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Article

To Guide or to Self-Guide?: Predictors of Preferring a Guided Introduction to Digital Resources That Promote Postpartum Mental Health

by
Ariana M. Albanese
1,*,
Betsy E. Smith
2,3,
Pamela A. Geller
4,
Joan R. Bloch
5,
Chris Sikes
6,
Anthony J. Kondracki
3 and
Jennifer L. Barkin
3
1
Department of Psychiatry & Human Behavior, The Warren Alpert Medical School, Brown University, Providence, RI 02912, USA
2
Department of Internal Medicine, Mercer University School of Medicine, Macon, GA 31207, USA
3
Department of Community Medicine, Mercer University School of Medicine, Macon, GA 31207, USA
4
Department of Psychological and Brain Sciences, Drexel University, Philadelphia, PA 19104, USA
5
College of Nursing and Health Professionals, Drexel University, Philadelphia, PA 19104, USA
6
Houston County Health Department, Georgia Department of Public Health, Warner Robins, GA 31088, USA
*
Author to whom correspondence should be addressed.
Psychiatry Int. 2023, 4(3), 208-219; https://doi.org/10.3390/psychiatryint4030021
Submission received: 10 April 2023 / Revised: 26 June 2023 / Accepted: 7 July 2023 / Published: 18 July 2023
Versions Notes

Abstract

:
The first postpartum year presents threats to the mental health of birthing parents and obstacles to accessing care. Digital mental health interventions (DMHIs) hold potential to increase postpartum mental healthcare access. However, DMHIs tend to promote limited engagement particularly when they are self-guided (when they do not involve contact with a provider). Yet, given that provider support is a limited resource, a balance must be struck between accessibility and intervention intensity (i.e., involving more human contact). Towards achieving this balance, this analysis seeks to identify characteristics that are associated with a reported preference for a human-guided introduction to digital resources aimed at promoting postpartum mental health. In a sample of largely White, non-Latinx, employed, married, and graduate school-educated individuals, multivariate logistic regression revealed that age (p = 0.0095), level of postpartum functioning (p = 0.0057), depression symptoms (p = 0.0099), and anxiety symptoms (p = 0.03) were associated with guide preference. Specifically, more anxious or lower-postpartum-functioning individuals were more likely to report preferring a guide while older or more depressed individuals were less likely to report preferring a guide. These findings can inform clinical recommendations surrounding who is most likely to engage with, and thus benefit from, exclusively self-guided DMHIs during the postpartum period.

1. Introduction

The year following childbirth is a time in which great psychosocial and physical transitions take place for birth parents, and these individuals are vulnerable to health issues caused directly by childbirth and indirectly by neglected self-care [1]. Notably, the term “birthing parent” is used (as opposed to “mother”) to refer to individuals who have given birth and are raising their infants [2]. This is intended to promote the inclusion of individuals who do not identify as women [3]. Regarding mental health specifically, the postpartum period is a time of increased risk for mood and anxiety disorders, with a period prevalence rate of 21.9% for depression [4] and a rate of 17.1% for anxiety disorders [5]. The COVID-19 pandemic further exacerbated birthing parents’ mental health vulnerability by increasing rates of worry, distress, and depression [6,7,8,9]. Making matters worse, birthing parents face unique obstacles to healthcare utilization including neglected self-care needs (which can reduce engagement in health-promoting behaviors as well as healthcare utilization) [1], parents feeling too busy to balance the needs of their new baby with pre-existing responsibilities [10,11], discomfort with disclosing feelings and seeking help [12,13], stigma surrounding postpartum mental health struggles [14], and difficulty addressing mental health within maternal–child healthcare settings [15]. Concerningly, only 15.8% of birthing parents with postpartum depression receive treatment [16].
Digital mental health interventions (DMHIs) which deliver mental health support via the Internet or mobile health, “mHealth”, applications show promise in overcoming these obstacles and increasing mental healthcare access for postpartum individuals [17]. Specifically, DMHIs can offer convenience and schedule flexibility as they do not require face-to-face session attendance and, for self-guided interventions, can be completed at an individuals’ own pace. Additionally, they can offer anonymity which can serve to combat stigma. A systematic review of studies on reproductive, maternal, newborn, and child health-related mHealth interventions found 16 studies focused on delivery and the postpartum and noted that the number of studies in this area is increasing [18]. There is also evidence to suggest that self-guided online intervention can effectively improve outcomes for postpartum individuals [19].
However, a key concern regarding the use of DMHI with perinatal patients is the risk of dropout and other threats to engagement which can reduce intervention effects [20]. Work in the general (non-perinatal) population has revealed a suboptimal uptake and poor adherence to online interventions [21]. In particular, unguided interventions have been found to have the highest attrition rates [22]. Correspondingly, it has been suggested that adherence and engagement with DMHIs could be improved through the provision of human support such as therapist interaction (regular coaching, and telephone calls) or even administrative support (reminders) [17]. However, given the limited human support resources and the current shortage of mental health providers [23], there is a balance to be struck between accessibility and intervention intensity (i.e., the level of human contact integrated into the intervention).
One way to work towards achieving this balance is to better understand individual factors that contribute to engagement in minimal-contact practice interventions, such as self-guided DMHIs to promote postpartum mental health. Indeed, investigators focused on other minimal contact interventions such as mindfulness home practice have called for a better understanding of individual factors impacting engagement [24]. This analysis therefore sought to identify participant characteristics (e.g., demographics, and level of mental health symptomatology) associated with a preferring human-guided introduction to digital resources that promote postpartum mental health. This work could inform future clinical recommendations surrounding who is most likely to prefer, and thus benefit from, a self-guided intervention aimed at promoting postpartum mental health versus those who would be better served by a higher-intensity intervention involving more built-in human contact.

