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Creating accessible and acceptable care options for postpartum depression : a qualitative inquiry to… Lackie, Madison 2019

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CREATING ACCESSIBLE AND ACCEPTABLE CARE OPTIONS FOR POSTPARTUM DEPRESSION: A QUALITATIVE INQUIRY TO ASSESS POSTPARTUM MENTAL HEALTH NEEDS IN BRITISH COLUMBIA  by  Madison Lackie BScH, Queen’s University, 2017  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Reproductive and Developmental Sciences)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  December 2019  © Madison Lackie, 2019 ii   The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis entitled:  Creating accessible and acceptable care options for postpartum depression: A qualitative inquiry to assess postpartum mental health needs in British Columbia  submitted by Madison Lackie in partial fulfillment of the requirements for the degree of Master of Science in Reproductive and Developmental Sciences  Examining Committee: Lori Brotto, Department of Obstetrics & Gynaecology Supervisor  Alexander Beristain, Department of Obstetrics & Gynaecology Supervisory Committee Member  Hamideh Bayrampour, Department of Family Practice (Midwifery) Supervisory Committee Member Joelle LeMoult, Department of Psychology Additional Examiner   Additional Supervisory Committee Members: Andrea Kennedy, Department of Psychiatry Supervisory Committee Member iii  Abstract  Despite approximately 10% of new mothers in Canada developing postpartum depression (PPD), they face many barriers when accessing care. eHealth offers a unique opportunity to provide psychosocial skills and support to new mothers; however, treatment development does not consistently engage women directly in this process, thus often ignoring the unique needs that women express and the diversity of women who may use those tools.  This study engaged women from a variety of backgrounds and locations around British Columbia who had previously experienced PPD, for the purposes of determining the unmet psychoeducational needs of women with PPD and how a web-enabled platform used to deliver psychosocial skills and education to assist in the treatment of PPD could fulfill those needs. Focus groups were conducted in seven cities across British Columbia with a total of 31 women (mean age = 34.5 years), discussing participants’ needs, ideas, and opinions as they relate to the use of technology in treatment. Transcripts were analyzed using the approaches of qualitative description and emergent thematic analysis. Five themes emerged: bridging gaps to meet needs; providing validation to combat stigma; nurturing capacity to cope, manage, and/or reach wellness; empowering people to take ownership over their mental health; and offering customization to ensure relevance. At the intersection of these themes was the overarching idea of promoting agency for women experiencing PPD. Ultimately, new mothers require accessible mental health care that ensures their agency in mental health care decision-making. Our participants believed a web-enabled intervention iv  could help meet this need. These data will be used to guide the design of such an intervention, with the eventual implementation of this resource as a first-line treatment option for PPD. v  Lay Summary  Postpartum depression (PPD) affects approximately 10% of new mothers and can have many negative outcomes for both mother and baby. Despite the existence of many effective treatment options, women often face a variety of barriers when attempting to access care. This research evaluated the unmet psychoeducational needs of women experiencing PPD, as well as how a web-enabled intervention could specifically help to meet the needs of women. To do this, focus groups were run with women across the province of British Columbia who have had PPD to learn about their needs, ideas, and experiences. The feedback from these groups suggested that women face many gaps in learning about PPD and accessing care. However, participants provided recommendations to bridge these gaps by using a web-enabled intervention to validate and normalize their experiences, and empower them to become partners in their own mental health care.           vi  Preface  This thesis is an original intellectual product of the author, Madison Lackie, under the supervision of Dr. Lori Brotto.  Dr. Brotto brought to me the idea of designing a web-enabled intervention to assist in treating postpartum depression, and I went on to independently design and carry out the study protocol for the first phase of research to inform that idea. I also led the analysis and interpretation phase of this research, with support and assistance from Julia Santana-Parrilla, a qualitative analyst, and Brynn Lavery, a research assistant.   The study procedures were approved and carried out in accordance with the guidelines set by the University of British Columbia/BC Children’s and Women’s Research Ethics Board (Certificate No. H18-00364).           vii  Table of Contents  Abstract ......................................................................................................................................... iii  Lay Summary .................................................................................................................................v  Preface ........................................................................................................................................... vi  Table of Contents ........................................................................................................................ vii  List of Tables ..................................................................................................................................x  List of Figures ............................................................................................................................... xi  List of Abbreviations .................................................................................................................. xii  Acknowledgements .................................................................................................................... xiii Dedication .....................................................................................................................................xv  Chapter 1: INTRODUCTION ......................................................................................................1  1.1 Postpartum depression .................................................................................................... 1 1.1.1 Definition .................................................................................................................... 1  1.1.2 Prevalence and impact ................................................................................................ 1 1.1.3 Barriers to accessing care ............................................................................................ 2 1.2 eHealth ............................................................................................................................ 4  1.2.1 Mental health uses....................................................................................................... 4 1.3 Objectives ....................................................................................................................... 5  Chapter 2: METHODS..................................................................................................................6  2.1 Overview ......................................................................................................................... 6 2.2 Study population ............................................................................................................. 6  2.2.1 Participants .................................................................................................................. 6  viii  2.2.2 Eligibility .................................................................................................................... 7 2.2.3 Recruitment ................................................................................................................. 7 2.3 Procedures ....................................................................................................................... 8  2.3.1 Demographic questionnaire ........................................................................................ 8  2.3.2 Focus groups ............................................................................................................... 9 2.3.3 Member-checking ..................................................................................................... 10 2.4 Qualitative analysis ....................................................................................................... 11 2.4.1 Focus group analysis ................................................................................................. 11 Chapter 3: RESULTS ..................................................................................................................13  3.1 Demographics ............................................................................................................... 13 3.2 Themes .......................................................................................................................... 14 3.2.1 Bridging gaps to meet needs ..................................................................................... 14 3.2.2 Providing validation to combat stigma ..................................................................... 18 3.2.3 Nurturing capacity to cope, manage, and/or reach wellness ..................................... 20 3.2.4 Empowering people to take ownership over their mental health .............................. 23 3.2.5 Offering customization to ensure relevance ............................................................. 25 Chapter 4: DISCUSSION............................................................................................................28  4.1 Making Connections ..................................................................................................... 28 4.2 Current eHealth interventions for PPD ......................................................................... 30 Chapter 5: CONCLUSION .........................................................................................................32  5.1 Significance................................................................................................................... 32 5.2 Limitations .................................................................................................................... 32 5.3 Future directions ........................................................................................................... 33 ix  References .....................................................................................................................................35  Appendices ....................................................................................................................................40  Appendix A - Recruitment ........................................................................................................ 40 A.1 Pacific Postpartum Support Society recruitment email ............................................ 40 A.2 Facebook recruitment blurb ...................................................................................... 41 A.3 Recruitment advertisements ...................................................................................... 42  A.4 Recruitment breakdown ............................................................................................ 44 Appendix B - Demographic questionnaire ............................................................................... 45 Appendix C - Focus groups ...................................................................................................... 51  C.1 Location information ................................................................................................ 51 C.2 Focus group interview guide ..................................................................................... 51  C.3 Focus group post-assessment tool ............................................................................. 55 Appendix D - Analysis.............................................................................................................. 57  D.1 The analysis team ...................................................................................................... 57 D.2 Positionality .............................................................................................................. 58  D.3 Philosophical and theoretical assumptions ............................................................... 58 D.4 Trustworthiness ......................................................................................................... 58 D.5 Demographic questionnaire analysis ........................................................................ 59 D.6 The codebook ............................................................................................................ 62 D.7 Conceptualizing categories ....................................................................................... 77 D.8 The categories ........................................................................................................... 86 D.9 Conceptualizing themes ............................................................................................ 86 D.10 The themes ................................................................................................................ 90  x  List of Tables  TABLE 1 Number of participants in each group location .............................................................. 7 TABLE 2 Sociodemographic characteristics of focus group attendees........................................ 13 TABLE 3 Overview of how the emergent themes relate to specific features and contents details....................................................................................................................................................... 28  SUPPLEMENTAL TABLE 1 Focus group details ...................................................................... 51 SUPPLEMENTAL TABLE 2 Independent t-test results comparing focus group attendees to non-attendees on continuous demographic variables ........................................................................... 60 SUPPLEMENTAL TABLE 3 Chi-Square test results comparing focus group attendees to non-attendees on categorical demographic variables ........................................................................... 61  xi  List of Figures  FIGURE 1 Intersection of the five themes leading to the overarching goal of promoting agency....................................................................................................................................................... 27 SUPPLEMENTAL FIGURE 1 Recruitment and sample breakdown .......................................... 44 SUPPLEMENTAL FIGURE 2 Defining the interplay between the different spheres of life and how this relates to an app .............................................................................................................. 78  SUPPLEMENTAL FIGURE 3 The role of perceived needs within the spheres of life ............... 79 SUPPLEMENTAL FIGURE 4 The role of interpersonal relationships within the spheres of life....................................................................................................................................................... 80  SUPPLEMENTAL FIGURE 5 The role of healthcare within the spheres of life ........................ 81 SUPPLEMENTAL FIGURE 6 How the complexity of experiences and diversity of needs interface with the spheres of life ................................................................................................... 82  SUPPLEMENTAL FIGURE 7 The “what”: how app development needs interface with the spheres of life ................................................................................................................................ 83  SUPPLEMENTAL FIGURE 8 The “why”: how app development and unmet needs interface with the spheres of life .................................................................................................................. 84  SUPPLEMENTAL FIGURE 9 The relationships between the emergent categories ................... 85 SUPPLEMENTAL FIGURE 10 Conceptualization of themes based on the established categories....................................................................................................................................................... 89  SUPPLEMENTAL FIGURE 11 Illustrating the relationships between the emergent themes and the study objectives ....................................................................................................................... 