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Xiao M, Huang S, Liu Y, Tang G, Hu Y, Fu B, Lei J. Stigma and its influencing factors for seeking professional psychological help among pregnant women: A cross-sectional study. Midwifery 2024; 132:103973. [PMID: 38442529 DOI: 10.1016/j.midw.2024.103973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Although the stigma associated with seeking professional psychological help has received significant attention, few studies have focused on the status and factors influencing this stigma among pregnant women, especially those with a Chinese cultural background. This study aimed to assess the status of stigma associated with seeking professional psychological help and its influencing factors. METHODS A total of 1325 pregnant women were recruited from Hunan Province, China. The Stigma for Seeking Professional Psychological Help questionnaire, Patient Health Questionnaire-9, Perceived Social Support Scale, Simplified Coping Style Questionnaire, and questionnaires on sociodemographic characteristics and pregnancy-related information were used. Descriptive, univariate, correlation, and multivariate linear regression analyses were used to investigate the status of stigma and identify its influencing factors. FINDINGS Pregnant Chinese women experienced a mild to moderate level of stigma associated with seeking professional psychological help, and self-stigma was more common than social stigma associated with seeking psychological help. The results of the multivariate analysis suggested that perceived social support, positive coping styles, negative coping styles, and depressive symptoms were the factors influencing self-stigma and social stigma associated with seeking professional psychological help. Advanced age and a low educational level were the only predictors associated with self-stigma, while a history of multiple pregnancies had an effect only on social stigma associated with seeking professional psychological help. CONCLUSION Chinese pregnant women experienced a mild to moderate level of stigma associated with seeking professional psychological help. Destigmatizing interventions focusing on self-stigma and social stigma should be designed according to maternal characteristics, social support, coping style, and depressive symptoms.
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Affiliation(s)
- Meili Xiao
- Department of Nursing, Hunan Normal University School of Medicine, 371 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China.
| | - Sasa Huang
- Nursing Department, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China; Xiang Ya Nursing School of Central South University, 172 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China
| | - Yongrong Liu
- Nursing Department, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China; Department of Obstetrics and Gynecology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China
| | - Guanxiu Tang
- Nursing Department, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China; Department of Obstetrics and Gynecology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China.
| | - Ying Hu
- Nursing Department, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China; Xiang Ya Nursing School of Central South University, 172 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China
| | - Bing Fu
- Nursing Department, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China; Department of Obstetrics and Gynecology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China
| | - Jun Lei
- Nursing Department, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China; Department of Obstetrics and Gynecology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China.
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Aston M, Price S, MacLeod A, Stone K, Benoit B, Joy P, Ollivier R, Sim M, Etowa J, Jack S, Marcellus L, Iduye D. Examining How Postpartum Videoconferencing Support Sessions Can Facilitate Connections between Parents: A Poststructural and Sociomaterial Analysis. NURSING REPORTS 2024; 14:99-114. [PMID: 38251187 PMCID: PMC10801463 DOI: 10.3390/nursrep14010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
Postpartum support for new parents can normalize experiences, increase confidence, and lead to positive health outcomes. While in-person gatherings may be the preferred choice, not all parents can or want to join parenting groups in person. Online asynchronous chat spaces for parents have increased over the past 10 years, especially during the COVID pandemic, when "online" became the norm. However, synchronous postpartum support groups have not been as accessible. The purpose of our study was to examine how parents experienced postpartum videoconferencing support sessions. Seven one-hour videoconferencing sessions were conducted with 4-8 parents in each group (n = 37). Nineteen parents from these groups then participated in semi-structured interviews. Feminist poststructuralism and sociomaterialism were used to guide the research process and analysis. Parents used their agency to actively think about and interact using visual (camera) and audio (microphone) technologies to navigate socially constructed online discourses. Although videoconferencing fostered supportive connections and parents felt less alone and more confident, the participants also expressed a lack of opportunities for individual conversations. Nurses should be aware of the emerging opportunities that connecting online may present. This study was not registered.
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Affiliation(s)
- Megan Aston
- Faculty of Health, School of Nursing, Dalhousie University, Halifax, NS B3H 4R2, Canada; (S.P.); (D.I.)
| | - Sheri Price
- Faculty of Health, School of Nursing, Dalhousie University, Halifax, NS B3H 4R2, Canada; (S.P.); (D.I.)
| | - Anna MacLeod
- Faculty of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Kathryn Stone
- Department of Human and Social Development, University of Victoria, Victoria, BC V8P 5C2, Canada;
| | - Britney Benoit
- Faculty of Science, Rankin School of Nursing, St. Francis Xavier University, Antigonish, NS B2G 2W5, Canada;
| | - Phillip Joy
- Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, NS B3M 2J6, Canada;
| | - Rachel Ollivier
- BC Women’s Hospital & Health Centre, Vancouver, BC V6H 3N1, Canada;
| | - Meaghan Sim
- Research, Innovation and Discovery, Nova Scotia Health, Halifax, NS B3J 0E8, Canada;
| | - Josephine Etowa
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON K1H 8M5, Canada;
| | - Susan Jack
- School of Nursing, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Lenora Marcellus
- Department of Human and Social Development, School of Nursing, University of Victoria, Victoria, BC V8P 5C2, Canada;
| | - Damilola Iduye
- Faculty of Health, School of Nursing, Dalhousie University, Halifax, NS B3H 4R2, Canada; (S.P.); (D.I.)