2. Materials and Methods

Data for this analysis were collected as part of a study examining the feasibility, acceptability, and pilot efficacy of The Postpartum Toolkit, a digital clinical tool providing resources to enhance postpartum functioning and emotional well-being. A detailed description of the study methods, including participant recruitment enrollment and flow, as well as the reported utilization of toolkit resources, is available in previously published work [25], and an overview of the study methods is presented here.
This study used an online survey disseminated through a secure platform for data collection. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Drexel University Institutional Review Board (IRB; protocol number: 2011008200; date of approval: 13 January 2021). All subjects provided consent to participate in the study.

2.1. The Postpartum Toolkit

The Postpartum Toolkit provides personalized online resources to users based upon each user’s pattern of responses on The Postpartum Toolkit Checklist. The checklist presents 24 items which represent factors that influence birth parent functioning as identified in previous qualitative work [26]. For each item, users are asked to select the degree to which an item is a strength for them. The options for responses are “This is a strength for me”, “This is going ok for me, but could be better” or “I would like help with this”. Resources which corresponded to items not reported to be a strength (meaning the participant chose “this could be going better for me” or “I would like help with this”) would appear in the individualized feedback that automatically appeared once the checklist was completed. These resources consisted of a mix of information presented in the form of text and links to empirically supported educational content (e.g., websites, videos). Care was taken to include materials that were not geographically restricted (usually online resources), were low- or no-cost, and attended to the diversity of the subject population. In their individualized feedback, each participant’s most needed resources appeared first, meaning that resources corresponding to checklist items on which the participant responded “I would like help with this” appeared before those which were mapped to items on which the participant responded “This is going ok for me, but could be better.”
To develop the toolkit, previously uncovered factors impacting postpartum functioning [26] were first transformed into checklist items. The resources that were mapped to each item were then collected by the first author, with assistance from two research assistants. The toolkit was then reviewed by a multidisciplinary group of experts in perinatal and family health. These individuals provided feedback on user experience and theoretical completeness which was integrated into the toolkit. It was then considered finalized for testing.