90  xii  List of Abbreviations  CAD  Canadian dollar CBT  Cognitive behavioural therapy CCBT  Computerized cognitive behavioural therapy EPDS  Edinburgh Postnatal Depression Scale iKT  Integrated knowledge translation IPT  Interpersonal psychotherapy PPD  Postpartum depression QD  Qualitative description REDCap Research Electronic Data Capture xiii  Acknowledgements  First, I would like to thank my graduate supervisor, Dr. Lori Brotto, for the opportunity to work under her guidance and expertise on such an exceptional project, as well as to learn from and collaborate with her teams at multiple institutions. Her assistance, advice, and understanding were invaluable. I would also like to thank my supervisory committee members, Dr. Alexander Beristain, Dr. Hamideh Bayrampour, and Dr. Andrea Kennedy, for their support and flexibility throughout my graduate studies.  This research would not have been possible without a generous donation from COBS Bread, coordinated by the BC Women’s Health Foundation. Additional funding was provided through the incredible fundraising of the SHOPPERS. LOVE.YOU. Run for Women, organized by Shoppers Drug Mart and the BC Women’s Health Foundation. My salary was also supported in part by the Canadian Graduate Scholarship – Master’s Award through the Canadian Institutes of Health Research.  Thank you to all the members of the UBC Sexual Health Lab and the Women’s Health Research Institute, for their amazing support, assistance, and friendship – especially my office-mates, who answered my endless questions with patience. A special thank you to Brynn Lavery, without whom I would still be coding transcripts – your dedication and assistance on this project was truly invaluable. As well, my deepest gratitude to Julia Santana-Parrilla, for providing exceptional insight, guidance, and support throughout the analysis phase of this research, as well as life-changing visualization techniques.  Finally, I would like to thank my family and friends; without their support and encouragement, I would not be where I am today. To Sam, who is always there to listen, and to xiv  bounce ideas off of, and to edit, and to brighten my day. To my Uxbridge girls, for being a home away from home at home. To my parents, who are supportive no matter what (even when it means moving across the country), and to my sisters, who are always there for me. Lastly, to my grandparents, whose encouragement and optimism over the course of my entire life has been a driving force in everything I do.  xv  Dedication  This work is dedicated to all of the women who have suffered from postpartum depression, and those who work to reduce the burden these women face every day. 1  Chapter 1: INTRODUCTION  1.1 Postpartum depression  1.1.1 Definition Postpartum depression is a leading cause of maternal morbidity and mortality in high income countries,[1] and indiscriminately affects new mothers around the world. Defined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders as a depressive episode with peripartum onset, including onset during pregnancy and for up to four weeks postpartum,  [2] postpartum depression is a clinical illness which often requires professional medical or psychological intervention. However, research shows that the point prevalence of depressive symptoms appears to peak between two and seven months postpartum.[3] Due to this discrepancy, it is likely that many cases are missed.    In addition to the symptoms of depression, many women will also experience co-morbid symptoms, including those of: generalized anxiety disorder, panic disorder, social phobia, and posttraumatic stress disorder.[4]  1.1.2 Prevalence and impact In Canada, 10% of new mothers experience symptoms consistent with PPD, and an additional 8% experience PPD and anxiety symptoms together.[5] When combined, this figure is approximately equal to the worldwide prevalence rate of PPD symptoms, which has been calculated to be 17.7%.[6] As such, PPD affects a substantial number of Canadian women each year, and if left untreated can have significant negative impacts on the mother, child, and family.  2  A recent systematic review assessing 122 studies found negative impacts of PPD on mothers’ physical and mental health, infants’ physical health and development, mother-infant bonding, and familial factors, including finances and relationships with partners.[7] Outside of the immediate family structure, PPD can continue to have severe consequences. An economic analysis of perinatal mental illnesses in the United Kingdom found that the economic burden of these illnesses was £6.6 billion ($10.8 billion CAD) for live births in 2013, based on productivity losses, health and social care use, and resultant impairments and needs of the child.[8] When broken down to costs per woman by condition, perinatal depression was determined to cost £75,728 ($124,133 CAD) per woman with the condition in the same year, with £10,237 ($16,780 CAD) of that cost paid for by the public sector.[8] Based on our similar sociodemographic makeup and socialized healthcare system, it is likely that Canadian figures align greatly with this estimate. As such, ensuring that women have access to effective, acceptable, and usable treatment options is a matter of societal and economic importance, in addition to advancing the health and wellness of individuals and families.  1.1.3 Barriers to accessing care There is a wealth of available treatment options for postpartum depression, with a strong evidence-base supporting the use of psychological treatments, including cognitive behavioural therapy (CBT) and interpersonal therapy (IPT); psychosocial treatments, including peer support and non-directive counselling; and pharmacological treatments, specifically antidepressants.[9] Despite these options, a large proportion of women suffering from PPD do not seek or engage with these options – even when referred.[10-12] The literature has shown consistently that help-3  seeking behaviours in these women are impacted by a wide range of barriers, including social, instrumental, and structural barriers.[13-15]  The main social barrier, which can have wide-ranging effects on all levels of help-seeking, is stigma. In many cases, societal and cultural stigma lead to feelings of shame and guilt, as well as feeding into a pervasive fear of child apprehension in women suffering from PPD – all of which leads to a lack of disclosure.[13-15] On a more personal level, a lack of social support from family and friends can also create a barrier to accessing care, and contributes to instrumental barriers that exist, such as a lack of childcare to attend appointments.[13-15]  Financial constraints are another major factor in help-seeking.[13-15] A recent study in British Columbia found a significant association between socioeconomic status and access to health services, indicating a gap in care for women who may already be underserved.[16] The concentration of care options in urban centres can also be detrimental, as transportation is often identified as a barrier to accessing care.[13-15]  Finally, there are structural factors that impact access, with a lack of knowledge and information identified as a key element, both in patients and care providers.[13-15] This can lead to women remaining undiagnosed for longer than is necessary, and once these women are identified and directed to resources, they may be met with provider barriers and wait times that continue to impede their help-seeking.[13-15]  Throughout each sphere of life, women face barriers and gaps in accessing in-person care that contribute to and exacerbate their experiences of PPD. As such, there is a need to create and implement mental health resources and interventions that are effective, affordable, and accessible, and that can overcome the inescapable stigma present in different cultural and social settings. 4   1.2 eHealth The field of eHealth, involving the translation of psychological and other health interventions via telephone, application interfaces, or web-based platforms, has been instrumental in the movement towards making healthcare accessible and personalized. By making information and resources readily available, eHealth allows individuals to “become partners in their own health”, [17] empowering them to make decisions alongside their care providers.  1.2.1 Mental health uses eHealth interventions have been created and assessed for a wide range of common mental health conditions and are considered a cost-effective and accessible way to deliver care.[18] Several such interventions have been created using computerized cognitive behavioural therapy (CCBT) as the foundation of the provided therapeutic modules, and have demonstrated efficacy in treating common mental health disorders, including depression and anxiety.[18-21] As well, in recent years, there has been the introduction of multiple web-based interventions for the treatment of perinatal mental health conditions. Two recent systematic reviews found that these interventions are moderately effective (g = 0.60) at improving maternal mood; however, both indicated a need for more research in this area to provide additional evidence and address existing limitations.[22-23]  In the literature, accounts of these existing interventions are found in the United Kingdom, the United States, Australia, and Sweden, with randomized controlled trials demonstrating significant reductions in depressive symptoms following treatment compared to 5  control groups.[24-26] However, the only indication of feedback on the design and content of these interventions is found in the Australian-United States collaboration and the United Kingdom study, wherein participants were invited to comment on preconceived ideas for content and user interface features.[24,27]  As outlined in established standards for evaluating eHealth interventions, a crucial time for evaluation is during the conceptualization and design phase.[28] However, similar to above, research has shown that many eHealth interventions are only evaluated at the end of a study period, once the intervention has been fully developed and tested.[29] This study aimed to inform the design and development of a proposed web-enabled intervention by first identifying the gaps in care and assessing the needs of women experiencing PPD. As such, it employed the principles of integrated knowledge translation (iKT), which asserts that “involving knowledge users as equal partners alongside researchers will lead to research that is more relevant to, and more likely to be useful to, the knowledge users”.[30] A more significant inclusion of participants during the formative phases of content design and development would likely be beneficial in creating more useable, and therefore effective, interventions.  1.3 Objectives This was the first stage of a multi-phase study aiming to develop a web-enabled intervention that delivers psychosocial skills and education to women suffering from postpartum depression. This preliminary phase had the following objectives: 1. Determine the unmet psychoeducational needs of women with PPD. 2. Explore how a web-enabled intervention could help to meet those needs, including what specific features and content this intervention must have for women to utilize it. 6  Chapter 2: METHODS  2.1 Overview As the first stage of a multi-phase project, this study used focus groups to assess and understand the needs, ideas, and experiences of non-Indigenous Canadian women who have experienced PPD, as they relate to the development of a web-enabled intervention used to support the treatment of PPD. This protocol will inform future studies assessing the needs of Indigenous women and immigrant women in Canada to ensure that the intervention is accessible and acceptable for members within these diverse populations.  2.2 Study population  2.2.1 Participants To ensure that a diverse set of experiences and needs were captured, participants were recruited from seven different communities across British Columbia, as shown in Table 1, which vary in location, size, population demographics, and access to resources. These locations included Vancouver, Burnaby, Surrey, Kelowna, Prince George, Comox, and Victoria. Additionally, women who lived outside of these specific communities, but who were interested in participating and lived in the general vicinity, were invited to attend focus groups in-person or via Skype.    7  TABLE 1 Number of participants in each group location Location Surrey Vancouver Burnaby Prince George Kelowna Victoria Comox Total Participants 7 6 5 2 5 4 2 31 Mean Age (SD) 34.7 (5.6) 36.0  (3.5) 32.2 (4.4) 34.0 (7.1) 31.0 (4.3) 36.5 (4.9) 40.0 (5.7) 34.5 (4.9) Mean Number of Children (SD) 1.6 (0.5) 1.5  (0.5) 1.4  (0.5) 2.0 (1.4) 2.2  (0.4) 1.5 (0.6) 2.0 (1.4) 1.7 (0.6)  2.2.2 Eligibility Eligibility criteria were set to ensure that focus group participants were able to provide insightful reflections on the helpfulness of mental health management strategies for PPD. To meet inclusion criteria, participants were required to be 18 years or older; assigned female at birth and identify as a woman; identify as a non-Indigenous Canadian1; be able to read, write, and speak conversational English; and have experienced PPD within the last five years, but no longer meet diagnostic criteria. Prior to enrollment, participants were screened for current depressive symptomatology over the phone using the Edinburgh Postnatal Depression Scale (EPDS < 12), which is the screening tool currently recommended by Perinatal Services BC.[31]   2.2.3 Recruitment Ethics approval was obtained from the University of British Columbia/BC Children’s and Women’s Hospital Research Ethics Board. Ethical considerations included providing all                                                  1 Note: This phase of the study explicitly included only non-Indigenous Canadians due to planned phases for Indigenous and immigrant focus groups, which will be run separately to determine each population’s unique needs. 8  participants with a list of mental health resources available online and across the province of British Columbia following the phone screen process and following each focus group due to the potential for triggering distress. Additionally, a protocol was developed for participants who endorsed thoughts of self-harm which ensured that they had access to mental health supports. Purposeful sampling was used to identify participants, with enrolled participants encouraged to aid in snowball recruitment through their own social networks. Study advertisements were promoted through social media and local service providers, with the majority of participants responding to ads on local Facebook groups and through the Pacific Postpartum Support Society – a community partner in the Lower Mainland.  2.3 Procedures Three distinct phases of participation were created, including completion of a demographic questionnaire, attendance at one focus group session, and an optional chance to perform member-checking with participants’ transcripts.  2.3.1 Demographic questionnaire A demographic questionnaire was completed by all enrolled participants, collecting information relating to participants’ personal life experiences, including socioeconomic data, relationship and family data, and medical history data. Participants were offered the option of completing the questionnaire at home via an emailed unique survey link or mailed paper copy, or completing it at their focus group session on an iPad provided by the researchers. Study data were collected and managed using REDCap electronic data capture tools hosted at BC Children's Hospital. REDCap (Research Electronic Data Capture) is a secure, web-based application 9  designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources.[32] Descriptive statistics were analyzed using Statistical Package for the Social Sciences (SPSS Version 26.0).[33]  2.3.2 Focus groups As described above, focus groups were conducted in seven communities across British Columbia, and were held in local public venues, such as public libraries and community centers. These focus groups ranged from one to two hours in length. In addition to the study coordinator acting as a facilitator, each focus group also employed an experienced co-facilitator from the local community to create a more accessible and acceptable environment for the participants.  The research team created a semi-structured interview guide, which was not piloted prior to collecting study data. The interview guide posed a series of questions that transitioned from an open discussion of participants’ experiences with PPD and available treatment options to more specific questions regarding their ideas for the design of the proposed web-enabled intervention, including interactive features, peer support options, and the inclusion of partners. Each group concluded with a discussion of what participants regarded to be the most important factor in their personal recovery and what would be necessary for the research team to consider when designing the eventual intervention platform. At least one focus group was run in each community, with no further groups run when saturation was reached – that is, no new ideas or information was emerging.