent of respondents were single and 32% lived with a romantic partner. 20% of respondents reported a history of at least one preterm birth, and one-fourth (25%) a prior pregnancy loss.      


Acceptability of PV Model

Mean acceptability score was 91.9 (SD = 14.4) overall, 90.5 (SD = 15.7) for pregnant and postpartum recipients, and 93.4 (SD = 12.9) for family member recipients (Table 2). 

     

 Relationships between sociodemographic characteristics, experiences of discrimination, and pregnancy and obstetric factors and acceptability of PV

In bivariate analyses, respondents who spoke Spanish, had limited English proficiency, at least one preterm birth, preferred not to disclose their medical insurance status, did not disclose their food insecurity status, and reported experiencing discrimination during prenatal care encounters on some occasions had lower perceptions of PV acceptability than respondents who spoke English, reported to be proficient in English, did not report a history of preterm birth, had private or employer-provided insurance, reported no food insecurity, and reported never being discriminated against during prenatal care encounters, respectively (Table 3; appendix 1). Respondents who reported to worked part-time, owned a home or apartment, and reported food insecurity on some occasions had higher perceptions of PV acceptability than those who were unemployed, lived in a homeless shelter, and often experienced food insecurity, respectively. In our final multivariate model for acceptability score (Table 4), acceptability score was found to be significantly associated with language, medical insurance, and experience of discrimination during prenatal care encounters. Respondents who spoke Spanish scored, on average, 7.9 points lower than those who spoke English (95% CI: -15.6 - -0.2). Respondents who reported to have no medical insurance scored, on average, 13.3 points lower than those with private or employer-provided insurance (95%CI; -26.2 - -0.4). Respondents who reported discrimination during prenatal care encounters scored on average, 10.2 points lower than those who reported no experiences of discrimination during prenatal care encounters (95% CI: -15.5 - -5.0).



Accessibility

Mean accessibility score was 76.0 (SD = 21.0) overall, 73.7 (SD = 24.4) for the pregnant and postpartum recipients, and 78.5 (SD = 18.6) for family members (Table 2). 


Relationships between sociodemographic characteristics, experiences of discrimination, and pregnancy and obstetric factors and accessibility perspectives

In the bivariate analyses, respondents who were between ages of 25 and 34, reported limited English proficiency, worked full-time, lived in other areas of San Francisco, reported “somewhat” when asked if they had support, had no medical insurance, and experienced discrimination during prenatal care encounters on some occasions had lower perceptions of PV accessibility than respondents between the ages of 15 and 24, proficient in English, unemployed, lived in the Bayview, reported “definitely” when asked if they had support, had private or employer-provided insurance, and reported no experiences of discrimination during prenatal care encounters. Respondents who reported to own a home or apartment and were single had higher perceptions of PV accessibility than respondents who lived in a homeless shelter or were married or partnered and living together (Table 5; appendix 2). 


In our final multivariate model for accessibility score (Table 6), accessibility was found to be significantly associated with English proficiency level, residence, support, medical insurance status, and experiences of discrimination during prenatal care encounters. Respondents who preferred not to disclose their English proficiency level scored, on average, 19.6 points lower than respondents who reported to be proficient in English level (95% CI -33.1 – -6.2). Respondents who lived in other areas of San Francisco, on average, scored 17.9 points lower than respondents who lived in the Bayview (95% CI -25.0 – -10.9). Respondents who reported not having any medical insurance scored, on average, 30.0 points lower than those who had private or employer-provided insurance (95% CI -48.2 – -11.8). Respondents who experienced discrimination during prenatal care encounters on some occasions scored, on average, 8.7 points lower than those did not experience discrimination (95%CI: -16.6 - -0.8).


Sensitivity analyses

The sensitivity analysis of the acceptability score, in which missing and duplicate responses were excluded, resulted in an equivalent standardized average acceptability score of 90.8 (SD = 15.2) for the main sample (N = 85), 90.7 (SD = 15.8) for pregnant and postpartum respondents (N = 46) and 91.0 (SD = 14.6) for family members (N = 39). Regarding the accessibility score, the sensitivity analysis in which “Not applicable” responses were recoded to missing values and duplicate responses were excluded resulted in an equivalent average accessibility score of 75.1 (SD = 23.0) for the main sample (N = 87), 72.0 (SD = 24.9) for pregnant and postpartum recipients (N = 47) and 78.8 (SD = 20.2) for family members (N.= 40). 


Qualitative 

Overview of findings

Most participants reported positive sentiments regarding PV and stated that it either met or exceeded their expectations, noting PV’s inviting environment and provision of pregnancy-related resources and information. Recipients also reported they felt good participating in PV due to PV’s community-centered, vibrant, and healing environment. In addition, recipients said they felt welcomed and valued at PV. However, a few recipients reported their expectations not being met because they did not receive adequate guidance about services available to them. The majority of recipients reported high self-efficacy in accessing services at PV and outside of PV, owing to the excellent referral system and plethora of resources and information. However, a few recipients reported low self-efficacy in accessing resources, claiming a lack of awareness about services available to them. PV was highly effective, according to recipients, since it met the needs of the community, cultivated an uplifting environment, and centered black women. Provider responsiveness, reduced wait times, and PV’s physical infrastructure all facilitated access to services. Despite the minimal burden of accessing PV services, reported barriers to access included a lack of language-concordant navigation services for Spanish-speaking recipients and provider follow-up. We summarized the data using six deductive domains on acceptability of PV based on the TFA (5), as well as facilitators and barriers of access to services at PV.  


