ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
A randomized controlled trial of the effectiveness of a postnatal psychoeducation programme on self-efficacy, social support and postnatal depression among primiparas Shefaly Shorey, Sally Wai Chi Chan, Yap Seng Chong & Hong-Gu He Accepted for publication 11 November 2014
Correspondence to H.-G. He: e-mail: [email protected] Shefaly Shorey MSc PhD RN RM Lecturer School of Health Sciences, Nanyang Polytechnic, Singapore Sally Wai Chi Chan PhD RN Professor and Head School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia Yap Seng Chong MD Senior Consultant/Associate Professor Department of Obstetrics and Gynecology, National University Hospital, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore Hong-Gu He MD PhD RN Assistant Professor Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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S H O R E Y S . , C H A N S . W . C . , C H O N G Y . S . & H E H . - G . ( 2 0 1 5 ) A randomized controlled trial of the effectiveness of a postnatal psychoeducation programme on self-efficacy, social support and postnatal depression among primiparas. Journal of Advanced Nursing 71(6), 1260–1273. doi: 10.1111/jan.12590
Abstract Aim. To examine the effectiveness of a postnatal psychoeducation programme in enhancing maternal self-efficacy and social support and reducing postnatal depression among primiparas. Background. Primiparas experience various challenges during the early postnatal period with low self-efficacy, depression and lack of social support. Support in the form of postnatal educational programmes is needed to improve these outcomes of primiparas. Design. A randomized controlled two-group pre-test–post-test design was adopted. Methods. Data were collected from June–December 2012 in a public hospital in Singapore from 122 primiparas, who were randomly assigned to the intervention (n = 61) or control group (n = 61). The intervention group received postnatal psychoeducation programme and routine care while the control group received routine care only. The Maternal Parental Self-Efficacy scale, Perinatal Infant Care Social Support scale and Edinburgh Postnatal Depression Scale were used to measure outcomes of maternal parental self-efficacy, social support and postnatal depression. The mean percentage changes of all three outcome variables from baseline to 6 and 12 weeks postpartum between groups were used when performing repeated measures multivariate analysis of covariance. Results. The intervention group had significantly higher scores of maternal parental self-efficacy and social support and lower scores of postnatal depression at 6 and 12 weeks postpartum when compared with the control group. Conclusion. The postnatal psychoeducation programme was effective in improving maternal outcomes and hence could be introduced as routine care with ongoing evaluation in the postnatal period. Future studies could focus on the effects of this programme on other populations. Trial registration no: ISRCTN15886353.
© 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
Effectiveness of a postnatal psychoeducation programme
Keywords: depression, midwifery, nurses, nursing, postnatal, primiperas, psychoeducatoin, self-efficacy, social support
psychoeducation programme should be tested on varied
for primiparas is associated with lower maternal self-efficacy and increased risk of depression in the early postnatal period (Horowitz et al. 2001, Lee et al. 2001). Maternal parental self-efficacy (MPSE), the cognitive belief mothers hold in their ability to perform newborn-care tasks (Leahy-Warren 2005) is one of the most crucial components for the smooth transition to motherhood (LeahyWarren 2005, Sanders & Wooley 2005, Ngai et al. 2010). Earlier studies (Kapp 1998, Leahy-Warren 2005, Ong et al. 2013, Shorey et al. 2013) have highlighted that primiparas have low MPSE in performing various newborn-care tasks. Based on Bandura’s self-efficacy theory (Bandura 1997), interventions have been developed to enhance self-efficacy of various health behaviours for use in nursing research (Lenz & Shortridge-Baggett 2002) to bring about behavioural change (Cheal & Clemson 2001, Dijkstra & Wolde 2005, Tan et al. 2011). Cheal and Clemson (2001) recommended that multi-focused interventions including health education, skills practice and mastery experience, role modelling and self-affirming verbal persuasion produced the best results in enhancing self-efficacy, which may help to reduce postnatal depression (PND). PND was found to affect 13% of women in a landmark meta-analysis (O’Hara & Swain 1996) while the other more recent meta-analysis (Gavin et al. 2005) of 28 studies across different countries and cultures showed a PND prevalence rate of 192%. A study in Singapore reported that 122% of primiparas suffered from depressive symptoms in the first 6 weeks postpartum (Chee et al. 2005). With an annual birth rate of approximately 42,600 (Singapore Department of Statistics 2012), it is estimated that 5,200 women suffer from PND every year, which is indicative of the need for more rigorous supportive interventions (Chee et al. 2005).
group of mothers including multiparas and depressed mothers.
Background
Why is research needed? ● Primiparas experience physical, emotional and social challenges in the early postpartum period; many of them verbalized the need of continuity of support. ● Psychoeducation interventions are effective in improving maternal self-efficacy and psychosocial well-being in the antenatal period. ● No previous study has established the short and long-term effectiveness of a postnatal psychoeducation programme provided in the early postpartum period on interrelated maternal outcomes including maternal self-efficacy, social support and postnatal depression.
What are the key findings? ● The postnatal psychoeducation program was effective in enhancing maternal parental self-efficacy and social support and reducing postnatal depression at six and 12 weeks postpartum. ● Providing educational programme formally in the form of home visits by midwives is feasible in the early postpartum period.
