JOGNN
RESEARCH
Community Awareness of Postpartum
Depression
Patricia A. Sealy, Julie Fraser, Joanne P. Simpson, Marilyn Evans, and Ashley Hartford
Correspondence
Patricia A. Sealy, RN, PhD,
Middlesex-London Health
Unit, The University of
Western Ontario, 50 King
Street, London, ON, Canada
N6A 5L7
pat.sealy@mlhu.on.ca
ABSTRACT
Keywords
postpartum depression
women
evaluation
awareness
Method: Logistic regression and chi-square test were used to analyze awareness of postpartum depression and its
symptoms, the baby blues, and sources of assistance for women with postpartum depression.
Objective: To explore awareness of postpartum depression and its symptoms and available community resources
for women with postpartum depression.
Design: Cross-sectional surveillance research, using population-based data.
Setting: Eight communities in southern and eastern Ontario, Canada.
Participants: A random selection of adults 18 years of age and older with telephones.
Results: The vast majority of respondents were aware of postpartum depression (90.1% 0.6% confidence interval)
(n 5 8,750) as compared with the baby blues (62.5% 1.1%). Awareness of postpartum depression, its symptoms,
the baby blues, and sources of assistance varied according to the demographic profiles of the respondents (family
structure, education, and language spoken at home).
Conclusion: Awareness of the term postpartum depression does not necessarily imply awareness of its symptoms
or sources of assistance. Public education is needed to address this fact in order to provide social support and
encourage treatment for symptomatic women and their families. Education should target individuals with lower levels
of education and non-English–speaking groups.
JOGNN, 38, 121-133; 2009. DOI: 10.1111/j.1552-6909.2009.01001.x
Accepted November 2008
Patricia A. Sealy, RN, PhD,
is a nurse researcher/
educator in the Public
Health Research, Education
and Development Program,
Middlesex-London Health
Unit and a casual assistant
professor in the School of
Nursing, University of
Western Ontario, London,
ON, Canada.
Julie Fraser, PhD, is a
program evaluation
specialist in the WindsorEssex County Health Unit
and an adjunct professor in
the Faculty of Psychology,
University of Windsor, ON,
Canada.
Joanne P. Simpson, BScN,
is a public health nurse for
Family Health Services,
Middlesex-London Health
Unit, ON, Canada.
(Continued)
http://jognn.awhonn.org
plethora of research studies have evaluated
methods to prevent and treat postpartum
depression (PPD) and many recommend public
education (Heh & Fu, 2003; Letourneau et al.,
2006; Logsdon, Wisner, Billings, & Shanahan,
2006; Sealy, Simpson, & Evans, in press; Ugarriza,
2002; Wrobleski & Tallon, 2004). Over the past 5 to
10 years, residents of Ontario have been exposed
to information on PPD from health professionals,
public health units, and numerous media sources
including television, radio, Internet, newspapers,
and magazines. However, there have been no studies on awareness of PPD in the community.
Concerns exist that approaches to public education on PPD may be problematic. Research has
identi¢ed that consumer information materials on
PPD have been beyond the recommended reading
level of Grade 5 (Logsdon & Hutti, 2006), Web sites
may display inaccurate information (Summers &
Logsdon, 2005), and primarily passive approaches
to education on PPD that rely on the use of predeveloped literature rather than face-to-face com-
A
munication have been used (Garg, Morton, &
Heneghan, 2005). The purpose of this research
was to measure awareness of PPD in the general
population. This research is signi¢cant because
postpartum women’s social support networks
(partners, parents, family, and signi¢cant others)
are crucial to providing social and instrumental
support to new mothers who are experiencing PPD
(Letourneau et al.; Scrandis, 2005).
Postpartum depression is one of the most common
complications that can occur during the postpartum period and can have serious e¡ects on the
mother, infant, and family (A¡onso, De, Horowitz, &
Mayberry, 2000; Beck, 2002; Dennis, 2004; Dennis
& Creedy, 2005; Ogrodniczuk & Piper, 2003). Unlike
the symptoms of the baby blues that women often
experience during the ¢rst few days after birth
(crying spells, irritability, sadness, and feeling overwhelmed) (Rondo¤n, 2003), PPD often requires
medical intervention (Ross, Dennis, Blackmore, &
Stewart, 2005). The incidence of the baby blues is
& 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
121
RESEARCH
Community Awareness of Postpartum Depression
Postpartum depression is one of the most common
complications after childbirth, and can have serious effects
on the mother, infant, and family.
reported to be between 26% and 85% (Rondo¤n),
whereas the reported incidence of PPD ranges
between 6.5% and 20% in the general population. (Beck, 2002; Dennis, 2004; Dennis & Creedy,
2005; Gaynes et al., 2005; Stowe, Hostetter, & Newport, 2005; Verkerk, Pop, Van Son, & Van Heck,
2003). Some women, however, are more vulnerable
to experiencing PPD, related to a lack of social
support, a history of depression, and/or recent immigration (Beck; Dennis, 2003;Dennis & Creedy;
Gaynes et al., 2005; Mosack & Shore, 2006; Stowe,
Hostetter, & Newport, 2005).