1.1  Affective Attitude

Affective attitude, how the study participants felt about the intervention, includes two sub-themes capturing anticipated and experienced expectations.


1.1.1  Anticipated affective attitude

In response to questions about their expectations of PV prior to attending an event, some respondents noted they expected PV to be a health fair – a venue to receive resources and information about pregnancy. When reflecting on their experience at PV, respondents reported that their expectations were met, noting the inviting and uplifting atmosphere, the plethora of resources, and their increased awareness and knowledge about services to help ensure a positive pregnancy experience. Narratives from pregnant and postpartum participants about how PV met their anticipations included the following:    

  

 “[I expected PV to be] kind of similar to what it is. So, definitely organizations and businesses who have resources for pregnant people. Yes. Mainly that. Mainly resources. I didn’t expect there to be that many giveaways for pregnant people, or services in terms of massages. So, more just like resources, knowing like, 'Hey, this is where you can get XYZ. This is available to you here in San Francisco.' And the education part I kind of did expect, like the breast-feeding education.” Pregnant      recipient, less than 30 years old 


     “Before I came, I thought it would be kind of like – basically, kind of like it was – kind of a street fair kind of vibe, different providers – things like that. Yeah. That’s what I thought. Because I heard that it was going to be very resource-based. So I kind of knew. I've been to events like that before. So it seemed in line with what I was thinking.” – Black Postpartum recipient, 45 years old or above


A few respondents, however, did not have any expectations of the event as they were unfamiliar with community-centered events where people can learn about and receive resources. For example, one pregnant/postpartum respondent noted:


 “Well, you know, I was just – I didn’t have any expectations. I didn’t – I never heard of anything like that, never been to a community gathering of that such. So, I didn’t have a whole lot of expectation. But, as I read the flyer and read the different organizations that were going to be there, I kind of felt good about attending and felt like it was worthwhile.” –  Black family member, less than 30 years old 


 

1.1.2. Experienced Affective Attitude

In general, respondents described the PV atmosphere as positive, vibrant, community-centered, down-to-earth, and healing. When asked how they felt upon arriving to PV, respondents expressed feeling welcomed, excited, and filled with anticipation. Participants appreciated the environment, the services, and the resources that were provided. For instance, one Black postpartum respondent 45 years old or above had this to say:


“I was happy. I was like, 'Wow. Look at all of this.'[…] because I had my son there – he’s, you know, seven-and-a-half months. And I was like, “Look!” You know? He really loved the color of the tents and the way the tents were kind of blowing in the wind. He loved the live music. It was just like, “Wow. Okay. Yes.” And it was like it was our first time being out in community ever. And so I was pleased that it was such a warm, welcoming, fun environment for us to walk into. You know? You walk in and you see like the bags of groceries that, you know, were being handed out and things like that.” 

 

Respondents also expressed their delight and appreciation for the new services and resources that were added at each event, which was unexpected.  

“I was excited to see what was new - because you guys don’t always have the same things; sometimes what you all give away and what you all do for us is unexpected, especially for the resources. I didn’t think the CalWORKS people were going to be there for the moms that don’t have any type of income.”  Multiracial pregnant recipient      

 

Some respondents' recollection of their initial impressions of PV included that it was a community-centered and curated space for Black people to come together to enjoy each other and learn about pregnancy-related services and resources.  Respondents noted that they felt at home because they were comfortable being with other Black people or other mothers to be free and openly do the things they want to do without judgment. 


“I felt kind of like at home. Because I wasn’t like the only one pregnant or there was mothers that was there that were very comfortable breastfeeding and stuff. So seeing that was like, oh, this is a place for us to just be open and free without no judgment.” – Multiracial Pregnant      recipient, 30-44 years old (P2522).


“It was about seeing Black people coming together without fussing or arguing. We were there, we enjoyed each other, we laughed. That makes you feel good when Black people come together and everybody enjoys themselves..... “I looked around. I’m like, 'Wow, this is neat. This could help a lot of young girls.' You know, teach them. That’s what we need to do is teach them the right way.”” – Black family member recipient, 45 years old or above

 

The community-centeredness of PV was especially relevant in the context of the social isolation people felt during lockdown. A Black postpartum respondent 45 years old or above – who was pregnant during the early phase of the COVID-19 pandemic – noted how it was healing to be out with other mothers in the fresh air and sunshine: 


“Because I was pregnant from 2020, all the way through 2021. That was like the height of when everything was like shut down, isolated. We were having fires. I couldn't go outside to walk even, hardly. It was just like very – it was extremely isolating. And, so one of the benefits that I don't think that you all are necessarily picking up on is that, for people who have been isolated because you're trying to follow COVID protocols and all of that, it was healing to just be out in the fresh air, in the sunshine, with other mothers. Like that, in and of itself, was the healing thing for me.” 


     When asked to reflect on their experience at PV, respondents held positive feelings about their time, with several appreciating the newly learned information regarding resources. A Latine family member less than 30 years old stated that that she felt comfortable at Pop-Up because she was able to learn new information: 


“I felt comfortable because I know that there are many more things to learn about, more than what I knew. I knew that there were groups and that they did meetings and everything, but I did not know that there was one like the one I went on Saturday. I walked, learned new things; know things and you inform yourself of more things.  I liked that a lot.” 


