INVESTIGACIÓN ORIGINAL / ORIGINAL RESEARCH
Depression help-seeking attitudes and behaviors among an Internet-based sample of Spanish-speaking perinatal women
Actitudes y comportamientos de búsqueda de ayuda para la depresión en una muestra basada en internet de mujeres de habla hispana en período perinatal
Alinne Z. Barrera; Alexandra D. Nichols
Palo Alto University, Palo Alto, California, United States of America. Send correspondence to Alinne Z. Barrera, email: firstname.lastname@example.org
OBJECTIVE: To examine attitudes and beliefs related to help-seeking for depression among an international sample of pregnant women, a majority of whom were Spanish-speakers residing in Latin America.
METHODS: More than 6 000 (n = 6 672) pregnant women met eligibility criteria and consented to participate between 15 January 2009-12 August 2011. Of these, 1 760 with a Latino/Hispanic background completed a baseline survey as part of a larger study. Group comparisons analyzed attitudes and behaviors related to seeking help for depression, while a logistic regression was conducted to identify demographic characteristics related to help-seeking support.
RESULTS: Of the participants, three-fourths reported experiencing depression during or after their current or past pregnancies. The majority of participants did not seek help, and generally reported ambivalence about their depressive symptoms and uncertainty as to the helpfulness of others. However, 44.8% did seek help, mostly by speaking to family or partners and reported feeling fear, shame, and embarrassment about their symptoms. A current major depressive episode and an income less than or equal to US$ 10 000 were significant predictors of help-seeking behaviors.
CONCLUSIONS: Data from this study suggest that when feeling sad or depressed, perinatal Latinas tend to seek emotional support first from family and friends and may underutilize mental health services when needed. The Internet is an effective means for reaching perinatal women, especially those in areas of the world where there may be barriers to accessing psychological resources.
Key words: Depression, postpartum; health behavior; information seeking behavior; perinatal care; peripartum period; Internet; Latin America.
OBJETIVO: Analizar las actitudes y las creencias relacionadas con la búsqueda de ayuda para la depresión en una muestra internacional de mujeres embarazadas, la mayor parte de ellas hispanohablantes y residentes en América Latina.
MÉTODOS: Más de 6 000 mujeres embarazadas (n = 6 672) cumplieron los criterios de selección y aceptaron participar entre el 15 de enero del 2009 y el 12 de agosto del 2011. De estas, 1 760 de origen latino o hispano completaron una encuesta básica que formaba parte de un estudio más amplio. Mediante comparaciones de grupo, se analizaron las actitudes y los comportamientos relacionados con la búsqueda de ayuda para la depresión, mientras que, mediante regresión logística, se determinaron las características demográficas relacionadas con la búsqueda de ayuda o apoyo.
RESULTADOS: De todas las participantes, tres cuartas partes notificaron sentimientos de depresión durante o después de los embarazos actuales o pasados. La mayor parte de ellas no buscaron ayuda, y en general manifestaron ambivalencia acerca de sus síntomas depresivos e incertidumbre en cuanto a la capacidad de ayuda de otras personas. Sin embargo, 44,8% buscaron ayuda, principalmente hablando con familiares o compañeros, y notificaron sentimientos de temor, culpabilidad y vergüenza acerca de sus síntomas. Un episodio depresivo mayor actual y unos ingresos iguales o inferiores a US$ 10 000 fueron factores predictivos significativos de comportamientos de búsqueda de ayuda.
CONCLUSIONES: Los datos de este estudio indican que, cuando se sienten tristes o deprimidas, las mujeres latinas en período perinatal tienden a buscar en primer lugar el apoyo emocional de la familia y los amigos, y podrían subutilizar los servicios de salud mental cuando son necesarios. La internet es un medio eficaz para llegar a las mujeres en período perinatal, especialmente a las que viven en zonas del mundo donde pueden existir barreras para el acceso a los recursos psicológicos.
Palabras clave: Depresión postparto; conductas saludables; conducta en la búsqueda de información; atención perinatal; período periparto; internet; América Latina.
Major depression is a significant public health concern with a worldwide impact on illness, disability, and mortality (1). Compared to men, women have a higher risk of experiencing major depression during their lifetime (2), with an added risk of developing perinatal depression (3-5). Among Latinas in the United States and Mexico, the rate of postpartum depression (PPD) ranges from 16%-56% (6), far higher than the 10%-15% incidence of depression and anxiety reported in the general population during the year following childbirth (4, 7). This disparity marks perinatal depression in women with Latin American origins as an important area for investigation.
