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 http://jognn.awhonn.org 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/ 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. 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 http://jognn.awhonn.org 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 RESEARCH 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. REFERENCES A¡onso, D. D., De, A. K., Horowitz, J. A., & Mayberry, L. J. (2000). An international study exploring levels of postpartum depressive symptomatology. Journal of Psychosomatic Research, 49(3), 207-216. Beck, C. T. (2002). Postpartum depression: A metasynthesis. Qualitative Health Research, 12(4), 453-472. Future Research Research should be conducted to determine the most e¡ective sources of information on PPD. Research is needed to speci¢cally evaluate awareness of PPD among non-English^speaking groups, because there may be cultural di¡erences in the awareness of the symptoms and sources of assistance for PPD. Additional research is needed to understand the public’s understanding of selfcare strategies, such as adequate nutrition, sleep, exercise, sharing thoughts and feelings, emotional support, socialization, and seeking professional assistance when necessary (Ross et al., 2005). A policy needs to be developed to direct the content and timing of information on PPD for the general public, perinatal women and their social support networks, and health professionals. 132 Dennis, C. L. (2003). E¡ect of peer support on postpartum depression: A pilot randomized controlled trial. Canadian Journal of Psychiatry, 48(2), 115-124. Dennis, C. L. (2004). Preventing postpartum depression part II: A critical review of nonbiological interventions. Canadian Journal of Psychiatry, 49(8), 525-538. Dennis, C. L., & Chung-Lee, L. (2006). Postpartum depression help-seeking barriers and maternal treatment preferences: A qualitative systematic review. Birth, 33(4), 323-331. Dennis, C. L., & Creedy, D. (2005). Psychosocial and psychological interventions for preventing postpartum depression (Cochrane Review). In The Cochrane Library (Issue 2). Retrieved November 1, 2005, from http://www.thecochranelibrary.com Garg, A., Morton, S., & Heneghan, A. (2005). A hospital survey of postpartum depression education at the time of delivery. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 34(5), 587-594. Gaynes, B. N., Gavin, N., Meltzer-Brody, S., Lohr, K. N., Swinson, T., Gartlehner, G., et al. (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes. Evidence Report/ Technology Assessment, 119,1-88. 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. Heh, S. S., & Fu, Y. Y. (2003). E¡ectiveness of informational support in Riecher-R˛ssler, A., & Hofecker, F. (2003). Postpartum depression: Do we reducing the severity of postnatal depression in Taiwan. Journal still need this diagnostic term? Acta Psychiatrica Scandinavica, of Advanced Nursing, 42(1), 30-36. Institute of Social Research. (2007). The 2007 Rapid Risk Factor Surveillance System (RRFSS) technical documentation. Toronto, ON: York University. Kish, L. (1995). Survey sampling. New York: John Wiley & Sons. Letourneau, N., Du¡ett-Leger, L., Stewart, M., Hegadoren, K., Dennis, C. L., 108(418), 51-56. Rondo¤n, M. B. (2003). Maternity blues: Cross-cultural variations and emotional changes. Primary Care Update Ob/Gyn, 10(4),167-171. Ross, L. E., Dennis, C. L., Blackmore, E. R., & Stewart, D. E. (2005). Postpartum depression: A guide for front-line health and social services providers. Toronto, ON: Centre for Addiction and Mental Health. Rinaldi, C. M., et al. (2006). Canadian mothers’ perceived support Scrandis, D. (2005). Normalizing postpartum depression symptoms with needs during postpartum depression. Journal of Obstetric, Gyn- social support. American Psychiatric Nurses Association, 11(4), ecologic & Neonatal Nursing, 36(5), 441-449. 223-230. Logsdon, M. C., & Hutti, M. (2006). Readability: An important issue impact- Sealy, P., Simpson, J., & Evans, M., (in press) E¡ect of an educational ing healthcare for women with postpartum depression. Journal of pamphlet on women’s experiences with postpartum depression. Maternal Child Nursing, 11(6), 350-355. Logsdon, M. C., Wisner, K., Billings, D. M., & Shanahan, B. (2006). Raising awareness of primary care providers about postpartum depression. Issues in Mental Health Nursing, 27, 59-73. Moore, D., & McCabe, G. (1999). Introduction to the practice of statistics. New York: W. H. Freeman and Company. Mosack, V., & Shore, E. (2006). Screening for depression among pregnant and postpartum women. Journal of Community Health Nursing, 23(1), 7-47. Murray, L., Woolgar, M., Murray, J., & Cooper, P. (2003). Self-exclusion from health care in women at high-risk for postpartum depression. Journal of Public Health, 25(2),131-137. Canadian Journal of Community Mental Health. Statistics Canada. (2006). Community Pro¢les. Retrieved July 22, 2008, from http://www12.statcan.ca/census-recensement/ 2006. Stowe, Z. N., Hostetter, A. L., & Newport, D. J. (2005). The onset of postpartum depression: Implications for clinical screening in obstetrical and primary care. American Journal of Obstetrics and Gynecology, 192(2), 522-526. Summers, A. L., & Logsdon, M. C. (2005). Web site for postpartum depression: Convenient, frustrating, incomplete, and misleading. MCN American Journal of Maternal/Child Nursing, 30(2), 88-94. Ugarriza, D. (2002). Postpartum depressed women’s explanation of depression. Journal of Nursing Scholarship, 34(3), 227-233. Ogrodniczuk, J. S., & Piper, W. E. (2003). Preventing postnatal depression: Verkerk, G. J., Pop, V. J., Van Son, M. J., & Van Heck, G. L. (2003). Prediction A review of research ¢ndings. Harvard Review of Psychiatry, 11(6), of depression in the postpartum period: A longitudinal follow-up 291-307. study in high-risk and low-risk women. Journal of A¡ective Disor- Rapid Risk Factor Surveillance System. (2005). Postpartum mood disor- ders, 77(2), 159-166. ders (PPMD) module. Retrieved January 8, 2009, from http://www. Vilder, H. (2005). Women making decisions about self-care and recover- rrfss.on.ca/resources/Postpartum%20Mood%20Disorders%20% ing from depression. Women’s Studies International Forum, 28, 28PPMD%29%20-%20July%202005.doc Registered Nurses’Association of Ontario. (2005). Nursing best practices 289-303. Wrobleski, M., & Tallon, D. (2004). Implementing a comprehensive guidelines: Interventions for postpartum depression. Retrieved postpartum November 2, 2006, from http://www.rnao.org/Page.asp?PageID= Women’s Health, Obstetric and Neonatal Nursing Lifelines, 8(3), 924&ContentID=806 248-252. JOGNN 2009; Vol. 38, Issue 2 depression support program. Association of 133