How should the findings be used to influence practice/ research? ● The postnatal psychoeducation programme is relatively brief and can be delivered by postnatal unit nurses after minimal training. It can be incorporated into routine care to facilitate continuity of care in the early postpartum period. ● Bandura’s self-efficacy theory and social exchange theorybased psychoeduaction is effective and feasible in maternal and child health nursing specifically, in the early postpartum period. ● Further evaluation of the cost-effectiveness of the postnatal
Introduction The early postpartum period is a stressful transition period during which primiparas face numerous physical and emotional challenges (Kapp 1998, Bashour et al. 2008, Forster et al. 2008) including fatigue, the demanding responsibility of caring for newborn and profound changes in roles and responsibilities (Tulman & Fawcett 2003). Lack of support © 2014 John Wiley & Sons Ltd
Supportive interventions can be facilitated by providing social support in the form of education and maintaining the continuity of care with postnatal follow-up home visits by healthcare professionals after hospital discharge (Bennett & Tandy 1998, Fenwick et al. 2010, Ngai et al. 2010, Shorey et al. 2013). However, the provision of supportive interventions is not widely practiced during the postnatal period as the focus has been mainly limited to pregnancy and childbirth education (Kapp 1998, Ip et al. 2009, Ngai et al. 1261
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2009). This limited support provided in the form of home visits, focuses mainly on instrumental support with baby care tasks or the screening of the baby by the varied support providers including midwives, community health nurses and non-healthcare professionals such as home care workers (Morrell et al. 2000, D’Amour et al. 2003). Social support plays an extremely important role in the adaptation to major life events such as the transition to motherhood, by enabling new mothers to attain their maternal role. Blau (1964) and Homans (1961) in their social exchange theory explained that social support entails networking between two people that enables them to cope with stressful events. Lack of support from healthcare professionals and significant others during the stressful early postnatal period may complicate the issue further. Mothers with low social support were found to have poor maternal adaptation including low MPSE during the early postpartum period (Horowitz et al. 2001, Gao et al. 2010). MPSE is one of the fundamental components for maternal adaptation to motherhood that not only affects the maternal psychological well-being, but also has an impact on the child’s psychosocial development (Coleman & Karraker 2000, Sanders & Wooley 2005). Various factors such as age, ethnicity, marital status, educational level, employment status, monthly household income, antenatal class attendance and type of birth were found to influence maternal self-efficacy (Tarkka 2003, Salonen et al. 2009, LeahyWarren & McCarthy 2010, Ngai et al. 2010, Shorey et al. 2013, 2014b). The positive relationship was found between self-efficacy and multi-parity, higher maternal age, being Chinese, higher monthly household income, better employment status, social support and higher marital satisfaction level (Leahy-Warren & McCarthy 2010, Ngai et al. 2010, Shorey et al. 2013, 2014b). The mothers who underwent normal vaginal delivery and had attended antenatal classes had higher MPSE (Kapp 1998, Tarkka 2003, Ngai et al. 2010). A negative relationship between self-efficacy and maternal stress and postnatal depression was also reported (Salonen et al. 2009, Leahy-Warren & McCarthy 2010, Shorey et al. 2013, 2014b). Among many factors influencing self-efficacy, positive social support was one of the most important factors that enhanced MPSE whereas postnatal depression reduced MPSE (Haslam et al. 2006, Leahy-Warren & McCarthy 2010, Ngai et al. 2010, Shorey et al. 2013, 2014b). The assessment of MPSE, social support and PND in the early postnatal period was recommended by the previous literature (Leahy-Warren & McCarthy 2010, Ngai et al. 2010, Shorey et al. 2013, 2014b). MPSE, social support and PND are three inter-related components (Ngai et al. 2010, Leahy-Warren et al. 2011, 1262
Shorey et al. 2014b); however, no intervention studies have examined these important components together. Most of the available educational programs reviewed lack the support of a theoretical framework. Furthermore, there is a lack of culturally competent psychoeducation interventions suitable for Asian culture to improve maternal outcomes (Cunningham & Zayas 2002). A systematic review involving 28 trials on the effects of psychosocial and psychological interventions for postnatal depression prevention revealed that these interventions might significantly prevent postnatal depression especially when the interventions were introduced in the postpartum period (Dennis & Dowswell 2013). However, some of the trials in the review had poor compliance rate and information on the standardization of the intervention protocol was not available. Dennis and Dowswell (2013) recommended that by overcoming methodological flaws and planning individualized culturally appropriate interventions in the postnatal period could prevent postnatal depression. Fisher et al. (2010) developed such a psychoeducation program in the postnatal period, which aimed at communicating modifiable risk factors related to postnatal mental disorders for Caucasian couples with 1-week-old infants. However, the study might have selection bias as the couples were not randomized to the control and intervention groups. This implies the need for innovative psychoeducation interventions with sound research methodology for providing salient knowledge, active learning opportunities and skills training in baby care in the early postpartum period. A review of the literature found a lack of valid theorybased, randomized controlled trials that evaluate the effectiveness of psychoeducation interventions in the postnatal period on maternal self-efficacy, social support and postnatal depression. Given the growing evidence of postnatal depression among primiparas and its harmful effects on them and their families, developing effective interventions to facilitate maternal psychosocial well-being is essential and a priority (Lee et al. 2001, Chee et al. 2005, Ngai et al. 2009, Dennis & Dowswell 2013, Shorey et al. 2013).
The study Aim The aim of this study was to evaluate the effectiveness of a postnatal psychoeducation program in enhancing MPSE and social support and reducing PND among primiparas at six and 12 weeks postpartum. © 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
Hypothesis When compared with those in the control group, mothers in the intervention group will have a statistically significant improved maternal parental self-efficacy (primary outcome) and social support and reduced postnatal depression symptoms over time (from baseline, to 6 weeks and 12 weeks postpartum), controlling for maternal age, ethnicity, marital status, educational level, employment status, monthly household income, antenatal class attendance and type of birth.