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Lapping-Carr L, Dennard A, Wisner KL, Tandon SD. Perinatal Depression Screening Among Sexual Minority Women. JAMA Psychiatry 2023; 80:1142-1149. [PMID: 37531104 PMCID: PMC10398540 DOI: 10.1001/jamapsychiatry.2023.2619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/31/2023] [Indexed: 08/03/2023]
Abstract
Importance A substantial number of births in the US are to sexual minority women (17% based on a nationally representative survey), yet there is little research on perinatal depression screening rates or symptom endorsement among sexual minority women (including women who identify as lesbian, bisexual, queer, pansexual, asexual, demisexual, and kinky as well as other-identified women who have sex with women). High rates of risk factors for perinatal depression (eg, intimate partner violence and history of mental illness) among sexual minority individuals magnify this gap in the literature. Objective To describe the prevalence of female-identified sexual minority people giving birth in an academic medical center and compare perinatal depression screening rates and scores among sexual minority women and heterosexual cisgender women. Design, Setting, and Participants This retrospective cohort study used deidentified medical record review of 18 243 female-identified individuals who gave birth at an academic medical center in Chicago, Illinois, between January 1 and December 31, 2019. Data were analyzed from April 5, 2021, to August 1, 2022. Main Outcomes and Measures Proportion of women identified as having sexual minority status in the medical record, rates of standard care administration of the 9-item Patient Health Questionnaire between sexual minority women and heterosexual women, and depression screening scores and rates of positive depression screening results for sexual minority and heterosexual women. Results Among 18 243 women (mean [SD] age, 33.8 [5.1] years; 10 453 [57.3%] of non-Hispanic White race and ethnicity), only 280 (1.5%; 95% CI, 1.3%-1.7%) were identified as having sexual minority status in the medical record. Significantly more sexual minority women vs heterosexual women attended at least 1 prenatal care visit (56 [20.0%] vs 2459 [13.7%]; P = .002) and at least 1 postpartum care visit (52 [18.6%] vs 2304 [12.8%]; P = .004). Sexual minority women were more likely to be screened for depression during postpartum care (odds ratio, 1.77; 95% CI, 1.22-2.52; P = .002) and more likely to screen positive for depression during the postpartum period (odds ratio, 2.38; 95% CI, 0.99-5.02; P = .03) than heterosexual women. Conclusions and Relevance In this cohort study, sexual minority women identified in the medical record were highly engaged in obstetric care yet at high risk of postpartum depression. In addition, their sexual orientation was largely undocumented in medical records. These results highlight the need for investigations that include strategies for measuring sexual orientation because medical record review is unlikely to reliably capture these sexual identities during the perinatal period.
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Affiliation(s)
- Leiszle Lapping-Carr
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ashley Dennard
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katherine L. Wisner
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - S. Darius Tandon
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
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4
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MacLeod A, Aston M, Price S, Stone K, Ollivier R, Benoit B, Sim M, Marcellus L, Jack S, Joy P, Gholampourch M, Iduye D. "There's an Etiquette to Zoom That's Not Really Present In-Person": A Qualitative Study Showing How the Mute Button Shapes Virtual Postpartum Support for New Parents. QUALITATIVE HEALTH RESEARCH 2023; 33:1005-1016. [PMID: 37554077 PMCID: PMC10494476 DOI: 10.1177/10497323231187541] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Virtual spaces that allow parents in the postpartum period to connect, support each other, and exchange information have been increasing in popularity. With the COVID-19 pandemic, many parents had to rely on virtual platforms as a primary means to connect with others and attend to their postpartum health. This study explored virtual postpartum support sessions through the web-based videoconferencing software, Zoom. Guided by feminist poststructuralism and sociomaterialism, we held seven virtual support sessions for parents caring for a baby 0-12 months in age, in Canada, and interviewed 19 participants about their experiences in the sessions. Our methodological approach allowed us to analyze discourses of (1) parenthood, (2) material realities of virtual environments, and (3) support and information on this virtual platform. The purpose of this research was to understand how technology influences postpartum support and learning through online videoconferencing for parents. Our findings document an overarching discourse of Zoom etiquette by which muting was a discursive practice that all participants used. The consistent use of the mute button while not talking structured conversation in virtual postpartum sessions and resulted in three themes: (1) minimizing disruptions; (2) taking turns; and (3) staying on task. The norm of using the mute button changed how parents received and gave support and information. Based on findings and broader literature, we discuss considerations for facilitation of virtual postpartum support sessions.