2.2. Participants

To be considered eligible, a participant had to (a) have given birth in the past 10 months, (b) currently live in the United States, (c) be able to access the Internet, (d) be aged 18 or older, (e) and understand written English. Participants were ineligible if they were not living with their infant or infants. Of note, 10 months was chosen as the maximum time since birth as one of our main outcomes of interest was postpartum functioning as indexed by the Barkin Index of Maternal Functioning. This questionnaire measures functioning during the first 12 months postpartum. Thus, recruiting individuals who were within 10 months postpartum at baseline would allow for the completion of the study within the 12-month postpartum window. Participants were recruited online between February and April 2021 via online postings within support communities and social networking platforms. Specifically, a member of the team (AA) reached out to individuals within her network who professionally work with new parents or who are themselves new parents and asked them to share a virtual flyer about the study within their online communities. This resulted in postings of the flyer in venues such as personal Facebook profiles, personal Twitter pages, and within “new parent” support groups on Facebook. Other online communities (such as Instagram accounts focused on topics such as lactation and Black motherhood) were also contacted about posting the flyer though few responses were received via this form of outreach. These other accounts were discovered through an Internet search. Participants were compensated with a $20 gift card for their participation in the study. This resulted in a sample of 124 participants. As mentioned, full information on participant enrollment and flow has been published elsewhere [25].

2.3. Data Collection and Procedure

After interested individuals reached out to the study team and were confirmed to meet the inclusion criteria, participants were sent their baseline survey via email or text (depending on participant preference). This survey featured The Postpartum Toolkit Checklist (which determined the resources presented to participants, as discussed in Section 2.1) and a brief set of questionnaires inquiring about the participant’s background and providing an assessment of postpartum functioning, perceived stress, and symptoms of anxiety and depression. Each measure is briefly discussed below in Section 2.3.1, Section 2.3.2, Section 2.3.3 and Section 2.3.4.
Upon completion of the baseline survey, an individualized feedback form featuring resources appeared on the screen of the participant’s device. For the participant’s reference, a PDF version of this feedback form was also sent via email within 24 hours of completion. Midway through the study (three weeks after baseline), a two-item survey was sent to participants asking whether any resources had been used and for a 1–10 rating of the helpfulness of resources if use was endorsed. A final follow-up survey was sent six weeks after baseline which included the same measures of postpartum functioning, perceived stress, and symptoms of anxiety and depression as well as a feasibility and acceptability questionnaire created for the study. The feasibility and acceptability questionnaire included a series of eleven questions, one of which was “Would you have been more likely to use these resources if you had a person introducing them to you rather than looking into things yourself?” (answered with a dichotomous yes or no response). While the pilot study of The Postpartum Toolkit sought to examine whether an intervention without human contact could confer benefit, the study team was still interested in assessing participant preference for human contact.

2.3.1. Participant Background

Information was collected regarding participants’ socio-demographic information (i.e., age, infant age, race, ethnicity, education, employment status, and marital status) as well as reproductive and psychiatric history (i.e., number of children, NICU hospitalization, medical conditions complicating pregnancy, and previous psychiatric diagnosis). These elements of the participants’ background were selected for data collection following a focused discussion among study team members who have expertise in perinatal health (AA, PG, JRB, and JLB). Efforts were made to capture key information while also minimizing participant burden.

2.3.2. Postpartum Functioning

The Barkin Index of Maternal Functioning (BIMF) measures an individual’s ability to perform the activities and roles required to maintain well-being during the first postpartum year [27]. This 20-item measure features a series of statements which cover seven functional areas of new parenthood and participants must rate their level of agreement with each statement. Higher scores on the measure indicate higher functioning. This measure has demonstrated good psychometric properties such as those demonstrated by Barkin and colleagues in which the BIMF had an internal consistency of 0.87 and convergent validity with a measure of mental functioning (r = 0.39, p < 0.0001) [27]. In this sample, the BIMF measure also demonstrated acceptable internal consistency with a Cronbach’s alpha value of 0.81.

2.3.3. Perceived Stress

The Perceived Stress Scale (PSS-10) [28] inquires about the degree to which participants feel their life is uncontrollable, unpredictable and stressful. A higher score indicates more perceived stress. The 10-item scale has been validated in a number of studies, such as Roberti and colleagues’ work which found the measure to have an internal consistency of 0.89 and to correlate significantly (r = 0.73, p < 0.0001) with the State Trait Anxiety Inventory total score [29]. It has also been utilized in postpartum populations [30]. In this sample, this measure demonstrated acceptable internal consistency with a Cronbach’s alpha value of 0.88.