Design/methodology A randomized controlled two-group pre-test–post-test design was adopted. The study protocol has been published (Shorey et al. 2014c). Participants Participants were recruited from a public tertiary hospital in Singapore, which has an annual birth rate of approximately 3000 births. The inclusion criteria were primiparas who were: (1) 21 years old and above (legal adult age in Singapore); and (2) able to read and speak English. The exclusion criteria were primiparas who: (1) had medical and psychiatric history before and during pregnancy as identified by medical records; (2) had complicated assisted delivery such as vacuum or forceps with 4th degree tear; (3) had delivered a newborn with apparent congenital anomalies or delivered a stillbirth; (4) had a newborn not to be discharged home with the mother; and/or (5) were not able to stay in Singapore after hospital discharge in the first 12 weeks postpartum. Participants with (1) to (4) conditions were excluded because these might affect the outcomes (Brown & Lumley 2000, Ngai et al. 2010) and pose a threat to the internal validity of the study. Sample size calculation Power analysis of independent t-test for the primary outcome of self-efficacy was used to calculate the sample size. To achieve a medium effect size of 060 on the primary outcome of self-efficacy (Ip et al. 2009, Ngai et al. 2009), power of 80% at the significance level of 005 (2-sided), a minimum of 44 participants in each group was required (Cohen 1992). Considering 30% attrition rate (Ip et al. 2009), a total of 114 primiparas (57 per group) were needed. This study recruited 122 mothers. Intervention Control group. The control group received routine care only. The routine care involved postnatal support by nurses © 2014 John Wiley & Sons Ltd
Effectiveness of a postnatal psychoeducation programme
and midwives in the hospital and a follow-up (around 1–6 weeks postdelivery) outpatient appointment with the doctor. The content of the support focused on providing didactic information on basic baby care tasks while in the hospital and inspection of wound (if any) and breastfeeding advice during the follow-up hospital visit. No continuity of care in the form of home visits by midwives or community nurses is available in the local context (Phang 2009). Intervention group. The intervention group received a postnatal psychoeducation program plus routine care. The postnatal psychoeducation programme was developed based on Bandura’s self-efficacy theory (Bandura 1997), social exchange theory (Homans 1961, Blau 1964), and the local (Chee et al. 2005, Ong et al. 2013, Shorey et al. 2013) and international studies on the postnatal needs of primiparas (Kapp 1998, Ngai et al. 2009, Fenwick et al. 2010, Gao et al. 2010, Leahy-Warren et al. 2011). Details of the theoretical framework, contents of the intervention and the standardized intervention protocol can be found in the study protocol recently published (Shorey et al. 2014c). Six experts including two academic experts, a clinical obstetrician, one midwife and two mothers validated the contents of the intervention. Based on their comments more topics including sleeping behaviour of the baby and breastfeeding issues were introduced and revised. The experts also affirmed the cultural relevance of the intervention. The postnatal psychoeducation program consisted of a 90-minute face-to-face educational session during the home visit, an educational booklet and three follow-up telephone calls. The first author, who is a midwife educator and has considerable experience of facilitating postnatal educational programs, conducted the face-to-face sessions for all mothers in the intervention group. The topics covered included physical and psychological challenges after birth, the importance of family dynamics and means of enhancing self-efficacy and help-seeking behaviours. Significant others were encouraged to participate in the educational session so that they were aware of the maternal needs. Hence, as per the social exchange theory (Homans 1961, Blau 1964) the intervention focused on providing both the formal and informal structural support and all types of functional support to the mothers during the home visits. The session was conducted within the first two weeks postpartum, as it was considered the most stressful period for primiparas (Kapp 1998). After the home visit, the educational booklet was provided to the mothers for reinforcement of what was taught during the session. Summary statements, a list of further readings, important contacts in case of emergency and 1263
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colourful pictures were well liked by the primiparas, as shown during the process evaluation (Shorey et al. 2014a). Following the face-to-face sessions, the three follow-up phone calls (about 30 minutes per session) were delivered on a weekly basis up to 6 weeks postdelivery. Any new stressors and queries after the home visit were explored and answered according to their individual needs. Any doubts from the booklet were also addressed and the mothers were encouraged to continue to read the booklet. An outlined phone call protocol was strictly followed and the same midwife delivered all follow-up calls to ensure standardization. Outcome measures Outcomes were measured at three time points: Baseline (on the day of discharge between 1-3 days postpartum), at 6 weeks postpartum and at 12 weeks postpartum. Figure 1 shows the CONSORT flowchart of the study. The primary outcome MPSE was measured by the 20item Perceived Maternal Parental Self-Efficacy (PMPS-E) scale (Barnes & Adamson-Macedo 2007). Social support was measured by the Perinatal Infant Care Social Support (PICSS) scale (Leahy-Warren 2005), which contains 22 items measuring functional support (type of support) and 36 items measuring structural support (sources of support). Postnatal depression was measured by the 10-item Edinburgh Postnatal Depression Scale (EPDS) (Cox et al. 1987). It was recommended that scores of 13 and above meet the diagnostic criteria of depression (Cox et al. 1987, Elliott et al. 2000). All instruments were valid and reliable. The Cronbach’s alpha values of PMPS-E scale and PICSS scale were 095 and 086 respectively when used in a local study (Shorey et al. 2013). The Cronbach’s alpha value of EPDS was 082 in Cox and Holden’s (2003) study. For this sample, the Cronbach’s alpha values for PMPS-E scale, PICSS scale EPDS were 089, 078 and 078 respectively (Shorey et al. 2014b). More detailed description of the three instruments can be found in other papers published by the same team (Shorey et al. 2014b,c). Socio-demographic and obstetric data sheet was used to collect mothers’ age, ethnicity, marital status, highest education level, employment status, monthly household income, antenatal class attendance and the type of delivery. Data collection procedure Data were collected from June–December 2012 after obtaining Research Ethics Committee approval. The midwife researcher (SS) shortlisted mothers potentially meeting the eligibility criteria based on the medical records. The nurses-in-charge were then approached to ascertain the shortlisted mothers’ physical and emotional well-being. 1264
The mothers were contacted at the postnatal wards on the day of discharge. The baseline data (n = 122) were collected after mothers provided written consent (Figure 1). They were then randomized to either the intervention or control group based on the set of 61 unique random numbers generated by the last author using the Research Randomizer (Urbaniak & Plous 2011). The mothers were asked to pick colour-coded slips with numbers from 1–122 from an opaque envelope. The mother whose slip number matched a number in the random number set and pink in colour was assigned to the intervention group, otherwise to the control group. This process ensured the concealment of the participant allocation. At 6 weeks (immediately after the intervention) and 12 weeks postpartum, the same researcher who conducted the intervention collected the data via phone. To avoid inconvenience, mothers were contacted via text messages for a convenient and preferred time slot before they were called. The reason for collecting data via phone was to minimize the inconvenience of posting questionnaires and hence avoiding the possibility of high attrition rates (Pugh et al. 2002, Dennis 2003). Data analysis Data were analysed using IBM SPSS 22.0 (IBM Corporation, Armonk, NY, USA). Intention to treat (ITT) analysis was adopted with missing data replaced by mean. Descriptive statistics were used to summarize the demographic data and outcome variables. Chi-square tests, Fisher’s Exact tests or independent sample t-tests were used to compare the differences of the demographic variables between the intervention and control groups. Independent sample t-test was used to examine the difference of the baseline scores of the three variables between the intervention and control group. A repeated measures multivariate analysis of covariance (MANCOVA) was performed to examine differences of the mean percentage change of the outcome variables between groups over time, which was adjusted for confounding factors of age, ethnicity, marital status, educational level, employment status, monthly household income, antenatal class attendance and type of birth. Baseline scores were normalized to zero when performing the repeated measures MANCOVA; P < 005 was considered statistically significant.