Upon reflection, respondents stated that attending PV had made them more aware of the things that they shared with people in their community, which for some, had given rise to a desire to become more actively involved in their community:


 “And going to the pop-up, I really since then, it just opened my eyes to there’s so many people out there that I have common ground with. And we can all work on ourselves together. We could help each other. Some people don’t know where to start. So, that’s where I’m at. It kind of inspired me to definitely see what I could do for my community. But first, yeah, I felt very good.” – Latine postpartum recipient, between 30 and 44 years old

 

 Most respondents said their expectations were met, with some acknowledging that their expectations were exceeded. Respondents cited the plethora of resources and services, including resources that catered to physical, psychological, and spiritual enrichment, and the feeling of being valued and acknowledged, as reasons for their expectations being met. For example, a Black pregnant recipient between the ages of 30 and 44 years old noted that she appreciated the pregnancy-related and childcare information she received at the Village: 


“They [ My expectations] were met. I received a lot of information from different groups on childcare, doula services, even when the baby starts growing her first teeth, even a dentist that’s nearby my house. And, chiropractic services for pregnant women - didn't even know you can get realigned as a pregnant woman.” 


Others noted that their expectations were met because they felt acknowledged and valued at the Village, as one pregnant person less than 30 years old shared: “I really felt acknowledged and seen, and people were really trying to take care of me because they saw that I was pregnant” 

 

However, a few respondents reported that their expectations were not met due to having inadequate guidance regarding the resources available to them, as a Latine postpartum respondent between 30 and 44 years old said that no one initiated contact with her and helped her navigate the various resources at PV: 


“Yeah, so once, once again I have, you know, a totally different expectations, so when I went there and I see just a bulletin and nobody, nobody like welcoming you, you know, but if someone doesn’t know anything, like where do you go. I just had to ask around, and they told me, like, “okay, you can get some information here in that first booth.” But I didn't really get that well information”  


 

1.1.3      Self-efficacy

Self-efficacy is defined as respondents’ confidence in accessing services at PV, as well as outside of PV. Overall, respondents were very confident accessing services at PV, as well as outside of PV after attending.  Respondents attributed their increased confidence to PV’s strong referral system learning about new services, and receiving adequate information from service providers: 


“ I feel like it was a linkage sort of situation. So that, if I needed something more extensive, then I would have the information to know like where to go, who to talk to – all of that – maybe even set up an appointment. So that, when I did need to go and access that deeper level of services, I could go out into the community, and then do that.” – Black postpartum recipient, 45 years or older      

 

 “What I liked about it was how it was so informative. She had more of an idea of what to expect after and before – I should say before and after. And she also was very confident about getting the necessary help before and after as well.” – Black family member, less than 30 years old  


“Honestly, I guess it helped my confidence in a way to know that there are these resources out there instead of just regular checkups. If you need help with like finding food or insurance, I know that I can come here, and they can help me.” – Latine postpartum recipient, less than 30 years old      


However, a few respondents stated that PV didn’t increase their confidence in accessing the services they needed due to lack of knowledge of the services that providers offered to community. For instance, a Latine pregnant person between 30 and 44 years old said that PV didn’t increase her confidence because she didn’t receive information from organizations where she was not a recipient of their services:


 “I don’t think so, I mean, the only, the only things that I saw that it was convenient for me was the programs that I already know. But anything else that I don't know, I don't know. The Homeless Prenatal, like I've been a customer before. And then for, for WIC, you know, I’m a client already. So anything else, I have no idea.” 


1.1.8 Appropriateness

Respondents generally found the services appropriate for a pop-up setting. Some respondents perceived services to be appropriate because they were aimed at meeting the needs of the community, including resources for children:  


“I feel like they're appropriate because the need is so great right now. A lot of people are on hard times. A lot of people are struggling. And, with these organizations being implemented the way they have to help families, it just, you know, it just kind of lightens the load. It gives me just that great feeling of knowing – even though I’m on hard times right now – that I don’t have to worry. Because I can get the help that I need until I’m in a better place and can do better for myself. So I feel like it’s totally appropriate.” –  Black family member, less than 30 years old 


“But I went to the childcare table – this was a great thing. They had, you guys had everything from pregnancy, all the way up to childcare. And that's something the parent needs, and that's something, especially being in a congested city like San Francisco, you have to plan ahead of time for childcare and school. That's something you really have to think about, because at those ages, from birth to five years old, those are critical years because their brain is soaking up everything.” - Black pregnant recipient, between 30 and 44 years old


Other respondents found the services appropriate because they were meant to help pregnant and postpartum women and found that the services aligned with the mission of PV. For example, a Multiracial pregnant respondent less than 30 years old  stated: 


“Because everything has something to do with your health and pregnancy or having a baby. So, all the resources there were for the definition of pregnancy pop-up I felt like. Any service that you feel that you needed, if it was a massage, or acupuncture, or diapers, it all would come back to pregnancy.” - Multiracial pregnant recipient, less than 30 years old 


Respondents felt the services were appropriate because it provided education about pregnancy; a pregnant respondent less than 30 years old (S6997) explained the lack of support and guidance pregnant people have regarding breastfeeding and how PV services helps to fulfill this need: 


“Even though I have already been through breastfeeding when I first started with my first child, I realized it is really something that women need support on. Even though it is natural, it doesn’t come natural to a lot of people. And just knowing that there was this booth that really educated people on the latch, and how breast milk is established, and that it might take a while.” - Pregnant recipient, less than 30 years old 


A few respondents, however, thought some services were inappropriate for a pregnancy pop-up setting due to a perceived lack of pregnancy-related services, as explained by this Latine pregnant respondent between 30 and 44 years old : 


“Once again, I went for information for pregnancy related, and when I went there, I didn't find anything kind of related at least, you know, with my eye at the beginning. And then I guess it was a couple of books for that, but I didn't see anybody, or was expecting to see more people, you know, kind of with a similar concern that I have, and I see nobody.”