2.3.4. Symptoms of Anxiety and Depression

The Hospital Anxiety and Depression Scale (HADS) is used to identify symptoms of anxiety and depression and produces two subscale scores (HADS-depression, HADS-D, and HADS-anxiety, HADS-A). Higher scores on either subscale indicate more severe symptoms [31], and a score of 8 or higher on either subscale is considered elevated. In this sample, this measure demonstrated acceptable internal consistency with a Cronbach’s alpha value of 0.83 for HADS-A and 0.74 for HADS-D.

2.4. Statistical Analyses

Categorical variables were reported as frequencies (with percentages). Continuous measures were reported as means (with standard deviations) or medians (with interquartile ranges). For bivariate analyses, characteristics between participants who preferred having a guide to introduce toolkit resources and participants who did not prefer having a guide were analyzed with the chi-square test or Fisher’s exact test for categorical variables and the independent t-test or Mann–Whitney U test for continuous variables. All variables were assessed for normality. The independent t-test was used for normally distributed variables (BIMF and PSS-10) as indicated by the reporting of the mean and standard deviation in Table 1. The Mann–Whitney U test was used for non-normally distributed variables (number of children, HADS-A, and HADS-D) as indicated by the reporting of the median and IQR in Table 1. All tests performed for bivariate analyses were two-sided.
The association between guide preference and participant characteristics was assessed with univariate and multivariate logistic regression. All variables assessed (see Table 1 for full list) except for marriage status were included in the multivariate model regardless of statistical significance from bivariate analyses and univariate logistic regression. This was to account for factors that could be confounders and factors that could have the direction of significance changed in multivariate analyses due to confounding factors. Marriage status was not included in the model due to the majority of participants being married and therefore causing unstable results when comparing the odds of guide preference between married and not married. Several variables were condensed into fewer categories to have stable results when comparing odds of guide preference (due to small cell sizes). Importantly, age was condensed into 18–35 and 35 and older as there were very few participants aged 18–25 or 46 and older [26]. Additionally, 35 is a meaningful demarcation as it constitutes the cut-off for “advanced maternal age” [32]. Anything not reported or left blank was set to missing and therefore not part of the analyses. Backwards elimination was used to obtain a final model that best describes factors independently associated with guide preference. Unadjusted and adjusted odds ratios and 95% confidence intervals were generated and reported.
For both bivariate and multivariate analyses, statistical significance was determined with p ≤ 0.05, and SAS version 9.4 was used (SAS Institute, Cary, NC, USA).

3. Results

3.1. Participant Characteristics

Overall participants’ sociodemographic, reproductive, psychiatric, functioning, and well-being characteristics are included as totals in Table 1 and have been reported previously [25]. The majority were White, non-Hispanic or Latinx, reported access to support for infant care, were employed, possessed a graduate degree, had an estimated annual income above USD 75,000, and were between the ages of 18 and 35 [25]. Additionally, the majority were within their first six months postpartum at baseline, had a median number of one child, did not have a medical condition complicating pregnancy, did not experience NICU hospitalization, did not report a psychiatric history, reported ideal functioning as captured by the BIMF, reported subclinical levels of depressive and anxious symptoms as captured by the HADS, and reported higher perceived stress compared to the population norm as captured by the PSS-10 [25].

3.2. Bivariate Analyses

Of the 124 participants, 58% preferred a guide for using the postpartum toolkit while 42% did not prefer a guide (Table 1). When comparing guide preference, participants did not significantly differ for most sociodemographic characteristics including race, level of education, annual household income, number of children and psychiatric history. However, participant age (p = 0.043), baseline BIMF score (p = 0.05) and baseline HADS-A score (p = 0.018) differed significantly for those reporting a preference for a guided introduction to resources compared to those who did not (see Table 1). A greater percentage of women aged 18–35 reported preferring a guide to resources while a greater percentage of women aged 35 or older preferred a self-guided introduction to resources. Participants who preferred a guide also had a lower postpartum functioning score than those who did not prefer a guide, and participants who preferred a guide had a higher anxiety score compared to participants who did not prefer a guide.