Ethical considerations The ethics approval was obtained from the Institutional Review Board of the study hospital. All participants were assured that participation in the study was voluntary and © 2014 John Wiley & Sons Ltd
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Assessed for eligibility (n = 197)
Approached to participate (n = 140)
Randomization (n = 122)
Intervention group (n = 61) -Completed baseline assessment on self-efficacy (SE) social support (SS) and postnatal depression (PND) (n = 61)
Pretest Baseline assessment
Intervention group (n = 57) -Received postnatal psychoeducation program + Routine care (n = 57) -Refused to participate (n = 4) Reasons: Physical discomfort (n = 2); Busy (n = 2)
Intervention group (n = 56) - Completed assessment on SE, SS and PND (n = 56) - Lost to follow-up (n = 5) Reasons: Physical discomfort (n = 2) Busy (n = 2) Not contactable (n = 1)
Effectiveness of a postnatal psychoeducation programme
Excluded: (n = 57) Reason: -Not meeting the inclusion criteria
Excluded: (n = 18) Reasons: -Physical discomfort (n = 3) -Not interested in the study (n = 3) -Having guests (n = 4) -Not staying in Singapore in the first six weeks postpartum (n = 8)
Control group (n = 61) -Completed baseline assessment on self-efficacy (SE) social support (SS) and postnatal depression (PND) (n = 61)
Control group (n = 61) -Received routine care (n = 61) -Refused to participate (n = 0)
Posttest-1 Follow-up at 6 weeks
Control group (n = 54) - Completed assessment on SE, SS and PND (n = 54) - Lost tofollow-up (n = 7) Reasons: Loss of interest in study (n = 2) Busy (n = 2) Not contactable (n = 3)
Posttest-2 Follow-up at 12 weeks
Control group (n = 51) - Completed assessment on SE, SS and PND (n = 51) - Lost to follow-up (n = 10) Reasons: Physical discomfort (n = 1) Unwell newborn (n = 1) Loss of interest in study (n = 2) Busy (n = 2) Not contactable (n = 4)
- Process evaluation (n = 18)
Intervention group (n = 57) - Completed assessment on SE, SS and PND (n = 57) - Lost to follow-up (n = 4) Reasons: Busy (n = 2) Not contactable (n = 2)
Intention-to-treat analysis (n = 61)
Intention-to-treat analysis (n = 61)
Figure 1 CONSORT flowchart of the study.
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that they could choose to withdraw from the study at any time without any negative consequences. Written informed consent was obtained and the data collected were kept confidential. The participants who scored more than 13 on the EPDS were referred back to their obstetrician for further follow-up.
Mean scores of outcome variables at baseline, post-test 1 and post-test 2 Table 2 shows the means, standard deviations of three outcome variables across three measurements (baseline, posttest-1 and post-test-2) in the intervention and control groups.
Validity and reliability The valid and reliable instruments were used to collect data in this study. As the participants were randomized to the control and intervention groups, all the participants had an equal chance of receiving the intervention. To maintain consistency, same researcher delivered the intervention to all the participants in the intervention group. An intervention protocol was used to standardize the intervention (Shorey et al. 2014c).
Results Comparison of socio-demographic and clinical characteristics and scores of three outcome variables between groups at baseline The baseline data of all 122 mothers were reported in another paper (Shorey et al. 2014b). The mean age of the mothers was 286 years (SD 44, range = 19–39 years). Most of the participants were married (n = 115, 943%), working (n = 85, 697%) with a monthly household income of S$3000 (US$2500) and above (n = 84, 689%). More than half of the mothers had a university degree and above (n = 65, 533%). The majority of participants (n = 95, 779%) did not attend antenatal education and almost half of them (n = 67, 549%) had normal vaginal delivery or assisted delivery. There were no statistical significant differences on demographic and clinical characteristics except for type of birth between the intervention and control groups (Table 1). The mothers (n = 122) had a mean MPSE score of 316 (SD 70) and a mean social support score of 568 (SD 67). The mean PND score was 82 (SD 41) with 17 women (139%) scoring 130 and above and 27 women (22%) scoring 10 and above at baseline (Table 1). There was statistically significant difference of the MPSE scores (t = 0246, d.f. = 120, P = 0015) between the two groups, with mothers in the control group reported higher MPSE scores. No significant differences were found for social support scores (t = 111, d.f. = 120, P = 027) and PND scores (t = 141, d.f. = 120, P = 016) between the two groups (Table 1). 1266
Comparison of percentage change of composite and individual outcome variables from baseline between groups over time The repeated measures MANCOVA showed that Mauchly’s test of sphericity was significant for all three outcome variables. Hence, the p values were accepted as such. Table 3 shows a significant group effect for the composite variable (F = 832, P < 0001) and individual variable of all three outcomes: MPSE (F = 777, P < 0001), social support (F = 244, P < 0001) and PND (F = 88, p = 0 0004). Table 3 also shows the group and time interaction (group * time) effect were statistically significant for the composite scores (F = 431, P < 0001) and individual scores of outcome variables: MPSE (F = 683, P < 0001), social support (F = 1817, P < 0001) and PND (F = 76, p = 0 0003). Figure 2a-c presents a graphical representation of the percentage change in MPSE, social support and PND scores between intervention and control groups from baseline (normalized to zero) to post-test 1 and 2. The hypothesis is supported.
