Abstract
Background:
Perinatal depression (PND) is one of the most common psychiatric illnesses in women, with a prevalence around 22% in India. Leveraging mobile-based technologies could help in the prevention and treatment of perinatal depression even in remote places. Understanding the experiences and barriers of using such technology interventions by perinatal mothers could help in the better design and in delivery of these interventions. We aimed to study the experiences of the perinatal women using a mobile phone-based intervention, Interactive Voice Response System (IVRS), for the prevention and management of perinatal depression in a rural district of Bihar, India.
Materials and methods:
A total of 12 in-depth interviews (IDIs) and one focus group discussion (FGD) with eight participants were conducted with perinatal mothers using the mobile-based IVRS to explore the experiences and perspectives of women receiving mobile phone-based interventions for the treatment of PND. Thematic analysis was done to identify major themes.
Results:
Five major themes emerged from the study around accessibility, usability, community participation, cost and preference to either intervention. Women found the mobile-based intervention useful as it made them feel lighter. They considered mental health as a health issue and wanted help to address their problems. They became familiar with terms like anxiety, depression, helplessness and burden and bean using them in their conversations. The patients used therapeutic strategies such as breathing, coping and relaxation. They even agreed to take up sessions for their peer group.
Conclusion:
Women in rural Bihar seemed satisfied with the technology-based intervention. It has made mental health issues more visible and acceptable even in the rural hinterlands of Bihar.
Keywords
Introduction
Perinatal depression (PND) is one of the most common psychiatric illnesses occurring in women (Alhusen & Alvarez, 2016). PND is defined as the presence of depression either during pregnancy or within 1 year of delivery (Rathod et al., 2018). Though the prevalence of perinatal depression varies widely in Indian studies, a recent meta-analysis has shown the prevalence to be around 22% in India (Upadhyay et al., 2017). Women experiencing PND usually present with sadness, loss of interest, suicidal ideations or attempts and anxiety symptoms. In severe cases, they can present with psychotic symptoms such as delusions and hallucinations.
PND has a huge impact not only on the immediate health of the mother and the child, but also has long term consequences on the growth of the child (Myers & Johns, 2018). Research points out that the children of the women with peri-partum depression have higher risk of future psychiatric disorders when compared with the children born to normal women (Brentani & Fink, 2016; Lefkovics et al., 2014; Liu et al., 2017; Madigan et al., 2018). Despite these consequences, less than 25% of women who have PPD receive treatment for it (Dennis & Chung-Lee, 2006; Huang et al., 2007). Lack of access to qualified mental health care is certainly one of the reasons for this (Kopelman et al., 2008).
Numerous studies identified help-seeking barriers among women at risk of psychological issues, namely lack of knowledge, practical barriers (e.g. financial difficulties and work), and attitudinal barriers (e.g. stigma) (Dennis & Chung-Lee, 2006; Fonseca et al., 2015; O’Mahen & Flynn, 2008).
Very few studies from India have explored qualitatively the experiences of using a technology-based intervention for perinatal depression among women and the advantages and barriers in their use in rural settings in India. We therefore set out to understand the experiences of the postpartum women using a mobile phone-based intervention, Interactive Voice Response System (IVRS), for the prevention and management of PND in a rural district of Bihar, India using qualitative research methodology.
Materials and methods
Study setting
The study was conducted in a sub-divisional headquarter of Samastipur, Bihar. Bihar is one of the underdeveloped states in India with low female literacy rate of 63.85% (General, 2011), a high maternal and neonatal mortality rate and a high total fertility rate. Hence it was enlisted in the not improved category by NITI Aayog (Kole, 2019). The current study was a part of a larger research project carried out in the same setting examining the impact of a mobile phone-based intervention, Interactive Voice Response System (IVRS), along with community level worker led intervention for the prevention and management of PND among women.
Under the IVRS intervention arm, we released seven episodes (audio dramas) on IVRS fortnightly for perinatal women in the study locality. The content was based on seven themes namely, Nutritional intake, ante-natal care practices, well-being through exercises and meditation, gender issues (family planning and domestic violence) and stress management. Women would receive a call wherein they would hear the short plays and would be able to connect with a lay counsellor on a hotline, if and when they wanted to discuss their mental health issues.