Marilyn Evans, RN, PhD, is
an assistant professor in the
School of Nursing,
University of Western
Ontario, London, ON,
Canada.
Ashley Hartford, BA, is a
research assistant in the
Public Health Research,
Education and
Development Program,
Middlesex-London Health
Unit, London, ON, Canada.
122
Heh and Fu (2003) identi¢ed that postpartum
women who were considered at a higher risk of
PPD and who received informational support at
6 weeks postpartum had lower Edinburgh Postnatal Depression Scale (EPDS) scores at 3 months
postpartum. A limitation of the Heh and Fu study
was that awareness of the symptoms of PPD and
sources of assistance were not measured. Sealy
et al. (in press) identi¢ed that postpartum women
who were considered at a lower risk of PPD and
who received an educational pamphlet at 4 weeks
postpartum that outlined the symptoms of PPD
and sources of assistance had lower EPDS scores
at 3 months postpartum. These researchers found
no signi¢cant di¡erences in women’s awareness
of the symptoms of PPD as a result of receiving an
educational pamphlet; however, they noted that
there may have been a selection e¡ect, because
all women (n 5 256) reported that they were aware
of PPD. The most common symptoms recognized by
women were sadness (87.1%), thoughts of harming
the baby, frustration/anger, sleep/appetite problems (range: 44.5%-46.1%), as well as feelings
of guilt toward the baby, thoughts of harming self,
and anxiety/fears (range: 28.1%-34.4%). Symptoms that may indicate the need for treatment,
such as isolation and hopelessness, were less recognized (less than 10%).
This research also revealed that women were
most likely to access public health nurses (10.2%)
or a physician/obstetrician (6.3%) for assistance.
Services such as well baby and breastfeeding clinics, Web sites, and the health unit phone line were
rarely accessed by these women (less than 5%).
Other limitations of this research were that a post-
partum mood disorders educational campaign
was conducted in 2005, before the implementation
of this research, that may have sensitized women
to the symptoms of PPD, and that awareness of
PPD among women’s social networks was not
investigated.
Logsdon et al. (2006) argued that a major barrier
for postpartum women and their families in becoming aware of PPD is the primary health caregivers’
lack of awareness of this disorder. They argued
that the process of recognizing the symptoms of
PPD is crucial to early intervention. Based on their
¢ndings that the PPD content in textbooks and
Internet resources for health professions was limited, these researchers suggested a curriculum on
PPD including an overview of the problem, assessment, treatment, engaging women in treatment, and
sources of additional information to be developed.
In 2005, the Registered Nurses’ Association of
Ontario (RNAO) published the ‘‘Nursing Best Practices Guidelines on Interventions for Postpartum
Depression’’ that recommended that PPD content
be included in nursing education curriculum, orientation, and continuing education programs for
nurses who provide care to new mothers to enhance awareness, recognition of the symptoms of
PPD, and initiate appropriate intervention involving
family members in the mother’s care.
Research on public awareness of PPD is important
because support from postpartum women’s social support networks can a¡ect the help-seeking
behaviors of postpartum women with depressive
symptoms as well as with their recovery (Dennis
& Chung-Lee, 2006; RNAO, 2005; Ross et al.,
2005; Vilder, 2005). Scrandis (2005) argued that
postpartum women mobilize social support
through the process of normalizing their symptoms
of PPD. Through connection with family and signi¢cant others, postpartum women assess the degree of their problem and obtain mutual empathy
and empowerment. Experiences of having their
symptoms discredited can contribute to feelings
of negative self-worth, psychological isolation,
decreased energy, and a decreased sense of wellbeing. Women who experienced low self-con¢dence
in their mothering role or whose families suggested
that they would be ‘‘¢ne’’ were less likely to initiate
socialization.
Symptomatic women stayed with their social networks if they received emotional support that
validated their feelings. Informational support was
considered helpful, but Scrandis (2005) suggested
that informational support may not have the same
JOGNN, 38, 121-133; 2009. DOI: 10.1111/j.1552-6909.2009.01001.x
http://jognn.awhonn.org
Sealy, P. A., Fraser, J., Simpson, J. P., Evans, M. and Hartford, A.
impact in helping the women cope with their feelings.
Reasons for women drifting away from their social
support networks included cliquish behaviors in
groups, exposure to women more symptomatic than
themselves, lack of pertinent information, or the
perception that they were feeling more con¢dent
in their mothering role. Women’s abilities to voice
their needs to others facilitated the process of incorporating self into their new mothering role.
Similarly, Letourneau et al. (2006) identi¢ed that
many women assumed that their symptoms were a
normal part of motherhood and the result of fatigue,
relationship di⁄culties, or personal weakness,
rather than depression. These perceptions were often supported by family members, thus interfering
with timely support.
In summary, a knowledgeable social support network, especially family members and signi¢cant
others, is crucial in assisting new mothers to identify
symptoms of PPD, provide information and social
support, and encourage professional treatment.
Nevertheless, there is a paucity of communitybased research on awareness of PPD, its symptoms, and sources of assistance. This research was
designed to answer the following questions: (a) To
what extent is the general population aware of
PPD? (b) What socio-demographic factors are
associated with awareness of PPD? (c) To what
extent is the general population aware of the symptoms and sources of assistance for PPD and the
baby blues?