Discussion The main strengths of the study lie in its theory-based intervention program and the methodology, the randomized controlled trial which is a more rigorous way of determining cause and effect relationships between intervention and outcome (Naser et al. 2012). In this study, the mean age of first-time mothers was 286 years and the majority of them were well-educated, middle income, working mothers. Similar characteristics have been reported in other local studies, which found that participating mothers were generally older and had a higher level of education and family income (Chee et al. 2005, Ong et al. 2013). The participants’ mean MPSE score (316) was lower than those reported in previous studies on Caucasian first-time mothers (Mean = 59-66) (Barnes & Adamson-Macedo 2007, Leahy-Warren et al. 2011). This could be due to data collection time points in these studies were different, from 6 weeks postpartum (Leahy-Warren et al. 2011), to within the first 28 days postpartum (Barnes & Adamson-Macedo 2007). The participants had a © 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
Effectiveness of a postnatal psychoeducation programme
Table 1 Comparison of demographic characteristics between groups (n = 122). Characteristics Age Mean (SD) Range Ethnicity Chinese Malay Indian Others Marital status Married Single/others Educational level Primary/secondary school ITE/polytechnic/junior college University degree/higher degree Employment status Working Not-working Monthly household income
A randomized controlled trial of the effectiveness of a postnatal psychoeducation programme on self-efficacy, social support and postnatal depression among primiparas Shefaly Shorey, Sally Wai Chi Chan, Yap Seng Chong & Hong-Gu He Accepted for publication 11 November 2014
Correspondence to H.-G. He: e-mail: [email protected] Shefaly Shorey MSc PhD RN RM Lecturer School of Health Sciences, Nanyang Polytechnic, Singapore Sally Wai Chi Chan PhD RN Professor and Head School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia Yap Seng Chong MD Senior Consultant/Associate Professor Department of Obstetrics and Gynecology, National University Hospital, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore Hong-Gu He MD PhD RN Assistant Professor Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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S H O R E Y S . , C H A N S . W . C . , C H O N G Y . S . & H E H . - G . ( 2 0 1 5 ) A randomized controlled trial of the effectiveness of a postnatal psychoeducation programme on self-efficacy, social support and postnatal depression among primiparas. Journal of Advanced Nursing 71(6), 1260–1273. doi: 10.1111/jan.12590
Abstract Aim. To examine the effectiveness of a postnatal psychoeducation programme in enhancing maternal self-efficacy and social support and reducing postnatal depression among primiparas. Background. Primiparas experience various challenges during the early postnatal period with low self-efficacy, depression and lack of social support. Support in the form of postnatal educational programmes is needed to improve these outcomes of primiparas. Design. A randomized controlled two-group pre-test–post-test design was adopted. Methods. Data were collected from June–December 2012 in a public hospital in Singapore from 122 primiparas, who were randomly assigned to the intervention (n = 61) or control group (n = 61). The intervention group received postnatal psychoeducation programme and routine care while the control group received routine care only. The Maternal Parental Self-Efficacy scale, Perinatal Infant Care Social Support scale and Edinburgh Postnatal Depression Scale were used to measure outcomes of maternal parental self-efficacy, social support and postnatal depression. The mean percentage changes of all three outcome variables from baseline to 6 and 12 weeks postpartum between groups were used when performing repeated measures multivariate analysis of covariance. Results. The intervention group had significantly higher scores of maternal parental self-efficacy and social support and lower scores of postnatal depression at 6 and 12 weeks postpartum when compared with the control group. Conclusion. The postnatal psychoeducation programme was effective in improving maternal outcomes and hence could be introduced as routine care with ongoing evaluation in the postnatal period. Future studies could focus on the effects of this programme on other populations. Trial registration no: ISRCTN15886353.
© 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
Effectiveness of a postnatal psychoeducation programme
Keywords: depression, midwifery, nurses, nursing, postnatal, primiperas, psychoeducatoin, self-efficacy, social support
psychoeducation programme should be tested on varied
for primiparas is associated with lower maternal self-efficacy and increased risk of depression in the early postnatal period (Horowitz et al. 2001, Lee et al. 2001). Maternal parental self-efficacy (MPSE), the cognitive belief mothers hold in their ability to perform newborn-care tasks (Leahy-Warren 2005) is one of the most crucial components for the smooth transition to motherhood (LeahyWarren 2005, Sanders & Wooley 2005, Ngai et al. 2010). Earlier studies (Kapp 1998, Leahy-Warren 2005, Ong et al. 2013, Shorey et al. 2013) have highlighted that primiparas have low MPSE in performing various newborn-care tasks. Based on Bandura’s self-efficacy theory (Bandura 1997), interventions have been developed to enhance self-efficacy of various health behaviours for use in nursing research (Lenz & Shortridge-Baggett 2002) to bring about behavioural change (Cheal & Clemson 2001, Dijkstra & Wolde 2005, Tan et al. 2011). Cheal and Clemson (2001) recommended that multi-focused interventions including health education, skills practice and mastery experience, role modelling and self-affirming verbal persuasion produced the best results in enhancing self-efficacy, which may help to reduce postnatal depression (PND). PND was found to affect 13% of women in a landmark meta-analysis (O’Hara & Swain 1996) while the other more recent meta-analysis (Gavin et al. 2005) of 28 studies across different countries and cultures showed a PND prevalence rate of 192%. A study in Singapore reported that 122% of primiparas suffered from depressive symptoms in the first 6 weeks postpartum (Chee et al. 2005). With an annual birth rate of approximately 42,600 (Singapore Department of Statistics 2012), it is estimated that 5,200 women suffer from PND every year, which is indicative of the need for more rigorous supportive interventions (Chee et al. 2005).
group of mothers including multiparas and depressed mothers.
Background
Why is research needed? ● Primiparas experience physical, emotional and social challenges in the early postpartum period; many of them verbalized the need of continuity of support. ● Psychoeducation interventions are effective in improving maternal self-efficacy and psychosocial well-being in the antenatal period. ● No previous study has established the short and long-term effectiveness of a postnatal psychoeducation programme provided in the early postpartum period on interrelated maternal outcomes including maternal self-efficacy, social support and postnatal depression.
What are the key findings? ● The postnatal psychoeducation program was effective in enhancing maternal parental self-efficacy and social support and reducing postnatal depression at six and 12 weeks postpartum. ● Providing educational programme formally in the form of home visits by midwives is feasible in the early postpartum period.
