Awareness, Attitudes, and Help-Seeking Intention Towards Perinatal Depression Among Women from Different Ethnic Groups in Western Rural China

Introduction

Perinatal depression (PND) denotes the presence of depressive symptoms experienced by women during pregnancy and up to one year postpartum.^1,2 Extensive reviews of recent literature indicate that the global prevalence of PND was approximately 12%, with a notably higher prevalence among women in low- and middle-income countries (13.1%) compared to those in high-income countries (11.4%).³ In China, the reported prevalence of PND has demonstrated a steady increase over the past decade, reaching 16.0% in recent years, particularly prevalent in less developed regions.² Empirical studies have confirmed that PND can significantly heighten the likelihood of complications during pregnancy and childbirth (eg. gestational diabetes), exert substantially adverse effect on the physical and mental health of affected mothers, thereby disrupting family functioning and social relationships.^2,4–7 Additionally, PND can detrimentally affect infants’ growth and their cognitive and emotional development,^8,9 and even pose potential risks of maternal suicide or infanticide.¹⁰ Given the profound negative impact on maternal and infant well-beings, PND has become a predominant challenge in the realm of public health.

The existing body of evidence consistently supports the notion that the early assessment and provision of safe, effective, and accessible mental health care for women experiencing PND can significantly enhance the well-being of both mothers and infants.^10–12 Unfortunately, a substantial proportion of women suffering from PND either postpone health care-seeking or do not seek at all.^13–15 Merely 22% of women who were detected positively for PND utilized mental health services.¹⁶ In the context of China, only 19% of pregnant women with depression or anxious symptoms had expressed their proactive intention to seek health services.¹⁷

However, current national data largely stem from developed urban centers, neglecting the marked disparities in China’s underdeveloped western rural regions.² Western rural China, characterized by relatively scarce health resources, underdeveloped infrastructure, geographic remoteness, and a high concentration of ethnic minority populations, represents an important setting for understanding inequities in perinatal mental health. Women in these areas may face a “double burden” of increased vulnerability to perinatal depression and reduced access to mental health services. Such disparities may further hinder the recognition, timely help-seeking, and treatment of perinatal depression.¹⁸

Differentiating ethnic groups is important in this context because ethnicity in western rural China is closely linked to language, cultural understandings of emotional distress, stigma, family decision-making, trust in health institutions, and access to care. These factors may influence how women recognize perinatal depressive symptoms, perceive professional treatment, and choose sources of support. Without considering ethnic differences, important disparities in awareness, attitudes, and help-seeking may be overlooked, limiting the development of culturally appropriate interventions.¹⁸ This study was conducted in a rural multi-ethnic county in Yunnan Province, where Han, Zhuang, and other ethnic minority populations live together. These groups were examined because they represent the major population groups in the study area and may differ in cultural and service-access experiences related to mental health. In this setting, mental health resources are limited, particularly at the township level, while specialized services are mainly concentrated in county-level or higher-level institutions. Women in remote villages often need to travel across townships or counties to seek care, which adds transportation, time, and financial burdens. In addition, routine maternal and child health services may have limited capacity for mental health screening, counseling, and referral.

In such resource-constrained and culturally diverse settings, reluctance to seek help for perinatal depression may arise from three broad categories of barriers: structural, sociocultural, and individual. Structural barriers primarily pertain to impediments in service accessibility, including inadequate availability of mental health providers or resources, geographical distances, and inadequate health insurance coverage.^7,14,19 Sociocultural barriers predominantly revolve around the passive role of stigma and discrimination towards mental health, which significantly contributes to the underutilization of mental health services among women.^20–25 Meanwhile, protective mechanisms such as social support and trust were identified as pushing factors, motivating help-seeking intentions and behaviors among women.^13,22,26,27 Finally, at individual level, barriers encompass personal stigmatization towards mental health, lower educational attainment, limited health literacy, a diminished perceived necessity for mental healthcare, inadequate comprehension of the health system, as well as constrained leisure time and reduced household income.^{7,10,14,28,29}

Knowledge-attitude-practice theory posits that acquired knowledge and attitudes of women towards perinatal depression treatment play a pivotal role in mediating their help-seeking behaviors.^7,14,27,30 In particular, women with more positive attitudes towards depression treatment are more likely to have stronger intentions to seek help and a higher likelihood of actually doing so.^7,22,31 While several studies have explored women’s attitudes and help-seeking intentions towards perinatal depression in countries like the US and Portugal,^15,20 there is a notable lack of granular data dissecting these aspects in the context of China, especially regarding the subgroup differences among ethnic minority women.