Method
RESEARCH
Setting
This research occurred within the counties of the
participating health units (Brant; Hastings and
Prince Edward County; Halton; Leeds, Grenville
and Lanark; Middlesex-London; Peel; Region of
Waterloo; and Windsor-Essex) in southern and
eastern Ontario, from January 2005 to June 2006
(Figure 1). These counties represent both urban
and rural areas in Ontario, with some variance in
socioeconomic status; median income ranged
from approximately $58,000 to $92,000 (Statistics
Canada, 2006).
Sample
Approximately 100 participants per month, from
each of the health units that participated in the
Postpartum Mood Disorders Module, who were
18 years of age and older were telephoned monthly
from January 2005 to June 2006 (maximum 800
respondents per month). It is important to note,
however, that not all eight health units included the
Postpartum Mood Disorders Module in their RRFSS
data collection in any given month. It was estimated
that this design would allow for an intended sample
of 9,000 participants, yielding a 95% con¢dence
interval (CI) with no greater than 1% error for
any dichotomous survey question (Kish, 1995;
Moore & McCabe, 1999). Multiple telephone calls
were made to enlist the participants. When more
than one adult lived in a given household, random
selection was used, and the adult with the next
birthday was asked to participate. Household
sampling weights were used to re£ect the probability of being the adult in the household who was
selected.
Design
The researchers used a cross-sectional design with
population-based surveillance data from the Rapid
Risk Factor Surveillance System (RRFSS, 2005)
Survey: Postpartum Mood Disorders Module. The
purpose of RRFSS is to support program planning
and evaluation, to advocate for public policy development, and to improve community awareness
(RRFSS). Using random digit dialing, the Institute
of Social Research (ISR) collected RRFSS data
on multiple topics/modules on health beliefs and
behaviors using a computer-assisted telephone
interview system. Annual response rates for the
RRFSS survey from the eight health units in 2005
and 2006 varied from 57% to 62% (ISR, 2007).
Ethical review of the study was completed by the
Middlesex-London Health Unit Research Advisory
Committee. Permission to use the RRFSS data from
the eight participating health units was obtained in
the fall of 2006.
JOGNN 2009; Vol. 38, Issue 2
Instrumentation
The RRFSS (2005) Postpartum Mood Disorders
Module consists of seven questions that probe
(a) the awareness of PPD, (b) the symptoms of
PPD, (c) awareness of the baby blues, (d) the symptoms of the baby blues, (e) the typical length of the
baby blues, (f) whether the mother with PPD requires professional help, and (g) the sources of assistance for PPD (http://www.rrfss.on.ca) (Table 1).
The respondents were not prompted for their answers with respect to the symptoms of PPD and the
baby blues, but a list of choices was provided for the
duration of the baby blues. This RRFSS Module was
developed by a group of epidemiologists and other
interested personnel from the 21 RRFSS-participating health units in Ontario and piloted by ISR.
Reliability and validity statistics for this module have
not been evaluated.
123
RESEARCH
Community Awareness of Postpartum Depression
4
3
3
6
2
7
1
5
Health Unit
8
1
2
3
4
5
6
7
8
Brant County Health Unit
Halton Regional Health Unit
Hastings and Prince Edward Counties Health Unit
Leeds, Grenville and Lanark District Health Unit
Middlesex-London Health Unit
Peel Regional Health Unit
Waterloo Health Unit
Windsor-Essex County Health Unit
Ontario
Total Population
(2006)
Median Family
Income (2005)
125,136
439,256
155,970
162,991
422,333
1,159,405
478,121
393,402
$66,830
$92,416
$58,293
$65,333
$68,728
$70,541
$74,070
$71,605
12,160,282
$69,156
Figure 1. Participating units in Ontario for the Rapid Risk Factor Surveillance System Mood Disorders Module. Statistics Canada information is used with the permission of Statistics Canada. Users are forbidden to copy the data and redisseminate them, in an original or
modified form, for commercial purposes, without permission from Statistics Canada. Information on the availability of the wide range of
data from Statistics Canada can be obtained from Statistics Canada’s Regional Offices, its World Wide Web site at http://www.statcan.gc.
ca, and its toll-free access number 1-800-263-1136.
Analysis
Analyses were based on all respondents who
participated in the telephone survey. First, the proportion of individuals who were aware of PPD was
calculated using 95% CIs. Logistic regression was
used to evaluate awareness of PPD related to the
demographic pro¢les of the respondents (gender,
presence of children under 13 years of age at home,
the interaction between gender and the presence of
children under 13 years of age at home, education,
124
and language spoken at home). A chi-square test
was used to compare the four subgroups formed
by gender and the presence of children under
13 years of age at home as to their awareness
of PPD, its speci¢c symptoms, and sources of assistance for PPD, as well as awareness of the baby
blues (as dichotomous variables: yes/no). The total
number of symptoms of PPD reported was calculated and analysis of variance was used evaluate
whether there were signi¢cant di¡erences with re-
JOGNN, 38, 121-133; 2009. DOI: 10.1111/j.1552-6909.2009.01001.x
http://jognn.awhonn.org
RESEARCH
Sealy, P. A., Fraser, J., Simpson, J. P., Evans, M. and Hartford, A.