How should the findings be used to influence practice/ research? ● The postnatal psychoeducation programme is relatively brief and can be delivered by postnatal unit nurses after minimal training. It can be incorporated into routine care to facilitate continuity of care in the early postpartum period. ● Bandura’s self-efficacy theory and social exchange theorybased psychoeduaction is effective and feasible in maternal and child health nursing specifically, in the early postpartum period. ● Further evaluation of the cost-effectiveness of the postnatal
Introduction The early postpartum period is a stressful transition period during which primiparas face numerous physical and emotional challenges (Kapp 1998, Bashour et al. 2008, Forster et al. 2008) including fatigue, the demanding responsibility of caring for newborn and profound changes in roles and responsibilities (Tulman & Fawcett 2003). Lack of support © 2014 John Wiley & Sons Ltd
Supportive interventions can be facilitated by providing social support in the form of education and maintaining the continuity of care with postnatal follow-up home visits by healthcare professionals after hospital discharge (Bennett & Tandy 1998, Fenwick et al. 2010, Ngai et al. 2010, Shorey et al. 2013). However, the provision of supportive interventions is not widely practiced during the postnatal period as the focus has been mainly limited to pregnancy and childbirth education (Kapp 1998, Ip et al. 2009, Ngai et al. 1261
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2009). This limited support provided in the form of home visits, focuses mainly on instrumental support with baby care tasks or the screening of the baby by the varied support providers including midwives, community health nurses and non-healthcare professionals such as home care workers (Morrell et al. 2000, D’Amour et al. 2003). Social support plays an extremely important role in the adaptation to major life events such as the transition to motherhood, by enabling new mothers to attain their maternal role. Blau (1964) and Homans (1961) in their social exchange theory explained that social support entails networking between two people that enables them to cope with stressful events. Lack of support from healthcare professionals and significant others during the stressful early postnatal period may complicate the issue further. Mothers with low social support were found to have poor maternal adaptation including low MPSE during the early postpartum period (Horowitz et al. 2001, Gao et al. 2010). MPSE is one of the fundamental components for maternal adaptation to motherhood that not only affects the maternal psychological well-being, but also has an impact on the child’s psychosocial development (Coleman & Karraker 2000, Sanders & Wooley 2005). Various factors such as age, ethnicity, marital status, educational level, employment status, monthly household income, antenatal class attendance and type of birth were found to influence maternal self-efficacy (Tarkka 2003, Salonen et al. 2009, LeahyWarren & McCarthy 2010, Ngai et al. 2010, Shorey et al. 2013, 2014b). The positive relationship was found between self-efficacy and multi-parity, higher maternal age, being Chinese, higher monthly household income, better employment status, social support and higher marital satisfaction level (Leahy-Warren & McCarthy 2010, Ngai et al. 2010, Shorey et al. 2013, 2014b). The mothers who underwent normal vaginal delivery and had attended antenatal classes had higher MPSE (Kapp 1998, Tarkka 2003, Ngai et al. 2010). A negative relationship between self-efficacy and maternal stress and postnatal depression was also reported (Salonen et al. 2009, Leahy-Warren & McCarthy 2010, Shorey et al. 2013, 2014b). Among many factors influencing self-efficacy, positive social support was one of the most important factors that enhanced MPSE whereas postnatal depression reduced MPSE (Haslam et al. 2006, Leahy-Warren & McCarthy 2010, Ngai et al. 2010, Shorey et al. 2013, 2014b). The assessment of MPSE, social support and PND in the early postnatal period was recommended by the previous literature (Leahy-Warren & McCarthy 2010, Ngai et al. 2010, Shorey et al. 2013, 2014b). MPSE, social support and PND are three inter-related components (Ngai et al. 2010, Leahy-Warren et al. 2011, 1262
Shorey et al. 2014b); however, no intervention studies have examined these important components together. Most of the available educational programs reviewed lack the support of a theoretical framework. Furthermore, there is a lack of culturally competent psychoeducation interventions suitable for Asian culture to improve maternal outcomes (Cunningham & Zayas 2002). A systematic review involving 28 trials on the effects of psychosocial and psychological interventions for postnatal depression prevention revealed that these interventions might significantly prevent postnatal depression especially when the interventions were introduced in the postpartum period (Dennis & Dowswell 2013). However, some of the trials in the review had poor compliance rate and information on the standardization of the intervention protocol was not available. Dennis and Dowswell (2013) recommended that by overcoming methodological flaws and planning individualized culturally appropriate interventions in the postnatal period could prevent postnatal depression. Fisher et al. (2010) developed such a psychoeducation program in the postnatal period, which aimed at communicating modifiable risk factors related to postnatal mental disorders for Caucasian couples with 1-week-old infants. However, the study might have selection bias as the couples were not randomized to the control and intervention groups. This implies the need for innovative psychoeducation interventions with sound research methodology for providing salient knowledge, active learning opportunities and skills training in baby care in the early postpartum period. A review of the literature found a lack of valid theorybased, randomized controlled trials that evaluate the effectiveness of psychoeducation interventions in the postnatal period on maternal self-efficacy, social support and postnatal depression. Given the growing evidence of postnatal depression among primiparas and its harmful effects on them and their families, developing effective interventions to facilitate maternal psychosocial well-being is essential and a priority (Lee et al. 2001, Chee et al. 2005, Ngai et al. 2009, Dennis & Dowswell 2013, Shorey et al. 2013).
The study Aim The aim of this study was to evaluate the effectiveness of a postnatal psychoeducation program in enhancing MPSE and social support and reducing PND among primiparas at six and 12 weeks postpartum. © 2014 John Wiley & Sons Ltd
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Hypothesis When compared with those in the control group, mothers in the intervention group will have a statistically significant improved maternal parental self-efficacy (primary outcome) and social support and reduced postnatal depression symptoms over time (from baseline, to 6 weeks and 12 weeks postpartum), controlling for maternal age, ethnicity, marital status, educational level, employment status, monthly household income, antenatal class attendance and type of birth.