To date, only five studies have been conducted in China that specifically examined either women’s attitudes towards perinatal depression or their help-seeking intentions, with two studies focusing on the urban area of Changsha City in eastern China^7,22 and the remaining three encompassing nationwide online surveys and semi-structured interviews.^17,32,33 It is important to note that none of these five studies classified women based on their ethnicity. Therefore, further evidence is needed to understand Chinese women’s attitudes towards perinatal depression treatment and their intentions to seek help, especially in less-developed western regions and among ethnic minorities.

Against this background, this study had two primary objectives: first, to investigate awareness, attitudes, and help-seeking intentions toward perinatal depression among women from different ethnic groups in a rural multi-ethnic county in western China; and second, to examine factors associated with these outcomes. Ultimately, this study aimed to inform culturally appropriate public health strategies to improve help-seeking for perinatal depression in this underserved region, while also providing insights for maternal mental health promotion in other rural, multi-ethnic, and resource-constrained settings facing similar barriers to awareness and help-seeking.

Materials and Methods

Research Design and Participants

This cross-sectional survey was conducted in May 2022 in a rural county situated in Yunnan Province, China. By the end of 2021, the rural population in the county accounted for 72.0% of the total population, with ethnic minorities comprising 61.8%. The predominant ethnic groups are Zhuang and Han, constituting 42.6% and 38.2% of the total population, respectively. In addition, there are other ethnic minorities including Miao, Yi, Yao, Hui, Mongolian, Dai, Lahu, Buyi, and 11 other ethnic groups.

The sample size was estimated using the standard formula for prevalence studies:

, where represents the estimated prevalence of perinatal depression among women in mainland China, reported as 16.30%.² The level of significance was set at = 0.05, corresponding to =1.96. The allowable margin of error () was set at 0.03. Based on these parameters, the minimum required sample size was calculated to be 583 participants. After accounting for a 20% non-response or invalid questionnaire rate, the required sample size was increased to 729 participants.

The study targeted women who were pregnant or within one year postpartum as of May 2022. A total of 1,217 women were surveyed. Eligible participants were required to have resided in the county for at least three months and to have effective communication skills. Women with intellectual disabilities or those unwilling to participate were excluded. Prior to data collection, a comprehensive list of eligible women was compiled. Face-to-face surveys were then conducted via visits to health institutions, including maternity and child health care hospitals, general hospitals, primary health care facilities, as well as household visits. All interviewers received standardized training covering research ethics, informed consent procedures, questionnaire administration, and confidentiality protection prior to fieldwork. To maintain data quality during face-to-face interviews, daily field supervision and random spot checks were conducted.

Questionnaire

The questionnaire consisted of two parts: a self-designed section and standardized scales. The self-designed section included items on socio-demographic characteristics, history of negative emotions, mental health service utilization, and awareness, attitudes, and help-seeking intentions towards perinatal depression. The full questionnaire, including the exact item wording and response options, is provided in Supplementary Appendix 1. Before the formal survey, the questionnaire was pilot-tested among women from the target population, and minor revisions were made to improve clarity and feasibility. Standardized scales developed by previous researchers were used to assess participants’ perinatal depressive symptoms and the level of social support received from family, friends, and other sources.

Self-Designed Section

The socio-demographic information gathered included age, perinatal period (pregnant or postpartum), place of residence, marital status, ethnicity (Han, Zhuang, or other ethnic minorities), education level, employment status (unemployed, farmer, hourly employee, or salaried employee), medical insurance coverage, monthly household income (RMB), history of negative events within the past 12 months, satisfaction of relationship with husband or partner, family history of mental illness, spouse’s ethnicity, spouse’s employed status, living arrangements with spouse, parents, or parents-in-law.

Negative emotions history refers to experiences of negative emotions lasting more than two weeks prior to the initiation of the current study, including but not limited to symptoms of depression, anxiety, tension, fear, irritability, agitation, and low mood. Mental health service utilization includes utilization of formal mental health services, the type of services sought from psychiatrists, psychological counselors, or non-professionals, online services or interpersonal interviews, the number of service utilized, and the cost of mental health services.

