Barriers and facilitators to implementing a digital perinatal mental health screening and referral pathway in primary care: a qualitative implementation study in Portugal

Abstract Background: Digital tools are increasingly promoted to improve the reach, timeliness and continuity of perinatal mental health screening and referral. However, less is known about how digitally integrated screening pathways are adopted by primary care professionals in routine practice. This study examined the implementation of the Matter digital perinatal mental health screening and referral pathway in primary care in Central Alentejo, Portugal, focusing on barriers and facilitators shaping use among healthcare workers. Methods: This qualitative implementation monitoring evaluation examined the Matter programme. A purposive maximum-variation sample of 14 primary care professionals (10 physicians and four nurses) from eight units was recruited from 29 eligible staff. Participants with at least one recorded digital pathway activation before recruitment were classified as users, whereas those with none were classified as non-users. Semi-structured telephone interviews were conducted in June and July 2025 by an external behavioural science monitoring team independent of programme delivery. Data were analysed in Portuguese using thematic analysis, combining coding informed by the Capability, Opportunity, Motivation-Behaviour model (COM-B) and the Theoretical Domains Framework with inductive theme development; the Behaviour Change Wheel informed implementation recommendations. Results: Participants in both groups recognised the clinical relevance of perinatal mental health screening and considered the Matter programme's digital pathway useful for earlier identification and referral. Positive perceptions did not, however, ensure routine use. Five themes were identified: time pressure and competing clinical demands; technical and workflow barriers; role clarity and team-based implementation; local champions and organisational support; and equity challenges related to language and communication. Adoption was shaped principally by physical and social opportunity, including staff availability, and by variable psychological capability. Facilitators included intuitive platform design, routines outside consultation time, nurse-physician collaboration, responsive support and evidence-informed recommendations. Conclusions: Uneven adoption of the Matter programme's digital pathway was not primarily explained by rejection of perinatal mental health screening, but by whether the pathway could be embedded in routine workflows and team-based care. Sustainable implementation requires role clarity, protected time, reliable technical infrastructure, local support and equity-oriented adaptations. Trial registration: ClinicalTrials.gov NCT07659977.