Design/methodology A randomized controlled two-group pre-test–post-test design was adopted. The study protocol has been published (Shorey et al. 2014c). Participants Participants were recruited from a public tertiary hospital in Singapore, which has an annual birth rate of approximately 3000 births. The inclusion criteria were primiparas who were: (1) 21 years old and above (legal adult age in Singapore); and (2) able to read and speak English. The exclusion criteria were primiparas who: (1) had medical and psychiatric history before and during pregnancy as identified by medical records; (2) had complicated assisted delivery such as vacuum or forceps with 4th degree tear; (3) had delivered a newborn with apparent congenital anomalies or delivered a stillbirth; (4) had a newborn not to be discharged home with the mother; and/or (5) were not able to stay in Singapore after hospital discharge in the first 12 weeks postpartum. Participants with (1) to (4) conditions were excluded because these might affect the outcomes (Brown & Lumley 2000, Ngai et al. 2010) and pose a threat to the internal validity of the study. Sample size calculation Power analysis of independent t-test for the primary outcome of self-efficacy was used to calculate the sample size. To achieve a medium effect size of 060 on the primary outcome of self-efficacy (Ip et al. 2009, Ngai et al. 2009), power of 80% at the significance level of 005 (2-sided), a minimum of 44 participants in each group was required (Cohen 1992). Considering 30% attrition rate (Ip et al. 2009), a total of 114 primiparas (57 per group) were needed. This study recruited 122 mothers. Intervention Control group. The control group received routine care only. The routine care involved postnatal support by nurses © 2014 John Wiley & Sons Ltd
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and midwives in the hospital and a follow-up (around 1–6 weeks postdelivery) outpatient appointment with the doctor. The content of the support focused on providing didactic information on basic baby care tasks while in the hospital and inspection of wound (if any) and breastfeeding advice during the follow-up hospital visit. No continuity of care in the form of home visits by midwives or community nurses is available in the local context (Phang 2009). Intervention group. The intervention group received a postnatal psychoeducation program plus routine care. The postnatal psychoeducation programme was developed based on Bandura’s self-efficacy theory (Bandura 1997), social exchange theory (Homans 1961, Blau 1964), and the local (Chee et al. 2005, Ong et al. 2013, Shorey et al. 2013) and international studies on the postnatal needs of primiparas (Kapp 1998, Ngai et al. 2009, Fenwick et al. 2010, Gao et al. 2010, Leahy-Warren et al. 2011). Details of the theoretical framework, contents of the intervention and the standardized intervention protocol can be found in the study protocol recently published (Shorey et al. 2014c). Six experts including two academic experts, a clinical obstetrician, one midwife and two mothers validated the contents of the intervention. Based on their comments more topics including sleeping behaviour of the baby and breastfeeding issues were introduced and revised. The experts also affirmed the cultural relevance of the intervention. The postnatal psychoeducation program consisted of a 90-minute face-to-face educational session during the home visit, an educational booklet and three follow-up telephone calls. The first author, who is a midwife educator and has considerable experience of facilitating postnatal educational programs, conducted the face-to-face sessions for all mothers in the intervention group. The topics covered included physical and psychological challenges after birth, the importance of family dynamics and means of enhancing self-efficacy and help-seeking behaviours. Significant others were encouraged to participate in the educational session so that they were aware of the maternal needs. Hence, as per the social exchange theory (Homans 1961, Blau 1964) the intervention focused on providing both the formal and informal structural support and all types of functional support to the mothers during the home visits. The session was conducted within the first two weeks postpartum, as it was considered the most stressful period for primiparas (Kapp 1998). After the home visit, the educational booklet was provided to the mothers for reinforcement of what was taught during the session. Summary statements, a list of further readings, important contacts in case of emergency and 1263
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colourful pictures were well liked by the primiparas, as shown during the process evaluation (Shorey et al. 2014a). Following the face-to-face sessions, the three follow-up phone calls (about 30 minutes per session) were delivered on a weekly basis up to 6 weeks postdelivery. Any new stressors and queries after the home visit were explored and answered according to their individual needs. Any doubts from the booklet were also addressed and the mothers were encouraged to continue to read the booklet. An outlined phone call protocol was strictly followed and the same midwife delivered all follow-up calls to ensure standardization. Outcome measures Outcomes were measured at three time points: Baseline (on the day of discharge between 1-3 days postpartum), at 6 weeks postpartum and at 12 weeks postpartum. Figure 1 shows the CONSORT flowchart of the study. The primary outcome MPSE was measured by the 20item Perceived Maternal Parental Self-Efficacy (PMPS-E) scale (Barnes & Adamson-Macedo 2007). Social support was measured by the Perinatal Infant Care Social Support (PICSS) scale (Leahy-Warren 2005), which contains 22 items measuring functional support (type of support) and 36 items measuring structural support (sources of support). Postnatal depression was measured by the 10-item Edinburgh Postnatal Depression Scale (EPDS) (Cox et al. 1987). It was recommended that scores of 13 and above meet the diagnostic criteria of depression (Cox et al. 1987, Elliott et al. 2000). All instruments were valid and reliable. The Cronbach’s alpha values of PMPS-E scale and PICSS scale were 095 and 086 respectively when used in a local study (Shorey et al. 2013). The Cronbach’s alpha value of EPDS was 082 in Cox and Holden’s (2003) study. For this sample, the Cronbach’s alpha values for PMPS-E scale, PICSS scale EPDS were 089, 078 and 078 respectively (Shorey et al. 2014b). More detailed description of the three instruments can be found in other papers published by the same team (Shorey et al. 2014b,c). Socio-demographic and obstetric data sheet was used to collect mothers’ age, ethnicity, marital status, highest education level, employment status, monthly household income, antenatal class attendance and the type of delivery. Data collection procedure Data were collected from June–December 2012 after obtaining Research Ethics Committee approval. The midwife researcher (SS) shortlisted mothers potentially meeting the eligibility criteria based on the medical records. The nurses-in-charge were then approached to ascertain the shortlisted mothers’ physical and emotional well-being. 1264
The mothers were contacted at the postnatal wards on the day of discharge. The baseline data (n = 122) were collected after mothers provided written consent (Figure 1). They were then randomized to either the intervention or control group based on the set of 61 unique random numbers generated by the last author using the Research Randomizer (Urbaniak & Plous 2011). The mothers were asked to pick colour-coded slips with numbers from 1–122 from an opaque envelope. The mother whose slip number matched a number in the random number set and pink in colour was assigned to the intervention group, otherwise to the control group. This process ensured the concealment of the participant allocation. At 6 weeks (immediately after the intervention) and 12 weeks postpartum, the same researcher who conducted the intervention collected the data via phone. To avoid inconvenience, mothers were contacted via text messages for a convenient and preferred time slot before they were called. The reason for collecting data via phone was to minimize the inconvenience of posting questionnaires and hence avoiding the possibility of high attrition rates (Pugh et al. 2002, Dennis 2003). Data analysis Data were analysed using IBM SPSS 22.0 (IBM Corporation, Armonk, NY, USA). Intention to treat (ITT) analysis was adopted with missing data replaced by mean. Descriptive statistics were used to summarize the demographic data and outcome variables. Chi-square tests, Fisher’s Exact tests or independent sample t-tests were used to compare the differences of the demographic variables between the intervention and control groups. Independent sample t-test was used to examine the difference of the baseline scores of the three variables between the intervention and control group. A repeated measures multivariate analysis of covariance (MANCOVA) was performed to examine differences of the mean percentage change of the outcome variables between groups over time, which was adjusted for confounding factors of age, ethnicity, marital status, educational level, employment status, monthly household income, antenatal class attendance and type of birth. Baseline scores were normalized to zero when performing the repeated measures MANCOVA; P < 005 was considered statistically significant.