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Affiliation(s)
| | | | | | | | - Rachel Ollivier
- Dalhousie University, Halifax, NS, Canada
- Queen’s University, Kingston, ON, Canada
| | | | | | | | - Susan Jack
- McMaster University, Hamilton, ON, Canada
| | - Phillip Joy
- Mount Saint Vincent University, Halifax, NS, Canada
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Yao H, Yang J, Lo IPY. Lesbian couples’ childbearing experiences using assisted reproductive technology: A netnography study. Midwifery 2023; 121:103656. [PMID: 37019000 DOI: 10.1016/j.midw.2023.103656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/17/2023] [Accepted: 03/01/2023] [Indexed: 04/05/2023]
Abstract
OBJECTIVE This study aimed to explore how Chinese lesbian couples perceived having children through assisted reproductive technology (ART) and its impact on their experiences of family formation. DESIGN This study adopted netnography to investigate online forum data created by self-identified lesbian couples in relation to assisted reproduction. Summative content analysis was used to analyse data. FINDINGS Based on data analysis, A luan B huai, in which a lesbian conceives a child using her partner's egg, was seen as the best way to establish a family because it created a sense of symbolic connectedness with the child for both of them. Moreover, lesbian couples also indicated the crucial role that having children plays in maintaining family harmony, despite their opposition to heterosexual family traditions. With the stratification of reproductive tourism, certain groups of lesbians for instance, those with limited social and cultural capital- might be at a disadvantage in the global setting of reproductive tourism. CONCLUSIONS AND IMPLICATIONS Lesbian couples valued the benefits of ART in assisting them to achieve their childbearing goals and build a family. Healthcare providers should take the initiative to enhance fertility care by addressing the concerns and unique challenges faced by lesbian populations.
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Affiliation(s)
- Hong Yao
- School of Ethnology and Sociology, Minzu University of China, Beijing, China
| | - Jieyi Yang
- School of Ethnology and Sociology, Minzu University of China, Beijing, China
| | - Iris Po Yee Lo
- Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, China.
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6
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Salzmann-Erikson M, Eriksson H. A Mapping Review of Netnography in Nursing. QUALITATIVE HEALTH RESEARCH 2023:10497323231173794. [PMID: 37192601 PMCID: PMC10387728 DOI: 10.1177/10497323231173794] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
People use the Web to seek health-related information and to discuss health issues with peers. Netnography, a qualitative research methodology, has gained the attention of researchers interested in people's health and health issues. However, no previous reviews have accounted for how netnography is used in nursing research. The purpose of this mapping review was to generate a map of netnographic research in nursing. The search was conducted in PubMed, Academic Search Elite, the Cumulative Index to Nursing and Allied Health Literature, Medline, PsycINFO, Scopus, and Web of Science. Data were extracted from 53 original articles. The results show an increasing trend in published netnographies over time; 34% of the total sample was published in 2021. Of the total, 28% originated from Sweden, and 81% had used a covert approach. In studies in which the researchers used more participatory designs, the time spent on online forums ranged between 4 weeks and 20 months. Informed consent is found to be an issue in netnographic studies. We discuss the fact that nursing researchers have used netnography to address a wide range of research topics of concern and interest, from self-care support in an online forum for older adults to nursing students' perspectives on effective pedagogy. In line with the digital transformation in society in general, we discuss the fact that netnography as a research methodology offers great opportunities for nurse researchers to monitor new spaces and places that presuppose online methodological knowledge.
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Affiliation(s)
- Martin Salzmann-Erikson
- Faculty of Health and Occupational Studies, Department of Caring Sciences, University of Gävle, Gävle, Sweden
| | - Henrik Eriksson
- Department of Health Sciences, University West, Trollhättan, Sweden
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7
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Howat A, Masterson C, Darwin Z. Non-birthing mothers' experiences of perinatal anxiety and depression: Understanding the perspectives of the non-birthing mothers in female same-sex parented families. Midwifery 2023; 120:103650. [PMID: 36893549 DOI: 10.1016/j.midw.2023.103650] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/06/2023] [Accepted: 02/11/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Partners of birthing mothers can themselves experience perinatal mental health (PMH) difficulties. Despite birth rates increasing amongst LGBTQIA+ communities and the significant impact of PMH difficulties, this area is under-researched. This study aimed to examine the experiences of perinatal depression and anxiety of non-birthing mothers in female same-sex parented families. DESIGN Interpretative Phenomenological Analysis (IPA) was used to explore the experiences of non-birthing mothers who self-identified as having experienced perinatal anxiety and/or depression. SETTING AND PARTICIPANTS Sevenparticipants were recruited from online and local voluntary and support networks for LGBTQIA+ communities and for PMH. Interviews were in-person, online or via telephone. MEASUREMENTS AND FINDINGS Six themes were generated. Distress was characterised by feelings of "Failure and Inadequacy in Role" (i.e., parent, partner and individual) and "Powerlessness and Intolerable Uncertainty" in their parenting journey. These feelings were reciprocally influenced by perceptions of the "Legitimacy of (Di)stress as a Non-birthing Parent", which impacted help-seeking. Stressors that contributed to these experiences were: "Parenting Without" a parental role template, social recognition and safety, and parental connectedness; and "Changed Relationship Dynamics" with their partner. Finally,participants spoke about "Moving Forward" in their lives. KEY CONCLUSIONS Some findings are consistent with the literature on paternal mental health, including parents' emphasis on protecting their family and experiencing services as focusing on the birthing parent. Others appeared distinct or amplified for LGBTQIA+ parents, including the lack of a defined and socially recognised role; stigma concerning both mental health and homophobia; exclusion from heteronormative healthcare systems; and the importance placed on biological connectedness. IMPLICATIONS FOR PRACTICE Culturally competent care is needed to tackle minority stress and recognise diverse family forms.