[34]  10  In most groups, time permitting, a discussion of an existing web-based cognitive behavioural therapy (CBT) program called BounceBack was included, in addition to the regular interview guide. BounceBack is a physician-recommended program available in multiple provinces across Canada.[35] It has a significant evidence base to support its efficacy in treating a range of mild to moderate mental health disorders, including anxiety, depression, and eating disorders.[36-38]  The group discussion of BounceBack was used to inform the design and delivery of CBT through the proposed web-enabled intervention, and entailed an interactive walk-through of the website and a discussion of its strengths, weaknesses, and relevance to PPD.  Childcare resources were available, with participants encouraged to bring their young children if necessary. Participants were provided a catered meal during the group and were offered a $50 honorarium and parking reimbursement for their participation. Each session was audio-recorded and transcribed by a contracted company, with additional context provided by qualitative notes taken by a research assistant during each group. Prior to transcription, each employee at the transcription company was required to sign a confidentiality agreement, and participants were informed of this process to ensure their informed consent was provided.   2.3.3 Member-checking Participants were provided the optional opportunity to review their transcripts prior to the final analysis to ensure that their ideas were being accurately represented in the analysis. This practice ensures descriptive validity, which adds to the trustworthiness and transferability of the ensuing analysis.[39] Out of the 31 participants who attended focus group sessions, 7 participated in member-checking.  11   2.4 Qualitative analysis  2.4.1 Focus group analysis Anonymized, verbatim focus group transcripts were analyzed using the qualitative analysis software NVivo 12, which allowed for streamlined data management and synthesis across multiple research staff.[40] The three researchers who performed the analysis – all of whom were white, cis-gendered, nulliparous women – approached the data guided by a social constructivist framework; thus, exploring and acknowledging how the interactions within the focus group setting are shaped by who is in the room, opportunities to speak, and perceptions of safety in sharing.[41]  A qualitative descriptive approach was used to analyze the data, with inductive thematic analysis employed to identify themes. Qualitative description (QD) is a qualitative approach often used in health research and is especially effective in informing the development of interventions or policies that can improve health outcomes for various populations.[42] Based on exploring “the who, what, and where of events and experiences”,[43] QD provides a straight description based on participants’ responses, making use of participants’ own language to support the themes that emerge.[43-45] Based on its usefulness in informing interventions, as well as its ability to assist in translating findings directly and rapidly to improving care, QD is a well-suited approach for the development of a web-enabled intervention.[42] As is consistent in the literature for QD, inductive thematic analysis was used to explore and explain the collected focus group data.[44] Thematic analysis is described as a method of “identifying, analyzing, and reporting patterns” that exist within a qualitative data set.[46] Thus, 12  an inductive approach to data investigation was used in conjunction to develop codes directly based on the data, often using the explicit descriptions provided by participants.[46]  The basic approach of qualitative analysis outlined by Miles, Huberman, and Saldana (2014) was followed,[47] which involved creating a series of codes, establishing relationships between the identified codes to create categories, and finally determining what overarching themes existed. The appraisal of qualitative research differs from that of quantitative research, and so the criteria developed by Lincoln and Guba (1985) were used to assess trustworthiness.[48] This included the use of inter-coder reliability,[49-50] investigator triangulation,[51] member-checking,[39] and verbatim quotes to provide credibility – a marker of internal validity. Additionally, providing contextual and demographic information about the participants, and the use of detailed memoing,[52] lent transferability, dependability, and confirmability to the findings.  The creation and use of high-quality data is a significant step towards creating accessible, acceptable, and relevant care for women suffering from PPD across British Columbia. 13  Chapter 3: RESULTS  3.1 Demographics A total of 31 women participated in the seven focus group sessions. The mean age was 34 years (range 24-44), with a mean of 2 children (range 1-3). This sample of women was predominantly white, highly educated, and married. Sociodemographic characteristics of the sample are presented in Table 2.   TABLE 2 Sociodemographic characteristics of focus group attendees Variable Mean (SD) or n (%) Age (years) – Mean (SD) 34.48 (4.946) Sexual orientation – n (%) Heterosexual 29 (93.5) Bisexual 2 (6.5) Ethnicity – n (%) Chinese 2 (5.9) Hispanic or Latin American 1 (2.9) Indigenous 1 (2.9) Japanese 1 (2.9) South Asian (East Indian, Pakistani, Sri-Lankan, etc.) 1 (2.9) White European 28 (82.3) Education – n (%) Graduated high school or earned G.E.D 2 (6.5) Attended some college/university 4 (12.9) Graduated 2-year college/university 8 (25.8) Graduated 4-year college/university 9 (29.0) Post-Graduate degree 8 (25.8) Employment – n (%) Full time 13 (32.5) Part time 7 (17.5) On maternity leave 5 (12.5) Self employed 2 (5.0) Stay-at-home caregiver 8 (20.0) Student 2 (5.0) Unemployed 3 (7.5) 14   TABLE 2 Sociodemographic characteristics of focus group attendees (cont.) Variable Mean (SD) or n (%) Annual household income – n (%) Less than $20,000 2 (6.5) Between $20,000 and $39,999 2 (6.5) Between $40,000 and $59,999 7 (22.6) Between $60,000 and $79,999 3 (9.7) Between $80,000 and $99,999 4 (12.9) Between $100,000 and $119,999 2 (6.5) Between $120,000 and $139,999 2 (6.5) Between $140,000 and $159,999 2 (6.5) More than $160,000 5 (16.1) Relationship status (%) Never married 2 (6.3) Dating 1 (3.1) In a relationship 1 (3.1) Married 25 (78.1) Common-law 1 (3.1) Separated 2 (6.3) Number of children – Mean (SD) 1.68 (0.653) Number of PPD diagnoses – Mean (SD) 1.10 (0.301)  3.2 Themes Five major themes emerged: bridging gaps to meet needs; providing validation to combat stigma; nurturing capacity to cope, manage, and/or reach wellness; empowering people to take ownership over their mental health; and offering customization to ensure relevance. Each of these themes identifies a need (ex. combatting stigma) and a way to address that need (ex. providing validation).  3.2.1 Bridging gaps to meet needs  Participants identified gaps that exist in knowledge about PPD and care options for PPD, contributing to unmet needs, such as being unaware of the manifestations of PPD and finding 15  care to be inaccessible. Opportunities for a web-enabled intervention to assist in bridging these gaps in the interests of meeting their needs were discussed.   The gaps described by participants ranged from access to care (i.e. eligibility), care provision (i.e. availability and acceptability), and awareness and understanding of postpartum mental health concerns. Multiple participants identified that the current definition of “postpartum” compromises responsiveness to their needs, and contributes to those needs remaining unmet, as illustrated by the following participants: “… because one thing I have to say is the postpartum period is not a year. And that, that bothers me because I was in a race the first time for this to be done with. […] I struggled for four years after my second.” (SUP21, 36, Vancouver, 2 children) “… so I only saw (doctor) the one time. […] Then when I called back and my son was already a year old, they said, ‘Well, it’s too late.’ Like, I guess they only offer help for up to a year.” (SUP7, 39, Surrey, 2 children) They explained how a web-enabled intervention could bridge these gaps: “I guess that seems like it might be a nice advantage of an app. Like, you wouldn’t need to be one-year. Under one-year postpartum. You can just access it any time. And benefit from it.” (SUP28, 31, Burnaby, 1 child, 2 additional children as surrogate) Even when eligible for care – for example, less than one year postpartum – many participants discussed the barriers they faced in accessing available options, such as the timing of appointments for care and the impact of long wait times to see specialists. “… I got referred to the group so often. It’s like, ‘Yes, you need help. This is the help option,’ and I couldn’t access that option. […] I have friends that volunteered to call in 16  sick so they could look after my son [tearful voice] so I could go, you know? And it’s just that option wasn’t there.” (SUP25, 42, Victoria, 2 children) “This was in November, and they weren’t able to give me an appointment until March. So unfortunately, I wasn’t diagnosed until March, like, officially, and that kind of, like, does break my heart and breaks my husband’s heart.” (SUP12, 37, Burnaby, 1 child) A web-enabled intervention was recommended as a way to provide care to women who face these barriers, as a first-line intervention or as a supplement to in-person care. “[…] in my situation here, because resources are scarce, I would need something, well, yes, especially in northern, rural B.C., it’s hard to access things, so whether that be a counsellor or sometimes even a good internet connection, right? So, I would need a resource to be as self-directed as possible.” (SUP13, 29, Prince George, 3 children) “[It] would be great for supplementing and helping a woman before they actually get to see a therapist or start on their medication or something and then would support them through that as well.”  (SUP11, 32, Surrey, 2 children) A pervasive topic across the focus groups was a lack of awareness and understanding regarding PPD. Awareness was defined as knowing of PPD, and its existence as a mental health concern, whereas understanding went deeper into knowing about it, including symptoms and potential treatment options. Participants expressed how a lack of knowledge in their friends and family regarding the existence and presentation of PPD could contribute to unmet needs, and how a web-enabled intervention could engage and educate these support people to better assist women, through providing information about PPD, ways to help, and how to access care. 17  “Well, I think it’s important for [partners] to be involved. I don’t think that, they don’t understand either. Like, they don’t, I know mine wasn’t. Like, he had no idea.” (SUP26, 29, Prince George, 1 child) “Or even signs, too, because I think, a lot of times, they notice that things are going on but don’t necessarily know what to do with that information or what it’s really reflecting, especially if they don’t have any, they’ve never even been exposed to information on postpartum depression.” (SUP32, 30, Kelowna, 2 children)  Although this investigation was focused on the role of a web-enabled intervention in mental health management, most participants expressed the value of its use as a preventive and promotive tool to feel better equipped in what to expect from the postpartum period. “I almost wish they made more of a case of it during, like, your pregnancy, you know? Like, ‘You should anticipate this. This could totally happen to you.’” (SUP28, 31, Burnaby, 1 child, 2 additional children as surrogate)  “I don’t know if I would have been able to really look at anything while I was in it, but I think beforehand, like if it was available to people that are pregnant, then that might help […] if I had already been on that app beforehand and, you know, knew what it was all about, then I would have been more open to that.” (SUP1, 32, Surrey, 1 child) Unmet needs, such as a lack of knowledge regarding PPD, were thought to persist due to gaps that exist and are perpetuated because of stigma, and participants have underscored how the normalization and validation of postpartum mental health is an effective way to combat stigma. “[…] normalization of the experience helps because most of us are sobbing in our homes, you know, thinking that this sucks. And we have nobody to tell, and there’s guilt and shame and all this stuff that comes with it. And it’s actually really common 18  [laughter], um, but […] it’s supposed to be positive, right?” (SUP32, 30, Kelowna, 2 children)  3.2.2 Providing validation to combat stigma  Participants spoke to their experiences with stigma, especially as it relates to notions of being a good mother. They described how it can become internalized, as well as its effects on their mental health. For example, one woman expressed: “Like, for me, for example, because I was feeling so, um, like, um, low, and like so hard on myself, feeling inadequate. You know, like, maybe I should be suffering, so when my husband said, ‘You should take care of yourself,’ it’s like, ‘No. Like, I deserve to not feel good.’” (SUP41, 31, Victoria, 1 child) Validation of their feelings and experiences was key in addressing this internalized stigma, both through education and normalization of postpartum mental health concerns before they occur, as well as through the sharing of stories from other women who have had PPD to fight feelings of isolation.  “[…] in the support group, I never felt that. Like, everybody was saying their truth. It was like, ‘Oh, she is experiencing that. Wow. Okay. I am okay.’ There was no repercussion. It was just a safe place to, to feel okay.” (SUP8, 43, Surrey, 2 children) Examples of how a web-enabled intervention can integrate these features were provided, with one participant describing the inclusion of peer and professional encouragement: “Yeah, I think just some way of encouraging women whether it be through success stories or a connection with a counsellor, whatever it is, through the app that, um, would just 19  encourage them not to give up and encourage them that it will get better.” (SUP30, 36, Comox, 1 child) And another describing what she found useful in the resources she used, and how they could be adapted: “And seeing that stuff, I don’t know if it was for you guys too, but, like, knowing that it’s not, you’re not crazy. It was just relief to know. I mean, when you read that, you’re like, ‘Oh my gosh. This is totally what I’m going through.’ And it was so relieving, so having stuff on the app like that would be [good].” (SUP23, 39, Victoria, 1 child)  In addition to appreciating validation, participants described how they would want to reciprocate that validation by mobilizing their experiences and knowledge in the interest of demystifying and normalizing PPD, raising public awareness and combatting stigma. “Every chance I get to talk about my experience, I do. Like, I posted […] on Facebook, and I asked everyone to share it. […] I want someone to feel better, so I think just talking about it is important. Yeah, so you don’t feel like a crazy person, right?” (SUP26, 29, Prince George, 1 child) They identified that pervasive stigma towards PPD impacted attitudes expressed by family and friends, which was damaging to their mental health. “[…] so like, my mom would be like, ‘This is so weird. I have no idea what’s wrong with you.’ Like, she’d actually say that to me. Yeah. She’s like, ‘I loved my babies instantly. Like, as soon as I saw them, I was, like, in love.’ I’m like, ‘Oh God.’” (SUP41, 31, Victoria, 1 child) The effects of stigma regarding PPD were woven throughout personal and social interactions, and greatly impacted the mental health and help-seeking of women suffering from it. However, 20  through these experiences they discovered the power of validation and normalization to combat those attitudes. They also described lessons for nurturing capacity in other women to assist on their journey to wellness. “I think it would be helpful in terms of normalizing it. Because I think the more resources via app or in person or whichever, helps to normalize it. Yeah, the more information you have, and the more, and right at your fingertips because you can’t always leave the house. Right?” (SUP30, 36, Comox, 3 children)  3.2.3 Nurturing capacity to cope, manage, and/or reach wellness The need for tools to assist in management was clear when participants identified the challenges they faced in coping with and managing their mental health concerns, as well as on their journey to wellness.  “Yeah, I’d add, like CBT is great, but you have to have so many other things in place before it works. […] I think a lot of people who don’t have their basic practical needs met, like, ‘I don’t actually have time to have a break because I have nobody to help me.’” (SUP10, 30, Vancouver, 1 child) “I knew that there was something really wrong, so I went, I think, once a week for support group and we did, my doctor tried to get me on meds, too, and I did not want to, so I just went to the support group. We learned meditation. We learned CBT, which was really helpful.” (SUP8, 43, Surrey, 2 children) “Also, I, like, had extreme panic attacks about taking the medication. I was so afraid […] And so I worked with a therapist for probably four sessions before I even took one. […] within a month, I was like, ‘Holy shit. I am like a complete, I love my child. I love my life. 21  Wow, the sky is blue.’ I was like I can’t believe I was so worried about taking medication that has completely changed my life and made me such a better mother.” (SUP15, 36, Vancouver, 1 child) Many described how a web-enabled intervention could be utilized to nurture their capacity, thus providing the tools and education necessary to facilitate their ability to reach each of these levels of mental health management. Often these tools were identified as being most helpful prior to mental health concerns arising, when they could be used as a preventive measure. However, once PPD occurs, many women suggested supports such as connecting them to peers with lived experience and providing evidence-based knowledge to deepen their understanding of PPD and ability to determine their path to wellness: “I think there’s a lot of benefits to having both peers and professionals on it? Because you, you’re gonna trust a professional. They’ll tell you, ‘Drink 20 cups of water,’ and you’re going to be downing the 18th one. As opposed to, like, a peer. A peer is a little bit more approachable, right? And you’re almost… you’re on the battlegrounds with them, so there’s a lot of validity in both.” (SUP19, 36, Vancouver, 1 child) “I was obsessed with the question, ‘Would I ever get better?’ and I would ask everybody. […] I would just plead with everybody, ‘Does this end?’ So, to have success stories built into the app. Might be really helpful.” (SUP10, 30, Vancouver, 1 child) “[…] a community hub or a portal where, like, all that information is just. In one place. Because […] I didn’t like reading about it. But the little bit I did read was from different sources, so if you just had everything in one place.” (SUP12, 37, Burnaby, 1 child) 22  They also discussed how gaining knowledge from peers and professionals can lead to personal insights, and suggested ways of including opportunities for self-reflection to promote these insights within a web-enabled intervention: “[…] mood tracking and stuff as just a way of, uh, paying attention to it, I think, was the point. Because a lot of the time when you’re depressed, you’re not… really thinking about the specifics of why you feel like you feel.” (SUP10, 30 Vancouver, 1 child) Outside of educating themselves, participants endorsed engaging family and friends to assist in nurturing their capacities to cope, manage, and reach wellness.  “Yeah, I think anyone who might be involved, like someone, if they don’t have a partner or maybe if it’s their roommate or their mom or whoever it is that’s kind of closely tied to them. That could be that support partner.” (SUP30, 36, Prince George, 3 children) Participants explained how having their experiences validated and their capacity nurtured empowers them to trust that they know what their needs are and how best to meet them. However, they also discussed how having their capacity minimized and their needs dismissed by those they seek support from can leave them feeling disempowered, and as though they have no control over their care. “[…] when I talked to the person […] on the help line, um, […] it was kind of strange, but I, because she almost sounded, made it sound like I was some kind of helpless victim of this thing, you know? But, which to me, didn’t sound like, […] not very empowering […] And I told her, ‘I am not a helpless victim. I know I can’t help the hormones and all of that, but there are things I can do.’” (SUP43, 44, Prince George, 3 children)  23  3.2.4 Empowering people to take ownership over their mental health  When feeling disempowered, participants often reflected on power dynamics within the healthcare system. Specifically, how their perceived lack of power was a detriment to their mental health, and how a web-enabled intervention could promote agency in their pursuit of mental well-being. “I didn’t want to do medication, which is what I felt the psychiatrist just kind of pushed. She was very nice about it, but she kind of, I felt like she pushed it too hard.” (SUP2, 29, Surrey, 2 children) “[…] did I get help? I don’t think it was helpful. I think that the midwives thought it was helpful.” (SUP9, 39, Surrey, 2 children) “I find certain questions very intimidating because… what’s going to happen if I say, if I say I am having thoughts of hurting myself or someone else, it doesn’t mean I need to be slammed into a cage.” (SUP9, 39, Surrey, 2 children)  When describing how a web-enabled intervention could bridge these power dynamics, they discussed how it could supplement their relationships with care providers and ensure that they are able to make informed choices as partners in their own care.  “[…] like, even if it was like, ‘Hey, if you’re in B.C., like, this is what you need to know in B.C.’ Like, step by step by step, ‘Do this. Do this. Do this.’” (SUP12, 37, Burnaby, 1 child) An idea that often came up centred around tracking your mental health using a web-enabled intervention to facilitate care: “Then yeah, if you are seeing someone […] you can take out your app, and you can tell them, ‘Actually, I’ve noticed that over the last week, I’ve been more anxious. Let’s talk 24  about that’ or ‘I’ve noticed that when I send my son to school, I start feeling like this.’” (SUP11, 32, Surrey, 2 children) Additionally, they discussed the importance of their personal insights in determining the best pathway for them to achieve mental well-being. For example, identifying preferences in care options, such as self-care versus specialist care. Many identified self-care as a necessary way to make up for gaps in other care options. “[…] the piece that really turned the corner for me was […] she drew a teapot, and she said, you know, like, […] ‘You have all the things going into the tea kettle that are creating the pressure.’ So, she listed all of the things that I had talked about, and she said, ‘You have no outlet to let the pressure out, so and now your brain is exploding, basically.’ […] And so when I feel that buildup of rage, because it usually expresses itself as rage, that’s what I think about like, ‘My teapot is going to explode. How do I relieve the pressure?’ So I either take the pressure off myself and leave things that are putting pressure on or I go for a walk or I do something else that’s going to help me to calm down. And I know what those things are, so I have my tools in my toolbelt, right?” (SUP25, 42, Victoria, 2 children) Once self-care preferences are realized, participants expressed how a web-enabled intervention could support them: “I would like to see something that popped up, like a pop-up that said, ‘Self-care’ [laughter]. Because this is a word I had no idea existed until postpartum.” (SUP8, 43, Surrey, 2 kids) 25  Overall, participants considered how a web-enabled intervention could assist women by nurturing their capacity and empowering them to reach wellness on their own terms. They also identified how ensuring relevance is integral to these goals.   3.2.5 Offering customization to ensure relevance  Participants suggested how a web-enabled intervention could offer relevance by providing a customizable interface through which people curate their journey towards mental well-being. Across themes, participants spoke to how current strategies and supports are not specific to their experiences of pregnancy and postpartum. Consequently, the need to ensure relevance was highlighted throughout their discussions. Specifically, participants explained how a web-enabled intervention could offer customizable features to tailor resources to meet their needs. “I think that’s a really important point for an app because it can’t be one thing for all people. It needs to be, um, personalized to your, you know, what would help you the most.” (SUP24, 34, Victoria, 2 children) Based on these customizations, women would then be able to access resources and support on their own terms: “[…] just, like, a tiny bite, just a tiny bite because that’s all I could have taken. And then maybe once I’ve taken that bite, there are, like, bigger bites going down. […] so, like, little, tiny bread crumbs to be like, ‘Try this’ or ‘Try that’ and then, ‘If you try it and you like it, well here’s a something a little bit different but the same. It might help you differently, better.’” (SUP31, 32, Kelowna, 2 children) 26  “Yes, I think maybe different levels, right? Different levels because sometimes you just need a mom that understands. And then sometimes you need to go to a suicide hotline.” (SUP1, 32, Surrey, 1 child) They also reflected on their preferences for content delivery strategies and recommended interactive features. These contributions were often informed by their responsibilities and time constraints as parents, and what would be considered accessible and acceptable. “So even if it takes 20 pages, but 20 pages of smaller information because then it’s easier to be like, ‘Okay. I was on page 5. I’ll continue it later,’ rather than getting lost on a whole book […] but something you can just quickly scroll through while you are breastfeeding, feeding a child, or anything, right?” (SUP2, 29, Surrey, 2 children) “You almost have to, like, you almost need to BuzzFeed it [laughter], you know? […] I’d love to see, like, you know, ‘Three self-care tips you can do right now.’” (SUP12, 37, Burnaby, 1 child) “I think, like, if you don’t want to sit there and read for. Then you can watch the video. You can, like, pick and choose out what you want or what you think relates to you.” (SUP26, 29, Prince George, 1 child)  Ultimately, participants identified gaps, and expressed how a web-enabled intervention could fill their needs for validation, increased capacity, and empowerment by offering relevant content through such an intervention. As shown in Figure 1, at the intersection of these five themes exists the overarching goal of promoting agency in women experiencing PPD, so that they can determine and pursue the most effective and acceptable path to personal mental health and wellness.   27                 Providing validation to combat stigma Nurturing capacity to cope, manage, and/or reach wellness Empowering people to take ownership over their mental health Bridging gaps to meet needs Offering customization to ensure relevance Promoting agency FIGURE 1 Intersection of the five themes leading to the overarching goal of promoting agency 28  Chapter 4: DISCUSSION  4.1 Making Connections  This work aimed to determine the unmet needs that persist for women experiencing PPD, and to explore how a web-enabled intervention for PPD could assist in meeting those needs. These findings clearly demonstrate that there are a range of unmet needs, including a need for education, validation, empowerment, and accessible care. Explicit examples of how a web-enabled intervention could help to fulfill those needs were provided across the focus groups. Table 3 provides an overview of some specific features mentioned by participants to meet their needs, and how those features relate to the emergent themes.  TABLE 3 Overview of how the emergent themes relate to specific features and contents details Theme Features & Content Bridging gaps to meet needs  Pathway to local services  Self-directed therapies (CBT, mindfulness, etc.)  Availability throughout maternal trajectory Providing validation to combat stigma  Chat forum (with moderators)  Peer buddy system  Blog posts to share stories Nurturing capacity to cope, manage, and/or reach wellness  Resource hub  Evidence-based information  Resources for support people Empowering people to take ownership over their mental health  Daily prompts/check-ins  Mental health tracking  Self-care information  Resources for holistic care Offering customization to ensure relevance  Profile/baseline assessment  Options for opting in/out of features  Content delivery for different learning styles (i.e. written, videos, audio, etc.) 29  These findings reflect the current knowledge base regarding women’s perceived barriers to accessing care and their unmet needs in PPD. As described throughout our themes, these gaps exist on multiple fronts and at multiple levels of mental health management. Stigma is consistently described as a significant barrier to help-seeking behaviour.[13-15] As seen in the current study, cultural stigma relating to pregnancy and postpartum experiences can lead to guilt and shame in women, which is supported in the literature.[13] Additionally, we demonstrated how a lack of validation and normalization of postpartum mental health concerns exacerbates these feelings.[53]  Woven throughout the themes is a lack of knowledge and understanding of postpartum mental health – another significant barrier to the pursuit of mental well-being.[13-15] Related to stigma, validation, nurturing capacity, and empowerment, much of what participants discussed in these themes involved feeling alone in their experiences, not having the information and tools to manage their mental health, and requiring education to become partners in their journey to mental well-being. A lack of knowledge regarding PPD in general, as well as available resources and supports, has been identified consistently in the literature, contributing to unmet needs.[13-15]   Through these discussions, the importance of providing an intervention that can be tailored to, and addresses, the diversity of needs and complexity of experiences faced by women is clear. Additionally, ensuring that interventions are made accessible for women, regardless of factors such as location or income, is crucial.  Despite this sample of participants being predominantly well-educated and affluent, the majority struggled to access care for PPD. However, financial constraints (which could be linked to income) and a lack of knowledge about PPD (which could be indirectly impacted by education level) are consistently highlighted as barriers to accessing care in the literature.[13-15] The 30  financial aspect is especially important in Canada, where the universal healthcare system does not fund mental health services. Due to this absence of funding, many Canadians have unmet mental health needs, especially when those needs include psychosocial, rather than pharmacological, treatments.[54] This suggests that mental health concerns and costs for care are prohibitive, even for those of affluent status. As well, it seems that social factors, such as stigma and social support, and structural factors, such as location, wait times, and healthcare provider knowledge, may play a strong role in facilitating access to care options for this population.  Although out of the scope of this analysis, which pooled all seven focus groups from across British Columbia into one assessment, geographic location expectedly played a role in the needs of women experiencing PPD. When discussing a web-enabled intervention, women based in urban areas – especially the Lower Mainland of British Columbia – expressed a need for connecting with local in-person resources, whereas women from rural and remote communities, who don’t have in-person resources available, required a support that could be used as a stand-alone, first-line intervention. Research has shown that women in rural settings have lower rates of PPD detection and treatment, which leads to health disparities in these populations,[55] further bolstering the importance of exploring the diverse needs of women experiencing PPD to create an accessible and acceptable intervention that fills the gap.  4.2 Current eHealth interventions for PPD  Patient engagement and acceptability is often overlooked in interventions using eHealth to treat perinatal mental health concerns. All existing interventions to this end rely solely on delivering psychotherapy via technology.[24-26,56] As evidenced by the current study, this approach to management fails to address many of the key unmet needs of women. Some of these 31  missed opportunities include providing education to address a lack of knowledge surrounding PPD, including peer support and evidence-based information, and incorporating partners in care to support women.  In addition, half of the existing interventions simply adapt existing treatment modalities and content, but do not engage mothers to provide feedback on these adaptations.[26,56] Although the others pilot tested with participants to ensure acceptability and updated to reflect those findings, [24-25] none engaged women directly and integrated their preferences from the design phase to build something from the ground up based on their specific needs and experiences. This has left an opportunity to design and develop an eHealth intervention that can truly meet the needs of women experiencing PPD, which this study will be used to inform.        