Ethical considerations The ethics approval was obtained from the Institutional Review Board of the study hospital. All participants were assured that participation in the study was voluntary and © 2014 John Wiley & Sons Ltd
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Assessed for eligibility (n = 197)
Approached to participate (n = 140)
Randomization (n = 122)
Intervention group (n = 61) -Completed baseline assessment on self-efficacy (SE) social support (SS) and postnatal depression (PND) (n = 61)
Pretest Baseline assessment
Intervention group (n = 57) -Received postnatal psychoeducation program + Routine care (n = 57) -Refused to participate (n = 4) Reasons: Physical discomfort (n = 2); Busy (n = 2)
Intervention group (n = 56) - Completed assessment on SE, SS and PND (n = 56) - Lost to follow-up (n = 5) Reasons: Physical discomfort (n = 2) Busy (n = 2) Not contactable (n = 1)
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Excluded: (n = 57) Reason: -Not meeting the inclusion criteria
Excluded: (n = 18) Reasons: -Physical discomfort (n = 3) -Not interested in the study (n = 3) -Having guests (n = 4) -Not staying in Singapore in the first six weeks postpartum (n = 8)
Control group (n = 61) -Completed baseline assessment on self-efficacy (SE) social support (SS) and postnatal depression (PND) (n = 61)
Control group (n = 61) -Received routine care (n = 61) -Refused to participate (n = 0)
Posttest-1 Follow-up at 6 weeks
Control group (n = 54) - Completed assessment on SE, SS and PND (n = 54) - Lost tofollow-up (n = 7) Reasons: Loss of interest in study (n = 2) Busy (n = 2) Not contactable (n = 3)
Posttest-2 Follow-up at 12 weeks
Control group (n = 51) - Completed assessment on SE, SS and PND (n = 51) - Lost to follow-up (n = 10) Reasons: Physical discomfort (n = 1) Unwell newborn (n = 1) Loss of interest in study (n = 2) Busy (n = 2) Not contactable (n = 4)
- Process evaluation (n = 18)
Intervention group (n = 57) - Completed assessment on SE, SS and PND (n = 57) - Lost to follow-up (n = 4) Reasons: Busy (n = 2) Not contactable (n = 2)
Intention-to-treat analysis (n = 61)
Intention-to-treat analysis (n = 61)
Figure 1 CONSORT flowchart of the study.
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that they could choose to withdraw from the study at any time without any negative consequences. Written informed consent was obtained and the data collected were kept confidential. The participants who scored more than 13 on the EPDS were referred back to their obstetrician for further follow-up.
Mean scores of outcome variables at baseline, post-test 1 and post-test 2 Table 2 shows the means, standard deviations of three outcome variables across three measurements (baseline, posttest-1 and post-test-2) in the intervention and control groups.
Validity and reliability The valid and reliable instruments were used to collect data in this study. As the participants were randomized to the control and intervention groups, all the participants had an equal chance of receiving the intervention. To maintain consistency, same researcher delivered the intervention to all the participants in the intervention group. An intervention protocol was used to standardize the intervention (Shorey et al. 2014c).
Results Comparison of socio-demographic and clinical characteristics and scores of three outcome variables between groups at baseline The baseline data of all 122 mothers were reported in another paper (Shorey et al. 2014b). The mean age of the mothers was 286 years (SD 44, range = 19–39 years). Most of the participants were married (n = 115, 943%), working (n = 85, 697%) with a monthly household income of S$3000 (US$2500) and above (n = 84, 689%). More than half of the mothers had a university degree and above (n = 65, 533%). The majority of participants (n = 95, 779%) did not attend antenatal education and almost half of them (n = 67, 549%) had normal vaginal delivery or assisted delivery. There were no statistical significant differences on demographic and clinical characteristics except for type of birth between the intervention and control groups (Table 1). The mothers (n = 122) had a mean MPSE score of 316 (SD 70) and a mean social support score of 568 (SD 67). The mean PND score was 82 (SD 41) with 17 women (139%) scoring 130 and above and 27 women (22%) scoring 10 and above at baseline (Table 1). There was statistically significant difference of the MPSE scores (t = 0246, d.f. = 120, P = 0015) between the two groups, with mothers in the control group reported higher MPSE scores. No significant differences were found for social support scores (t = 111, d.f. = 120, P = 027) and PND scores (t = 141, d.f. = 120, P = 016) between the two groups (Table 1). 1266
Comparison of percentage change of composite and individual outcome variables from baseline between groups over time The repeated measures MANCOVA showed that Mauchly’s test of sphericity was significant for all three outcome variables. Hence, the p values were accepted as such. Table 3 shows a significant group effect for the composite variable (F = 832, P < 0001) and individual variable of all three outcomes: MPSE (F = 777, P < 0001), social support (F = 244, P < 0001) and PND (F = 88, p = 0 0004). Table 3 also shows the group and time interaction (group * time) effect were statistically significant for the composite scores (F = 431, P < 0001) and individual scores of outcome variables: MPSE (F = 683, P < 0001), social support (F = 1817, P < 0001) and PND (F = 76, p = 0 0003). Figure 2a-c presents a graphical representation of the percentage change in MPSE, social support and PND scores between intervention and control groups from baseline (normalized to zero) to post-test 1 and 2. The hypothesis is supported.
Discussion The main strengths of the study lie in its theory-based intervention program and the methodology, the randomized controlled trial which is a more rigorous way of determining cause and effect relationships between intervention and outcome (Naser et al. 2012). In this study, the mean age of first-time mothers was 286 years and the majority of them were well-educated, middle income, working mothers. Similar characteristics have been reported in other local studies, which found that participating mothers were generally older and had a higher level of education and family income (Chee et al. 2005, Ong et al. 2013). The participants’ mean MPSE score (316) was lower than those reported in previous studies on Caucasian first-time mothers (Mean = 59-66) (Barnes & Adamson-Macedo 2007, Leahy-Warren et al. 2011). This could be due to data collection time points in these studies were different, from 6 weeks postpartum (Leahy-Warren et al. 2011), to within the first 28 days postpartum (Barnes & Adamson-Macedo 2007). The participants had a © 2014 John Wiley & Sons Ltd
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Table 1 Comparison of demographic characteristics between groups (n = 122). Characteristics Age Mean (SD) Range Ethnicity Chinese Malay Indian Others Marital status Married Single/others Educational level Primary/secondary school ITE/polytechnic/junior college University degree/higher degree Employment status Working Not-working Monthly household income