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Affiliation(s)
- Alexandra Howat
- Leeds Institute of Health Sciences, School of Medicine, Worsley Building, Clarendon Way, University of Leeds, Leeds, LS2 9NL United Kingdom.
| | - Ciara Masterson
- Leeds Institute of Health Sciences, School of Medicine, Worsley Building, Clarendon Way, University of Leeds, Leeds, LS2 9NL United Kingdom
| | - Zoe Darwin
- School of Human and Health Sciences, Department of Allied Health Professions, Sport and Exercise, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH United Kingdom
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Kirubarajan A, Barker LC, Leung S, Ross LE, Zaheer J, Park B, Abramovich A, Yudin MH, Lam JSH. LGBTQ2S+ childbearing individuals and perinatal mental health: A systematic review. BJOG 2022; 129:1630-1643. [PMID: 35048502 DOI: 10.1111/1471-0528.17103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/29/2021] [Accepted: 01/06/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND The perinatal period may uniquely impact the mental health and wellbeing of lesbian, gay, bisexual, transgender, queer, and Two-Spirit (LGBTQ2S+) childbearing individuals. OBJECTIVES To characterise and synthesise the experiences of LGBTQ2S+ childbearing individuals regarding perinatal mental health, including symptomatology, access to care and care-seeking. SEARCH STRATEGY We conducted and reported a systematic review following PRISMA guidelines of eight databases (EMBASE, MEDLINE-OVID, CINAHL, Scopus, Web of Science: Core Collection, Sociological Abstracts, Social Work Abstract, and PsycINFO) from inception to 1 March 2021. SELECTION CRITERIA Original, peer-reviewed research related to LGBTQ2S+ mental health was eligible for inclusion if the study was specific to the perinatal period (defined as pregnancy planning, conception, pregnancy, childbirth, and first year postpartum; includes miscarriages, fertility treatments and surrogacy). DATA COLLECTION AND ANALYSIS Findings were synthesised qualitatively via meta-aggregation using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI), and the ConQual approach. MAIN RESULTS Our systematic search included 26 eligible studies encompassing 1199 LGBTQ2S+ childbearing participants. Using the JBI SUMARI approach, we reported 65 results, which we synthesised as six key findings. The studies described unique considerations for LGBTQ2S+ individuals' perinatal mental health, including heteronormativity, cisnormativity, isolation, exclusion from traditional pregnancy care, stigma, and distressing situations from the gendered nature of pregnancy. Many participants described a lack of knowledge from healthcare providers related to care for LGBTQ2S+ individuals. In addition, LGBTQ2S+ individuals described barriers to accessing mental healthcare and gaps in health systems. Strategies to improve care include provider education, avoidance of gendered language, documentation of correct pronouns, trauma-informed practices, cultural humility training and tailored care for LGBTQ2S+ people. CONCLUSIONS Pregnancy, postpartum, and the perinatal period uniquely impacts the mental health and wellbeing of LGBTQ2S+individuals, largely due to systems-level inequities and exclusion from perinatal care. Healthcare providers should implement the identified strategies to improve perinatal care and address inequities.
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Affiliation(s)
- Abirami Kirubarajan
- University of Toronto Faculty of Medicine, Toronto, ON, Canada.,University of Toronto Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada
| | - Lucy C Barker
- University of Toronto Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada.,University of Toronto Department of Psychiatry, Toronto, ON, Canada.,Department of Psychiatry, Women's College Hospital, Toronto, ON, Canada
| | - Shannon Leung
- University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Lori E Ross
- University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada
| | - Juveria Zaheer
- University of Toronto Department of Psychiatry, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto, ON, Canada
| | - Bomi Park
- University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Alex Abramovich
- University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto, ON, Canada
| | - Mark H Yudin
- University of Toronto Department of Obstetrics and Gynaecology, Toronto, ON, Canada.,Department of Obstetrics and Gynaecology, Unity Health, St Michael's Hospital, Toronto, ON, Canada
| | - June Sing Hong Lam
- University of Toronto Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada.,University of Toronto Department of Psychiatry, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
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9
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Domoney J, Trevillion K, Challacombe FL. Developing an intervention for paternal perinatal depression: An international Delphi study. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2020. [DOI: 10.1016/j.jadr.2020.100033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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10
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Moore D, Drey N, Ayers S. A meta-synthesis of women's experiences of online forums for maternal mental illness and stigma. Arch Womens Ment Health 2020; 23:507-515. [PMID: 31646392 DOI: 10.1007/s00737-019-01002-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 09/11/2019] [Indexed: 11/24/2022]
Abstract
Perinatal mental illness affects 15% of women; however, only half of these women access treatment. Some women with untreated perinatal mental illness may continue to suffer with mental illness after the perinatal period. Evidence suggests that one barrier to accessing treatment is stigma. Forums may provide an acceptable place for women to converse about the stigmatised symptoms of maternal mental illness. Reducing stigma may increase treatment uptake. This study aimed to review and synthesise the qualitative research on maternal mental illness forums and stigma so that stigma can be addressed and treatment improved. A meta-synthesis was conducted to describe and interpret qualitative studies regarding forum use and maternal mental illness stigma. A systematic search of seven electronic databases and Google Scholar was performed. Additional references were collected through screening references of the identified studies. Five studies were identified that reported women's experiences of online forums for maternal mental illness and stigma. The synthesis identified four key themes: (1) a safe place to talk; (2) virtual support; (3) stigma and identity; and (4) repair of the mother identity. Stigma maybe reduced by forum discourse that reconceptualises what is to be a "good mother" and separates stigma and maternal identity. This synthesis provides a novel and more detailed framework for the stigma of maternal mental illness and forum use. This suggests forums may enable women to explore their dual identity and repair their maternal identity, and this may reduce stigma. Healthcare providers could discuss forum use with their clients.