Table 1: Rapid Risk Factor Surveillance System Postpartum Mood Disorders Module Questions and Coded
Responses
Questions
Coded Responses
Type of Data
Statistic
1. Have you heard of the
Yes
Binary variable: yes 5 1, no 5 0, all
Logistic regression in
other responses recoded as 0
the model with the
phrase ‘‘postpartum
depression?’’
demographic
variables
No
Respondent insists they do not want to answer
the questions
Don’t know
Refused
2. What are some of the
symptoms of postpartum
Sadness/Crying: feeling down, depressed,
tearful, emotional, feel empty
depression?
Binary variable for each symptom:
Chi square
yes 5 1, no 5 0, all other
responses recoded as 0
Frustration/Irritability/Anger: moody, can’t stand
baby crying, annoyed, resentment, overwhelmed, di⁄culty concentrating, stressed
Anxiety/Fears: worry, panic attacks, scary
thoughts, fear they cannot take care of baby
Sleep/Appetite/Energy changes: can’t sleep,
sleeping too much, tired, exhausted, fatigue,
constantly having to do something, not eating,
eating too much
Guilt/Feelings for baby: feeling inadequate,
ashamed, incapable, no feeling for baby, don’t
feel connected to baby, don’t love baby
Other, specify: answers were recoded as
Isolation, and Helplessness/Hopelessness
3. Have you heard of the
Count of number of symptoms identi¢ed
Interval
F
Yes
Binary variable: yes 5 1, no 5 0, all
Chi square
phrase ‘‘baby blues’’?
other responses recoded as 0
No
Don’t know
Refused
4. What are some symptoms
of baby blues?
Sadness/Crying: feeling down, depressed,
tearful, emotional, feel empty
Binary variable for each symptom:
Chi square
yes 5 1, no 5 0, all other
responses recoded as 0
Frustration/Irritability: moody, touchy, can’t
stand baby crying, annoyed
Anxiety/Fears: worrying, feeling inadequate
Sleep/Appetite/Energy changes: can’t sleep,
sleeping too much, tired, exhausted, fatigue,
constantly having to do something, not eating,
eating too much
JOGNN 2009; Vol. 38, Issue 2
125
RESEARCH
Community Awareness of Postpartum Depression
Table 1. Continued
Questions
Coded Responses
Type of Data
Statistic
About 2 weeks is the correct
Chi square
Feelings for baby: no feelings, don’t feel
connected to baby, don’t love baby
Same/similar to postpartum depression but less
serious and or last for a short time, etc.
Other, specify
If respondent says don’t know or refused the ¢rst
response is coded as 8 for don’t know or 9 for
refused
5. How long do you think the
1 week or less
baby blues last after the birth
answer; binary variable: yes 5 1,
of a baby: one week or less,
no 5 0, all other responses
about two weeks, about three
recoded as 0
weeks, about four weeks, or
About 2 weeks
¢ve weeks or longer?
About 3 weeks
About 4 weeks
5 weeks or longer
Don’t know
Refused
6a. Do you think postpartum
Yes, baby blues
Yes PPD is the correct answer;
depression requires
binary variable: yes 5 1, no 5 0,
professional help?
all other responses recoded as 0
Chi square
Yes, postpartum depression
Yes, both
No
Don’t know
Refused
6b. Do you think baby blues
Chi square
require professional help?
6c. Do you think the baby blues,
Chi square
postpartum depression, both
or none of these require
professional help?
7. Where do you think a woman
could go for help?
Physiciançdoctor, family doctor/physician,
Binary variable source of
OBGYN, walk-in clinic, hospital, emergency
assistance: yes 5 1, no 5 0, all
room
other responses recoded as 0
Chi square
Mental Health Servicesçpsychiatrist,
psychologist, social worker, Canadian
Mental Health Association, nurse, nurse
practitioner
Support Groupçchurch, peer support group
Family/Friends
126
JOGNN, 38, 121-133; 2009. DOI: 10.1111/j.1552-6909.2009.01001.x
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RESEARCH
Sealy, P. A., Fraser, J., Simpson, J. P., Evans, M. and Hartford, A.
Table 1. Continued
Questions
Coded Responses
Type of Data
Statistic
Local Health Unit/Department
Telephone Help Lineçdistress line, Telehealth
Self HelpçInternet, books, magazines, library
Other, specify
Note. Used with permission from Rapid Risk Factor Surveillance System. Available at http://www.rrfss.on.ca/index.php?pid=11
spect to family structure. Probability (p) values less
than .05 (two-sided) were considered to be statistically signi¢cant.
Results
Sample Characteristics
Of the 8,750 respondents, most were female (55.8%)
and spoke English at home (90.9%) (Table 2). The
median age group was between 45 and 54 years.
Approximately half of respondents had some postsecondary education (48.5%) and 38.3% of respondents had an annual family income between
$30,000 and $79,999; however, 20.8% of respondents did not report their income. Fewer respondents reported having children under 13 years of
age at home (26.9%).