 

1.1.4 Perceived Effectiveness

The perceived effectiveness of PV was generally positive for the respondents. Respondents said PV was effective because it cultivated an uplifting environment that centered around black women. A Black pregnant recipient between 30 and 44 years old had this to say:


 “I think they did a good job of providing that really positive atmosphere. Especially I feel like it was centering around women of color and black women, and sometimes we will often feel like society look down, like “oh you are pregnant and [inaudible].” I think they did a good job of making it feel like a positive thing you're pregnant.” 



Other respondents attributed the effectiveness of PV to its ability to meet the needs of the community. For instance, a Multiracial pregnant respondent appreciated PV’s outreach to community and their ability to deliver resources in an accessible way:


“I like that you guys like to be part of the community and you like to see what is going on in the community. And it is really hard right now, especially to be homeless, and not have a lot of resources - that’s one thing I like - for you guys to go and give back to the community and say “Hey, we have resources. We want you guys to come out and have a good time as well.” And on top of that, it also helps with depression.” - Multiracial pregnant recipient, age unknown 


“Because there were services where there were people that actually came to me to assist me with things that I needed, as far as items, and then, assistance with like the nurses coming to your home. So, I mean I didn’t get that part yet. But I already did like the little intake or something. So just knowing that I may have help at home is kind of a relief.” - Multiracial pregnant recipient, between 30 and 44 years old       


The same respondent added that PV was able to successfully connect her to additional organizations and resources: “I received a lot of services that I didn’t have, compared to when I got there. Like I say, I was assisted with one or two programs. But now I feel like I’m connected with like at least five.”

 

1.1.5 Burden/Barriers to access 

Though respondents reported experiencing a low burden accessing and receiving services at PV, some respondents discussed difficulty accessing services at the Village. Respondents, for instance, attributed their burden in learning about services to a lack of navigators providing guidance on available services at the Village:


 “Like somebody you know, can approach you, and can give you details, and maybe people already know, you know, people go there and know what it is for, but I have no idea what it was, you know. I thought it was going to go like a meeting with these kind of people, and then I didn't see anybody, so I was confused. And nobody explained it to us, until someone told me, you know, “you can go there and get some information.” So, I said maybe I went to a different place. I guess it's just me, you know, my expectations, I was going to a prenatal group, according to me.” – Latine pregnant recipient, between 30 and 44 years old 

   

“I really liked everything. I think that they should improve a little more. It was hard for me a little when I arrived to look for someone who spoke Spanish.  We know English, but we would like to speak more Spanish, as in the entrance there should be someone who speaks Spanish […] I have almost seen that there are more people who speak Spanish and sometimes people walk by [a service], but since they do not know what it is, they do not come close.” - Latine family member, less than 30 years old


Other respondents commented that the layout of the PV made it burdensome accessing services:


 “The arrangement, and, when you, when you get there, I have to go, I have to go, you know, to each booth to kind of see what they were offering. So, when you go there, like people probably expect you to know, you know what they're offering. And maybe because I'm coming here with WIC already, I knew what they were offering, and I could be more, you know, effective with my, with my question, so, at least you know tell them a little bit more, what about my needs, but you know the other booths, I didn't know anything.” - Latine postpartum recipient, between 30 and 44 years old 

 

Some respondents noted that that they received an overwhelming amount of information, thus making access to services more burdensome, as a Black pregnant respondent between 30 and 44 years old explained: 


“I think that’s what I was saying earlier; it was a lot of information. I have like four flyers of things that I am going to follow up with. I really hope people will call me back, because I don’t even know- with baby brain [ laughs] I’m like I don’t remember anything. But with the flyers, I do plan to look into the resources.” – Black pregnant recipient, between 30 and 44 years old 


A few respondents noted that lack of follow-up from providers after the event made it difficult to access the services they needed, as this respondent recounted of their experience: 


Well, with [X organization] my experience was good up until they didn’t call me back. They didn’t follow up. So, I was like they were not accountable for their word. So, I felt like that was pointless because that was like the main focus of why I wanted to go. And that’s why my doctor encouraged me to go, to get that interaction with them and to set that all up with a doula.”- Multiracial pregnant recipient, less than 30 years old


1.1.6 Facilitators of accessibility 

Respondents cited provider responsiveness, short wait times, and the physical infrastructure of PV as facilitators to accessing services at PV. When asked what made it easier for them to access services, respondents said provider’s willingness to meet them where they are at and working to meet their needs, as a Multiracial pregnant respondent less than 30 years old explained: 


“Because you can go up to them, but 9 times out of 10, they are going to come up to you and ask you, “Do you need some of these services?” or “Try this service out.” Because I never got any acupuncture before and that was a new experience for me. But she reached out to me. I didn’t – it wasn’t like I was going over there, so yes.” 