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Affiliation(s)
- D Moore
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK. .,The Open University, Walton Hall, Milton Keynes, UK.
| | - N Drey
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - S Ayers
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
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11
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Darwin Z, Domoney J, Iles J, Bristow F, Siew J, Sethna V. Assessing the Mental Health of Fathers, Other Co-parents, and Partners in the Perinatal Period: Mixed Methods Evidence Synthesis. Front Psychiatry 2020; 11:585479. [PMID: 33510656 PMCID: PMC7835428 DOI: 10.3389/fpsyt.2020.585479] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/21/2020] [Indexed: 01/17/2023] Open
Abstract
Introduction: Five to 10 percentage of fathers experience perinatal depression and 5-15% experience perinatal anxiety, with rates increasing when mothers are also experiencing perinatal mental health disorders. Perinatal mental illness in either parent contributes to adverse child and family outcomes. While there are increasing calls to assess the mental health of both parents, universal services (e.g., maternity) and specialist perinatal mental health services usually focus on the mother (i.e., the gestational parent). The aim of this review was to identify and synthesize evidence on the performance of mental health screening tools and the acceptability of mental health assessment, specifically in relation to fathers, other co-parents and partners in the perinatal period. Methods: A systematic search was conducted using electronic databases (MEDLINE, PsycINFO, Maternity, and Infant Care Database and CINAHL). Articles were eligible if they included expectant or new partners, regardless of the partner's gender or relationship status. Accuracy was determined by comparison of screening tool with diagnostic interview. Acceptability was predominantly assessed through parents' and health professionals' perspectives. Narrative synthesis was applied to all elements of the review, with thematic analysis applied to the acceptability studies. Results: Seven accuracy studies and 20 acceptability studies were included. The review identified that existing evidence focuses on resident fathers and assessing depression in universal settings. All accuracy studies assessed the Edinburgh Postnatal Depression Scale but with highly varied results. Evidence on acceptability in practice is limited to postnatal settings. Amongst both fathers and health professionals, views on assessment are mixed. Identified challenges were categorized at the individual-, practitioner- and service-level. These include: gendered perspectives on mental health; the potential to compromise support offered to mothers; practitioners' knowledge, skills, and confidence; service culture and remit; time pressures; opportunity for contact; and the need for tools, training, supervision and onward referral routes. Conclusion: There is a paucity of published evidence on assessing the mental health of fathers, co-mothers, step-parents and other partners in the perinatal period. Whilst practitioners need to be responsive to mental health needs, further research is needed with stakeholders in a range of practice settings, with attention to ethical and practical considerations, to inform the implementation of evidence-based assessment.