3.3. Univariate and Multivariate Analyses

Age, baseline BIMF, and baseline HADS-A were significantly associated with guide preference in both the univariate and multivariate analyses (Table 2). Baseline HADS-D was not significantly associated with guide preference in the univariate analyses but became significant when adjusting for age, BIMF, and HADS-A (Table 2). Specifically, the adjusted odds of preferring a guide for participants aged 35 or older was 71% lower (95% CI [0.11, 0.74]) for participants aged 35 or older compared to participants 18–35 years old while holding BIMF, HADS-A, and HADS-D constant. Additionally, the adjusted odds of preferring a guide decreased by 6% (95% CI [0.90, 0.98]) for each unit increase in BIMF score; the adjusted odds of preferring a guide increased by 15% (95% CI [1.02, 1.30]) for each unit increase in HADS-A; and the adjusted odds of preferring a guide decreased by 21% (95% CI [0.66, 0.95]) for each unit increase in HADS-D while adjusting for the other variables in the model (Table 2). Thus, individuals who were older than 35 and more depressed were less likely to prefer a guide to the resources, and individuals who were more anxious and lower in postpartum functioning were more likely to prefer a guide.

4. Discussion

Recent years have seen an increase in DMHIs for managing perinatal mental health, but the effectiveness of these interventions is threatened by issues with engagement, particularly when the intervention is self-guided. To better achieve a balance of accessibility with intervention intensity (i.e., integrating more human contact into the intervention) in a climate with a dearth of mental health providers, this analysis sought to identify participant characteristics that are associated with a reported preference for a human-guided introduction to digital resources that promote postpartum mental health. This preference was captured by individuals responding “yes” to the question “Would you have been more likely to use these resources if you have a person introducing them to you rather than looking into things yourself?” in a study assessing the acceptability, feasibility, and pilot efficacy of The Postpartum Toolkit, a digital clinical tool providing resources to enhance postpartum functioning and emotional well-being. This analysis can thus help identify individuals who are most likely to benefit from an exclusively self-guided postpartum DMHI allowing for a better match of the individual with an intervention format. Multivariate logistic regression revealed that older birthing parents and birthing parents experiencing more depressive symptoms were less likely to report that a guide would have increased engagement with digital resources, while more anxious and lower postpartum functioning birthing parents were more likely to report that a guide would have increased their engagement.

4.1. Guide Preference and Participant Age

There is evidence to suggest that individuals that give birth at an older age experience easier adjustment to new parenthood and thus may only require a self-guided level of intensity for postpartum DMHI. A literature review focused on older birthing parent age and child outcomes found that the positive factors associated with older parenthood (educational, economic, and psychologic) may facilitate positive psychologic adjustment for these parents [33]. In addition to the lower risk of parental adjustment problems [34], older birthing parents demonstrated more psychological maturity and sensitive interactive behavior [35], more nurturing child rearing, a lowered risk of child exposure to abuse and physical punishment, and a lowered risk of family instability [34].
There is also evidence to suggest that older individuals may be more open and less skeptical of DMHIs and thus may be more likely to engage in the absence of a guide. A recent systematic review of barriers and facilitators to using DMHIs found that individuals between the ages of 30 and 50 demonstrated higher engagement compared to other age groups [36]. Another study assessing attitudes towards Internet interventions among individuals with mild-to-moderate depression symptoms also found that older age was associated with reduced ‘Skepticism and Perception of Risk’ as well as lower ‘Technologization Threat’ on the Attitudes Towards Psychological Online Interventions Questionnaire [37].

