Developing a Vignette based Questionnaire to Assess Help Seeking Intention, Stigma and Perception regarding Peripartum Depression

Objectives Depression is the commonest mental health problem in pregnancy. Health seeking for peripartum depression is heavily influenced by stigma and disease perceptions which need to be studied in order to design interventions to improve health seeking. Since quantitative studies on this are scares we decided to study stigma and perception regarding peripartum depression and its association with help seeking intention among pregnant women in Sri Lanka. This paper reports how a tool was designed and validated for this study. Results A self-completed questionnaire was developed based on a vignette of a postpartum mother with symptoms of peripartum depression. Vignette was used as people are not familiar with western disease descriptions. It also provided opportunity to study how participants construct meaning to typical symptoms of peripartum depression. Stigma and perception regarding peripartum depression were presented as statements. Agreement to these statements after reading the vignette was to be marked in a likert scale. The vignette and statements were constructed following discussions with local stakeholders, assessment of diagnostic criteria, global literature and survival stories. Expert validation by a multidisciplinary team and cognitive validation by pregnant women were conducted and pretested. It was developed in Sinhalese and translated to Tamil and English.


Introduction
Depression is the commonest mental health problem in pregnancy [1]. Peripartum depression has been defined as current or, if full criteria are not currently met for a major depressive episode, most recent episode of major depression where onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery [2]. Peripartum depression can cause severe morbidity and even mortality to the affected woman and her children as well, hence timely identification and treatment of the condition is of paramount importance.
Health seeking behaviors for mental health conditions such as peripartum depression are 3 heavily influenced by stigma, disease perception and socio-cultural beliefs [3]. These factors need to be studied in order to find effective strategies to ensure timely treatments for peripartum depression.

Main Text
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). 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).  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. 6 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.

Conclusions
In this paper we report how a vignette based questionnaire was designed and validated to quantify the perceptions and stigmatizing views on peripartum depression among pregnant women; the at risk population for the said condition. To our knowledge, this is the first of such tools reported in scientific literature. We hope that identifying most prevalent stigmatizing views and incorrect perceptions in a community by using this tool will allow designing 'culturally-tailored' health promotion activities to improve help seeking for peripartum depression which is a rising challenge for maternal health in many communities today.

Limitations
Using a vignette design can introduce courtesy bias. This was anticipated and to minimize this, participants were given a structured introduction before data collection. Participants were reassured that identification information are not collected in the questionnaire and responses will not be checked when they handover the filled questionnaire. They were also informed about the value of providing responses genuinely representing their perception and thoughts without worrying about being right or wrong.
Even though validation of the vignette was done according to professional and community view points (details given in results section), no data was collected to quantify the agreement between the intended vignette (peripartum depression) and the specialists' diagnosis about it. Availability of data and material No data was generated but the study tool described in the manuscript is available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.