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Affiliation(s)
- Zoe Darwin
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, United Kingdom
| | - Jill Domoney
- Section of Women's Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Jane Iles
- Department of Psychology, University of Surrey, Surrey, United Kingdom
| | - Florence Bristow
- Community Perinatal Mental Health Service for Croydon, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Jasmine Siew
- Department of Experimental Clinical and Health Psychology, Research in Developmental Disorders Lab, Ghent University, Ghent, Belgium.,Department of Forensic and Neurodevelopmental Sciences, Sackler Institute for Translational Neurodevelopment, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Vaheshta Sethna
- Department of Forensic and Neurodevelopmental Sciences, Sackler Institute for Translational Neurodevelopment, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
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12
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Escobar-Viera C, Shensa A, Hamm M, Melcher EM, Rzewnicki DI, Egan JE, Sidani JE, Primack BA. "I Don't Feel Like the Odd One": Utilizing Content Analysis to Compare the Effects of Social Media Use on Well-Being Among Sexual Minority and Nonminority US Young Adults. Am J Health Promot 2019; 34:285-293. [PMID: 31698919 DOI: 10.1177/0890117119885517] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Although there is evidence of associations between social media (SM) use and mental well-being among the general population, these associations among lesbian, gay, and bisexual (LGB) persons are poorly understood. This study compared the influence of SM experiences on mental well-being between LGB and non-LGB persons. DESIGN AND SETTING Online cross-sectional survey. PARTICIPANTS National sample of 2408 US adults aged 18 to 30 years. METHOD We asked participants to provide examples of when SM affected their well-being separately in good and bad ways. We coded, summed, and used rate ratios (RRs) to compare responses of LGB and non-LGB individuals. Thematically similar codes were described and grouped into categories. RESULTS Most responses described positive SM effects. However, of 6 codes that were significantly more frequent among LGB respondents, only social capital (RR = 1.58, 95% confidence interval [CI], 1.17-2.12) described a positive effect. Five codes described negative effects of SM for LGB users: negative emotional contagion (RR = 1.28, 95% CI, 1.04-1.58), comparison with others (RR = 1.28, 95% CI, 1.01-1.62), real-life repercussions (RR = 1.86, 95% CI, 1.18-2.94), envy (RR = 2.49, 95% CI, 1.48-4.19), and need for profile management (RR = 2.32, 95% CI, 1.07-5.03). CONCLUSION These findings suggest that, for LGB persons, gaining social capital from SM is valuable for establishing and maintaining connections. Increased negative SM experiences may pose a risk for the mental well-being of LGB individuals.
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Affiliation(s)
| | - Ariel Shensa
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Megan Hamm
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - James E Egan
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jaime E Sidani
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian A Primack
- College of Education and health Professions, University of Arkansas Fayetteville, Fayetteville, AR, USA
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13
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Jones A. Help Seeking in the Perinatal Period: A Review of Barriers and Facilitators. SOCIAL WORK IN PUBLIC HEALTH 2019; 34:596-605. [PMID: 31242074 DOI: 10.1080/19371918.2019.1635947] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Perinatal depression affects approximately 10 to 20 percent of women during pregnancy or the first 12 months postpartum. Increased attention has been given to the prevalence of and screening for perinatal depression, yet little research addresses help seeking for this issue. The overall barriers and facilitators of help seeking among these women have yet to be addressed in a systematic way. A systematic literature review was conducted to identify studies that focused on help seeking among women with perinatal depression. Nineteen articles met the inclusion criteria discussed below and were included in this review. Barriers to help seeking for women with perinatal depression include social (e.g. stigma), structural (e.g. provider unavailable) and instrumental factors (e.g. cost). Facilitators of help seeking for women with perinatal depression were limited in scope. Recommendations for policy and the role of social workers are discussed.
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14
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Escobar-Viera CG, Whitfield DL, Wessel CB, Shensa A, Sidani JE, Brown AL, Chandler CJ, Hoffman BL, Marshal MP, Primack BA. For Better or for Worse? A Systematic Review of the Evidence on Social Media Use and Depression Among Lesbian, Gay, and Bisexual Minorities. JMIR Ment Health 2018; 5:e10496. [PMID: 30037786 PMCID: PMC6079300 DOI: 10.2196/10496] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/18/2018] [Accepted: 06/01/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Over 90% of adults in the United States have at least one social media account, and lesbian, gay, and bisexual (LGB) persons are more socially active on social media than heterosexuals. Rates of depression among LGB persons are between 1.5- and 2-fold higher than those among their heterosexual counterparts. Social media allows users to connect, interact, and express ideas, emotions, feelings, and thoughts. Thus, social media use might represent both a protective and a risk factor for depression among LGB persons. Studying the nature of the relationship between social media use and depression among LGB individuals is a necessary step to inform public health interventions for this population. OBJECTIVE The objective of this systematic review was to synthesize and critique the evidence on social media use and depression among LGB populations. METHODS We conducted a literature search for quantitative and qualitative studies published between January 2003 and June 2017 using 3 electronic databases. Articles were included if they were peer-reviewed, were in English, assessed social media use either quantitatively or qualitatively, measured depression, and focused on LGB populations. A minimum of two authors independently extracted data from each study using an a priori developed abstraction form. We assessed appropriate reporting of studies using the Strengthening the Reporting of Observational Studies in Epidemiology and the Consolidated Criteria for Reporting Qualitative Research for quantitative and qualitative studies, respectively. RESULTS We included 11 articles in the review; 9 studies were quantitative and cross-sectional and 2 were qualitative. Appropriate reporting of results varied greatly. Across quantitative studies, we found heterogeneity in how social media use was defined and measured. Cyberbullying was the most studied social media experience and was associated with depression and suicidality. Qualitative studies found that while social media provides a space to disclose minority experiences and share ways to cope and get support, constant surveillance of one's social media profile can become a stressor, potentially leading to depression. In most studies, sexual minority participants were identified inconsistently. CONCLUSIONS This review supports the need for research on the role of social media use on depression outcomes among LBG persons. Using social media may be both a protective and a risk factor for depression among LGB individuals. Support gained via social media may buffer the impact of geographic isolation and loneliness. Negative experiences such as cyberbullying and other patterns of use may be associated with depression. Future research would benefit from more consistent definitions of both social media use and study populations. Moreover, use of larger samples and accounting for patterns of use and individuals' experiences on social media may help better understand the factors that impact LGB mental health disparities.