4.2. Guide Preference and Participant Level of Postpartum Functioning, Anxiety Symptoms, and Depression Symptoms

It is not surprising that more anxious and lower-functioning participants were more likely to report that a human-guided introduction to resources would have increased engagement. In general, individuals with more severe mental health symptoms tend to experience more difficulty engaging with DMHIs [36]. Additionally, high rates of attrition have specifically been identified in self-guided online programs targeting anxiety disorders compared to therapist-assisted online treatment [38]. It also stands to reason that individuals who have lower postpartum functioning (experiencing more difficulty performing the activities and roles required to maintain well-being) would engage more with resources when they have the support and accountability of a guide. For these individuals, it may be particularly difficult to find the time and energy to engage with resources on their own.
It is interesting that the opposite finding was true for depression, namely that individuals who were more depressed were less likely to report that a guide would have increased engagement. It is possible that this finding captures the fact that depressive symptoms inhibit one’s motivation to interact with an online intervention [36]. Perhaps, participants therefore felt that a guide would not have effectively reduced their amotivation and thereby increased engagement. It is also possible that, for individuals with depression at a mild to moderate level who were recruited in a nonclinical context, such as those in the sample, the anonymity provided by a self-guided intervention may be particularly valuable. Another study, conducted at a similar level of severity, found that non-clinically recruited individuals perceived a higher benefit of anonymity in DMHIs compared to clinically recruited individuals [37].
Anonymity may be particularly valued by individuals experiencing postpartum depressive symptoms given feared repercussions of disclosing their depression. One of these fears is that such a report will be met with judgment. Indeed, a systematic qualitative meta-aggregation review of postpartum health-seeking behavior found that fear of being judged for reporting symptoms of depression prevented individuals from seeking help [39]. This fear of judgement can also extend to fears surrounding the impact of reporting these symptoms on the perceptions of parenting ability, such as worries that such a report could threaten child custody [14,39]. These fears are particularly notable for depression symptoms as these symptoms may be more readily associated with traits that are not considered desirable in birth parents or may even be considered dangerous (e.g., “laziness” or neglect), as supported by the reported finding that birthing parents associate a diagnosis of postpartum depression with being a “bad mother” [14]. Anxiety symptoms on the other hand may be more aligned with societal expectations of birth parents (e.g., being vigilant). Therefore, fear of judgment may be more pronounced with depression symptoms and thus anonymity is more valued. Exclusively self-guided interventions preserve anonymity and thus allow access to mental health support without risking judgment or other associated repercussions.

4.3. Limitations

While this study possesses several strengths including questionnaires with high reliability and validity as well as seeking to address an area with little prior work, there are several limitations to this study which are worthy of mentioning. First, this study did not collect any objective measures of DMHI engagement. Rather, conclusions about the impact of participant characteristics on engagement with DMHIs (specifically The Postpartum Toolkit in this case) are based on participant reports of whether they believed a guide would have increased engagement with the intervention. Participant opinions about whether a guide would have improved engagement may or may not have aligned with objective indices of engagement with the intervention. Future work should involve objective indices of engagement to better clarify the relationship between participant factors and engagement with interventions of varying intensities (i.e., guided versus self-guided). Second, given the cross-sectional nature of this study, conclusions related to causality are limited. Third, there is always risk of misreporting given that the data collected were completed in a self-report format. Fourth, age was collected as a categorical variable (age ranges) in the sample which limited the analyses that could be conducted. Fifth, as discussed in prior published work presenting The Postpartum Toolkit [25], although the Toolkit includes digital resources that are of no or low cost and are inclusive of diverse postpartum populations, the study sample was rather homogeneous and included participants of a more privileged background potentially limiting the generalizability of findings. This may have been the result of our recruitment process, as the majority of recruitment postings for the study were made by individuals with whom the research team had a personal relationship. Though other organizations who interface with a wider, and potentially more diverse, audience were approached about publicizing the study, limited responses were received. Future work should seek to replicate findings in a more diverse sample. Relatedly, it is also important to note that, per the Centers for Disease Control, in 2021 19.9% of births were by birthing parents aged 35 and older [40]. This suggests that we may be overrepresenting individuals aged 35 and older which may further threaten the generalizability of our sample. Lastly, as the vast majority of the participants were married, our results may not be generalizable to non-married parents.

5. Conclusions and Future Directions

In conclusion, the postpartum period is rife with threats to birthing parent mental health, and postpartum patients are a uniquely difficult population to reach. While DMHIs have shown promise to increase the accessibility of mental healthcare access for this population, difficulties with engagement hamper DMHI effectiveness especially when interventions are self-guided. This analysis sought to identify factors which are associated with a reported preference for a human-guided introduction to digital resources for postpartum mental health. Multivariate logistic regression revealed that older birthing parents and birthing parents experiencing more depressive symptoms were less likely to report that a guide would have increased engagement with digital resources, while more anxious, younger (below age 35), and lower-postpartum-functioning birthing parents were more likely to report that a guide would have increased their engagement. This analysis helps to identify individuals who are more likely to engage with DMHIs when assisted by a guide—particularly birth parents below the age of 35 as well as those with greater anxiety and lower postpartum functioning. With further replication, these findings can inform future clinical recommendations surrounding postpartum mental health interventions to ensure that intervention formats are selected to best match participant need. Specifically, these preliminary findings suggest that individuals who are experiencing higher anxiety or who are younger than 35 could benefit from being recommended online or mHealth self-guided resources, while younger individuals or those experiencing depression may be better served by being connected to more formal treatment that involves provider contact.