Awareness of PPD
Table 2: Demographic Characteristics of
Study Participants (n 5 8,750)
n
%
Women
4,883
55.8
Children o13 years of age at home
2,354
26.9
18-24
980
11.2
25-34
1,356
15.5
35-44
1,829
20.9
45-54
1,916
21.9
55-64
1,243
14.2
651
1,286
14.7
149
1.7
Age group
The vast majority of respondents were aware of PPD
(90.1% 0.6% CI). Awareness of PPD, however,
varied according to the demographic pro¢les of
the respondents (Table 3). There was a signi¢cant
statistical interaction between gender and the presence of children under 13 years of age at home.
By summing the B coe⁄cients for women, the presence of children under 13 years of age at home, and
the interaction, the odds of women with children
Table 3: Association of Awareness of
Postpartum Depression and
Demographics
Variable
Missing
Significance
4.35 (3.60-5.27) o.001
Children o13 years of
2.47 (1.91-3.19)
o.001
age at home
Education
oHigh school
Odd Ratio (CI)
Women
1,190
13.6
WomenChildren o13 years
0.61 (0.41-0.93)
.021
of age at home
High school
3,255
37.2
Some postsecondary
4,244
48.5
Language spoken at home
English
14.09 (11.65-17.04) o.001
Total family income
Education
Under $30,000
1,251
14.3
$30,000-79,999
3,351
38.3
$80,0001
2,336
26.7
Missing
1,820
20.8
o.001
oHigh school
0.31 (0.25-0.38)
High school
0.61 (0.51-0.73)
Some postsecondary
Ref
Constant
0.74
.004
Language spoken at home
English
JOGNN 2009; Vol. 38, Issue 2
7,954
90.9
Note. Hosmer and Lemeshow test X 5 20.9, df 8, p 5 .08, indicating
that the model shows no evidence of lack of ¢t.
127
RESEARCH
Community Awareness of Postpartum Depression
Table 4: Awareness of the Symptoms of Postpartum Depression (PPD), its Symptoms, and Sources of
Assistance by Family Structure
Women
Men
Children 13 Years
Children 13 Years
Children o13 Years
of Age or Older or
Children o13 Years
of Age or Older or
of Age at Home
None at Home
of Age at Home
None at Home
Total
Awareness
(n 5 1,230)
(n 5 3,652)
(n 5 935)
(n 5 2,927)
(n 5 8,744)
p Values
Aware of PPD (%)
1,177 (95.7%)
3,443 (94.3%)
841 (89.9%)
2,418 (82.6%)
7,880 (90.1% 0.6%)
o.001
Aware of symptoms of PPD
(n 5 905)
(n 5 3,624)
(n 5 642)
(n 5 2,582)
(n 5 7,753)
Sadness
77.9%
67.8%
62.5%
51.9%
63.2% ( 1.1%)
o.001
Frustration/irritability
33.5%
24.8%
34.3%
23.1%
26.0% ( 1.0%)
o.001
Sleep/appetite problems
33.3%
22.2%
20.3%
14.2%
20.6% ( 0.9%)
o.001
Guilt toward baby
27.2%
24.0%
14.6%
10.2%
19.0% ( 0.9%)
o.001
Anxiety/fears
16.1%
12.9%
12.1%
9.9%
12.2% ( 0.7%)
o.001
Total number of symptoms
1.88 (1.04)
1.52 (1.05)
1.44 (1.01)
1.09 (0.99)
1.41 (1.06)
o.001
Aware of baby blues
85.1%
73.1%
49.4%
43.0%
62.5% ( 1.1%)
o.001
Symptoms of baby blues
33.6%
30.1%
23.8%
21.0%
28.1% ( 1.3%)
o.001
36.5%
32.9%
22.5%
19.2%
29.9% ( 1.4%)
o.001
of PPD mean (SD)
the same as PPD
Symptoms of baby blues:
2 weeks or less
under 13 years of age at home being aware of PPD
was 6.60 times (B 5 1.887) that of men with no children or children 13 years of age and older at home
(reference category). In addition, the odds of
respondents who spoke English at home being
aware of PPD was 14.09 times that of individuals
who spoke a language other than English at home.
Finally, the odds of respondents who had some
postsecondary education being aware of PPD were
3.23 times (1/0.31) that of individuals who had less
than a high school education.
Awareness of the Symptoms of PPD
For respondents who were aware of PPD, sadness
was the most frequently recognized symptom by all
groups (63.2%), followed by frustration/irritability
(26.0%), sleep/appetite problems (20.6%), feelings
of guilt toward the baby (19.0%), and anxiety/fears
(12.2%) (Table 4). Less than 5% of respondents
recognized harm to self or the baby, hopelessness/
helplessness, or social isolation as symptoms of
PPD.