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Affiliation(s)
- César G Escobar-Viera
- Center for Research on Media, Technology, and Health, School of Medicine, University of Pittburgh, Pittsburgh, PA, United States.,Center for LGBT Health Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Darren L Whitfield
- Center for LGBT Health Research, University of Pittsburgh, Pittsburgh, PA, United States.,School of Social Work, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Charles B Wessel
- Health Sciences Library, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ariel Shensa
- Center for Research on Media, Technology, and Health, School of Medicine, University of Pittburgh, Pittsburgh, PA, United States
| | - Jaime E Sidani
- Center for Research on Media, Technology, and Health, School of Medicine, University of Pittburgh, Pittsburgh, PA, United States
| | - Andre L Brown
- Center for LGBT Health Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Cristian J Chandler
- Center for LGBT Health Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Beth L Hoffman
- Center for Research on Media, Technology, and Health, School of Medicine, University of Pittburgh, Pittsburgh, PA, United States
| | - Michael P Marshal
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Brian A Primack
- Center for Research on Media, Technology, and Health, School of Medicine, University of Pittburgh, Pittsburgh, PA, United States
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15
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Moore D, Ayers S, Drey N. The City MISS: development of a scale to measure stigma of perinatal mental illness. J Reprod Infant Psychol 2018. [PMID: 29517314 DOI: 10.1080/02646838.2017.1313967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to develop and validate a scale to measure perceived stigma for perinatal mental illness in women. BACKGROUND Stigma is one of the most frequently cited barriers to seeking treatment and many women with perinatal mental illness fail to get the treatment they need. However, there is no psychometric scale that measures how women may experience the unique aspects of perinatal mental illness stigma. METHOD A draft scale of 30 items was developed from a literature review. Women with perinatal mental illness (n = 279) were recruited to complete the City Mental Illness Stigma Scale. Concurrent validity was measured using the Internalised Stigma of Mental Illness Scale. Factor analysis was used to create the final scale. RESULTS The final 15-item City Mental Illness Stigma Scale has a three-factor structure: perceived external stigma, internal stigma and disclosure stigma. The scale accounted for 54% of the variance and had good internal reliability and concurrent validity. CONCLUSION The City Mental Illness Stigma Scale appears to be a valid measure which provides a potentially useful tool for clinical practice and research in stigma and perinatal mental illness, including assessing the prevalence and characteristics of stigma. This research can be used to inform interventions to reduce or address the stigma experienced by some women with perinatal mental illness.
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Affiliation(s)
- Donna Moore
- a Centre for Maternal and Child Health, School of Health Sciences, City , University of London , London , UK
| | - Susan Ayers
- a Centre for Maternal and Child Health, School of Health Sciences, City , University of London , London , UK
| | - Nicholas Drey
- b School of Health Sciences, City , University of London , London , UK
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16
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Moore D, Drey N, Ayers S. Use of Online Forums for Perinatal Mental Illness, Stigma, and Disclosure: An Exploratory Model. JMIR Ment Health 2017; 4:e6. [PMID: 28219879 PMCID: PMC5339438 DOI: 10.2196/mental.5926] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/11/2016] [Accepted: 08/12/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Perinatal mental illness is a global health concern; however, many women with the illness do not get the treatment they need to recover. Interventions that reduce the stigma around perinatal mental illness have the potential to enable women to disclose their symptoms to health care providers and consequently access treatment. There are many online forums for perinatal mental illness and thousands of women use them. Preliminary research suggests that online forums may promote help-seeking behavior, potentially because they have a role in challenging stigma. This study draws from these findings and theoretical concepts to present a model of forum use, stigma, and disclosure. OBJECTIVE This study tested a model that measured the mediating role of stigma between online forum use and disclosure of affective symptoms to health care providers. METHODS A Web-based survey of 200 women who were pregnant or had a child younger than 5 years and considered themselves to be experiencing psychological distress was conducted. Women were recruited through social media and questions measured forum usage, perinatal mental illness stigma, disclosure to health care providers, depression and anxiety symptoms, barriers to disclosure, and demographic information. RESULTS There was a significant positive indirect effect of length of forum use on disclosure of symptoms through internal stigma, b=0.40, bias-corrected and accelerated (BCa) 95% CI 0.13-0.85. Long-term forum users reported higher levels of internal stigma, and higher internal stigma was associated with disclosure of symptoms to health care providers when controlling for symptoms of depression and anxiety. CONCLUSIONS Internal stigma mediates the relationship between length of forum use and disclosure to health care providers. Findings suggest that forums have the potential to enable women to recognize and reveal their internal stigma, which may in turn lead to greater disclosure of symptoms to health care providers. Clinicians could refer clients to trustworthy and moderated online forums that facilitate expression of perinatal mental illness stigma and promote disclosure to health care providers.