Other respondents said that services at PV were easier to access due to the short wait times, as respondent stated that typically waited a few minutes to before they engaged with providers: 


“And it wasn’t like a long line. It was just like, if I walked to the table, I would be like the first person or like the third. But it wasn’t like a long wait. So, it was like I got to visit majority of all of the programs.” –  Multiracial pregnant recipient, between 30 and 44 years old


Respondents also stated that services were easier to access because infrastructure enabled the services and resources to be highly visible and therefore more accessible, as a pregnant respondent less than 30 years old (S6997) stated: 


“I think the set-up and the location were pretty beneficial to making sure it is accessible, meaning it was this row, and on the left and the right, all the tents were popped up. So, if you were just walking down, you just passed by all the booths and you had a chance to look at what people were offering. Nothing was hidden or in a corner where you weren’t really able to reach it, especially with the stroller that I had for my daughter.” - Pregnant recipient, less than 30 years old 


1.1.7 Usefulness 

Respondents generally found the services and resources provided at PV useful. Some respondents cited pregnancy and postpartum-related education and mental health support as a reason for PV’s perceived usefulness. For instance, a Black family respondent 45 years old or above found PV useful because it taught pregnant and birthing people crucial skills related to infant care, such as newborn hygiene and nutrition:


“Well, at the one table that was in the middle, I overheard them talking about how to give baby a bath, how to do this with your baby, do that with your baby. That was so cool because I saw people with babies and stuff.] I was kind of listening a little bit. They were sitting there talking about their kids, what their kids do, what their kids eat, what they didn’t eat, what’s good for them and what’s not good for them. And that’s what they need. They need to know more about baby nutrition.” - Black family member, 45 years old or above 


“Because she said it was supposed to help just me not being in pain and being tense. Something like that she said. And that it would help – and it was a moment where you could just relax and close your eyes. So, that was helpful for me for that, and it did help.” - Multiracial pregnant recipient, less than 30 years old 


Several respondents found PV useful because they offered educational resources for children and children-related activities at the events. A Black family member 45 years old or above, for instance, had this to say:


 “I saw how they were with the kids. The little kids were up there drawing, doing all this stuff. You know, they were really, I think they were really supportive, helping all the little kids up there doing the thing.”


Service recommendations 

Recipients shared recommendations to improve the PV model. These included provider follow-up, better navigation of services, food, children-related activities and resources, education, mental health services, and community outreach.


Provider follow-up 

Recipients recommended that Pop-Up Village providers should follow up with individuals learning more about their services. For example, a recipient had this to say: 


“I mean, because I wasn’t necessarily looking for stuff, it’s not like I signed up for anything or left my information at booths. But I’d see it being helpful if I was really was looking for something that – you know, after I had that initial conversation with someone at the pop-up, that they would take down my contact information and followed up with me to see if they could support me in registering for something, signing up, or getting something, or asking if I needed anything else. Yes. I think that could be really useful.” –Pregnant recipient, less than 30 years old



Service navigation 

Recipients recommended improving navigation of services by having navigators guide visitors throughout the village and informing them of services that may be useful to them:


 “Yes, because from the first time we went, I got practically no information. They gave me diaper and things like that, but no information. Because we actually arrived at like 1 and it was like everyone was too scattered, so it wasn't informative at all. I feel that, if a person goes for the first time, someone should help them go through the different providers and make sure they go through everything. Because sometimes they may not need that resource, but it's never a bad thing to have.” – Latine postpartum recipient, between 30 and 44 years of age


Relatedly, recipients also indicated the need for more Spanish-speaking navigators to help guide Spanish-speaking visitors throughout the Village:

“ I really liked everything. I think that they should improve a little more. It was hard for me a little when I arrived to look for someone who spoke Spanish and then it is the only thing I would say if other people arrived as well as me.  We know English, but we would like to speak more Spanish, as in the entrance there should be someone who speaks Spanish.”  – Latine family member, less than 30 years old


Food

Recipients recommended more provision of snacks and lunches, especially for pregnant individuals who need to eat more often to help ensure a healthy pregnancy: 

"When I was pregnant, I was always hungry. So having some like boxed snacks would be helpful. I know it’s hard because everybody’s thinking about COVID and wanting to be, you know, safe and all of that. So that’s why I’m saying like prepackaged, boxed snacks that you could just pick up as you're walking by or whatever. That would have been really helpful. Like, when I was pregnant – and especially during the last few month- like month of my pregnancy – I had really bad heartburn. And so I would have heartburn before I got pregnant – I mean I would have heartburn when I was hungry, and then, afterwards, when digesting.  So like I needed – okay – hold on. I think I’m having a delivery right now. Let me just go handle that.” – Black postpartum recipient, 45 years old and above


Education

Recipients recommended providing more pregnancy-related education sessions, including how to have a safe pregnancy:

 It’s like to give them the awareness what to eat, what kind of the nutrients. You know. What you used to eat before you're pregnant and when you're pregnant is so different. To be very careful with the food you eat for baby’s life. Yeah. So how much water – like fluid they should drink. Not too much juices or sugar. For the life of the baby, they should know those things – the movement they should make, exercise, walk, avoiding stress, not to drink or to eat unnecessary stuff and food, and to feel how the baby inside them – to give attention. Yeah. Those things can be told.”- Black pregnant recipient, between 30 and 44 years of age



Mental health services

Recipients recommended providing more education and services related to mental health, particularly regarding postpartum depression and the stress of caring for a newborn: 