Study participants
Twelve women who were screened to be positive for PND and received the mobile phone-based intervention, IVRS, in the larger research project were approached for the interview. Nine of the twelve consented to participate and all the interviews were conducted in the homes of the women. Owing to our context, we chose to use in-depth interviews as it would allow women the freedom to express in their own way and pace. We also conducted a focused group discussion (FGD) with eight participants who were positive for PND and received IVRS intervention. This was done to triangulate the themes that emerged from the interviews and also identify any shared experiences that might have been missed in individual interviews. We conducted these FGDs in the common areas of the community and mobilised participants with the help of the Community Health Workers (CHWs) of the area. Consent was obtained from all the participants of the qualitative interviews. Hindi was the language that was used for communication with these women.
Data collection and analysis
Before the start of the qualitative data collection, interview guides pertaining to the research question were developed and circulated among the experts for their opinion. The interview guide was modified and finalised after incorporating the experts’ suggestions.
Authors (SJ, US and HK) conducted all interviews in Hindi or Maithili depending on participant preferences. Interviews were recorded through verbatim notes taken by three note takers during the interviews (notes included all words, hesitations and laughter). A thematic analysis of transcripts was conducted, using the inductive and deductive procedure outlined by Braun and Clarke (2013) in order to develop themes related to our research questions. In addition to developing themes to answer the research questions, we also developed themes outside this scope which may arise through the co-construction of meaning between participants and the analyst. The process of coding and building themes using a deductive approach was informed by literature on the research questions. An inductive and deductive approach to coding was applied to form initial codes, which underwent further refinement and additional coding until themes are developed. Two individuals (US and SJ) were engaged in the coding process and the building of theme.
Results
Socio-demographic profile of the participants
The participants interviewed were young with the average age being 23 years (youngest 18, oldest 30yrs), married for an average duration of 5 years with the marriage age ranging from 12 to 24 years. For a third of the participants, it was their first pregnancy while for the others it ranged from 2nd to 6th. Two-third of the women lived in joint families while the relatively older women (age 28 to 30) lived in nuclear families.
Access to phones
All the women had access to phones but the level of access varied. While some had their own phone, others could access their husbands or a family member’s phone during specific periods of time. There was no resistance from other family members to the woman using the phone. Though, there were instances where women could not access the phone throughout the day because there was only one phone in the household which the husband would carry to work. In most such cases the woman did not have a personal phone. The women would call to listen to the content late in the evening, once the husband was back’.
“I was able to access the phone barring times when my husband would take it to work,” said a woman during an FGD in the intervention area.
Useful
By and large, the women found the mobile phone-based intervention, both the IVRS content and the helpline useful. About a third of the women had accessed it within the preceding month. They reported that just listening to the IVRS content when they were upset or sad, had a soothing effect and helped them improve their mood. It helped them feel connected and less lonely. This was facilitated by the fact that the recorded information on the IVRS was in their local dialect and used colloquial terms that they could easily understand. They particularly enjoyed listening to an episode on stress management apart from an old folk song about health promotion which had been recently added into the IVRS. While only some of them had used the helpline those that did found the emotional support and advise/counselling provided helpful.
“I felt light-hearted due to the calls,” said Afsana (name changed) during an FGD in the intervention wing.
Community participation
About half of the women interviewed had connected to the IVRS and put it on speakerphone mode and had other family members also listen in. Two of the women had in fact gathered a group of women from the neighbourhood and have been conducting regular sessions wherein they all listen to the content from the IVRS. There were also several instances of the women sharing the IVRS number to other relatives who have accessed the service from different parts of the state and also country. The IVRS phone number had most frequently been shared by the woman when she went to visit her parents and she had shared it with other family members there such as her husband, sister, sister-in-law, etc. In fact, even some husbands dialled in to listen to the content and connected with the counsellor on the hotline too.
“We are three sisters-in-law’ that live next to each other. Every time I got a call, I would immediately put it on the speaker for the other two to listen.” Said Momina (name changed) in her interview.
“We loved listening to the content, I even got my neighbour to listen to it,” said a woman during FGD.
Cost
One of the constraints that they faced in accessing the service was the recent changes brought in by the telecom companies which mandated minimum amount recharge every month to keep their phone connections live. Most of the women revealed that there was some point of time within the last 3 months that their phone connection was not active due to non-payment to the service provider.
“I used to call 4-5 times a day and liked listening but on certain days I could not dial in though I wished to, as phone was away with husband.”