Regarding attitudes towards depression, the questionnaire covers the understanding of depression, agreement on the preventability and curability of depression, knowledge of available treatments for depression, awareness of facilities for depression treatments, agreement on the inclusion of mental services in health insurance coverage, satisfaction with current mental health services, and reasons for dissatisfaction with current mental health services.

Help-seeking intention towards perinatal depression encompassed three levels: intention to seek help for depression when needed, intention to seek help from other individuals when needed, and intention to seek help from professionals when needed. These items were asked of all participants. For the items on potential sources of help, multiple responses were allowed. These professionals included psychiatrists or psychologists working at general hospitals, psychiatric hospitals, or other institutions.

Standardized Scales Applied

The Edinburgh Postnatal Depression Scale (EPDS) was adopted to assess the perinatal depressive symptoms over the past seven days.³⁴ The EPDS questionnaire consists of 10 items, each scored on a 4-point Likert scale ranging from 0 (“never”) to 3 (“often”). The total score of the EPDS ranges from 0 to 30, with higher scores indicating more severe depressive symptoms. In our study, a total score of ≥9 was considered an indicator of the presence of perinatal depressive symptoms.³⁵ The EPDS has previously demonstrated good internal consistency (Cronbach’s α was 0.87) in the study conducted by Cox et al³⁴ The Cronbach’s α coefficient for this scale was 0.88 in our sample.

Social support was evaluated using the Multidimensional Scale of Perceived Social Support (MSPSS),³⁶ with the average score of the three subscales (family, friends, and others) being calculated. A score ranging from 1 to 5 was deemed low to moderate support, while a score from 5.1 to 7 represented strong support. The MSPSS has demonstrated good internal consistency and test-retest reliability.³⁶ The internal consistency of MSPSS in this study was sufficient (Cronbach’s α = 0.935).

Statistical Analyses

All analyses were conducted using Stata 15.1 software and a p-value of 0.05 was considered statistically significant. Categorical variables were described using frequency and percentage, while continuous variables (eg. age) were described using median or interquartile range for statistical description. Chi-square test and Fisher’s exact probability analysis were employed to explore the differences in awareness, attitudes, and help-seeking intentions towards perinatal depression among women from different ethnic groups and multiple logistic regression models were conducted to investigate the related factors. The models controlled for potential confounding factors, including age, place of residence, marital status, employment status, education level, monthly household income, family history of mental illness, spouse’s ethnicity, spouse’s employment status, history of negative events, relationship with husband or partner, level of social support, negative emotions history, utilization of mental health services, PND, and attitudes towards depression. As a sensitivity analysis, Firth penalized logistic regression was additionally performed using the same covariates as in the primary models to reduce potential sparse-data bias and improve the stability of estimates in subgroup analyses with limited event counts.

Results

Demographic Characteristics

A total of 1,217 women completed the questionnaires. After the exclusion of 65 incomplete questionnaires with missing key indicators, 1,152 validated questionnaires were included for analysis, resulting in a high effective response rate of 94.66%. The study sample comprised of 464 Han women (40.28%), 498 Zhuang women (43.23%), and 190 women from other ethnic minorities (16.49%). The average age of participants was 26.72±5.58 years. Notably, significant differences (P<0.05) were observed among these ethnic groups in terms of several factors, including age, education level, place of residence, monthly household income, employment status, and medical insurance.

Perinatal Depression and Negative Emotions History

Among the participants, 12.67% were identified with perinatal depressive symptoms by the EPDS, while 13.89% self-reported experiencing negative emotions for more than two weeks. Zhuang women exhibited a higher detection rate of perinatal depression (14.46%) compared to Han women (10.78%) or women from other ethnic groups (12.63%). Conversely, women from other ethnic minorities had a higher prevalence of negative emotions history (16.32%) in comparison to Zhuang women (13.45%) or Han women (13.36%). However, statistical analysis did not reveal significant differences between these groups in terms of perinatal depression and negative emotions history (Table 1).

Table 1 Women’s Demographic Characteristics, Perinatal Depression, and Negative Emotions History [n (%)]

Utilization of Mental Health Service

Only a small proportion of the participants (0.95%) reported having previously sought for mental health services. Among the 160 women who reported experiencing negative emotions, only seven (4.38%) sought out such services. They received services through face-to-face consultations (n=5) or via telephone/internet (n=2). The therapeutic interventions employed in the treatment encompassed medication therapy (n=3), psychological counseling/guidance (n=1), or therapeutic engagement with music/sports (n=3). The cost for an individual session varied from 200 to 2,700 RMB, with free services availed to four women.