Depression during pregnancy and postpartum is not limited to women residing in the United States (8). Across 11 developed countries, the rates of depression vary from 8.5%-11% during pregnancy and from 6.9%-12.9% during the year following childbirth (3). Recent reports suggest that Latin American women are experiencing perinatal depression at higher rates (9-12), but inconsistencies remain due to differences in measurement. Depression during pregnancy, as measured by self-report symptom scales, range from approximately 17% in Colombia (12) to as high as 35.2% in Chile (13). Similarly, rates of postpartum depression ranged from 10.8%-20.7% in Brazil (14, 15), and most recently, 17.1% during the months following childbirth, and up to 20% at 6 months postpartum in a sample of women in Mexico (16). Prevalence estimates of PPD based on diagnostic criteria are consistently lower and more reliable than symptom-rating scale reports. For example, prevalence rates based on diagnostic criteria in the same sample of postpartum women in Mexico hovered around 13% (16).
Pregnant and postpartum women are less likely to seek mental health treatment than are non-pregnant women (5). Low rates of referral to and utilization of mental health services have been reported among ethnic minority populations in the United States, in general, and among immigrant perinatal women specifically (17-20). Additionally, knowledge about mental healthcare in Latin America is generally limited, and utilization of services is low (21). Currently, little is known about the factors contributing to this deficiency and how to effect change on a large scale.
Beyond such possible factors as limited childcare, finances, and transportation (22), other major barriers contributing to the low rates of mental health service utilization may include the attitudes and beliefs held by women regarding mental health. Women express feeling uncomfortable discussing their emotions with mental health practitioners, and often, fear that they will be perceived negatively or misunderstood (23, 24). Perinatal women also describe having limited knowledge about where to access help and the type of treatment or support needed (23). Additionally, limited interest and confidence in the effectiveness of mental health services have been cited as contributing factors in the low utilization of these services during the perinatal period (23). Women of childbearing age are generally interested in psychosocial interventions, but may not seek them from medical or mental health providers due to cultural norms and expectations, attitudes, beliefs, or other perceived barriers. Informal sources of support, such as family, friends, and religious leaders within their community may be seen as more accessible, trustworthy, or effective. Callister (18) demonstrated that Latina immigrants were 2.1 times more likely to not seek services due to cultural expectations around childbearing; and, they also tend to hold negative associations towards using formal mental health services. When compared to white pregnant women, African-American women expressed greater confidence in help-seeking when provided in a religious setting by a pastor (25), rather than by a medical or mental health provider.
There is a strong need for adaptive mental health services that take into account the barriers experienced by women as low service utilization may reflect an inability to obtain even currently available services (26). Researchers and clinicians should focus on developing innovative techniques to identify and provide mental health services to at-risk and underserved populations. The Internet is an effective medium for delivering mental health services to targeted populations, especially those reluctant to seek help because of perceived internal and actual external barriers. In recent years, the Internet has developed as both a source of information-gathering and a method of delivering psychological services and resources. The Internet has the potential to reach a large number of pregnant and postpartum women, who are already seeking health information online (27). It is a viable medium for educating women about depression, with demonstrated effectiveness in reaching marginalized populations (26) and a proven usefulness of Internet-based educational materials focused on postpartum depression (28).
The objective of the current study was to examine attitudes and beliefs related to help-seeking for depression among an international sample of pregnant women, a majority of whom were Spanish-speakers residing in Latin America. The study presents demographic characteristics and reported depression rates; described beliefs and behaviors associated with help-seeking for depression during the perinatal period; and finally, explored the characteristics associated with seeking help during this high-risk time of a woman's life.
MATERIALS AND METHODS
Participants in this study were part of a larger study that examined the efficacy of an Internet intervention designed to prevent postpartum depression. Eligible participants were pregnant, over 18 years of age, and interested in the larger study for personal use. Once deemed eligible, participants were directed to an informed-cons ent form and a baseline survey that assessed for demographic, pregnancy history and depression status. All procedures were approved by the sponsoring university's Institutional Review Board.
More than 6 000 (n = 6 672) pregnant women met eligibility criteria, consented to participate, and provided data between 15 January 2009-12 August 2011. Of these, 2 765 identified their ethnic background as Latino/Hispanic and 1 760 completed the baseline survey (i.e., enrolled). Baseline data from enrolled participants were included in the final study analyses. Chi-square comparisons of demographic characteristics revealed proportional differences between enrolled and non-enrolled participants. Non-enrollees identified their racial background as African/Black and Asian (χ2 [5, n = 2 765] = 42.7, P < 0.001), had completed fewer years of education (χ2 [2, n = 2 706] = 12.5, P = 0.002), were unaware of their annual income in US$, and few earned more than US$ 10 000 annually (χ2 [2, n = 2 765] = 13.2, P = 0.001).