32  Chapter 5: CONCLUSION  5.1 Significance  This research provided a breadth and depth of insight into the needs of women experiencing PPD that has not been seen before in the literature, specifically as it relates to informing the development of an eHealth intervention. Participants described a multitude of unmet needs that persist due to varying gaps in care and knowledge; however, they also uncovered opportunities to bridge those gaps and meet their needs, in the interests of gaining ownership over their mental health journeys. These findings suggest that a web-enabled intervention is perceived as being a welcome addition to supplement currently available resources for PPD and provide concrete recommendations on how it can best serve this purpose. Overall, this study provides an exciting foundation on which to create an accessible, acceptable, and effective resource to assist in the treatment of PPD.  5.2 Limitations  Despite these findings, and the many strengths of the study protocol, gaps remain in the knowledge base that this study was unable to fill. First, based on the difficulty of recruiting for focus groups, we were unable to assess the needs of extremely rural and remote communities. As well, since this phase of the research included solely non-Indigenous Canadian women, the sample was not as diverse as it could have otherwise been. However, this study is part of a larger research project, which will be assessing the needs of Indigenous women and immigrant women who have experienced PPD, in the interests of representing and understanding the diverse needs of Canadian women. 33   Additionally, the use of focus groups invites some well-established limitations. Since focus groups necessitate having multiple participants, recruitment and attendance can be difficult to ensure.[57] This study struggled with recruitment, resulting in some focus groups having only two attendees. As well, a common side effect of focus group discussions is “group-think”, or the conversation becoming biased due to dominant personalities and the need to fit in.[57] Due to these dominant personalities, some people tend to be overrepresented in the transcripts of focus group sessions, while others are silenced.[58] However, one of the main strategies to combat these limitations is to employ experienced, well-trained facilitators.[57-58] By including multiple facilitators in each focus group session – one who is extremely familiar with the literature and study, and another who is familiar with the local community and available services for PPD – we were able to mitigate some of these potential outcomes. As well, despite these limitations, focus groups are thought to be extremely useful in projects that involve assessing the needs of a population or evaluating proposals, due to the ease of quickly building off each other in discussions to form ideas. As well, for this particular population of women, who are often isolated and ashamed of their experiences, the opportunity to meet and speak with peers to share their stories was expressed as being very therapeutic.   5.3 Future directions  This study is the first phase of a multi-phase study, with the overarching goal of creating a web-enabled psychosocial skills and education program to assist in the treatment of PPD. The next phase of research will involve concurrently running focus groups with Indigenous and immigrant women across British Columbia, as well as beginning to design and develop the intervention platform. Following integration of the new focus group data into the intervention 34  content, usability testing will be undertaken before the intervention is tested in a randomized controlled trial to ensure its efficacy in reducing depressive symptomatology in women experiencing PPD.  35  References  1. Oates M. 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The SAGE Encyclopedia of Qualitative Research Methods. Thousand Oaks, CA: SAGE Publications; 2008:446. 51. Rothbauer PM. Triangulation. In: Given LM, ed. The SAGE Encyclopedia of Qualitative Research Methods. Thousand Oaks, CA: SAGE Publications; 2008:893-894. 52. Groenewald T. Memos and memoing. In Given LM, ed. The Sage Encyclopedia of Qualitative Research Methods. Thousand Oaks, CA: SAGE Publications; 2008:506. 53. Thomas LJ, Scharp KM, Paxman CG. Stories of postpartum depression: Exploring health constructs and help-seeking in mothers' talk. Women Health. 2014;54(4):373-387. 39  54. Sunderland A, Findlay LC. Perceived need for mental health care in Canada: Results from the 2012 Canadian community health survey-mental health (Statistics Canada, Catalogue No. 82-003-X). Health Rep. 2013;24(9):3-9.  55. Geier ML, Hills N, Gonzales M, Tum K, Finley PR. Detection and treatment rates for perinatal depression in a state Medicaid population. CNS Spectr. 2015;20(1):11-19. 56. Pugh NE, Hadjistavropoulos HD, Dirkse D. A randomised controlled trial of therapist-assisted, internet-delivered cognitive behavior therapy for women with maternal depression. PloS One. 2016;11(3):e0149186. 57. Wong LP. Focus group discussion: A tool for health and medical research. Singapore Med J. 2008;49(3):256-261. 58. Leung FH, Savithiri R. Spotlight on focus groups. Can Fam Physician. 2009;55(2):218-219. 40  Appendices  Appendix A  - Recruitment  A.1 Pacific Postpartum Support Society recruitment email Dear Patient,  Re:  Research Study – The SUPPORT Study We are writing to inform you of a study involving the development of an online intervention delivered via mobile app for the treatment of postpartum depression, based on the needs of BC mothers. The Principal Investigator of the research study, Dr. Lori Brotto, is a researcher and Professor in the Departments of Obstetrics and Gynaecology, and Psychiatry, at the University of British Columbia, as well as being the Executive Director of the Women’s Health Research Institute at BC Women’s Hospital. Her research team is planning to investigate, through a series of focus group sessions, the needs and opinions of women across the province who have previously been diagnosed with postpartum depression. To ensure that any online intervention offering skills and support best meets the needs of women, it is important that their voices be heard. If you are interested in learning more about the study, or wish to arrange for your participation, please contact the study coordinator, Madison Lackie, at madison.lackie@cw.bc.ca.  Participation in the study is voluntary. If you choose not to participate, your care will not be affected in any way.   41  Efforts have been made to ensure this notification does not reach the families of patients who have passed away. If a grieving family member receives this letter, please accept our heartfelt condolences and our sincere apology.   Sincerely,  Program Manager or Appropriately Designated Departmental Level staff [insert name of Department(s) ] [insert name of Institution that has the patients personally identifiable information]  A.2 Facebook recruitment blurb “Have you suffered from postpartum depression in the past 5 years?  If so, you may be eligible to receive compensation and a free meal by sharing your experiences and opinions to help researchers develop an online treatment option!”          42  A.3 Recruitment advertisements     Survey and Development of a Universally Acceptable Postpartum Online Resource for the Treatment of Postpartum Depression: The SUPPORT Study  The purpose of the study:  Approximately 1 in 10 Canadian new mothers are diagnosed with postpartum depression (PPD)  There is a need to learn from the experiences of women who have faced PPD in order to develop an online intervention delivered via mobile app accessible by all women in BC What does the study involve?  Your participation in a single 2-hour focus group will help to foster discussions based on open-ended questions, your own personal experiences, and the responses of other participants  Compensation will be provided for your participation Who can participate in this study?  If you are 18 years of age or older  If you are able to read, write, and speak conversational English  If you are female by birth (cis-female)  If you have had a diagnosis of postpartum depression in the past five years, but are not currently diagnosed as having postpartum depression What are the benefits of participating in this study?  Learn from and interact with other women who have experienced postpartum depression  Provide crucial input for the creation of a tool which will benefit other women experiencing postpartum depression  Receive a catered meal during your session Who do I contact to sign up for the study?  Study Coordinator:  Madison Lackie  Email:   madison.lackie@cw.bc.ca  Phone:   604-875-4111, ext.68901  Lab Website:  www.brottolab.com/studies *Note: All inquiries are confidential 43                         44  A.4 Recruitment breakdown  SUPPLEMENTAL FIGURE 1 Recruitment and sample breakdown     45  Appendix B  - Demographic questionnaire                        46                         47            48   49    50   51  Madison (Lead facilitator) Local Co-facilitator Appendix C  - Focus groups  C.1 Location information SUPPLEMENTAL TABLE 1 Focus group details  # of Participants Venue Date Time Member-Checking Surrey 7 City Centre Branch, Surrey Libraries October 2nd, 2018 12pm-2pm 2 Vancouver 6 Firehall Branch, Vancouver Public Library November 13th, 2018 12pm-2pm 1 Burnaby 5 Fortius Sport & Health, Burnaby January 31st, 2019 5pm-7pm 1 Prince George 2 Prince George Civic Centre February 12th, 2019 4pm-6pm 1 Kelowna 5 Downtown Kelowna Branch, Okanagan Regional Library April 30th, 2019 1pm-3pm 0 Victoria 4 James Bay Branch, Victoria Public Library June 3rd, 2019 1pm-3pm 1 Comox 2 Holiday Inn Express Boardroom, Courtenay June 19th, 2019 7pm-9pm 1  C.2 Focus group interview guide  Introduction Hello, my name is (name) and I will be moderating today’s focus group session. This is (name) and she/he/they will be an assistant moderator, taking notes and handling the logistics of this session. I’d like to start by thanking each of you for taking the time to participate today. This session will run for approximately 2 hours, including the time for each of you to review the consent forms and study information, as well as to help yourself to the refreshments provided. If 52  you would like anything to eat or drink, please feel free to help yourself now, so that the flow of our session is not disrupted once we get into our discussion. Purpose The purpose of today’s session is to gather your opinions and ideas regarding your experiences with postpartum depression and its treatment options, as well as your feelings towards the use of technology in healthcare. We will be using the information and perspectives you provide to inform the creation of a web-enabled treatment intervention for women who are diagnosed with postpartum depression. As mentioned, I will be leading our discussion today by asking questions, then encouraging and moderating the discussions that emerge. I would like to inform you all that this focus group session will be tape recorded to allow analysis of the themes that emerge and to better inform our work. The identities of all participants will remain confidential in these recordings. Ground Rules Before we begin, there are some ground rules I would like to go over to ensure a respectful and free-flowing conversation: 1. Only one person may speak at a time. This is important for both the respect of everyone involved, as well as for the usefulness of our audio recording of the session. In this vein, please avoid any side conversations. 2. Please ensure that any cell phones are off or silenced, unless absolutely necessary. If you are required to take a phone call, please do so quickly and quietly away from the group. 3. You do not have to give a response for every question; however, I would like to hear from each of you at some point in our discussions and will try to make sure that everyone receives a chance to speak. 53  4. This discussion will be confidential in that I will not be using any of your names in any of the write-ups or data analysis that occurs in this project. However, I would like to stress to you all that, to keep these sessions confidential, we ask that you do not use names or anything directly identifying when discussing your personal experiences. We also ask that you do not discuss other participants’ responses outside of this session. 5. There are no “right” or “wrong” answers, just different opinions. We ask that you respect each others’ opinions and experiences, and say what is true for you without fear of judgement. 6. Let me know if you need a break. The bathrooms are (location). 7. Your participation is completely voluntary, and you can leave at any time. 8. Finally, do whatever you need to do to take care of yourself (and your baby) over the next 2 hours, and let the facilitators know if you need anything to help with that. Are there any questions before we move on? Participants Introductions Before we start, I’d like for all of us to get to know a little bit more about each other. Please tell me: 1. Your name 2. Your favourite place in BC and why?  Questions 1. Tell us whatever you feel comfortable sharing about your experience with PPD. a. Did you seek support or treatment for your PPD? i. If so, from who? 54  ii. If so, did it work? 1. What specifically worked best? iii. If so, for how long did you draw on those resources? b. How did you feel about the availability of resources for treatment/recovery? i. Did you feel as though the resources provided to you were culturally sensitive and safe for you? ii. What are some of the online resources, if any, you’ve used to support your recovery? 2. How do you feel about using technology to support PPD treatment? a. Which types of technology do you think would be most beneficial if used this way? 3. Imagine that there is an app or website with scientifically proven skills to help you manage PPD. Would you use it? a. What would make you use it? What features would it have to have? b. What types of interactive components do you think would be most useful? (i.e. videos, quizzes, etc.) Show Bounce Back website features, including trailer video and example exercises (https://cmha.bc.ca/programs-services/bounce-back/). Ask participants to point out what they do and don’t like about the platform, and what needs to be done differently to be acceptable to PPD. 4. How would you feel about your partner being involved in your PPD treatment regimen? 5. What would you say was the most important factor in your recovery? 6. Of all the things we have discussed today, what would you say is the most important to take into account when we design this intervention? 55  Closing (Read back a summary of what has been discussed.) Do you feel that this summary accurately represents what has been discussed here today? Does anyone have any final questions, comments, or concerns? We have come to the end of our session today. I want to thank you all for your honest opinions and input on this topic. This is an extremely important stage of this project, and you were extremely helpful in providing useful feedback.   If they come up organically: If you had access to discussion forums with other moms who have/had PPD, how often would you read posts or post yourself? When using an online program to treat PPD, would you like to receive a customized series of workbooks? When using an online program to treat PPD, would you make use of 4 to 6 coaching sessions delivered by phone or video conference? If so, who do you think should lead these coaching sessions? When using an online program to treat PPD, how would you feel about having access to an optional reminder/notification system?  C.3 Focus group post-assessment tool The following tool was completed immediately following each focus group session, with input from both facilitators and the note-taker.  56  (1) What are the main themes that emerged from this focus group?    (2) What did participants say that was unclear or confusing to you?    (3) What did you observe that would not be evident from reading a transcript of the discussion (e.g., group dynamic, individual behaviors, etc.)    (4) What problems did you encounter? (e.g., logistical, behaviors of individuals, questions that were confusing, etc.)    (5) What questions or issues are there for follow up in the future?     57  Appendix D  - Analysis   D.1 The analysis team Julia Santana-Parrilla – Qualitative Analyst Julia joined the study team in March 2019 as a contracted qualitative analyst. She is a Master of Science candidate in the School of Public and Population Health at UBC, and has 8 years of qualitative research experience, working with various research groups at the University of British Columbia. Her research interests focus on reproductive health and rights, especially as they intersect with minority and underserved populations. In her role, Julia assisted in the design of the analysis protocol and provided high-level guidance and expertise throughout the analysis phase. Additionally, she reviewed the coding of the first three focus group transcripts to provide feedback and ensure intercoder reliability between the two coders. Julia was instrumental in the conceptualization of codes, categories, and themes.  