Are Pregnant and Postpartum Women Interested in Health-Related Apps? Implications for the Prevention of Perinatal Depression

Abstract

Recent studies have shown that women are more likely than men to use the Internet to seek health information and that the use of technology is common among perinatal women. Access to the Internet is growing through the global use of mobile phones and apps, in both developed and less developed countries. This pattern is particularly relevant for clinicians and researchers who are interested in the use of technologies to disseminate perinatal depression interventions. In a cross-sectional anonymous online survey for English and Spanish-speaking perinatal women, 509 pregnant (77.6 percent) and postpartum (22.4 percent) women provided demographic and Information and Communication Technologies data. Results indicated that the single device with greatest access was the mobile phone (47.5 percent). The majority of the sample had Internet access through mobile phones, computers, or both. Significant differences in socioeconomic status were found for Internet seeking behavior of health-related information and downloading apps between those with and without Internet access. Ninety percent of respondents (n = 267) searched for health-related information and 72.3 percent had downloaded any kind of app. More than half of respondents (57 percent, n = 188) downloaded a health-related app and 26.9 percent reported having paid for the apps. This study shows preliminary evidence to suggest the need to design, develop, and test apps that aim to disseminate prevention programs for perinatal depression.

Introduction

Major depression is a debilitating mental health condition that affects 16 percent of the world's population.¹ Among high and middle-income countries, depression was the third highest ranked burden of disease in 2004 and is projected to rise in ranking by 2030.² Women are at an increased risk for depression, particularly those who are in the perinatal period (i.e., pregnant or recently postpartum³). Approximately, 18.4 percent of women experience symptoms of depression during pregnancy, while 19.2 percent may develop a depressive disorder.⁴ The presence of depressive symptoms during the perinatal period is associated with a negative impact on a women's health and holds consequences for the developing child.⁵

Many women with perinatal depression do not seek the appropriate psychological care⁶ or are unable to access quality care,⁷ all of which contribute to increases in mental health disparities among this vulnerable population.⁸ Reducing the barriers that prevent perinatal women from receiving adequate mental healthcare (e.g., limited or inadequate resources) is of utmost importance.

In the last decade, information and communication technology (ICT; i.e., computers, laptops, Internet, and mobile phones) tools have emerged as a potential solution to address treatment gaps, inequalities in care, and barriers to adequate perinatal mental healthcare.^8,9 The preferred and accessible ICT tools vary across groups, but it is clear that men and women are increasingly relying on them.^10,11

The use of ICTs is increasing worldwide, including in developing countries such as Latin American, Middle Eastern, and African countries.^12–14 Globally, 89 percent of the time spent on media is through the use of apps and 11 percent through mobile web. In addition, women are more likely to use the Internet to seek health information than men.¹⁵ A recent study demonstrated that use of the Internet is frequent and common for pregnant and postpartum women (94.0 percent Internet use, 90.0 percent use of e-mail, and 50.0 percent Facebook use) with overall access at ∼74.0 percent among various sociocultural groups,¹⁶ with 82 percent being open to an online intervention targeting women in the postpartum period.¹⁶

In a review of ICTs in the prevention of perinatal depression, Osma et al. concluded that between 2000 and 2013, no studies used apps for screening, prevention, or treatment objectives, despite their high rates of use among women.¹⁷ Despite the increased rate of health seeking behaviors among perinatal women,¹⁶ few studies have focused on assessing the interest of perinatal women and feasibility of using health interventions through an app. Thus, the purpose of this study was to evaluate access to ICT tools in an international sample of pregnant and postpartum women. In addition, we were interested in examining the frequency of health information seeking using online and mobile device methods. Finally, the study aimed to identify behaviors related to pregnant and postpartum women's access to health-related apps.

Method

Sample

Participants (N = 509) represented 59 unique countries, were English (51.3 percent) and Spanish speaking (48.7 percent), and had a mean age of 27.6 years (SD = 7.3). Table 1 describes the sociodemographic characteristics of the participants.

Table 1.

Sociodemographic Characteristics of Pregnant and Postpartum Women (N = 509)