Awareness and Attitudes Towards Depression

Among the participants, more than a quarter (26.91%) had demonstrated an absence of awareness regarding depression, 40.02% expressed disagreement with the idea that depression is amenable to prevention and cure. Moreover, a notable majority displayed a lack of knowledge concerning available treatment modalities (49.57%) or and healthcare facilities providing specialized care for depression (55.21%), and nearly 70% exhibited a lack of familiarity with mental health services in general.

It has been noted that 6.08% women expressed dissatisfaction with mental health services. The primary factors contributing to their discontent were identified as high costs (45.71%), geographical constraints in accessing medical facilities (30.00%), and perceived poor treatment outcomes (24.29%). However, a notable majority of the participants (63.98%) showed their support for the inclusion of mental health services, encompassing elements such as depression screening and early intervention, within the coverage provided by health insurance policies.

Further analyses revealed variations in attitudes towards depression and mental health services among different ethnic groups. Compared to Zhuang and Han women, women from other ethnic groups had lower levels of awareness regarding facilities available for depression treatments (47.59% vs 46.12% vs 34.21%, P=0.005) and expressed greater uncertainty regarding the inclusion of mental health service costs under health insurance coverage (30.12% vs 30.17% vs 40.00%, P=0.044). The findings above are list in Table 2.

Table 2 Women’s Awareness, Attitudes, and Help-Seeking Intention Towards Perinatal Depression [n (%)]

Help-Seeking Intention Towards Depression

The most participants (84.55%) reported that they would seek help for depression if needed. For those women who displayed a willingness to seek help, a substantial portion (75.36%) prefer to seek support from interpersonal sources. Moreover, a significant majority (72.07%) of participants favored consulting psychological professionals. However, there were no significant differences across ethnic groups in terms of help-seeking intention (Table 2).

The logistic regression analysis revealed that women who had given birth within one year (OR=1.559, 95% CI: 1.057–2.299), held the belief that depression is preventable and curable (OR=1.746, 95% CI: 1.141–2.672), and possessed knowledge about available facilities for depression treatments (OR=1.815, 95% CI: 1.111–2.965) were more inclined to seek help for depression when faced with such a need. Moreover, women with higher age were associated with lower help-seeking intentions for depression (OR=0.535, 95% CI: 0.307–0.931). In addition, women with higher monthly household incomes (OR=1.787, 95% CI: 1.294–2.468) were correlated with increased intention to seek help from other people. Furthermore, women who knew the facilities available for depression treatments were more willing to seek help from psychological professionals (OR=1.936, 95% CI: 1.272–2.947), while those with PND were more likely to seek help from non-professionals such as family members or friends (OR=0.550, 95% CI: 0.319–0.948).

Factors influencing help-seeking intentions differed across different ethnic groups. Among Han women, those who gave birth within one year (OR=2.008, 95% CI: 1.038–3.883) and knew the facilities available for depression treatments (OR=2.226, 95% CI: 1.019–5.034) exhibited a stronger intention to seek help. Women with higher education levels (OR=2.440, 95% CI: 1.123–5.301) and beliefs about the preventability and curability of depression (OR=2.679, 95% CI: 1.329–5.401) demonstrated a greater inclination to seek help from professionals, while women with a family history of mental illness expressed a stronger desire to seek help from non-professionals (OR=0.023, 95% CI: 0.002–0.307).

Zhuang women with higher monthly household incomes (OR=1.917, 95% CI: 1.034–3.554) and stronger family support (OR=2.660, 95% CI: 1.087–6.508) were associated with a greater likelihood of seeking help, while those who were farmers (OR=0.351, 95% CI: 0.154–0.800) and those with a family history of mental illness (OR=0.146, 95% CI: 0.028–0.773) displayed an decreased tendency to seek help. Additionally, women with higher age (OR=2.513, 95% CI: 1.001–6.310), higher monthly household incomes (OR=2.157, 95% CI: 1.266–3.675), stronger family support (OR=2.576, 95% CI: 1.110–5.980), employed spouses (OR=2.426, 95% CI: 1.127–5.221), medical insurance coverage (OR=11.180, 95% CI: 1.261–99.105), and living with their spouses, parents, or parents-in-law (OR=3.206, 95% CI: 1.058–9.711) were more likely to seek help from other people. Specifically, women who knew the facilities available for depression treatments presented a greater possibility of seeking help from professionals (OR=2.544, 95% CI: 1.304–4.963) while those women with employed spouses were found to be more inclined towards seeking help from non-professionals (OR=0.198, 95% CI: 0.058–0.677).