“I think they did have a booth for like mental health support. But definitely more education around health and depression, and the fourth trimester, and post-partum essentials that are really helpful for a mother for recovery, and then also for a baby. Just that it’s not just about the pregnancy or when you give birth, but then the first few weeks or the month after that might be really intense on women.” – Black pregnant recipient, less than 30 years old 



Child activities and resources 

Recipients recommended having more childcare services tailored for mothers and children to engage together:

“ If you guys have like some sort of guided mommy and me activity like with music and stuff like that, where you could just kind of come over with your baby and be led in some like movement activities and stuff. That would be fun.” – Black postpartum recipient, 45 years old and above 


 “ There should be something focused on young children, because there are many small children […] I have two children, one aged 9 and one newborn […]  They had like buff chair, my son was sitting there, and I noticed that almost all the stands have books. So, it would be a good idea if you bring the books where the buff chair are so that the children would be there. Or some ball with a small goal where children can play – Latine postpartum recipient, between 30 and 44 years of age


Infrastructure 

Recipients recommended improvement to the PV infrastructure such as providing more comfortable seating areas: More or less, I feel so. But I think for pregnant women, there should be more seats and chairs. As pregnant woman get tired and you want to rest, and there are very few seats from my point of view. – Latine postpartum recipient, between 30 and 44 years of age


Community outreach 

Recipients recommended that PV conduct more outreach to community, so more people can now about the services available to them: You guys had a lot there. You guys have food, books to give out, diapers. And I think overall, I wish more people knew about the event, because it was such a good opportunity for many people to get things. I guess more of just outreaching, letting people know that it's there and it's provided to the community. – Latine postpartum recipient, less than 30 years old



Discussion

The primary aim of this study was to understand PV recipients’ perceptions of acceptability and accessibility of the PV model, with a secondary aim of identifying participant factors associated with these outcomes. We found that recipients’ perceptions of acceptability was high with factors, such as language, history of preterm birth, medical insurance, food insecurity, and experiences of discrimination during prenatal encounters, being associated with acceptability. After controlling for other covariates, we found that recipients who spoke Spanish, had no medical insurance, and reported discrimination during prenatal care encounters on some occasions had poorer acceptability scores than those who spoke English, had private or employer-provided medical insurance, and never experienced discrimination during care encounters. The qualitative findings support the quantitative results such that many recipients found PV to be highly acceptable due to its vibrant, healing, and community-centered atmosphere; high perceived self-efficacy in utilizing services; and perceived effectiveness of the PV model in meeting the needs of the community. We also found that recipients perceived PV to be very accessible. After controlling for other covariates, we found respondents with limited English proficiency, had no medical insurance, and experienced discrimination during prenatal care encounters on some occasions had lower accessibility scores than those proficient in English, had private or employer-provided medical insurance, and had no experiences of racism and discrimination during prenatal care encounters. Though recipients found PV to be highly accessible due to short wait times and the physical infrastructure, respondents also noted barriers to access, including lack of navigators and language barriers. Overall, PV met recipients’ expectations and was found to be very welcoming, community-centered, vibrant, suggesting that this model is well-accepted and easily accessible by the community, and offers a pathway to improve the experiences of BIPOC pregnant and postpartum people and their families. 


Recipients ascribed their positive feelings about PV and, ultimately, their acceptance of the PV model to PV’s vibrant, friendly, and healing atmosphere. There is a large corpus of literature on the effect of the built environment on people’s emotions. The human experience is characterized as the impact of space on people’s mood, level of comfort, and engagement with their surroundings, and changes in architectural design features (e.g., openness and connectivity of spaces) (12–14). PV is hosted outside and has an open layout with brightly colored tents and seating areas, as well as a multitude of activities and services. Previous research has demonstrated that aspects of a restorative setting – natural daylight, absence of windows, openness and an aesthetically pleasant layout, and exposure to nature – can affect perceived restorativeness (14). Furthermore, a scoping review of the relationship between human experience and the built environment found that built environments with restorative elements are associated with positive moods (14). Recipients also stated that the welcoming environment at PV contributed to their acceptance of the PV model. A welcoming environment is one in which people feel themselves represented and reflected, and in which everyone is treated with respect and dignity – an environment that values all cultural identities (15). One reason for this finding is that a welcoming environment gives people hope because it allows them to meet new people, learn new things, and improve their health and wellness (16). These activities have the potential to improve one’s affect as well as one’s overall health and wellness, suggesting that a welcoming environment may be one of the avenues for increasing one’s affective attitude, and eventually, their acceptance of a community health intervention like PV (16–18).


 Recipients also reported that the community-centeredness of PV contributed to their acceptance of the model, particularly in light of the COVID-19 pandemic. This finding can be interpreted as visitors experiencing social support while observing and practicing health-promoting behaviors such as participating in food demos, dance classes, yoga classes, and sharing circles, all of which are provided at Pop-Up Village events, thereby influencing one’s perceived acceptance of the PV model (19–21). Research has demonstrated that a sense of community is positively associated with problem-focused coping practices that strive to address underlying issues, such as lack of access to resources (40,43,44), and other studies  that have found that a lack of a sense of community is associated with a decrease in problem-focused coping behaviors (19,24,25). Additionally, a sense of community has been demonstrated to be positively associated with a stronger ability to perform health-promoting behaviors, which may contribute to recipients’ acceptance of the PV model (23). 