Brynn Lavery – Research Assistant Brynn is a research assistant at the UBC Sexual Health Lab and was involved in both the data collection and analysis phases of this study. Brynn has a B.A. in Psychology and brings her knowledge of counselling and interviewing techniques to the study team.  During the data collection phase, Brynn acted as a note taker at six of the seven groups, noting down important quotes and non-verbal gestures. During the analysis phase, Brynn was responsible for coding half of the transcripts, and then reviewing the other half – coded by Madison Lackie – to establish intercoder reliability. She also assisted in re-coding transcripts 58  during the category development phase. Similar to Julia, Brynn was heavily involved in the conceptualization of codes, categories, and themes.  D.2 Positionality It is important to note that the three researchers involved in analysis are cis-gendered, white women who have not personally experienced birth and parenthood. All three researchers have a strong leaning towards social justice and transformative frameworks that take into account the multiplicity of identities and spaces that individuals embody and exist in. As such, our inferences and biases may impact how the descriptions of events and experiences from mothers are portrayed.  D.3 Philosophical and theoretical assumptions This analysis was guided by the idea that participants experience separate realities that are shaped by their experiences and interactions in their social world, and that these realities are known and expressed based on the influence of social interactions. For example, the discussions that emerge in each focus group session will be shaped by who is in the room, opportunities for each participant to speak, and perceptions of safety in sharing. As such, this research is guided by a social constructivist framework, which explores how subjective meanings of experiences are constructed by our interactions with our social, cultural, and historical worlds.[41]  D.4 Trustworthiness Trustworthiness was established via the practices of member-checking, memo-writing, and inter-coder reliability. Intercoder reliability is an important marker of internal consistency and 59  validity, allowing the study results to be generalizable to a larger body of similar work.[48-49] Similarly, having multiple researchers involved in the analysis process – two of whom were also involved in data collection – created investigator triangulation, which again increased the validity of the study findings.[50] Finally, each researcher created detailed memos during each stage of analysis, allowing a clear communication of their thoughts and ideas to the rest of the research team, as well as creating opportunities for reflexivity in their analysis, adding credibility and trustworthiness to the findings.[51]   This work is a significant step in creating accessible, acceptable, and relevant care for women suffering from PPD across British Columbia, and as such, it was crucial to design and implement a study protocol that included multiple approaches to lending validity and credibility to its findings.   D.5 Demographic questionnaire analysis Although 41 participants were enrolled in the study and completed a demographic questionnaire, only 31 women were able to attend the scheduled focus groups sessions. In order to make generalized statements about the results, it was important to ensure that the sample of focus group attendees did not significantly differ from those who were unable to attend. To assess this, an independent t-test was performed for the reported continuous variables, including participants’ current age, number of children, and number of PPD diagnoses, and a chi-square test of independence was performed for the reported categorical variables, including factors such as ethnicity, employment, and relationship status. It is important to note that multiple response questions were converted to dichotomous variables in order to perform this test effectively. As such, the following categorical variables were adjusted: relationship status was identified as in a 60  relationship, including the responses “in a relationship”, “married”, and “common-law”, versus not in a relationship; employment status was identified as employed full-time, including “full-time” and “self-employed”, versus not employed full-time; and ethnicity was identified as White European versus other ethnicities. As shown in Supplemental Table 2, there were no significant differences between enrolled participants who attended a focus group session and those who did not attend a session on key sociodemographic factors, including age (t(39) = -0.144, p = 0.886), number of children (t(39) = 0.089, p = 0.929), and number of PPD diagnoses (t(38) = 0.123, p=0.903). In addition, no significant associations were observed between attendance status and education (Χ2(5) = 4.994, p = 0.417), annual income (Χ2(8) = 11.433, p = -0.178), relationship status (Χ2(1) = 1.430, p = 0.232), employment status (Χ2(1) = 0.082, p = 0.775), and ethnicity (Χ2(1) = 2.267, p =0.132) (Supplemental Table 3).  SUPPLEMENTAL TABLE 2 Independent t-test results comparing focus group attendees to non-attendees on continuous demographic variables  FG Attendants FG Non-Attendants Statistics N Mean Std. Deviation N Mean Std. Deviation df t p Current age 31 34.48 4.946 10 34.20 6.713 39 -0.144 0.886 Number of children 31 1.68 0.653 10 1.70 0.823 39 0.089 0.929 Number of PPD diagnoses 31 1.10 0.301 9 1.11 0.333 38 0.123 0.903     61  SUPPLEMENTAL TABLE 3 Chi-Square test results comparing focus group attendees to non-attendees on categorical demographic variables  FG Attendees FG Non-Attendees Statistics % Count % Count df X2 p Education 5 4.994 0.417 Attended some high school 0 0 10 1  Graduated high school or earned G.E.D. 6.5 2 0 0 Attended some college/university 12.9 4 10 1 Graduated 2-year college/university 25.8 8 10 1 Graduated 4-year college/university 29 9 40 4 Post-Graduate degree 25.8 8 30 3 Annual Household Income 8 11.433 0.178 Less than $20,000 6.9 2 10 1  Between $20,000 and $39,999 6.9 2 0 0 Between $40,000 and $59,999 24.1 7 0 0 Between $60,000 and $79,999 10.3 3 40 4 Between $80,000 and $99,999 13.8 4 0 0 Between $100,000 and $119,999 6.9 2 20 2 Between $120,000 and $139,999 6.9 2 0 0 Between $140,000 and $159,999 6.9 2 0 0 More than $160,000 17.2 5 30 3 Relationship Status 1 1.430 0.232 In a relationship 87.1 27 100 10  Not in a relationship 12.9 4 0 0 Employment Status 1 0.082 0.775 Employed full-time 45.2 14 40 4  Not employed full-time 54.8 17 60 6 Ethnicity 1 2.267 0.132 White European 80.6 25 100 10  Other ethnicity 19.4 6 0 0   62  D.6 The codebook *Note – Sub-codes are right-justified. Code Name Code Description 1 App Dev't (Bucket Code)  App Dev't FG1P1 Where participant 1 (FG1) speaks re: App/ web-based supports development App Dev't FG1P2 Where participant 2 (FG1) speaks re: App/ web-based supports development App Dev't FG1P3 Where participant 3 (FG1) speaks re: App/ web-based supports development App Dev't FG1P4 Where participant 4 (FG1) speaks re: App/ web-based supports development App Dev't FG1P5 Where participant 5 (FG1) speaks re: App/ web-based supports development App Dev't FG1P6 Where participant 6 (FG1) speaks re: App/ web-based supports development App Dev't FG1P7 Where participant 7 (FG1) speaks re: App/ web-based supports development App Dev't FG2P1 Where participant 1 (FG2) speaks re: App/ web-based supports development App Dev't FG2P2 Where participant 2 (FG2) speaks re: App/ web-based supports development App Dev't FG2P3 Where participant 3 (FG2) speaks re: App/ web-based supports development App Dev't FG2P4 Where participant 4 (FG2) speaks re: App/ web-based supports development App Dev't FG2P5 Where participant 5 (FG2) speaks re: App/ web-based supports development App Dev't FG2P6 Where participant 6 (FG2) speaks re: App/ web-based supports development App Dev't FG3P1 Where participant 1 (FG3) speaks re: App/ web-based supports development App Dev't FG3P2 Where participant 2 (FG3) speaks re: App/ web-based supports development 63  App Dev't FG3P3 Where participant 3 (FG3) speaks re: App/ web-based supports development App Dev't FG3P4 Where participant 4 (FG3) speaks re: App/ web-based supports development App Dev't FG3P5 Where participant 5 (FG3) speaks re: App/ web-based supports development App Dev't FG4P1 Where participant 1 (FG4) speaks re: App/ web-based supports development App Dev't FG4P2 Where participant 2 (FG4) speaks re: App/ web-based supports development App Dev't FG5P1 Where participant 1 (FG5) speaks re: App/ web-based supports development App Dev't FG5P2 Where participant 2 (FG5) speaks re: App/ web-based supports development App Dev't FG5P3 Where participant 3 (FG5) speaks re: App/ web-based supports development App Dev't FG5P4 Where participant 4 (FG5) speaks re: App/ web-based supports development App Dev't FG5P5 Where participant 5 (FG5) speaks re: App/ web-based supports development App Dev't FG6P1 Where participant 1 (FG6) speaks re: App/ web-based supports development App Dev't FG6P2 Where participant 2 (FG6) speaks re: App/ web-based supports development App Dev't FG6P3 Where participant 3 (FG6) speaks re: App/ web-based supports development App Dev't FG6P4 Where participant 4 (FG6) speaks re: App/ web-based supports development App Dev't FG7P1 Where participant 1 (FG7) speaks re: App/ web-based supports development App Dev't FG7P2 Where participant 2 (FG7) speaks re: App/ web-based supports development 2 Background Info (Bucket Code) "Getting to Know You" info about participants, including # of children, what type of treatment they received, social support information, etc. # of Kids Number of children that the participant has. 64  Circumstances Surrounding Pregnancy and Birth Encompasses traumatic birth experiences, unplanned pregnancy, pregnancy complications, surrogacy, etc. Family & Friend Circumstances Encompasses single parent households, in-laws/family living/interacting with participants, experiences with their other children and with the child associated with the experience of PPD/A, and family/social support in MH journey Length and Impact of Time to Treatment How long between initial symptoms/diagnosis and receiving/accessing treatment, as well as related factors (i.e. if wait times were prohibitive enough to seek alternatives in the meantime). Life Stressors During Pregnancy and PP Period Encompasses socioeconomic factors, job loss, childcare responsibilities, housing situation, etc. Location of Birth Where the participant gave birth, both geographically and hospital vs home MH History Encompasses previous diagnoses of MH disorders, as well as recognition of previously undiagnosed MH problems (ex. when participants realize they've always had underlying anxiety). Postpartum Diagnosis What postpartum mental health disorder participants were diagnosed with (ex. PPD, PPA, PP OCD, etc.) Postpartum MH Treatment Encompasses whether participants received treatment, and what kind (i.e. counselling, psychotherapy, medication) PPD Circumstances and Development Encompasses how long before/after birth PP MH problems occurred, and circumstances related to PPD/A development (ex. PPD/A with multiple pregnancies, fertility issues, stress factors, etc.) Relationship Circumstances Encompasses relationship status (i.e. single, married, etc.), relationship experience (i.e. abuse, supportive, etc.), and relationship support through MH journey Acceptance of med's Acceptance of medications/ pharmaceutical interventions → the factors that influence the acceptance of medications as options to support mental health. Including: • Perceived necessity to support daily function  • Desperation to feel functional • Support/ encouragement to pursue meds o From interpersonal relationships o From HCPs • Awareness of peer success stories Support to pursue med's Support/ encouragement to pursue meds • From interpersonal relationships • From HCPs Accessing RMH Accessing Reproductive Mental Health (RMH) → how accessing the only pregnancy-specific mental health resource/support 65  shapes wellbeing • Waiting to access RMH • Awareness of RMH (as option) • RMH care options (distinctions between RMH and reproductive psychiatry: the latter being prescriptive) Agency re MH decision-making + self-management. Captures: how much agency women have/ feel they have in making decisions about their mental health • Perceived [mental health] needs (perceived by women) • Preferred steps toward wellness  • Power dynamics in HCP-patient dyads • Taking initiative and self-advocacy • Intimate partner & social network influences App + engaging support people in MH “Help you help me” kind of feature  Engaging inter-/personal supports (i.e. family/friends) in mental health → how providing options to get the people close to them [women] involved in their mental health could be done via the App • Teach women how to talk with him/them about it • Providing resources specifically for partners • Providing resources specifically for other network members App + guidance for support person[s] Ways to help support people to provide support to PP/mothers • Facilitating understanding of MH experience • Recommend concrete/clear ways to help PP o Educate about how to emotionally support PP • Recommend practical tasks to [offer to] assist PP • “What to/not to do” App + lived experience as resource how user experiences can be shared in app to help others • … to combat fear of the unknown • … to provide hope • … to share resources • … to create learning opportunities (e.g. Hearing about D-MER for the first time through a share) App + MH Tracking Tracking mental health journeys → for their own reference, or to supplement healthcare visits (substantiate their experiences with metrics) • Regular mood(s) tracking  • Goal tracking App + peer support feature[s] how peer support can be delivered via the app • Mode of peer support delivery (chat, forum, phone/video call, in-person meetings) o Preference for 1-no-1 vs group support (e.g. “buddy system”, group forum, etc.) • “Match-making” peer groups based on experience Community hub/ forum App + peer support delivery Mode of peer support delivery (chat, forum, phone/video call, in-person meetings) • Preference for 1-no-1 vs group support (e.g. “buddy system”, group forum, etc.) App + Providing a safe community Providing a safe community → how the App could foster a sense of safety and community + what is considered necessary to foster it • Having trained moderators and peer supporters • Providing anonymity to users • Addressing problematic messaging (in trauma-informed ways) 66  App + Readiness to use Timing of app uptake (in MH journey) → how uptake of the App is influenced by where women are in their mental health journey + influences their acceptability of the App (readiness to use) • Readiness to use App  • Dependent on severity of MH challenges/ concerns App + role in MH management how Apps intersect with / can be used in conjunction with other care options • App as a supplement to HCP care • App as a supplement to other management options • App as a resource hub App as pathway to resources • Feature/ direct to local resource options • Vetted/ reliable resource options • [Contains] information specific to variety of symptoms/ expressions • Resource/ support delivery options (i.e. peer, blog, organization, etc.) • Beyond mental health, into parenting logistics App + user interface what are considered accessible (and acceptable) forms of presenting/ organizing information; "aesthetics"  • Setting options • Opt in/out of prompts • Menu with content option headings • Community hub/ forum App as an accessible MH support App as an accessible MH support → how the app fills gaps in care accessibility + overcome barriers to care • Overcome geographic barriers • Overcome financial barriers • Overcome time barriers (to support MH while awaiting in-person care) App baseline self-assessment Where are you at/ what do you need? For customizable interface set-up App content What participants consider necessary information, reflecting on their experiences and needs App content delivery what women consider user-friendly necessities; how content is consumed • Quick, easy and effective • “bite-sized” info delivery • Direct & directive language App intrusive thoughts stopper  App prompts and check-ins Receiving prompts and check-ins → with reminders, questions, “did you know?”, etc. to bring women into their feelings/ mindful reflections of how they’re feeling and/or need • Self-care reminders • What’s making you feel stressed today? • Self-reflection question prompts App user & content safety Safety was a major concern, so participants mentioned the need for: • Trigger warnings • Disclaimers/ caveats • Resource pop-ups (when a certain threshold has been met, e.g. suicide hotline pop-up suggestion) • Mindful & up-to-date language • Anonymity & safety 67  Apprehensions about sharing How apprehensions women have about sharing their experiences with others impact their help-seeking behaviours due to: • Fear of judgement (captures feeling alone in their experiences) • Experiences of judgement (captures “judgey mommy groups”) Becoming