When the four subgroups based on gender and
presence of children under 13 years of age at home
were compared, there were signi¢cant among-group
128
di¡erences (po.001), with the group consisting of
women with children under 13 years of age at home
identifying a greater number of symptoms (mean of
1.08 1.04). A greater proportion of women with
children under 13 years of age at home were aware
of the symptom sadness (77.9%), as compared with
men with children under 13 years of age at home
(62.5%), women with no children or children 13 years
of age and older at home (67.8%), and men with no
children or children 13 years of age and older at
home (51.9%). Nevertheless, only one third of women with children under 13 years of age at home
were aware of the other symptoms of PPD (frustration/irritability, sleep/appetite problems, feelings of
guilt toward the baby, and anxiety/fears). Men with
children under 13 years of age at home were as likely
as women with children under 13 years of age at
home to be aware of frustration/irritability as symptoms of PPD (34.3%), but only approximately 20%
of these men were aware of sleep/appetite problems,
as compared with one third of these women.
Respondents who spoke English at home were
more aware of the symptoms of sadness (63.6%)
and frustration/irritability, (26.3%), as compared
with respondents who spoke a language other
than English at home (sadness 55.8%; frustration/
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RESEARCH
Sealy, P. A., Fraser, J., Simpson, J. P., Evans, M. and Hartford, A.
irritability 18.7%). In addition, respondents who had
less than a high school education were signi¢cantly
less aware of all of the symptoms of PPD, for example sadness (45.8%) and/or frustration/irritability
(17.7%), as compared with respondents with some
postsecondary education (sadness 69.7%; frustration/irritability 29.8%).
Awareness of the Baby Blues
Fewer respondents (62.5% 1.1%) were aware
of the baby blues (Table 4). Only 28.1% of these
respondents believed that the symptoms of the
baby blues were the same as PPD. In addition, only
29.9% of respondents were aware that the symptoms associated with the baby blues should not
extend beyond 2 weeks. Approximately 40% of respondents believed that PPD requires professional
treatment (41.4%), whereas 40.8% of respondents
believed that both PPD and the baby blues require
professional treatment.
Compared with men with children under 13 years of
age at home, women with children under 13 years of
age at home were also more aware of the baby
blues (women 85.1% vs. men 49.4%), the similarities of the symptoms between PPD and the baby
blues (women 33.6% vs. men 23.8%), and the
duration of the baby blues (women 36.5% vs. men
22.5%). In addition, women with children under
13 years of age at home were more likely to believe
that both PPD and the baby blues require professional treatment (women 53.5% vs. men 31.5%),
as compared with only PPD (women 36.5% vs.
men 43.8%).
Respondents who spoke English at home were
more aware of the baby blues (63.3%), as compared with respondents who spoke a language
other than English at home (50.5%). In addition,
respondents with less than a high school education were less aware of the baby blues (59.1%),
and of the similarities of the symptoms between
PPD and the baby blues (14.1%), as compared with
respondents with a postsecondary education
(awareness of baby blues 65.5%; symptoms are
the same 33.0%). There were no di¡erences with
respect to education and language spoken at
home in the belief that only PPD requires professional treatment.
Awareness of the Sources of Assistance
for PPD
The majority of respondents reported a physician/
obstetrician as a source of assistance for PPD
(85.2%), followed by a psychiatrist/mental health
worker (18.4%) (Table 5). Only 11.9% of respondents
identi¢ed their local health unit as a source of assistance. Less than 10% of all respondents identi¢ed
family/friends and church/support groups as
sources of assistance.
Women with children under 13 years of age at home
were also signi¢cantly more likely to identify a physician/obstetrician as a source of assistance for
PPD (90.3%), followed by their local health unit
(16.8%), and a psychiatrist/mental health worker
(13.9%). In contrast, men with children under 13
years of age at home were less likely to identify a
Table 5: Awareness of the Sources of Assistance for Postpartum Depression (PPD) by Family Structure
Women
Awareness
Men
Children o13 Years
Children 13 Years of
Children o13 Years
Children 13 Years of
of Age at Home
Age or Older or None
of Age at Home
Age or Older or None
(n 5 1,230)
at Home (n 5 3,652)
(n 5 935)
at Home (n 5 2,927)
Total (n 5 8,744)
PPD and baby blues require
p Values
o0.001
professional help
PPD only
36.5%
38.7%
43.8%
46.2%
41.4% ( 1.1%)
PPD and baby blues
53.5%
46.9%
31.5%
30.3%
40.8% ( 1.1%)
Sources of assistance
(n 5 814)
(n 5 3,097)
(n 5 484)
(n 5 1,974)
(n 5 6,369)
Physician/obstetrician
90.3%
88.7%
80.8%
78.5%
85.2% ( 0.9%)
o.001
Psychiatrist/mental health worker
13.9%
17.0%
16.7%
22.7%
18.4% ( 1.0%)
o.001
Local health unit
16.8%
11.6%
15.1%
9.7%
11.9% ( 0.8%)
o.001
Church/support group
8.6%
6.4%
5.8%
6.6%
6.7% ( 0.6%)
.126
Family/friends
8.7%
7.7%
6.2%
5.2%
6.9% ( 0.6%)
o.001
JOGNN 2009; Vol. 38, Issue 2
129
RESEARCH
Community Awareness of Postpartum Depression
physician/obstetrician (80.8%) as a source of assistance for PPD. Men with no children or children
13 years of age and older at home were more likely
than women with this family structure to identify a
psychiatrist/mental health worker as a source of assistance (22.7%).
