Shades of Blue: Postpartum Depression and Smartphone Applications

1. Shades of Blue: Postpartum Depression and Smartphone Applications Martha Ahmadi, Laura Carfagnini, Elizabeth Holmes, Saeeda Irfan, Alison Moore, Wajma Qaderi Department of Health Studies and Gerontology, University of Waterloo Selection of Public Health Issue Core Behavioural Product(s) Selection of Dissemination Channel Summary of Social Marketing Process The decision to create a smartphone application is based on data indicating a rising trend in purchase and use of smartphones and related applications. Data from 2009 reported 3.9 million Canadian users of mobile internet, an increase from 16% to 21.3% over a period of six months5. In a survey of 1000 Canadians, smartphone ownership was at 38% among 18 to 34 year olds and at 33% in 35 to 64-year olds6. Of those surveyed, 68% of 18 to 34-year olds and 64% of 35 to 64-year olds had downloaded an application. Of all respondents, 67% of iPhone users, 53% of BlackBerry users, and 58% of other smartphone users preferred a permanent application that allowed them to access information directly on their smartphone rather than mobile Internet browsers. Health and wellness/lifestyle applications had been downloaded by 9% across all users6, although this number was likely to be higher among 18 to 64 year olds. With the promotion of our product in highly accessible and noticeable locations and growing smartphone application downloads, the outlook for Shade of Blue downloads and usage as an application is very promising. The website created for Shades of Blue will contain the same information available on the smartphone application. The Internet remains a promising avenue to reach our target population. Statistics Canada reports that 96.5% of Canadians 34 years and under and 87.8% of 35 to 54 year-olds access the internet7. 73% use it to research matters such as parenting, while 70% search the internet for health related information. While Canadian data on reaching pregnant and postpartum women is unavailable, data from the States indicates the Internet is a viable option in reaching this group. An American survey reports that 55.2% and 43.1% of women used blogs and social networks, respectively, to obtain information on pregnancy and babies8. Another study reported that 36 million moms were online in 2008, a figure expected to rise to 40 million by 20129. Internet usage is also highly used by lower socioeconomic groups in Canada, suggesting reach is possible across a range of pregnant and postpartum women. Use is at 50.7% among users with less than high school education and at 76.2% and 69.9% among Canadians in the lowest and second personal income quartiles10. While a website will be created to supplement the smartphone application and ensure access to the remainder of the population without smartphones, it is hoped that the novelty of campaigning through a smartphone application will increase the appeal of the Shades of Blue campaign. Inspired by the initial stage of PPD and the concept that there are varying degrees of PPD, the campaign will be called “Shades of Blue”. To relay our message, a smartphone application has been chosen as the main product of our public health social marketing campaign with the assistance of a promotional poster. The poster will serve as the initial tool to capture the public’s interest about PPD through catchy phrases. It will also serve as a medium to campaign our main product - the smartphone application. The smartphone application will consist of four components: personal narratives, educational tool (background information, and survey with results), relevant links and resources, and finally a mood tracker which can be shared with a health professional. The smartphone application will be supplemented by a website to ensure broad access. The following are some identified outcomes: The majority (40-80%) of new mothers experience some form of mood disturbance (postpartum blues)1. Postpartum Depression (PPD) can occur 4 weeks to 1 year after delivery, and is a major depressive disorder that affects between 10-25% of mothers1,2. Women of diverse cultural backgrounds are equally susceptible3. The self-administered Edinburgh Postnatal Depression Scale (EPDS) is a quick, well-validated, and culturally diverse screening tool (has been vastly translated), which is a reliable indicator of depression, or risk thereof3. Coordination among health professionals for the timely and appropriate screening of PPD, as well as mental health follow-up, is sorely lacking, which is why less than 50% of PPD is accurately diagnosed3. Mothers with PPD experience many harmful psychological effects, including sleeplessness, relationship trouble, and loss of interest in life3. Women who experience postpartum psychosis, the most severe form of untreated PPD, are at risk for self-induced and infant-targeted physical harm3. Initial Planning Postpartum depression was selected as the topic of interest as it provides the opportunity to promote both maternal and mental health, and to address the stigma around mental health issues. Formative Evaluation Although 10-25% of mothers experience postpartum depression, it is still not a widely discussed or sufficiently acknowledged topic in either the general public or the Canadian health care system. It was identified that in particular, women were not receiving the information from their doctors during prenatal visits. Strategy Development Having identified the target audience and topic of interest, a plan was developed to determine the best way to present the material so that it would be accessible and easy to understand. This included poster placement at the aforementioned public places, plus an insert in the hospital package provided to registered pregnant women. Posters would grab attention and contain the information to download the app or look up the website. Program Development and Pre-Testing of Materials Two focus groups consisting of pregnant mothers and postpartum mothers were used to evaluate the product. These women had the collective experience of being pregnant, giving birth and exposure to information received from doctors and health professionals on postpartum depression throughout the perinatal period. Overall feedback was positive for the straightforward campaign. Based on this response, the materials were rolled out in select communities across Ontario. Surveys assessing knowledge of postpartum depression and where to access more information were performed before and after roll out of the pilot, showing an increase in awareness based on survey scores after the materials were in the community. As well as easily identifying where to find help with the map tracker