aware of pre-existing challenges How experiencing postpartum mental health concerns can be a catalyst to becoming aware of pre-existing challenges and accessing mental health care/supports. Captures: • Recognizing pre-existing challenges (becoming aware of) • Naming mental health concerns • Being granted the language to identify what’s going on and ask for help/support • Armed with knowledge and resources (for coping) Being a good mother How social narratives regarding pregnancy and motherhood affect women’s mental health. Captures: • Having the perfect pregnancy • Being able to breastfeed • Feelings of failure  • What your relationship with baby/ies should look like • Denial of struggle/ seeing the struggle • Cultural expectations of motherhood • Worrying as normal (erasing experiences of anxiety/depression) Being able to self-identify How and when PP come to self-identifying (predictor of accessing care). Includes: • Having the language (to identify and communicate needs) • Seeing the signs (that something’s wrong) • Accepting something’s wrong Accepting something's wrong As a determinant of being able to self-identify and communicate needs Having the language …to identify what’s going on and ask for what they need. Seeing the signs …that something’s wrong Birthing trauma How birthing experiences can impact mental wellbeing. This captures: Recovering from birthing Expectations re: performing motherhood (how much time is needed for recovery in conflict with motherhood duties) Relationships to their bodies and any sense of betrayal (from their bodies) Bounce Back (Bucket Code) Captures all responses directly relating to Bounce Back content and layout Complexity of experiences How the complexity and multiplicity of mental health experiences manifest. Including: • Multiple/varying manifestations of stress • Many ways of coping Confusion re what PPD looks like Confusion regarding the manifestation of anxiety/depression postpartum →  how being unsure of what counts as PPA/PPD impacts wellbeing. Includes: • Being unclear on what counts (as 68  PPd/PPa) • Doubtfulness of what counts as PPd/PPa (and whether what they’re feeling counts) Diversity of needs **Overlaps with complexity of experiences** how the multiplicity of stressors and complexity of experiences lead to diverse needs. Captures: • Trial and error regarding what works • Changing/shifting needs over time • Range of management options Changing needs over time How needs changes and shift over time in accordance with different stressors + access to care/support ER as pathways to care How PP are/not able access care through the ER & what that looks like/ where it leads • ER care provider capacity to address concerns. Captures: • ER as point of intervention o ER and timely referrals to specialists • ER conditions/ environment as compounding stressor • Acuity/severity of mental health concerns as predictor of ER use Familial roles & relationships How family dynamics lend themselves to mental health wellness/distress. Captures: • Adapting to changes (in dynamics, roles, responsibilities) • Feeling helpless  • Family attitudes/perspectives regarding mental health • Receiving help from family o Differences in what help looks like/ what’s helpful (help wanted versus help gotten) Parenting responsibilities How the roles & responsibilities are distributed within families as a determinant • Primary care giver/ing • Division of parenting labour • Stay-at-home parenting • Parenting multiple children Fear & anxiety during pregnancy How anxiety is expressed during pregnancy + what might predict such feelings. Including: Fertility & difficulty conceiving as a predictor of fear/anxiety during pregnancy Fear of/around the baby/ies’ health & birth outcomes - Fear of labour, pain, etc Pressure to experience the perfect pregnancy + Expectations regarding pregnancy - Uncertainty + unknowing Nulliparous vs multiparous (multiparous may be more informed re: what to expect as they’ve experienced it before) Physical dis/comfort during pregnancy Feeling dismissed + unsupported Whether by those closest to them, or HCPs, both are compounding stressors and determinants of mental health deterioration. Include how: • Focus on baby • Loss of identity Influence how alone/ lost women feel Feeling prepared **Not to be confused with “preparing for baby”** Refers to how feeling un/prepared for their experiences of pregnancy, birth, and postpartum impacts mental health outcomes. Captures: • Empowerment through education (to minimize anxieties associated with feeling unprepared) • Normalizing postpartum 69  experiences • Feeling equipped in case of postpartum mental health concerns Empowerment through education …to minimize anxieties associated with feeling unprepared Normalizing postpartum Normalizing postpartum experiences and demystifying the complexity + multiplicity of them Focus on Baby How throughout pregnancy & postpartum, much of the care women receive is focused on the baby, its development, wellbeing, etc. while hers is secondary. Includes thoughts on how: • Pregnancy is celebrated, postpartum is not • Resources focus on baby milestones • Postpartum care and postnatal check-ins focus on baby (and mom’s recovery from birth, but MH?) • Paediatric care offers opportunities to check in with mom as much a baby/ies Pregnancy is celebrated, postpartum is not How pregnancy is focused on baby/ies and women feel neglected once they are no longer carrying the baby/ies Geographic isolation How being geographically isolated impacts access to wellbeing. Captures: • Lack of social supports/ people near • Access to [local] resources Having the means How the affordability of care shapes outcomes (as barrier/facilitator to accessing care). Captures: - MSP and mental health care coverage - Extended health benefits and mental health - Supports to access care (including childcare and transportation) HC gaps + PP self-advocacy How perceived gaps in care lead to PP needing to self-advocate to be cared for/receive the care they need + how they need it **overlaps with taking initiative** HC opportunities to identify To identify MH concerns → how current practices present opportunities/missed opportunities to identify and support people experiencing mental health concerns • Lactation consultation as opportunity to identify • Hospital discharge as point of identification/intervention • Postpartum check-ups/ins as point of identification • Extended hospital stays as point of intervention o Postpartum hospital stays  o NICU involvement • Pediatric care as point HCPs are determinants of MH How HCPs act as gatekeepers of mental health. Captures their: Preparedness to address mental health  HCP-PP dyadic rapport HCP assumptions of PP needs HCP screening for mental ill-being  + their roles present opportunities to: Empower pregnant people: Preparing PP for what to expect; Demystifying common stressors;  Normalizing mood and changes therein 70  HCP assumptions (Of pregnant people’s needs) Captures: • HCP-PP power dynamics • Dismissive attitudes among HCPs HCP empowerment of pregnant people Captures HCP roles in • Preparing PP for what to expect • Demystifying common stressors • Normalizing mood and changes therein HCP preparedness to address MH Captures • HCP awareness of appropriate supports • HCP referrals to specialists HCP-PP dyadic rapport Captures: • PP trust of HCP (ability to help them without repercussions) • HCP perception of PP wants/needs re: help/support • PP-perceived repercussions of disclosure (to HCPs) • PP avoidance of care (due to lack of trust and fear) Holistic approach to management How the multiplicity of stressors and complexity of experiences require holistic approaches to management toward mental wellbeing. Captures: • Tailoring care for relevance (to PP and their needs) • Multi-pronged approaches to management • Range of management options Hormones & Mental Health How hormones/hormonal changes manifest in, and/or are determinants of anxiety and/or depression. Also captures how women attribute changes in mood to hormones. Informing choices re med's How decisions about pharmaceutical intervention is influenced by how much they and/or the people around them know about meds HCP role in informing medication choices Informing choices based on experience with medications Demystifying medications and the use(s) of them + Demystification of meds via personal narratives + Demystification of meds through scientific evidence + Demystification of meds through public campaigns and resources  AND Intimate partner and social network influences + peer success stories Demystification of med's Demystifying medications and the use(s) of them, via: • Demystification of meds via personal narratives • Demystification of meds through scientific evidence o Demystification of meds through public campaigns and resources HCP role in med choices Healthcare provider role in informing medication choices Insight to personal MH needs How experiencing mental health challenges shapes how they manage them (anticipating what to expect/ what their needs are) • Lessons on acceptance/ letting go • Learning to see the signs • Learning what works • Self-care lessons and needs (expressions of) • Learning where to access support/ resources • Learning the language (to express feelings and needs) 71  Self-care lessons (And needs) Expressions of self-care lessons and needs Interpersonal relationships How access to and quality of/security in relationships (and the support they do/don’t offer) impact perinatal mental health. Captures: Family Support Partner Support Social networks’ support (friends) **not to be confused with support networks (which include resources and care services)** Family Support Captures how • Geographic proximity of familial supports • Parenting assistance and supports from family • Emotional support from family (captures attitudes toward mental health) … impact MH outcomes Interpersonal relationship rapport Trusting interpersonal relationships as determinant of feeling supported/ not alone Intimate partner support How supportive a partner is and how secure/stable their relationships are influence experiences Relationship in/security Partner attitudes toward and perceptions of mental health Partner attitudes and perceptions re: treatment  Partner attitudes/ perspectives re: medicating Partner abuse/ trauma Economic dependence on partner Primary care-giving in relationships/ co-parenting Partners and postpartum mental health concern identification Partner support through mental health challenges (includes help coping) Journey to pregnancy How women’s journeys to and through pregnancy + postpartum shapes their experiences of anxiety/depression. Reflects: • Fertility and mental health • Past experiences of pregnancy loss • Past experiences of pregnancy termination • Surrogacy and mental health Length of care How care periods/ time spent accessing care/ periods care is available shape outcomes • Length of postpartum period (different lengths depending on resource) • Eligibility to access care (e.g. if a year postpartum, no longer eligible for RMH) Limitations of existing Apps & web-based resources [Missing opportunities] Existing resources: • Focus on gestation and baby • Exclusion of mental health • End at delivery (information given is during pregnancy and in preparation for birth, but nothing after) Lived experience as a resource How experiences of mental health challenges are used to serve others • Seeing the signs [in others] • Validating the experiences of others  To Raise public awareness → how public perceptions of postpartum mental health challenges need to change in order to help/support those who experience them • Dispel myths and misconceptions (such as exaggerated notions of what counts as PPd) • Understanding perinatal mental health and normalizing 72  changes (in mood) • Normalizing PPd/PPa (knowing it’s common and can happen to anyone) Harnessing their experiences to challenge stigma How people use their experiences (and the insights therein) to change public perceptions of pregnancy-related mental health challenges + in support of those who are/ may be experiencing them • Normalizing mental health challenges • Creating space to share (about challenges) Medication self-management Specific to those who have medication experience, this code speaks to how the ways they self-manage/administer their medication(s) impacts their outcomes • Self-weaning from medications • Medication dose management  • Medications and family planning (how approaches to taking meds are shaped by whether folks are pregnant, breastfeeding, etc.) Med's & family-planning How approaches to taking meds are shaped by whether folks are pregnant, breastfeeding, etc. Self-weaning from med's How women take control of their med self-management + what impacts their decisions to self-wean (e.g. family planning) MH history + HC pathways How previous experiences with mental health concerns shape experiences throughout the perinatal period, including in preparation for/ anticipation of postpartum and mental health challenges as well as how to manage them. Include: • Recognizing the signs  • Existing diagnoses • History of PPd/PPa • History of trauma (professional and/or self-identified) • Family history of mental health concerns (including postpartum) • Existing treatment Existing diagnoses How previous identified and diagnosed mental health concerns shape perinatal MH outcomes. Captures:  Existing treatments (i.e. counselling, meds, etc.) Recognizing the signs How history of MH concerns grants women the ability to see the signs for concern more readily MH management options Different mental health management options → how different options lead to differing pathways toward wellness (or not). Captures: • In/out patient care • Allopathic/curative vs prevention/promotive • Medicated management • Psychosocial interventions • Alternative/complimentary therapies Misconceptions re med's How the mystification of pharmaceutical mental health interventions impact people’s journeys/access to wellbeing + willingness to consider it as an option. Influenced by: • Stigma & shame about medications during and post-pregnancy • Social networks’ attitudes regarding medications • Intimate partner attitudes regarding medications 73  Moving FWD w generalized anxiety-depression How pregnancy and postpartum may be the first time people experience anxiety/depression, but folks will continue living with generalized anxiety/depression • Perinatal healthcare as opportunity to identify and manage mental health concerns Perinatal care as opportunity … to identify and manage mental health concerns + equip people with the supports/skills necessary to manage going forward with generalized, on-going mental health challenges Multiplicity of stressors How “it’s not just one thing” that leads to mental health concerns. Includes:  Compounding stressors Diversity of stressors No clear path to care How confusion about what’s going on/where to go impact outcomes. Captures how peoples • Don’t know needs (re: concerns) • Don’t know where to go (for help) And how Siloed care provision presents barriers in pathways t care Eligibility to access care (e.g. if a year postpartum, no longer eligible for RMH) **Intersects with “length of care** HC gaps  Siloed care How healthcare’s siloed nature impacts health outcomes via: • Lack of continuity of care/r • Lack of interprofessional communication • Lack of awareness regarding care options (by PP and HCPs alike) • Inconsistencies in care options Partner attitudes re MH Captures:  • Dismissive partners • The role of partners in identifying mental health concerns o Partner validation of mental health concerns/ mood changes • The role of partners in managing mental health concerns o Partner advocacy of treatment/ seeking help • Partner attitudes toward medications • Supportive partners (of PP’s mental health needs + decisions) Role of partner in management The role of partners in managing mental health concerns. Captures:  Partner advocacy of treatment/ seeking help Or Dismissive/ paternalistic attitudes  AND how these are determinants of MH Role of partners in identification …of MH concerns. Captures: • Partner validation of mental health concerns/ mood changes + Dismissive attitudes  AND how those are determinants of MH Peer group as a safe space How spaces dedicated to women’s experiences, run and held by peers, supports their mental health • Free of judgement • Creating community • Validating experiences (of PP) • Safest when facilitated by [knowledgeable] moderator [knowledgeable] group facilitators + safety Participants mentioned feeling safest in peer groups where the facilitator ensures safety by way of being knowledgeable, 74  addressing harmful messages/misinformation, recommending resources, etc. Peer support as resource How being with/having access to people who have “been there” is a determinant of mental health • Learning from each other • Not feeling alone anymore (validation, solace, etc.) • Nature of the group • Professional facilitation • Online mommy group Perceived impact of med's (once on) How being on medications changes perceptions of pharmaceutical interventions and/or how they