Author Contributions

Conceptualization, A.M.A., B.E.S., P.A.G., J.R.B., C.S., A.J.K. and J.L.B.; methodology, A.M.A., B.E.S., P.A.G. and J.L.B.; software, B.E.S.; validation, A.M.A., B.E.S. and J.L.B.; formal analysis, B.E.S.; investigation, A.M.A.; resources, A.M.A., B.E.S. and J.L.B.; data curation, A.M.A. and B.E.S.; writing—original draft preparation, A.M.A.; writing—review and editing, A.M.A., B.E.S., P.A.G., J.R.B., C.S., A.J.K. and J.L.B.; visualization, B.E.S.; supervision, P.A.G., B.E.S. and J.L.B.; project administration, A.M.A.; funding acquisition, J.L.B. All authors have read and agreed to the published version of the manuscript.

Funding

Funding for participant compensation was provided by the Georgia Department of Public Health, North Central Health District, Maternal Child Health Academic Health Department, Women’s Health Research Fund.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Drexel University (protocol number: 2011008200; date of approval: 13 January 2021).

Informed Consent Statement

All participants provided consent to participate in the study.

Data Availability Statement

The data are available upon request from the corresponding author.

Conflicts of Interest

The authors have no conflict of interest to declare.

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Table
Table 1. Bivariate analyses to assess the association between participant characteristics and guide preference for engaging with The Postpartum Toolkit (N = 124).
Table 1. Bivariate analyses to assess the association between participant characteristics and guide preference for engaging with The Postpartum Toolkit (N = 124).
“Would You Have Been More Likely to Use These Resources If You Had a Person Introducing Them to You Rather Than Looking into Things Yourself?”
Total
(N = 124)		Participant Response: Yes
(n = 72, 58%)		Participant Response: No
(n = 52, 42%)		p-Value a
Participant Age, years 0.043
18–3589 (71.8)57 (79.2)32 (61.5)
35 or older35 (28.2)15 (20.8)20 (38.5)
Youngest Infant’s Age, months 0.97
0–332 (25.8)18 (25.0)14 (26.9)
3–641 (33.1)25 (34.7)16 (30.8)
6–928 (22.6)16 (22.2)12 (23.1)
9–1223 (18.5)13 (18.1)10 (19.2)
Race 0.61
White101 (84.9)59 (83.1)42 (87.5)
Non-White18 (15.1)12 (16.9)6 (12.5)
Ethnicity 0.52
Hispanic10 (8.1)7 (9.7)3 (5.8)
Non-Hispanic or Latinx114 (91.9)65 (90.3)49 (94.2)
Education 0.28
High School, GED, or Less5 (4.0)4 (5.6)1 (1.9)
Associates, Some College,48 (38.7)31 (43.1)17 (32.7)
College Degree
Graduate Degree71 (57.3)37 (51.4)34 (65.4)
Employment Status 0.49
Employed101 (81.5)57 (79.2)44 (84.6)
Not Employed23 (18.5)15 (20.8)8 (15.4)
Annual Household Income 0.61
Less than USD 75,00026 (21.0)14 (19.4)12 (23.1)
USD 75,000– USD 124,99936 (29.0)24 (33.3)12 (23.1)
USD 125,000– USD 174,99922 (17.7)13 (18.1)9 (17.3)
USD 175,000 or more40 (32.3)21 (29.2)19 (36.5)
Marital Status 0.14
Married116 (93.5)65 (90.3)51 (98.1)
Single/Partnered8 (6.5)7 (9.7)1 (1.9)
Number of Children 0.47 b
Median (IQR)1.0 (1.0, 2.0)1.0 (1.0, 2.0)1.0 (1.0, 2.0)
Childcare Support 0.52
Yes114 (91.9)65 (90.3)49 (94.2)
No10 (8.1)7 (9.7)3 (5.8)
Have a Medical Condition 1.00
Complicating Pregnancy
Yes50 (40.3)29 (40.3)21 (40.4)
No74 (59.7)43 (59.7)31 (59.6)
Youngest Child Hospitalized in NICU 0.41
Yes15 (12.1)7 (9.7)8 (15.4)
