The Tool
A self-completed questionnaire with a vignette was designed. A vignette describing experience of ‘Ama’, a postpartum mother of a one month old baby who is experiencing symptoms of peripartum depression (without suicidal thoughts) was given in part A. In part B, the vignette was modified as the same mother getting suicidal thoughts frequently (Table 1).
Table 1- The vignette of peripartum depression
For conceptualizing stigma in the current study, mental illness stigma framework was used [7]. All three constructs of stigma from perspective of stigmatizer (stereotypes, prejudice and discrimination) as per mental illness stigma framework were included as statements. Similarly, perception about symptoms of peripartum depression (part A of vignette) and perceptions about suicidal thoughts in a woman with possible peripartum depression (part B of the vignette) were presented as statements (see table 2). A five point likert scale was used to assess level of agreement (from strongly disagree to strongly agree) to each statement considering how participants personally feel after going through the vignette.
Participants were asked about the likely course of action they will follow if they were the person described in the vignette. This included questions on help seeking intention (for part A and B of vignette), first choice of help seeking source, probability of turning to selected sources for help seeking (to be marked from a five point adjectival scale from never to definitely), preferred method of informing a health care provider about symptoms and perceived likelihood of receiving given responses for help seeking from selected sources (to be selected from a five point likert scale from extremely unlikely to extremely likely).
Table 2 - Statements included in the questionnaire to represent constructs of stigma and perceptions.
Stereotyping
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Prejudice
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Discrimination
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Perception
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“Ama must be lazy”
“Ama does not have the courage and strength that should be there in a mother”
“Ama is a danger to her baby”
“Ama doesn’t have a good family background”
“It is Ama’s karma/ God’s wish”
“Ama is not receiving enough support from her family”
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“I feel angry about behavior of Ama”
“I feel pity towards Ama”
“She should not have become a mother in the first place”
“I feel angry about her husband”
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“I do not wish to be a friend of Ama”
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“Ama's condition is normal. Almost everyone feels like that after having a baby”
“It is not normal but it will resolve on its’ own in a while”
“It is likely to be a mental health problem” (For part A only)
“Her life is at risk”(for Part B only)
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Development and validation of the tool
When a vignette is used the findings are heavily dependent on validity of the vignette. To increase the internal validity vignette should be constructed following assessment of existing literature, validated by a panel of experts and pretested [8].
This vignette was designed based on the Diagnostic and Statistical Manual V (DSM V) diagnosis criteria [2] and International Classification of Diseases (ICD) 10 classification of depression [9]. Survivor stories presented in scientific literature, qualitative studies, and internet based postpartum depression support groups (local and international) were also referred when designing the vignette and the statements on stigma and perception. Reproductive age females in the same community and midwives, and doctors in the public health sector were also interviewed during the process.
Expert validity for the vignette and the questionnaire were obtained from a panel of experts using a semi structured feedback form. The expert panel included a Consultant Psychiatrist, a Consultant Community Physician, a Medical Anthropologist, a Social Scientist, and two Medical Officers of Health and a panel of public health midwives. Feedback was obtained regarding technical accuracy, clarity, cultural appropriateness, sensitivity, ethically soundness and comprehensiveness of the vignette and questions.
Cognitive validation of the questionnaire was conducted with ten pregnant women admitted in obstetric ward of the teaching hospital Anuradhapura (THA). Since THA is the main hospital which drains people from across the entire district this sample was assumed to be compatible with the intended study population. Pregnant women were asked to read the vignette and answer questions in the tool that were asked verbally from them. Then the thought process of respondents after reading the vignette and when giving a particular answer was assessed using probing questions on three aspects; comprehension of key phrases in the question/ vignette, applicability of the question/vignette to the community and sensitivity of the question/vignette. Answers were documented, and the questionnaire and vignette were changed accordingly.
The original vignette and the questionnaire were developed in Sinhala language and were translated to English and Tamil by professional translators. Consensus was obtained from three native Tamil health professionals regarding the Tamil translation.
The questionnaire was pretested among thirteen pregnant women admitted in the obstetric wards for confinement in THA. Questionnaire was found to be understandable and participants could complete it within averagely 20 minutes.
Informed written consent was obtained from all participants of the study.