Recipients also linked accessibility of PV to it increasing their confidence in accessing and utilizing available resources both within and outside of the Pop-Up Village, implying that the intervention promoted self-efficacy. Learning about resources and having enough information about resources, in particular, increased recipients’ perceived self-efficacy. This finding is congruent with the findings of a meta-analysis, which indicated that persons who participated in public health interventions aimed at disadvantaged populations, such as PV, had considerably higher reported self-efficacy then those who did not (26). This may be explained in part by the health literacy-focused activities provided at events like PV, which has been linked to increased perceived self-efficacy in several studies (27–29). Given the unknown directionality in the relationship between one’s overall perceived self-efficacy and self-efficacy influenced byPV, it is possible that Pop-Up Village recipients who reported high perceived self-efficacy are more self-efficacious in terms of performing health-promoting behaviors, as previous research has found that people with higher self-efficacy are more likely to engage in health-promoting behaviors, such as participating in Pop-Up Village (30,31). This, in turn, may explain why recipients accept the PV model. 



     Recipients attributed PV’s perceived effectiveness in linking community to services and resources through to its referral system. This is significant because previous research has demonstrated that for black birthing populations, limited community resources and structured-referral provider networks result in higher rates of inpatient hospital-based treatment versus care in community-based settings (32–34). We also found that recipients’ perceived effectiveness was linked to PV’s capacity to meet their needs. This is consistent with a qualitative study evaluating the perceived effectiveness of a web-based mental health intervention, in which they found that functionality of the intervention – the quality of an intervention being able to serve the user’s purpose -contributed to participants’ perceived effectiveness of the intervention (35). Similar to our findings, they also found that the content of the intervention – content that was detailed and appropriate to the user – contributed recipients’ perceived effectiveness of participating in the intervention (35). Relatedly, a systematic review of community peer-based interventions for those with spinal cord injuries found that perceived effectiveness was linked to the intervention’s ability to address critical unmet needs of the participants (36). 


Our quantitative findings also revealed that recipients who experienced discrimination during prenatal care encounters scored significantly lower on acceptability than those who did not. One possible explanation for this significant association is that recipients’ earlier experiences with discrimination while seeking care, or prior unfavorable experiences with organizations that provide services at PV, may have influenced their perceived acceptability of the PV model. A qualitative study that explored the acceptability of social care interventions supports this notion. They found that previous negative experiences accessing care and services – ranging from patients’ knowledge of resource limitations, ineligibility for them, and the limited capacity of their healthcare team to address social risks – were reasons participants perceived social care interventions to be unacceptable (37). Furthermore, the study found that earlier experiences of discrimination were a reason why individuals rejected social care interventions (37). As a result, providing culturally sensitive care is critical to dispelling misapprehensions about perinatal care; one of the pillars of the PV model is to provide respectful, anti-racist care. We also found respondents with a history of at least one preterm birth had significantly lower perceptions of PV’s acceptability than those with no history of preterm birth. This could be due to the far-reaching consequences that preterm birth has on families, potentially negatively influencing their perceptions of the PV model. For instance, a previous study found that parents of infants/children born preterm associated their preterm birth experience with trauma, low expectations, and feelings of helplessness and despair (38). Furthermore, research has shown that families who have experienced a preterm birth are at a significantly higher risk for depression, post-traumatic stress disorder, and poorer overall well-being, with these ill effects reported to persist for a significant time, particularly following very preterm birth (39–46). 


The burden of participation reflected the effort required by recipients to participate in and access PV events and services, which influenced their decision to continue receiving care and resources through PV. Some recipients reported difficulties navigating services, language barriers, and perceived distance to PV as barriers to access. Although the resources provided at PV were viewed as valuable and useful, participants’ difficulty interacting with the resource suggests that there is a need to optimize service linkage and delivery, even in community care settings such as PV. Our qualitative findings reveal that recipients, particularly Spanish-speaking recipients, had lower perceptions of the PV model’s accessibility due to the language barrier, making it more difficult for recipients to obtain the services they needed. This is consistent with research indicating that a language barrier is an obstacle among migrant and diverse women who seek prenatal care (47,48). We also discovered that individuals who reported having no insurance found PV to be less accessible than those who had private or employer-provided insurance. Uninsured recipients encounter several barriers to access, resulting in missed care and poorer health outcomes, and hence may require more comprehensive care (49,50). While community health interventions such as PV help to minimize the gap in care access disparities, they may not entirely address the barriers that uninsured persons encounter (51), For example, while uninsured recipients may receive mental health services at PV, treating mental health concerns is a multifaceted, comprehensive, and holistic process that requires numerous sessions and hence cannot be fully addressed at a one-day community health intervention such as PV (51). 