The baseline survey included the informed consent and questions about participants' demographic characteristics (e.g., age, sex, country of origin), pregnancy history (e.g., weeks pregnant, number of previous pregnancies), and depression history (e.g., major depressive episode status, depressive symptoms). Participants completed questionnaire items that informally asked about sadness or depression during the pre-natal period and about related help-seeking attitudes, beliefs, and behaviors.
The Mood Screener-Current/Lifetime version (29) assesses for the presence of five or more DSM-IV (30) major depressive episode (MDE) symptoms experienced within a 2-week or longer period during a subject's lifetime, and, in the current version, during the past 2 weeks. In order to meet severity criteria for MDE, symptoms must also interfere with daily activities "a lot." The Spanish language version of the MDE Screener has demonstrated good sensitivity (κ=0.969; 95% Confidence Interval [95%CI]: 0.838-0.999), specificity (κ=0.967; 95% CI: 0.948-0.980), and accuracy (κ=0.968; 95%CI: 0.949-0.981) when compared to a clinical diagnosis using the Structured Clinical Interview for DSM Disorders (31).
Current depressive symptoms were also measured using the Center for Epidemiologic Studies-Depression (CES-D) Scale (32). The CES-D is a 20-item, self-report instrument that assesses for the presence of depressive symptoms during the past week. Total scores range from 0-60, with higher scores indicating more severe depressive symptoms. A score of 16 or above has been designated as a cutoff score for significant depressive symptoms (33).
Participants were asked if they had experienced periods of sadness or depression during or after pregnancy. Those who answered 'yes' were asked, "During this period of sadness or depression, did you seek help or talk to someone about how you were feeling?" (yes/no). Participants who answered 'yes' were asked to indicate the person with whom they spoke or from whom they sought help. To identify related attitudes and beliefs about seeking help, they were presented a list of statements and asked, "Did you have any of the following concerns and/or thoughts about how you were feeling?" Those who indicated that they did not seek help or speak to anyone about their feelings of depression during the perinatal period were presented with the same list of statements and queried with, "What are some reasons why you did not speak to or go to someone for help?"
Descriptive statistics were calculated to examine all baseline variables. T-test and Chi-square analyses were used to compare attitudes and behaviors related to seeking help for depression. A logistic regression analysis was used to identify characteristics that were related to seeking support for perinatal depression.
Participants were mostly Spanish-speaking women of Latino/Hispanic ethnic background, representing 51 countries worldwide, with a mean age of 28.3 years Â± 5.7. The majority resided in Latin America (16.9% Chile, 11.3% Colombia, 11.1% Venezuela, 10.2% Argentina, 15.5% Mexico) and Spain (10.6%), and were in the second trimester (mean gestation 16.5 weeks Â± 9.5) of their first (56.1%) or second (25.2%) pregnancy. Demographic characteristics are detailed in Table 1.
Depression history and help-seeking attitudes and behaviors
Depression characteristics are listed in Table 2. Experiencing feelings of sadness during/after a pregnancy was endorsed by 75.4% of participants. The mean CES-D score was 27.6 points Â± 13.8 with about one-third meeting DSM-IV diagnostic criteria for a current (18.6%) or past (12.4%) MDE. A family history of depression in either one or both parents/caretakers was reported by 42.5% of participants.
Of the participants who indicated that they had been sad or depressed during the perinatal period (n = 1 327), less than half (44.5%) sought help or support. Partners (82.5%), family members (75.5%), and health providers (49.4% medical and 42.8% mental) were the primary sources of support for these women. Approximately one-third (31.6%) of the total sample had previously accessed the Internet for depression-related information, with a higher proportion (42.8%) accessing the Internet for pregnancy-related depression. Of those who had not accessed the Internet for information about pregnancy-related depression (n = 1 007), a majority (87.7%) indicated that they would have, if they knew where to find it online.
Participants' perceptions about their depression experience and the relationship of those perceptions to help-seeking behavior were also examined (Table 3). Ambivalence and fear about the nature of depressive symptoms (84%), doubt about how long the symptoms would last (76.7%), and uncertainty about the complexity of their symptoms (75.6%) were frequently expressed by those who endorsed seeking help for depressive feelings during the perinatal period (n = 594). In contrast, those who did not seek support for depression (n = 733) were more focused on the temporal nature of their depressive feelings and on the inability of others to help improve their mood. Group differences in appraisals were found for all but one of the statements ("I didn't think that others would understand"). A further examination of the strength of the relationships between appraisals and probability of help-seeking revealed a small effect for all but one of the appraisals. "I was afraid of my feelings" had a medium (V = 0.326) effect on the probability of seeking help.