impact mental health. Captures attitudes re: • Medications as a “means to an end” (i.e. not their preferred choice, but effective) AND • Perceived effectiveness of medications (once accepted; after reluctance) Med's as means-to-an-end How meds were often not their preferred choice, but perceived as necessary in retrospect Preparing for baby How anxieties regarding uncertainties of logistics impact mental health throughout perinatal period. Includes: • Housing (having home security in preparation for a growing family) • Economic stability (feeling financially prepared to support growing family) • Childcare logistics (who’s going to take care of the baby/ies, particularly when returning to work) Pressures to get help + access care. Captures: how people may feel pressured to seek help and where this pressure comes from Refusal to take med's How and why women refuse to take medications • Fear and worry about medications (+ how they shape willingness to try medications)  AND How interpersonal relationships shape their willingness to take med’s Relationships to their bodies How relationships to bodies throughout the perinatal period change through conception, pregnancy, birth, and postpartum and their impact on mental health • Postpartum body dysphoria • D-Mer (dysphoria while breastfeeding) • Feelings of body betrayal Relationships w breastfeeding How relationships with and expectations of/pressures to breastfeeding affect mental health. Including: Ability to breastfeed + feelings of failure  Pressures to breastfeed Breastfeeding complications (milk production, no latching, mastitis, etc.) Fears of baby/ies’ health outcomes re: milk Breast vs formula On medication vs not on medication Hormones and breastfeeding (changes in mood depending on whether breastfeeding or not) Breastfeeding in public (and judgement) D-Mer (dysphoria while BF’ing) Reluctance to med's Reluctance to taking medications → how certain attitudes/ perceptions determine people’s willingness to take medications 75  during/post-pregnancy • Perceived harms of medications to baby/ies • Fear of unknowns associated with medications (i.e. side-effects)  AND How reluctance is shaped by the attitudes of the people around them (e.g. partner attitudes + decision-making re: med’s) Role of GPs How pregnant people’s relationships with their GPs shape their health outcomes. Captures: • Access to GP (geographic proximity, availability) • Pre-existing GP-pregnant person (PP) relationships → continuity of carer as determinant • GP-PP dyadic rapport • GP familiarity with PP and health needs • GP assumptions of PP needs Screening tools ….for postpartum depression/anxiety → how participants talk about the usefulness of standardized screening tools for identifying anxiety/depression • Perceived relevance of screening tools + questions • Test-anxiety and self-editing responses (fear of consequences of test results and their impact on their lives) o PP censoring of screening answers (fear of repercussions) Self-comparisons [in perinatal experiences] How previous experiences with pregnancy, birth, postpartum, etc. serve to observe differences and identify concerns • Differences in/during pregnancy between pregnancies • Differences in/during birth/labour between pregnancies • Differences in/during postpartum between pregnancies • Differences in relationships with baby/ies between pregnancies Socioeconomic stressors How socioeconomic status is a determinant of mental health. Includes: • Financial in/dependence (on/from partner) • Length of parental leave • Primary earner • Pressures to return to work Pressures to return to work Associated with Parental Leave and how the time spent at home with baby/ies is a determinant of mental health Stigma & alienation …as compounding stressors and determinants of mental health deterioration. Manifest in: • Fear of judgement • Social withdrawal (receding) Support network rapport How pregnant people’s relationships with the supports BEYOND their immediate supports (family, friends) impact their mental wellbeing • Relationships with peer support groups  • Relationships with care providers • Relationships with online networks Taking initiative How PP come to take ownership over their mental health journeys • PP motivations to access care • Severity as predictor of taking initiative  • Long wait times as predictor (of taking it on themselves/healing in the meantime) • History of mental health & 76  familiarity with navigating care • Self-awareness and asking for help PP motivations to access care **Overlaps with “HC gaps + PP self-advocacy”** The human piece How in-person contact provides things that other care/support delivery methods do not (how women value the human piece and how it shapes their acceptability of resources) • Value of having a person-to-person interaction • Value of communicating in real time The power of sharing How the sharing of stories/ experiences is healing  • Sharing as a cathartic experience • Sharing as a means of validation • Hearing about others’ experiences The role of the moderator How those who facilitate peer support groups impact the helpfulness of them + how trustworthy women perceive them to be • An experienced peer moderator/facilitator • A trained expert moderator/facilitator • A moderator/facilitator with lived experience • Moderator/facilitator as a resource • Moderator/facilitator as a gatekeeper to group • …to fact-check user contributions (captures addressing harmful messaging) Time in-hospital after birth How being in-hospital can serve as an opportunity to identify people experiencing mental health concerns postpartum • In-hospital due to birthing complications • In-hospital due to surgical intervention (including C-section) • Time in NICU • Hospital discharge as a time to identify and/or arm people with the knowledge/resources necessary to find/get help Timing of medication How when medication was introduced to them as an option, and when they decided to use pharmacological means for mental health impacts their wellbeing • Timing of when medication is recommended • Timing of uptake (when in their MH journey they decided to start taking medication) Trying to find help on the internet Reflections from when they were struggling and looking for support, including:  • Vastness of internet is overwhelming • Discerning who & what to trust on the internet •  Trial & error internet searches • Internet search avoidance • Fear of confirming their worst fears, shames, etc. • Fear of judgement/ rejection • Searching for people to connect with/ feel less alone Web-searches & feeling overwhelmed Not knowing & feeling overwhelmed → how searching for answers can compound stress • Searching for answers and being overwhelmed • Unclear trustworthiness of resources Understanding PP Mental Health Awareness/understanding of postpartum mental health → how being mis/informed re: postpartum mental health impacts it 77  Mental health stigma + Myths and misconceptions = Confusion regarding their manifestation + What postpartum mental health challenges look like Doubtful of experiences Unexpectedness of feelings Need to nurture awareness (in the interest of minimizing stress of unknowing and misinformation) Anticipated experiences of postpartum Fear of state of being + inability to control it Anticipated experiences …of postpartum + how they shape mental health outcomes Fear of state of being Fear of how they’re feeling and their inability to control it. Can be assuaged by knowing / being assured it gets better Nurturing awareness … of what postpartum mental health look like in the interest of minimizing stress of unknowing and misinformation Waiting for care How wait times impact/shape mental health trajectories. Captures: • Waiting for treatment/ time to referral • Accessing a specialist • Waiting and missing out on mental wellness • Lack of interim supports (while waiting) What is a peer What participants define as a peer: • Someone going through it with you • Someone who has gone through it (past tense) • Someone you identify with  D.7 Conceptualizing categories The diagrams and notes below outline the conceptualization of the categories developed based on the existing codes.         78                         InterpersonalHealthcarePerceived NeedsSocial Complexity of experiences  Diversity of  needs  Un/met needs “So what?”  App development  Needs (WHAT) Unmet needs (WHY) SUPPLEMENTAL FIGURE 2 Defining the interplay between the different spheres of life and how this relates to an app 79                         Self Healthcare Social Perceived Needs Interpersonal Misconceptions re: meds; Perceived impact of meds; Acceptance of meds, Meds as means-to-end; Reluctance/Refusal to take meds Understanding MH needs vs. Confusion re: PPD; Agency re: MH decision-making Pressures to get help Taking initiative; HC gap + PP self-advocacy Meds self-management; Timing of meds Being able to self-identify; Becoming aware of pre-existing MH concerns Informing choices re: meds Peer support; Power of sharing Self-comparisons; Personal insights; Self-care; Accepting something’s wrong; Harnessing experiences & lived experience as a resource Focus on baby SUPPLEMENTAL FIGURE 3 The role of perceived needs within the spheres of life 80                   Self External Supports Healthcare Social Interpersonal Partners/Family Partner support and rapport Role of partners in ID Role of partners in management Family support Feeling dismissed and unsupported Socioeconomic pressures Partner + Family attitudes re: MH Apprehensions about sharing The human piece Peer support and rapport HCP-PP dyadic SUPPLEMENTAL FIGURE 4 The role of interpersonal relationships within the spheres of life 81                         Self Perceived Interperson Social - Time in-hospital - Perinatal care as opportunity - HC opportunities to identify - Birth trauma - Journey to pregnancy - Diversity of needs - Changing needs over time - Insights to personal MH needs Length of care; Accessing RMH; Waiting for care; Eligibility to access care; HC gaps + PP self-advocacy; PP motivations to access care; taking initiative; MH history and HC pathways; No clear path to care; ER as pathway; Screening tools; HCPs are determining of MH; Role of GPs; Holistic approach to management; Apprehensions about sharing; Existing diagnoses; HCP roles in med choices; Meds as means-to-end; Support network rapport Agency re: MH decision-making; Partner attitudes re: MH Focus on baby; Pressures to get help; Refusal/Reluctance to take meds; Acceptance of meds; Misconceptions re: meds; Having the means Legend Meds   Gaps Pathways to care Decision-making Healthcare SUPPLEMENTAL FIGURE 5 The role of healthcare within the spheres of life 82                         Self Healthcare Social Complexity of Experiences Interpersonal Socioeconomic pressures Diversity of Needs Having the means Changing needs over time; Holistic approach to manage Geographic isolation Support vs dismissal Birthing trauma; No clear path to care Understanding MH vs Confusion re: PPD; Focus on baby Stigma & alienation SUPPLEMENTAL FIGURE 6 How the complexity of experiences and diversity of needs interface with the spheres of life 83                         Self External Supports Healthcare Social App Development Needs Partners/Family Self-care/Management Engagement/Guidance MH tracking & assessment Peer support features Pathway to resources; Accessible MH support Providing a safe community; Use & content safety; Lived experience as resource The human piece; Empowerment - Readiness to use app - Content + interface delivery - Normalize MH - Focus on baby SUPPLEMENTAL FIGURE 7 The “what”: how app development needs interface with the spheres of life 84                         Self Healthcare Social App Development + Unmet Needs Interpersonal The human piece App + MH tracking Geographic isolation App as accessible MH support; App as pathway to resources; Trying to find help on the Internet Limitations of existing apps; Focus on baby* App + lived experience as a resource App + providing safe App user + content safety App + engaging/guidance App content - App prompts + check-ins Legend Safety  Existing web things Accessibility  SUPPLEMENTAL FIGURE 8 The “why”: how app development and unmet needs interface with the spheres of life 85                         Knowledge sharing + exchange Resources + supports that work for you (personalized) App PP Mental Prevention Promotion Management Timing & Acceptability Empowerment Agency in MH Supplementing HC Trusting your perceived needs SUPPLEMENTAL FIGURE 9 The relationships between the emergent categories 86  D.8 The categories Category Name Category Description Agency in MH PP should be the primary decision-makers in their MH and wellness journey, which can be supplemented or undermined by cultural (stigma), social (determinants of health), interpersonal (family, friends, partner), and healthcare (HCPs, pathways) factors. Bridging gaps How the app can provide options and opportunities to compensate for gaps in knowledge, resources (perceived availability), and access to supports (personal, interpersonal + HC). Creating community Combats feelings of isolation and alienation by providing validation and support from peers to promote in MH and wellness. Empowerment of PP PP need to have the knowledge, support, and power to feel confident in making informed choices re their MH (trusting that they know their own needs). **Not self-care** Finding your path ...to resources and supports that are relevant, accessible, adaptable, and acceptable for you to feel well (MH well-being). Insights to MH Through previous experiences with PPD (diagnosed or undiagnosed), interactions with the healthcare system, and learning from others (knowledge-sharing and -exchange), PP gain insights into their own MH and MH in general. Knowledge sharing, exchange, and mobilization How relevant (amenable), accessible, and acceptable knowledge is and how that empowers PP to take charge of their MH. Tailoring for relevance How person-centered resources that account for the complexity of experiences and diversity of needs of PP are perceived to be more relevant and actionable in facilitating MH and wellness. The human piece The need to feel seen, heard, and validated by their support networks (peers), interpersonal relationships, and HCPs. Timing & Acceptability How PP’s MH journeys shape their readiness and willingness to access care options (meeting people where they’re at  person-centered considerations).  D.9 Conceptualizing themes The diagrams and notes below outline the conceptualization of the final themes developed based on the existing categories. 87                         Acceptability (+ accessibility) Knowledge Validation Person-Centered Continuity of care   Preparation (Prevention) 1. Bridging Gaps   TO    Meet Needs 2. Providing Validation TO   Combat Stigma Moving towards promoting agency in pursuing mental well-being Timeliness Finding your path Awareness Understanding Relevance Acknowledgement Insights Community Availability Management Prevention Lived experience as a resource Evidence-based knowledge Engaging family + friends  Mobilizing personal insights Internalized stigma Cultural stigma Understanding Acknowledgement … of complexity … of diversity (demystify/normalize) (empowerment) PROMOTE AGENCY PROMOTE AGENCY 88                         Taking initiative Self-advocacy Making informed choices Self-care Finding your path Supplement HCP-PP Moving towards promoting agency in pursuing mental well-being Finding your path Understanding Awareness Mental health education Reduce “motherload” Insights Validation MH education Insights *self-management (HCP, peers, family + friends) … to coping, etc. 4. Empowering People TO  Take Ownership Over       Their Mental Health 3. Nurturing Capacity TO  Cope, Manage, and/or        Reach Wellness Lived experience as a resource Evidence-based knowledge Relevance Engaging family + friends Opportunities for self-reflection/identification (acknowledge + accept) (what’s happening) (where to go) (how to…) PROMOTE AGENCY PROMOTE AGENCY 89                         Moving towards promoting agency in pursuing mental well-being Accessibility Acceptability Usability/actionability Engaging family + friends 5. Offering Customization TO   Ensure Relevance Awareness Content delivery MH tracking w/ prompts + check-ins Gauging severity + readiness PROMOTE AGENCY SUPPLEMENTAL FIGURE 10 Conceptualization of themes based on the established categories 90                   D.10 The themes  Bridging gaps to meet needs  Providing validation to combat stigma  Nurturing capacity to cope, manage, and/or reach wellness,  Empowering people to take ownership over their mental health  Offering customization to ensure relevance How can an app help? Why an app? Bridging gaps * + meeting needs Providing validation to combat stigma * Empowering people to take ownership* of their mental health Nurturing capacity * to cope, manage, and/or reach Ensuring relevance by offering customization Undermined by… PROMOTE AGENCY  SUPPLEMENTAL FIGURE 11 Illustrating the relationships between the emergent themes and the study objectives 

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