No109 (87.9)65 (90.3)44 (84.6)
Psychiatric History 0.84
Yes38 (30.6)23 (31.9)15 (28.9)
No86 (69.4)49 (68.1)37 (71.2)
Baseline BIMF 0.051
Mean (SD)87.9 (+12.3)86.1 (+11.9)90.4 (+12.4)
Baseline HADS-A 0.018 b
Median (IQR)8.0 (5.0, 10.0)8.0 (6.0, 11.0)6.0 (4.0, 9.0)
Baseline HADS-D 0.93 b
Median (IQR)5.0 (3.0, 8.0)5.0 (3.0, 8.0)4.5 (3.0, 8.0)
Baseline PSS-10 0.41
Mean (SD)18.2 (+6.3)18.6 (+5.7)17.6 (+7.0)
n(%) reported unless noted otherwise. GED = general education development; BIMF = Barkin Index of Maternal Functioning; HADS-A = Hospital Anxiety and Depression Scale—anxiety subscale; HADS-D = Hospital Anxiety and Depression Scale—depression subscale; PSS-10 = Perceived Stress Scale-10; SD = standard deviation; IQR = interquartile range. Note: 5 missing races; 1 missing child. a Derived from chi-square or Fisher’s exact test for categorical measures and independent t-test or Mann–Whitney U test for continuous measures. b Mann–Whitney U produces mean scores. Number of Children: Preferred Guide Yes, mean score of 60.2; Preferred Guide No, mean score of 64.4. HADS-A: Preferred Guide Yes, mean score of 69.0; Preferred Guide No, mean score of 53.5. HADS-D: Preferred Guide Yes, mean score of 62.8; Preferred Guide No, mean score of 62.1.
Table
Table 2. Unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between guide preference with the postpartum toolkit and participant characteristics.
Table 2. Unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between guide preference with the postpartum toolkit and participant characteristics.
CharacteristicUnadjusted
OR (95% CI)		p-ValueAdjusted
OR (95% CI)		p-Value
Participant’s Age, years 0.034 0.0095
18–351.001.00
35 or older0.42 (0.19, 0.94)0.29 (0.11, 0.74)
Baseline Functioning (BIMF)0.97 (0.94, 1.00)0.0540.94 (0.90, 0.98)0.0057
Baseline Anxiety
(HADS-A)		1.10 (1.00, 1.20)0.0491.15 (1.02, 1.30)0.03
Baseline Depression (HADS-D)1.01 (0.91, 1.13)0.840.79 (0.66, 0.95)0.0099
BIMF = Barkin Index of Maternal Functioning; HADS-A = Hospital Anxiety and Depression Scale—anxiety subscale; HADS-D = Hospital Anxiety and Depression Scale—depression subscale.
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MDPI and ACS Style

Albanese, A.M.; Smith, B.E.; Geller, P.A.; Bloch, J.R.; Sikes, C.; Kondracki, A.J.; Barkin, J.L. To Guide or to Self-Guide?: Predictors of Preferring a Guided Introduction to Digital Resources That Promote Postpartum Mental Health. Psychiatry Int. 2023, 4, 208-219. https://doi.org/10.3390/psychiatryint4030021

AMA Style

Albanese AM, Smith BE, Geller PA, Bloch JR, Sikes C, Kondracki AJ, Barkin JL. To Guide or to Self-Guide?: Predictors of Preferring a Guided Introduction to Digital Resources That Promote Postpartum Mental Health. Psychiatry International. 2023; 4(3):208-219. https://doi.org/10.3390/psychiatryint4030021

Chicago/Turabian Style

Albanese, Ariana M., Betsy E. Smith, Pamela A. Geller, Joan R. Bloch, Chris Sikes, Anthony J. Kondracki, and Jennifer L. Barkin. 2023. "To Guide or to Self-Guide?: Predictors of Preferring a Guided Introduction to Digital Resources That Promote Postpartum Mental Health" Psychiatry International 4, no. 3: 208-219. https://doi.org/10.3390/psychiatryint4030021

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