Regarding other ethnic minority women, those who were salaried employees reflected a lower potential to seek help (OR=0.044, 95% CI: 0.005–0.403). Women with senior age (OR=9.969, 95% CI: 1.112–89.387) and higher monthly household incomes (OR=3.312, 95% CI: 1.019–10.760) were more likely to seek help from others, while women who had experienced negative emotions were more inclined towards using self-help strategies such as web searching rather than seeking outside help (OR=0.136, 95% CI: 0.027–0.687). Detailed information pertaining to these findings is presented in Table 3. Sensitivity analyses using Firth penalized logistic regression yielded broadly similar results to the primary analyses, suggesting that the findings were robust to potential sparse-data bias (Supplementary Table 1).

Table 3 Factors Affecting Women’s Help-Seeking Intention Towards Perinatal Depression a [OR (95% CI)†]

Discussion

Although no significant difference in the risk of PND and negative emotions history had been found among women from different ethnicity, it is worth noting that the prevalence of PND (12.67%) in western rural China is relatively higher than certain eastern and central regions, such as Shanghai (12%), Jiangsu (11%), Hubei (9%), Jiangxi (9%).² Furthermore, the prevalence of negative emotions history (13.89%) in western rural China is also higher than women in Changsha city, China (5.1%).⁷ Disparities in the prevalence of PND and negative emotions history across different regions of China can be influenced by factors such as variations in the utilization of depression screening scales, their cut-off score, and the social characteristics of the surveyed population. The findings from this study underscore the significance of providing prioritized mental healthcare to all women and their families living in less-developed areas, regardless of their ethnicity and personal background. This study adds evidence from a rural multi-ethnic area in western China, where perinatal women may face overlapping barriers related to geography, limited service availability, and cultural diversity. By documenting low awareness, low service utilization, and relatively high help-seeking intention in this underserved population, our findings highlight an important gap between perceived need or willingness and actual access to mental health support.

Women from different ethnic groups were found to exhibit a common low level of awareness concerning depression. More than a quarter of women had never heard of PND, and nearly half were unaware of the available treatments or relevant services delivery facilities. The results, to some extent, reflect the underutilization of mental health services in the area. Therefore, the health awareness campaign should be first in place to facilitate the participation of women in help seeking while simultaneously increasing their knowledge about PND. The reported reasons, such as high service costs, poor treatment outcomes, long distance from home to health facilities, long waiting time, and the dissatisfaction with current mental health services were highlighted by women for their reluctance to the use of mental health services. Meanwhile, over 60% of women believed that medical insurance coverage could alleviate the economic burden associated with using such services. These findings align with another study conducted in Changsha city, China.³¹ In addition to awareness raising, we recommend addressing individual and sociocultural factors to support women in rural areas seeking quality mental health care.

Despite the lower level of awareness towards PND, a vast majority of women (84.55%) were willing to seek help when needed, and seeking help from professionals was the preferred way chosen by women (72.07%), which demonstrates a relatively positive intention in response to depression. Similar finding were also evident in the Ride J’s research conducted in Australia, which examined the willingness of women to utilize professional services for overcoming depression.³⁷ However, a noteworthy challenge arises when women’s intentions remain high but do not always translate into improved health-seeking behaviors due to the presence of various barriers such as fear of being judged, and gender inequities in professional treatment.³⁸ Hence, gender-based elements should be considered in current educational campaign to empower women and make more consistent impacts on substantial behavior change.^39,40

Factors influencing help-seeking intentions differed across different ethnic groups. Among Han women, those with a better awareness of depression exhibited a greater likelihood of seeking help from professionals, possibly indicating their higher confidence in help-seeking, and lower self-stigmatization related to mental illness.⁴¹ Furthermore, Han women who have given birth within the past year exhibit a heightened inclination to seek assistance, potentially attributed to an increased susceptibility to postpartum depression. Previous investigations have revealed a rising prevalence of postpartum depression among Chinese women due to fluctuations in postpartum hormone levels, amplified infant care responsibilities, and elevated societal expectations placed upon new mothers.^32,42–45