In the FGD, several women shared they could not dial-in to IVRS on certain days as the phone was with husband. With a hike (0.5$/month) in recharge tariff, these under-privileged women have slowly adapted themselves from using their own phone to sharing their husbands’ phone. They are so accustomed to the new practice that they do not consider complaining about the shift, they were slowly compelled to take about 6 months back. The FGD was held in the last phase of study, while the tariff hike by telecom companies and changes in mandate by regulatory authority were brought in when the IVRS was rolled out. The IVRS service was freely accessible but user should have minimum tariff of 0.5$/month, in their mobile handset to access the service.
Preference
All the women reported that they liked listening to content on the IVRS and would like to continue to receive the service. However, asked to choose between receiving telephone-based support versus face to face interaction with the counsellor the majority preferred face to face contact to phone-based contact.
“The phone content was great but I prefer sitting and talking my heart out to someone that I know.” said Kamala (name changed) during her interview.
Though, one client out of eight in an FGD preferred the phone service over home-based counselling as it took a considerable time out of her day. She felt socially bound to sit with her leaving aside her daily work, though others countered her saying that they could ask counsellor to visit again. She then shared that she was comfortable with phone counselling as she could do her work simultaneously. Few remembered and shared that phone-calling is limited to 5 pm only, while one reported that on occasions there are network issues due to which they cannot connect.
“I most definitely prefer the call, that way I can save a lot of time that would otherwise be gone sitting next to a counsellor,” said one of the women in an FGD in our intervention wing.”
Discussion
The aim of the study was to understand the experiences of the women with PND using a mobile phone-based intervention for the management of postpartum depression. The results indicate that most of the women interviewed found the service useful as it made them feel light hearted. The intervention has even mobilised the social capital in the communities with women coming together to hear the content in case of inaccessibility to others. They now consider it as a health issue and want to address their problems. Hence addition of IVRS has not only helped them recognise the issue but also paved the way for them to move beyond its stigmatisation. Technological innovations offer a unique opportunity to address limitations associated with traditional treatment such as access, suitability, expense, and stigma (Wolters et al., 2017).
Another important observation was that women in the catchment were observed using mental health vocabulary such as feeling burdened, anxious, helpless etc. proactively. The patients made sense of therapeutic strategies such as breathing, coping and relaxation. This eventually helped them feel light when they heard the content over the call. They even agreed to take up sessions for their peer group. Even studies suggest that the sharing of experiences among mothers helps to develop a tight-knit community, which promotes a sense of belongingness, improves one’s sense of self-worth, boosts parenting confidence, and prevents PND (Cohen et al., 2000; Holopainen, 2002; Shorey et al., 2019). This suggests that a support system involving sharing with another experienced mother who has undergone similar situations can potentially meet mothers’ needs in terms of empathy and having a non-judgemental listening ear (Shorey et al., 2019). Hence the women found a lasting peer-support in their communities due to the intervention.
Women in general preferred the home-based counselling owing to the rapport and connectedness women experienced during the sessions. Though, during FGDs, women did suggest coupling of the two interventions as they were satisfied with the content on the IVRS. Even research suggests that from a system delivery perspective, the use of this technology-enhanced intervention is designed to augment rather than replace existing one (Kobak et al., 2015). A major reason for them being attracted to the content was due to the language. Since the content was in thethi (a local dialect of the region) the women could relate to it. Even the hotline worked as an emergency number where women would dial in to seek general and mental health-related advice.
Looking at the evidence generated from the interviews, it appears to be clear that women in the community have not just accepted the intervention but also accepted the existence of mental Health issues. Hence, technology assisted in getting over some of the barriers such as stigma, access, suitability and costs. Studies in the past have accepted the ever-increasing integration of sophisticated electronic media into people’s lives as it seems to offer a good opportunity to use it for therapeutic purposes.
One of the major methodological limitations of the intervention was that it was a single site study. The IVRS catered only to the local population since it was made in that dialect. Another limitation was that women may have provided positive responses in the FGD to please the interviewer as they were familiar with the organisation. Though, everyone was trained and the regular staff was only involved till the time of introduction to avoid any biases while making assessments.
In conclusion, the user satisfaction with the technology was high for women. It has brought about change in an important direction of making mental health visible and acceptable in the rural hinterlands of Bihar.
Footnotes
Conflicts of interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Grand Challenges Exploration (GCE-USA) Round 21, Bill and Melinda Gates Foundation.
Ethical approval
Prior ethical approval was obtained before the start of the study from the Institutional Ethics Committee (IEC) of SCARF. Written informed consent was obtained from all the participants before recruiting into the study.