Respondents who spoke English at home were more
likely to identify a physician/obstetrician (85.6%) or
their local health unit (12.3%) as sources of assistance for PPD, as compared with respondents
who spoke a language other than English at
home (physician/obstetrician 77.1%; health unit
5.3%). Respondents with less than a high school
education were less likely to identify a physician/
obstetrician (78.2%), psychiatrist/mental health
worker (13.9%), and their local health unit (7%) as
sources of assistance for PPD, as compared with
respondents with some postsecondary education
(physician/obstetrician 87.3%; psychiatrist/mental
health worker 19.5%; local health unit 15.2%).
Discussion
The results of this study identi¢ed that the majority
of respondents within the community were aware of
PPD; however, awareness of PPD varied according
to the demographic pro¢les of the respondents
(family structure, education, and language spoken
at home). It is not surprising that almost all women
with children under 13 years of age at home (96%)
were aware of the term PPD because this group
likely would have been the primary target of educational campaigns on PPD over the past 10 to
15 years. Sealy et al. (in press) found that all women
who consented to participate in their randomizedcontrolled study of an informational educational
pamphlet at 4 weeks postpartum were aware of
PPD and reported that this ¢nding may have been
the result of a selection e¡ect. This current surveillance research would suggest that the vast
majority of women with young children have been
exposed to the term PPD.
The lack of awareness of the symptoms of PPD,
however, is concerning. It is not surprising that
women with children under 13 years of age at home
were less aware of the speci¢c symptoms of PPD
than women who were 3 months postpartum (Sealy
et al., in press). Only 77.9% of women with children
under 13 years of age at home in the general community were aware of sadness as a symptom of
PPD, as compared with 87.1% of postpartum women. Only one third of women with children under
13 years of age at home were aware of the symptom
of frustration/irritability, as compared with between
130
44.5% and 46.1% of postpartum women. Similarly,
one third of women with children under 13 years of
age at home were aware of sleep/appetite problems
and only 27.2% were aware of feelings of guilt toward the baby as a symptom, similar to postpartum
women. It is especially disturbing that less than
5% of respondents recognized harm to self or the
baby, hopelessness/helplessness, or social isolation as symptoms of PPD (less than 10%), the
symptoms that usually indicate an immediate need
for assistance.
In addition, 85.1% of women with children under
13 years of age at home were aware of the term
baby blues; however, only 33.6% of these respondents were aware of the similarities of the
symptoms between the baby blues and PPD, as well
as the duration of the baby blues. There are misconceptions among women with children under
13 years of age at home that the baby blues and
PPD both require professional assistance, rather
than solely PPD. Few respondents identi¢ed family/
friends, church/support groups, and self-help as
sources of assistance for PPD. One plausible explanation for these results is that women during the
perinatal period may be more likely to take interest
to information on PPD, because they may perceive
more immediate relevance. Another explanation is
that information on PPD is not retained over time
and that reeducation is necessary.
In addition, there is a concern that men with children under 13 years of age at home and men and
women with no children or children 13 years of age
and older at home were less aware of PPD and its
sources of assistance. Because these groups represent the social support networks of postpartum
women (partners, parents, family, and signi¢cant
others), the well-being of postpartum women may
be compromised with respect to the identi¢cation
of the symptoms of PPD, thus presenting a potential
barrier in the recognition of the need for support.
Symptomatic women may be vulnerable, because
their social support networks may attempt to normalize these symptoms as typical of all mothers,
or discredit or minimize the symptoms, which may
become a barrier to women initiating treatment
(Dennis & Chung-Lee, 2006; Scrandis, 2005).
When symptomatic, the quality of the mother’s social support network can have a major impact on
her well-being. Postpartum women’s social support networks need to encourage women to seek
support and treatment: negative social support
networks can contribute to the isolation of symptomatic women. Social support networks that recognize the symptoms of PPD (rather than discredit
JOGNN, 38, 121-133; 2009. DOI: 10.1111/j.1552-6909.2009.01001.x
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RESEARCH
Sealy, P. A., Fraser, J., Simpson, J. P., Evans, M. and Hartford, A.
the symptoms) and provide emotional support may
in£uence women to seek treatment and further social support. Social support networks (especially
spouses, family, and signi¢cant others) that are
aware of PPD may be in a better position to listen
to postpartum women’s emotional concerns, as
well as provide the needed emotional and social
support.
Implications for Education
Public health units and clinicians that provide care
to perinatal women must focus education on PPD
to target multiple audiences (women and their social support networks). Even though Sealy et al. (in
press) identi¢ed that 10.2% of postpartum women
who were considered to be at low-risk for PPD accessed public health nurses and 6.3% accessed
their family physician/obstetrician for PPD-related
services, the majority of respondents identi¢ed a
physician/obstetrician as a source of assistance
for PPD, followed by a psychiatrist/mental health
worker and local health unit. Clinicians who provide
care to perinatal women need to provide information
on the symptoms of PPD, highlighting the myths and
misconceptions and the multiple sources of assistance as well as the informal supports that social
support networks can provide to women with PPD
during this period of social adjustment. As primary
prevention, women need to be encouraged to share
this information with their social support networks
before the risk period for PPD.