Participants suggested continued improvements to the PV model. First, Pop-Up Village providers should follow up with recipients who are interested in learning about or receiving services, as this will make services more accessible. Establishing a structured method for provider-follow up is critical to ensure PV remains a trusted resource within the community. Provider follow-up in clinical settings has also been shown to confer several advantages which may also apply to the PV setting and goals: 1) increases the likelihood of behavior change; 2) provides recipients with individualized attention, which is especially important for those who do not have access to routine health care; 3) connects recipients to additional resources and services; and 4) has the potential to improve clinical outcomes (52,53). Second, PV should have navigators, who can advise and guide visitors to services that may be of interest to them. Third, the presence of translators and/or Spanish speaking PV providers was an important suggestion, as language concordant care has been linked to enhanced communication, higher satisfaction in care, engagement in care, and improved health outcomes (54). Fourth, PV should provide lunch or other food provisions to ensure that all visitors are fed. A study has found that provision of food  can address meeting community food needs and food access (55), foster community engagement (56) and encourage engagement in health-promoting behaviors (57). Fifth, recipients advocated for greater perinatal education. Prenatal education has been shown in studies to minimize childbirth anxiety (58–60), depression, and boost childbirth self-efficacy (60–63). Sixth, recipients suggested that PV increase its community outreach efforts, particularly to its target population of black birthing and postpartum people and their families. Other community-based ‘fair’ initiatives aimed at underserved populations have identified the need for investments in advocacy and targeted outreach to optimize the care received (64). Of note, the improvement suggestions described above also emerged through the community feedback mechanisms that were built into the PV model. As such, all of these suggestions have now been incorporated into the PV model, highlighting the importance of building in such mechanisms for feedback and community co-design


Strengths and Limitations

A strength of this study is the use of the Theoretical Framework of Acceptability as an orienting framework. Further, in-depth interviews enabled us to gain a more nuanced knowledge of participant perceptions across acceptability domains than was feasible with the quantitative assessment. During the course of our evaluation, our team discovered additional domains – such as perceived usefulness and appropriateness of the intervention - of acceptability relevant to our study that were used to supplement our analysis, resulting in suggested modifications to the Theoretical Framework of Acceptability domains that may be useful for other researchers evaluating the acceptability of community health interventions. Our intervention model’s dynamic co-creation allowed it to adapt to the expressed needs of the recipients; the PV model’s perceived acceptance was high during the evaluation period. Given that the PV model was designed to respond to community needs, the factors cited as barriers to access or reasons for recipients’ perceived low acceptance of the model became less prominent as the evaluation continued.  


This study has some limitations. First, because the evaluation was in the context of real-world implementation and the model’s dynamic co-creation approach allowed it to adapt to the expressed needs of the recipients, the model being evaluated was inconsistent over time. Second, our purposive and convenience sample limits generalizability to other populations. Nonetheless, the sample appeared to be representative of our target sample. 




Policy and practice implications 

Reducing disparities in maternal and neonatal health outcomes requires improving access to a wide range of support and care needs during pregnancy and the postpartum visit- beyond those that are traditionally considered within the healthcare setting, and doing so in a way that is culturally appropriate and acceptable. Our study demonstrates that providing one-stop-shop access to diverse services, within a community-based, culturally appropriate and uplifting setting can be  effective approach to meeting community needs; but supporting and sustaining such programs will require policies that are more holistic and community-centered (65,66).  One policy strategy is  to incentivize community-institutional collaborations that encourage integration and shift away from the current standard of services being delivered independently by different organizations, with little coordination (65,67). One approach may be through novel types of funding; for example, California’s CalAIM Population Health Management program requires Medicaid health plans to conduct regular community needs assessments within local health jurisdictions and to invest into community health improvement projects that address upstream drivers of health through integration of healthcare with public health and social services and build trust with and meaningfully engage members (68). Longer-term meaningful collaborations may also entail redesigning the health system to overcome structural hurdles and simplifying access to equitable care, which is our overarching goal when employing the PV model.


Our study also highlights the importance of critical implementation practices for programs focused on reducing health inequities. To ensure programs continuously meet recipients’ needs, it is critical to incorporate processes for inviting continuous feedback from recipients and iterating in response. Many of the improvement needs identified through our survey and interview data also emerged in the feedback mechanisms built into our events, such as feedback boards and other activities (reference: process paper), which allowed for responsive changes to be made in real time.   Another critical need is continued anti-racism training and education for program leaders and staff, that goes beyond interpersonal aspects to focusing on how racism can play out on institutional and systemic levels. Our findings that participants needed support with navigation even within our setting of service co-location, had challenges with access due to lack of transportation, and felt that food provision at events was critical highlight how people of color and those living on low incomes are impacted by structural inequities, and deep reflection and an intentional anti-racism lens is required to ensure new programs are designed and implemented in a way that tackles rather than propagates these inequities.




Conclusions

Intervention accessibility and acceptability is critical for participant engagement and adherence, as well as the sustainability of an intervention. The experiences and views of pregnant or postpartum women and family members who participated in our intervention were utilized to assess the accessibility and acceptability of this cross-sector community-engaged care model. The Pop-Up Village cross-sector community-engaged care model was highly acceptable for BIPOC pregnant people and their families living in and around San Francisco, California. Continued community-institutional co-creation of this model is a priority to ensure ongoing integration of community priorities. Future work will robustly assess the impact of the Family & Pregnancy Pop-Up Village model on care access, experience, and mental well-being, and eventually, on health outcomes. Ongoing process and planned impact evaluation of this model will inform transportability of this community-responsive model for service provision and support in other contexts. 





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Joint display ideas




     1. Gunja MZ, Seervai S, Zephyrin L, Williams II RD. Health and Health Care for Women of Reproductive Age: How the United States Compares with Other High-Income Countries. 2022 [cited 2023 Oct 5]; Available from: https://www.commonwealthfund.org/publications/issue-briefs/2022/mar/health-and-health-care-women-reproductive-age


2. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries [Internet]. 2020 [cited 2022 Mar 10]. Available from: https://www.commonwealthfund.org/publications/issue-bri