Variable (N)	n (%)
Age (n = 506)
18–24	174 (34.4)
25–34	265 (52.4)
35–45	67 (13.2)
Pregnancy status (n = 509)
Currently pregnant	395 (77.6)
Postpartum, not pregnant	114 (22.4)
Number of children (n = 442)
0	173 (39.1)
1	172 (38.9)
2	63 (14.2)
3	19 (4.3)
≥4	15 (3.4)
Preferred language (n = 509)
English	261 (51.3)
Spanish	248 (48.7)
Country of residence
English speakers (n = 249)
India	57 (22.9)
United States	51 (20.5)
Pakistan	39 (15.7)
Philippines	30 (12.0)
South Africa	17 (6.8)
Ghana	5 (2.0)
Others	50 (20.1)
Spanish speakers (n = 247)
Venezuela	69 (27.9)
Colombia	32 (12.9)
Ecuador	29 (11.7)
Argentina	27 (10.9)
Peru	25 (10.1)
Chile	17 (6.9)
Bolivia	9 (3.6)
Mexico	6 (2.4)
Others	33 (13.4)
Ethnicity (n = 433)
Latina or Hispanic	215 (49.6)
Not Latina or Hispanic	218 (50.4)
Racial background (n = 451)
African American or Black	37 (8.2)
Alaska Native or American Indian	3 (0.7)
Asian	83 (18.4)
European American or White	97 (21.5)
Mestizo	110 (24.4)
Native Hawaiian	2 (0.4)
Pacific Islander	3 (0.7)
More than one race	14 (3.1)
Others	102 (22.6)
Marital status (n = 453)
Married/cohabitating	354 (78.1)
Single	99 (21.9)
Employment (n = 77)
Full or part time	48 (62.3)
Temporary leave	8 (10.4)
Unemployed	21 (27.3)
Socioeconomic status (n = 456)
High	0 (0.0)
Middle	390 (85.5)
Low	66 (14.5)
Education (n = 444)
Trade school or professional school	22 (4.9)
20+ years (Doctorate, medical school, law degree)	47 (10.6)
17–19 years (Masters degree or equivalent)	73 (16.4)
13–16 years (University or equivalent)	177 (39.9)
7–12 years (Secondary/High school or equivalent)	97 (21.8)
0–6 years (Primary school or equivalent)	9 (2.0)
Others	19 (4.3)

Procedure

English and Spanish speaking women who were at least 18 years old and currently pregnant or within 1 year postpartum were recruited for participation using Google AdWords campaigns. Participation was self-guided and anonymous. Data from this study were extracted from a larger online survey for pregnant and postpartum women. The sponsoring institutional review board approved all procedures.

Measures

Demographic questionnaire (ad hoc)

Participants provided information on their age, language preference, racial background, marital status, annual income, country of origin and residence, education, employment, pregnancy status, and number of children.

Information and communication use in pregnancy survey (ad hoc)

Is a categorical (yes/no) and dimensional measure assessing an individual's availability and access to the Internet, knowledge, and use of the Internet as a means of obtaining information on health, perinatal mood, and treatment.

Results

Almost half (47.5 percent) of the total sample had access to mobile phones, television (42.0 percent), a laptop (28.7 percent) or desktop computer (28.3 percent), tablet (14.1 percent), and a reader (2.8 percent). More than half (n = 283, 56.7 percent) answered questions related to ICT use, with a majority indicating using both their desktop computer/Laptop and their mobile phone to access the Internet (66.1 percent). The remaining accessed the Internet only through one device—a desktop computer/Laptop (13.1 percent) or their mobile phone (12.4 percent) only.

Analysis of variance (Scheffe's test) was conducted to examine the relationship between sociodemographic variables and Internet access based on preferred device. Statistically significant differences were demonstrated based on socioeconomic status (low, medium, and high) between those who did not have access to the Internet and those who accessed it through a desktop computer/Laptop (p < 0.05) and through both types of devices (p < 0.001). Significant differences in whether participants searched the Internet for health-related information were demonstrated between those without any access to the Internet and those with access to the Internet through a desktop computer/Laptop (p < 0.05), mobile phone (p < 0.001), and through both devices (p < 0.05). Finally, there were significant differences in downloading apps between those who did not have access to the Internet and those who accessed it through a mobile phone (p < 0.05) or through both devices (p < 0.001). Differences in app downloading were also demonstrated between those who had access to the Internet through desktop computer/Laptop and those who had access through mobile phone (p < 0.05) or through both devices (p < 0.001).

Of participants who predominantly accessed the Internet through a mobile device (n = 216), daily use ranged from 0 to 2 hours (45.9 percent), 2 to 4 hours daily (25 percent), 4 to 6 hours (10.6 percent), and more than 6 hours (18.5 percent). Those who accessed the Internet through a desktop computer/Laptop (n = 246) appeared to do so from 0 to 2 hours (54.9 percent), 2 to 4 hours (22.4 percent), 4 to 6 hours (7.7 percent), and more than 6 hours daily (15.0 percent). Social contact (48.2 percent), leisure (28.6 percent), information searches (11.8 percent), and business matters (11.4 percent) were the most common reasons for using the Internet as described in Table 2.

Table 2.