Thus, women’s social support networks can be
sensitized to the symptoms of PPD, provide emotional and functional support, and encourage
contact with professionals when necessary. It is important that information on PPD be tailored to the
demographic pro¢les of women, especially for respondents who speak a language other than
English at home and for those with less than a high
school education, since they may experience a
higher risk related to economic strains and/or lack
of social support (Beck, 2002; Dennis, 2003, 2004;
Dennis & Creedy, 2005; Mosack & Shore, 2006).
Strategies need to recognize how language, literacy, and culture can act as barriers for women to
successfully access available resources on PPD
(Murray, Woolgar, Murray, & Cooper, 2003; RNAO,
2005).
The authors support the argument posed by Logsdon et al. (2006) that primary health care providers
who have signi¢cant contact with perinatal women
must be aware of PPD, its symptoms, and sources of
assistance in order to support women to be aware
of PPD and to care for symptomatic postpartum wo-
JOGNN 2009; Vol. 38, Issue 2
Awareness of the term postpartum depression does not
necessarily imply awareness of symptoms or sources of
assistance.
men and their families. Health units need to clarify
the role of public health nurses in terms of postnatal
support services for women with PPD, because they
are a primary group providing care through home
visits and telephone calls from women and others
who express concerns about PPD. Health units
should also develop campaigns to educate the
general public on PPD. Because the symptoms of
the baby blues are similar to PPD and respondents
were less aware of the term baby blues, the authors
recommend that education be focused on the
symptoms of PPD (sadness, frustration/irritability,
feelings of guilt toward the baby, sleep/appetite
problems, anxiety/fears, thoughts of harming self
or the baby, hopelessness/helplessness, and isolation), with an emphasis on when to seek assistance
for PPD. The bene¢t of focusing on the symptoms
of PPD and when and where to obtain assistance
requires that individuals only master one set of
symptoms, potentially reducing the cultural biases
in the recognition of the term the baby blues (Rondo¤n, 2003).
Further, the authors recommend that multiple
forms of public education be used including faceto-face communication, television, radio, Internet,
and newsprint. Clinicians need to ensure that all
information on PPD be culturally sensitive and
accurate, and agencies supplying inaccurate information should be contacted for clari¢cation.
Printed information and Web sites on PPD must be
checked for content accuracy and to ensure that
the literacy level does not exceed a Grade 5 reading level (Logsdon & Hutti, 2006; Summers &
Logsdon, 2005). It would be advantageous if local
communities had an inventory of sources of information, especially if the media present misinformation after a suicide or infanticide related to
PPD. Nurses are in pivotal positions to teach symptomatic women and their social support networks
the symptoms of PPD, normalize current experiences, and suggest methods of social support in
order to reduce fears and dispel myths and stereotypes/stigma (Riecher-R˛ssler & Hofecker, 2003;
Scrandis, 2005). Nurses may also need to encourage women with lower levels of self-esteem and
self-con¢dence to connect with PPD support
groups, because some women may need additional assistance to participate in these forms of
social support (Scrandis).
131
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Community Awareness of Postpartum Depression
Conclusion
Nurses can play a pivotal role in educating childbearing
women, their social support networks, and the public about
postpartum depression.
Limitations
This research is only generalizable to populations
with similar demographic characteristics and to
those that have been exposed to information
through educational campaigns by public health
units such as the populations serviced by the eight
Ontario health units that were included in this study.
A limitation of this study is that these estimates may
be biased as a result of the under-representation of
the subgroups of individuals whose ¢rst language
is other than English or those with lower socioeconomic status. In Ontario, Statistics Canada (2006)
reported that the median level of income for married couple families in 2005 was $77,243 (in this
sample over one quarter of respondents had incomes of at least $80,000 and one ¢fth of
respondents did not disclose their ¢nancial status)
and 68.4% of the population was English-speaking
(sample 90.9%). A limitation of the RRFSS Postpartum Mood Disorders Module was that participants
were not asked their sources of information on
PPD or whether they have ever had a personal experience with PPD. Thus, this study cannot evaluate
whether the lower level of recognition of these
symptoms may be related to inadequate exposure
to educational materials from health professionals
or educational campaigns and/or the perceived
relevancy of the information.
In conclusion, awareness of the term PPD does not
necessarily imply awareness of its symptoms and
sources of assistance. Many individuals in the community were not aware of the symptoms of PPD and
its sources of assistance. Thus, new mothers and
their social support networks may be vulnerable,
due to their inability to recognize the symptoms of
PPD and seek assistance. Through lack of awareness of the symptoms of PPD, social support
networks may be inadvertently creating barriers
through normalizing or discrediting symptoms, thus
interfering with early intervention. Nurses can play a
pivotal role in educating perinatal women, their social support networks, and the public with respect
to PPD, by dispelling myths and reducing stigma.
Curricula to educate primary caregivers, health
care professionals, and the public on PPD need to
be reviewed as to cultural sensitivity and the e¡ects
on speci¢c target groups, especially those who do
not speak English as their ¢rst language and individuals with lower levels of education.
Acknowledgments
The authors thank the participating health units
and Mr. Larry Stitt, Department of Epidemiology &
Biostatistics, The University of Western Ontario, for
statistical consultation.
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depression
support
program.
Association
of
133