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Affiliation(s)
- Donna Moore
- Centre for Maternal and Child Health, School of Health Sciences, City, University of London, London, United Kingdom
| | - Nicholas Drey
- School of Health Sciences, City, University of London, London, United Kingdom
| | - Susan Ayers
- Centre for Maternal and Child Health, School of Health Sciences, City, University of London, London, United Kingdom
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17
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Everett BG, McCabe KF, Hughes TL. Unintended Pregnancy, Depression, and Hazardous Drinking in a Community-Based Sample of Sexual Minority Women. J Womens Health (Larchmt) 2016; 25:904-11. [PMID: 26977978 PMCID: PMC5311462 DOI: 10.1089/jwh.2015.5290] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
CONTEXT Unintended pregnancy is a stressful life event with important implications for women's health. Little research has examined sexual minority women's (SMW; lesbian, bisexual, mostly heterosexual) experiences of unintended pregnancy, and no studies have examined the relationship between unintended pregnancy, mental health, and negative coping behaviors in this population. METHODS We used the Chicago Health and Life Experiences of Women (CHLEW) Study (n = 454), a diverse sample of SMW, to examine the relationship between self-reported unintended pregnancy, depressive symptoms, and hazardous drinking. We used generalized linear model-building techniques and adjusted for key sociodemographic controls, as well as unintended pregnancy risk factors, including childhood physical and sexual abuse and age of sexual debut. RESULTS Twenty-four percent of the sample reported an unintended pregnancy. SMW who reported unintended pregnancies also reported significantly more depressive symptoms and greater risk of hazardous drinking. Adjusting for childhood abuse explained the relationship between unintended pregnancy and depressive symptoms, but not the relationship between unintended pregnancy and hazardous drinking. CONCLUSIONS Unintended pregnancy among SMW is an understudied topic. Our results suggest that unintended pregnancy is not uncommon among SMW and highlight the need for more research to investigate the mechanisms that link unintended pregnancy to depression and to hazardous drinking within this population.
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Affiliation(s)
| | - Katharine F. McCabe
- Department of Sociology, University of Illinois at Chicago, Chicago, Illinois
| | - Tonda L. Hughes
- Department of Health Systems Science, University of Illinois at Chicago, Chicago, Illinois
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18
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Wells MB, Lang SN. Supporting same-sex mothers in the Nordic child health field: a systematic literature review and meta-synthesis of the most gender equal countries. J Clin Nurs 2016; 25:3469-3483. [DOI: 10.1111/jocn.13340] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Michael B Wells
- Child and Adolescent Public Health Epidemiology Group; Department of Public Health Sciences; Karolinska Institutet; Stockholm Sweden
- Centre for Health Equity Studies (CHESS); Stockholm University/Karolinska Institute; Stockholm Sweden
| | - Sarah N Lang
- Department of Human Sciences; The Ohio State University; Columbus OH USA
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19
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Moore D, Ayers S. Virtual voices: social support and stigma in postnatal mental illness Internet forums. PSYCHOL HEALTH MED 2016; 22:546-551. [DOI: 10.1080/13548506.2016.1189580] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Moore D, Ayers S, Drey N. A Thematic Analysis of Stigma and Disclosure for Perinatal Depression on an Online Forum. JMIR Ment Health 2016; 3:e18. [PMID: 27197516 PMCID: PMC4909386 DOI: 10.2196/mental.5611] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Perinatal mental illness is a global health concern; however, many women do not get the treatment they need to recover. Some women choose not to seek professional help and get no treatment because they feel stigmatized. Online forums for various health conditions, including perinatal mental health, can be beneficial for members. Little is known about the role that online forums for perinatal mental illness play in reducing stigma and subsequent disclosure of symptoms to health care providers and treatment uptake. OBJECTIVE This study aimed to examine stigma and disclosure in forums and describe any potential disadvantages of forum use. METHODS An online forum for mothers was examined and 1546 messages extracted from 102 threads from the antenatal and postnatal depression section. These messages were subjected to deductive systematic thematic analysis to identify common themes regarding stigma and disclosure of symptoms and potential disadvantages of forum use. RESULTS Two major themes were identified: stigma and negative experiences of disclosure. Stigma had 3 subthemes: internal stigma, external stigma, and treatment stigma. Many women were concerned about feeling like a "bad" or "failed" mother and worried that if they disclosed their symptoms to a health care provider they would be stigmatized. Posts in response to this frequently encouraged women to disclose their symptoms to health care providers and accept professional treatment. Forum discourse reconstructed the ideology of motherhood as compatible with perinatal mental illness, especially if the woman sought help and adhered to treatment. Many women overcame stigma and replied that they had taken advice and disclosed to a health care provider and/or taken treatment. CONCLUSIONS Forum use may increase women's disclosure to health care providers by challenging their internal and external stigma and this may strengthen professional treatment uptake and adherence. However, a few posts described negative experiences when disclosing to health care providers.
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Affiliation(s)
- Donna Moore
- Centre for Maternal and Child Health, School of Health Sciences, City University London, London, United Kingdom.
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