Designing the Self-Report of Wellbeing in Pregnancy

Abstract

At the present moment, one in six adults living in England meets the diagnostic criteria for anxiety or depression. The significant and long-lasting intergenerational effects of maternal mental health in particular make perinatal wellbeing a public health priority. Every year, up to 15% of women are diagnosed with depression during pregnancy or within a year of giving birth. Perinatal depression affects women's quality of life, birth outcomes and children's emotional, cognitive, behavioural and social development. Suicide is the leading cause of maternal mortality within the United Kingdom (UK). Treatment and support needs to be made available to those who require it, but in order to do so, effective programs of assessment, particularly for those at risk of distress, must be in place. In the context of the UK's National Health Service (NHS), mental health screening in pregnancy is currently carried out verbally and using paper-based questionnaires completed in waiting rooms. However, it is estimated that at least 50% of perinatal depression cases go undiagnosed. Although 96% of midwives report asking women about their mental health during their first appointment, only one in ten women recall being asked. Mobile devices have the potential to facilitate the self-report and remote screening of wellbeing and depression throughout the antenatal period, extending care to under-served and at-risk groups, enabling timely assessment and intervention, gathering ecologically valid and longitudinal data, overcoming stigma, supporting disclosure, and fostering trust between women and midwives. However, we know little about the feasibility of employing mobile technologies for public health screening in practice, and significant design challenges currently impede their deployment. This thesis examines the design of mobile applications for the self-report of psychological wellbeing in pregnancy. It asks how technology shapes the self-report of wellbeing, how users engage and are engaged in the honest disclosure of mental health concerns, how health professionals might act upon reports of psychological wellbeing, and how technology might contribute to our evolving conception of wellbeing and its pursuit. Through collaboration with public health researchers, pregnant women and a variety of health professionals including midwives, this thesis seeks to establish a case for the feasibility of deploying mobile technologies for the self-report of psychological wellbeing and depression during pregnancy. This thesis contributes knowledge concerning the conception, theory, measurement and design of wellbeing, self-report, user engagement and ecological momentary assessment technologies. It provides insight into the experience of wellbeing and care in pregnancy as voiced by women, practice and research midwives, medical researchers, clinical studies officers, psychologists, psychiatrists, general practitioners, and clinicians in maternal and child health, obstetrics and midwifery. It details the design and evaluation of BrightSelf, a mobile application and online platform for the self-report of wellbeing and depression during pregnancy, and presents the results of the first longitudinal clinical deployment of a mobile technology for antenatal mental health screening. Using BrightSelf, 355 pregnant women attending 14 NHS midwifery clinics across England provided 2,280 momentary and retrospective reports of their wellbeing in daily life over a 9 month period. Women installed and engaged with this mobile application regardless of their age, education, number of children, marital status, employment status, past diagnosis of depression or level of wellbeing. Thirty-nine women reported a risk of depression, self-harm or suicide using this technology and received immediate midwife support. Two-thirds of participants who received support in this way registered no risk of depression according to the standard screening methods employed in-clinic at baseline, and women spoke positively of the experience; "Everyone should have access to the app as soon as they find out their [sic] pregnant, great way of communicating, especially for those less inclined to talk to anyone." Participant No. 349 | Arm 1 | Writing in the Post-Study Survey This thesis resulted in a new understanding of the feasibility and design of mobile technologies for public health screening and research.