Purpose and Frequency of Internet Use (N = 220)

	Frequency (%)
	1	2	3	4
	Most time			Least time
Leisure (e.g., music, movies, and shopping)	63 (28.6)	82 (37.3)	50 (22.7)	25 (11.4)
Social (e.g., keeping in touch with family/friends)	106 (48.2)	64 (29.1)	35 (15.9)	15 (6.8)
Business (e.g., work-related e-mail)	25 (11.4)	20 (9.1)	61 (27.7)	114 (51.8)
Information search (e.g., politics, news, and health)	26 (11.8)	54 (24.5)	74 (33.6)	66 (30.0)

In terms of health seeking behaviors, 92.1 percent of respondents (n = 267) searched for health-related information and 72.3 percent downloaded apps on their mobile devices. Of 181 respondents, 48.6 percent reported having downloaded between 1 to 5 apps, 20.9 percent 6 to 15 apps, 15.0 percent 16 to 30 apps, and 15.4 percent more than 31 apps. Of 188 respondents, 108 (57.4 percent) reported that the apps were health related. Finally, only 50 (26.9 percent) of the 186 respondents reported having paid for any of the apps downloaded.

Discussion

In this study, we examined three key variables among an international sample of perinatal women as follows: access to mobile phones and the Internet, use (utilization time and health-related search content), and acceptance (downloading mobile apps related to health issues). A major strength of this study is the significant geographical diversity of the sample, suggesting a rich multicultural representation of opinions about global technology access and use. Furthermore, a focus on use among pregnant and postpartum women has the potential of impacting maternal mental health disparities worldwide.

Results indicate that the mobile phone is the most used device among pregnant and postpartum women. Furthermore, respondents accessed the Internet on their mobile phones at similar rates as with the desktop computer/Laptop suggesting that both tools are accessible and accepted by pregnant and postpartum women. These data coincide with recent media statistics that report high percentages of Internet users who have access to the Internet through a desktop computer/Laptop and also through their use of a smartphone.¹²

Regarding the use of ICTs, a majority of respondents accessed the Internet on their mobile phones for more than 2 hours daily, which was a higher proportion of women who reported that they used the Internet more than 2 hours daily on their desktop computer/Laptop. Consequently, our sample used the Internet more frequently through mobile phones than on their desktop computer/Laptop. Regardless of device used and country of origin, our data confirm that pregnant and postpartum women use the Internet frequently, as is presented in a recent study by Peragallo et al. (94.0 percent Internet use).¹⁶ These data also replicate the statistical reports describing the penetration and increasing use of ICTs in developing countries.^13,14

Consistent with previous reports of how women are using technology, our study found that the majority of Internet time was dedicated to social and leisure activities and health information seeking.^13,15 The majority of the respondents reported positively to the prospect of using the Internet for these purposes. These data suggest that the integration of chat features and forum components into ICT interventions for perinatal women is a potentially good feature to include as it aligns with the preferences and behaviors of perinatal women. To date, several prevention intervention web applications have used these components successfully.¹⁸ ICTs for the prevention and treatment of perinatal depression are already being used with the majority focused on the development of web pages.^19,20 Current studies have not used apps, which our data suggest is a lost opportunity to address the prevention of perinatal depression.

Our assessment of acceptability of mobile technology suggests that pregnant and postpartum women commonly download apps to their mobile phones, including health-related apps, and that most of their apps are free of charge. These data are consistent with the higher percentages of free apps available as of 2013, that is, 90 percent of the available apps were free.²¹ This information is valuable for all researchers, clinicians, and app developers who are aiming to increase access to psychological tools through the use of technology. To conduct studies or offer mental health programs to perinatal women, it is advisable to provide these services free of charge.

This study has several limitations worth discussing. Despite the geographic and linguistic diversity of the study sample, it does not include women from many regions of the world who do not speak English or Spanish. It would be useful to increase the global representativeness of the sample. The cross-sectional design and anonymous participation contributed to the high rate of incomplete data and a limited sample size. Specific questions regarding using a free app for emotional screening, depression prevention, or psychological resources for depression or anxiety were not included and would be more informative for building future tools.

In summary, pregnant and postpartum women have access to mobile phones and the Internet, are using it frequently, and are interested in health-related content disseminated through the use of ICT tools. In addition, they are open to downloading health-related apps on their mobile phones, especially if they are free of charge. Consequently, there is evidence about the acceptability of apps for addressing the global need of perinatal depression and the use of technology to provide psychological resources to women worldwide.

Footnotes

Acknowledgments

This article preparation was supported by the “Estancias de movilidad en el extranjero José Castillejo para jóvenes doctores 2014” grant awarded to Jorge Osma from the Plan Estatal de Investigación Científica y Técnica y de Innovación 2013–2016 en I+D+I along with the Fulbright Commission. Additional support was provided by Gobierno de Aragón (Dpt. Industria e Innovación) and Fondo Social Europeo.

Recruitment was made possible by the generosity of Google, Inc. who awarded an Adwords grant to the research team (Ricardo F. Muñoz, P.I.). Finally, we appreciate all the women who took the time to participate in this study.

Author Disclosure Statement

No competing financial interests exist.

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