option on the smart phone application. Implementation of Program Pending this positive response, the initiative was rolled out to all communities across Ontario. Promotional posters were posted in doctor’s offices, on public transportation, in transit stations, and in public washrooms. Funding support was provided by the provincial government. Monitoring and Evaluation Prior to implementation, data was collected to analyze postpartum knowledge, incidence rates and treatment rates. Processes were put in place to continue monitoring this data for a formal evaluation at two and five years. Particularly since the app and website are computer based tools, both will be systematically monitored for usage. Theory Underlying Communication Campaign4 • Extended Parallel Processing Model • Illustrate risks of PPD to mothers, children, and fathers • Highlight costs of not addressing PPD and benefits of taking action for mothers dealing with PPD and their family members • Describe how women experiencing PPD or their loved ones can deal with potential obstacles to recommended courses of action • Knowledge Gap • Provide accessible information on PPD beyond current basic information in order to empower women and families to recognize PPD and access appropriate resources • Agenda Setting • Increase awareness of PPD in the general public, policy makers, and the media in order to raise the profile of this condition and create positive change in existing health care resources for diagnosis and management of PPD • Message Effect Theories • Narratives: use personal stories as a means of generating empathy and increased willingness to accept messages Target Audience Primary Audience The chief goal in this campaign is to increase awareness and support around PPD among women of childbearing years, specifically, those women who are pregnant, or have recently given birth. Normalizing this common perinatal mood disturbance is extremely important for this cohort, as presently 80% of women who believe they are suffering from PPD do not report it to their primary health provider. This is largely due to the social expectation that new mothers should be in the “happiest state of their lives”2 . Secondary Audience An indirect target group such as the partners and social support networks of the aforementioned women, after learning about PPD through our campaign, will be better positioned to acknowledge their loved ones condition, help them cope, and encourage them to access appropriate care. Tertiary Audience A final group inadvertently targeted by this campaign is the general public. As mentioned above, PPD seems to carry with it public shame, thus ostracizing those women who are suffering in isolation. Through a widespread campaign designed to saturate the public in Ontario, attitudes and behaviors may be altered, hence increasing comfort with the idea of the phenomenon. Hopefully, through the eventual normalization of this condition, women will feel free to seek help and be open about their struggles. Other Important Considerations for Your Campaign References/Citations Roles of Collaborators 1. McCoy, S.J.B (2011). Postpartum depression- An essential overview for the practitioner. Southern Medical Journal. 104(2): 128-132. Retrieved March 3, 2011 from http://www.medscape.com/viewarticle/73678_print. 2. Barclay, L. (2011). Diagnosis and management of postpartum depression reviewed. Medscape Medical News. Retrieved March 3, 2011 fromhttp://www.medscape.com/viewarticle/737312. 3. Lusskin, S.I. & Misri, S. (2010) Postpartum blues and depression. Retrieved March 3, 2011 from http://www.uptodate.com/contents/postpartum-blues-and-depression?source=search_result&selectedTitle=1~24. 4. Glanz, K., Rimer, B.K., & Viswanath, K. (2008). Health Behavior & Health Education: Theory, Research, and Practice (4th ed.). San Fransico, CA: Jossey-Bass Publishers. 5. The Nielsen Company. (2009). Nielsen is first to provide mobile internet audience measurement for the Canadian market [Press Release]. Retrieved March 14, 2011 from http://blog.nielsen.com/nielsenwire/wp-content/uploads/2009/06/canadia_mobileq12009.pdf. 6. Delvinia Interactive. (2010). Managing the Hype: The reality of mobile in Canada. Retrieved March 14, 2011 from: http://www.delvinia.com/digreport/#dig1 7. Statistics Canada. (2010). Canadian Internet Use Survey. Retrieved March 14, 2011 from http://www.statcan.gc.ca/daily-quotidien/100510/t100510a2-eng.htm. 8. BlogHer & Compass Partners. (2009). Women and Social Media Study. Retrieved March 14, 2011 from http://www.blogher.com/blogher-releases-second-annual-women-and-social-media-study-its-all- about-you. 9. Gafni, N. (2009, February 13). HOW TO: Attract and Engage Social Media Moms. Message posted to http://mashable.com/2009/02/13/social-media-moms/. 10. Statistics Canada. (2009). Internet use by individuals, by selected characteristics. Retrieved March 14, 2011 from http://www40.statcan.gc.ca/l01/cst01/comm35a-eng.htm. 11. Montazeri, A., Torkan, B., & Omidvari, S. (2007). The Edinburgh postnatal depression scale (EPDS); Translation and validation of the Iranian version. Biomed Central: Psychiatry 7(11), 1-6. Posters, the smart phone application and website material would need to be available in various languages. Specifically, translators would need to understand the implications of this campaign in order to ensure material was communicated in a culturally sensitive manner. The EPDS is already translated into several different languages, including: French, Dutch, Swedish, Spanish, Chinese, Thai, Turkish and Arabic.11 Because a secondary goal is to impact the partners and social support networks of pregnant women/new mothers, as well as changing the societal beliefs and attitudes about PPD, the campaign poster will need to be visible in a variety of public places including at health care provider offices (including ob/gyn clinics, family practitioner and midwives), public washroom stalls and buses/bus shelters, and not just in locations which are likely to be accessed by expectant or new mothers. After coming to consensus on a public health issue as a group, Alison and Laura performed a basic literature search to gain a better understanding of the knowledge gaps. This led to the development of the materials for “Selection of Public Health Issue”, “Target Audience”, and Other Important Considerations…”. Saeeda completed the “Selection of Dissemination Channel” . Elizabeth, Martha, and Wajma collaborated on the “Theory Underlying Communication Campaign”, “Core Behavioral Product(s)”, and “Summary of Social Marketing Process”. Team meetings conducted on Skype were used to review overall content uniformity and context. The development of product mock-ups was a group effort.