Predictors of depression help-seeking
Logistic regression analyses revealed a statistically significant main effect (χ2 [16; n = 1 189) = 33.27; P = 0.007) for two demographic help-seeking predictors entered into the model: current MDE (Odds ratio [OR] = 1.58; 95%CI: 1.04-2.39; P = 0.03) and income < US$ 10 000 (OR = 0.67; 95%CI: 0.49-0.92; P= 0.01). Age, language, race, marital status, education, and employment were not significant predictors of help-seeking.
This study provides initial evidence that Latin American women may be experiencing elevated rates of perinatal depression, but may not be seeking professional services. A majority of participants reported subjective experiences of sadness during pregnancy or the postpartum period, and endorsed current elevated symptoms of depression. It is of note, however, that more than one-half of participants did not meet diagnostic criteria for a history of MDE, therefore, potentially lowering their risk for the future onset of PPD. Affective changes in mood during and following pregnancy are not uncommon given the hormonal changes occurring in a woman's body. These biological changes (e.g., fluctuations in mood, concentration, appetite, sleep, etc.) overlap with experiences of depression, which can lead to confusion and misunderstanding of the actual psychological experience. As many as 31% of participants had a current or past experience with depression to the level of meeting diagnostic criteria for a major depressive episode, which suggests an increased risk for postpartum depression. Of concern, however, were how few indicated that they had sought or would seek psychological support. These data show the strong need for further study and further development of available screening and treatment options for all perinatal women, regardless of depression status or treatment- seeking behaviors, especially among those in Latin American communities.
Consistent with previous findings, the study suggests that those who sought help tended to approach family and intimate partners (34), with less than one-half seeking help from a health professional. A similar rate of help-seekers reported accessing the Internet for information about depression during the perinatal period. Strikingly, many other participants reported that they would use the Internet to seek information about depression if they knew where to look, suggesting a major avenue for future education and study. Reliable and accurate education about available resources and the nature of perinatal depression is needed. There are countless resources available for perinatal women online, however, few provide reliable and accurate information, and even fewer are available in Spanish. Additionally, because the results suggest that Latin American women tended to mainly speak to their family, it is important to identify community education efforts that inform family members about the symptoms, effects, and available treatments for perinatal depression.
Uncertainty and ambivalence about how they were feeling and being afraid, ashamed, or embarrassed of their symptoms, were concerns expressed among help-seekers. Non-help seekers, in contrast, described feelings that were more varied, potentially minimizing the impact of affective changes during the perinatal period. Furthermore, participants also reported, at nearly the same rate, that they did not believe that other people would understand their experience. Overall, results from this study suggest the need to normalize and educate perinatal women about the possible impact of perinatal mood changes, with the goal of reassuring help seekers and encouraging non-help seekers to obtain the support and care needed during this vulnerable period.
In contrast to previous reports (22), participants with incomes < US$ 10 000 were more likely to seek help than those with higher incomes. This finding highlights the prospective need for further research in low- to middle-income populations. Additionally, participants in the midst of a MDE were also more likely to seek help. This is promising, given the number of participants who reported present or past symptoms that met MDE criteria. This same group, facing the most severe symptoms of perinatal depression, has the greatest need for treatment. Other predictors-age, language, race, marital status, education, and employment-did not predict help-seeking behavior.
To the best of our knowledge, no other report exists that highlights these issues using an international sample of Spanish-speaking pregnant women. However, there were several limitations that restrict the generalizability of the findings. First, this study recruited participants through the Internet, which limits how the data may be generalized to communities or women who do not use or have access to the Internet. Second, our assessment of income may not reflect an accurate account of participants' socioeconomic status. Additionally, it proved difficult to enroll large numbers of women with limited education. Thus, these findings should be interpreted with caution, given global economic differences and the potential influence of educational attainment on the attitudes and beliefs associated with seeking psychological services. Third, empirically validated measures of help-seeking appraisals were not used. It is, therefore, difficult to interpret the results given differences in item presentation. Regardless of these limitations, the study findings provide an important picture of the help-seeking and depression symptom experiences of perinatal Spanish-speaking women in Latin America.
This study successfully used the Internet to recruit an international sample of women who provided useful information on help-seeking behaviors and attitudes during the perinatal period. It confirms that the Internet is an effective conduit for reaching perinatal women, and suggests that it would be equally helpful in educating patients and delivering psychological interventions. In this study sample, relatively few Latina women sought help from professionals, often because of negative attitudes about their symptoms or doubts that others could help. More research is needed to understand and expand help-seeking behavior in pregnant women experiencing mental health issues, especially women in low-income and diverse communities worldwide. Raising awareness of the mental health services available to expectant women and new mothers and diminishing the stigma around symptoms of depression during or after pregnancy would greatly benefit women in Latin America. Empowering the family and the friends in whom these women confide might also be effective.
Conflict of interests. None.
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Manuscript received on 17 August 2014
Revised version accepted for publication on 18 March 2015