For Zhuang women, strong family support were associated with a higher likelihood of seeking help and sharing their depressive feelings with other people, which was similar to the finding of an online survey of Spanish-speaking women around the world.²⁷ This preference might be influenced by their culture norms emphasizing the centrality of family unit.^46–48 Conversely, Zhuang women with a family history of mental illness were less likely to seek help, likely due to the stigma attached to mental disorders an concerns about preserving family honor.^49–53 Accordingly, there is an urgent need for educational campaigns and policies that promote the reduction of pervasive stigma against individuals with mental disorders through various means such as utilizing mass media effectively and implementing awareness-raising interventions.^54,55

Women from other ethnic minorities who in salaried employment displayed less willingness to seek help for depression. Again, the resistance to seeking assistance can be attributed to the prevailing stigma associated with both diseases and ethnic minorities.³⁸ It is noteworthy that ethnic minorities with higher incomes tend to harbor more unfavorable perceptions towards mental illness. Women with mental illness may suffer from multiple forms of discrimination resulted from a range of subordinative characteristics, such as age, socio-economic position, membership of a particular ethnic.^38,49 Moreover, ethnic minority women in salaried employment may disregard or negate their potential mental health needs due to the conflict with their self-perception as healthy, employed and independent individuals. Furthermore, women from ethnic minorities who had experienced trauma in the past preferred self-help strategies like web searching rather than seeking external help, possibly due to the reluctance of family members and health professionals to respond to their emotional and practical needs.¹³ Therefore, reliable online resources should be also included in mental health programs in rural areas to empower women with alternatives.

From a public health perspective, our findings highlight both demand-side and supply-side needs. On the demand side, awareness of PND and knowledge of available services should be improved through maternal health education, community outreach, and culturally appropriate communication. On the supply side, increasing the availability, affordability, and acceptability of mental health services is essential, particularly in low-resource rural settings. Given shortages of mental health specialists, scalable approaches such as task-shifting and non-specialist-delivered psychological interventions may be promising. Recent evidence suggests that non-specialist-delivered psychological interventions, including anxiety-focused cognitive behavioral approaches for perinatal women, can help prevent postnatal depression in low-resource contexts.⁵⁶ Similarly, primary care–based psychological interventions delivered by lay health workers have shown effectiveness for common mental disorders in community settings.⁵⁷ These models may be adapted for rural western China by integrating mental health screening, brief counseling, referral pathways, and follow-up support into existing maternal and child health services, primary care facilities, and community-based outreach. Training village doctors, maternal and child health workers, and other non-specialist providers to deliver basic psychoeducation, screening, guided self-help, and culturally sensitive support may help bridge the gap between high reported help-seeking intention and low actual service utilization.

Limitations

While this study provides valuable insights into awareness, attitudes, and help-seeking intentions towards perinatal depression among women from different ethnic groups in western China, several limitations should be noted. First, the study sample was drawn from only one county in Yunnan, China, which may limit the generalizability of the findings. Future studies should include a wider geographic area to improve external validity. Second, due to the cross-sectional design, the observed associations should not be interpreted as causal, and reported help-seeking intentions may not necessarily translate into actual behaviors. Longitudinal research could provide a more comprehensive understanding of how intentions relate to real-world help-seeking over time. Third, the questionnaire was self-designed and was not a validated psychometric instrument. Therefore, findings related to broader constructs, particularly attitudes and help-seeking intentions, should be interpreted with caution.

Conclusion

By exploring women’s awareness, attitudes, and help-seeking intentions towards perinatal depression in rural western China, this study highlights low levels of awareness of perinatal depression and mental health services among women from diverse ethnic groups in the region. Although many women expressed willingness to seek help, knowledge of where to seek professional support and actual use of mental health services remained limited. These findings highlight the need for educational campaigns to improve recognition of perinatal depression and awareness of available sources of help, as well as stronger referral pathways within maternal and primary health care services. Culturally adapted outreach and supportive interventions should also be considered to address the needs of ethnic minority women and other vulnerable women in underserved rural settings.