Title: Improving Knowledge, Attitudes and Beliefs: A Cross-Sectional Study of Postpartum
Depression Awareness Among Social Support Networks During Covid-19 Pandemic in
Malaysia
Version: 3 Date: 21 Feb 2022
Reviewer's report:
Abstract: Conclusions- I believe authors should mention what is the findings, i.e. is there good
knowledge among the social support system.
Introduction: “However, the social support intervention did not appear to treat PPD in
adolescents at six weeks postpartum. If social support was not provided during pregnancy, PPD
was more likely to occur”. Since social support is the backbone of the study, authors should
clearly define what social support and intervention is. Context should be given in more depth,
describing what the currently available social support intervention is in overseas and Malaysia.
Introduction: Authors mentioned that “Numerous research throughout the lockdown time
focused on the general population, economics of the country, and mental health during the
COVID-19 epidemic in the Klang Valley”, but no references provided.
Methods: Authors mentioned that “The questionnaire was directed at Malaysians who might
function as social support networks (husbands, friends, parents and in-laws, siblings) for
postpartum women during the COVID-19 epidemic”. How authors ensured that those who
answered the questionnaire belongs to this group? Is there any inclusion and exclusion checking
questions, or any statement in the information sheet? Please state them here if any.
Methods: Do you have a sample size calculation?
Methods, study design: Authors mentioned that “We investigated the impact of the Malaysian
Government's lockdown during the COVID-19 epidemic”. This does not seem very appropriate,
because authors did not measure the impact of lockdown, looking at the questionnaire itself. It
is actually just a study conducted during the lockdown period.
Questionnaire: The sentence “Part C then included ten items designed to measure respondents'
agreement on each topic” is vague. What topic does it refer to?
Questionnaire: It is not very clear what is meant “Data about PPD public education campaigns
were collected as part of the questionnaire's second component”. Second component or
secondary component? Also, how many item are there in this section?
Questionnaire: Please describe the process of questionnaire translation.
Data collection: Some of the information here had already mentioned in study design. Please
check and ensure there is no repetitive content.
Validity and reliability: Authors should describe the characteristics of the population who
answered the pre-test. Are they the same with the study population? And those who answered
the pre-test, are they allowed to participate in the actual study?
Validity and reliability: “Section 2 (Part A) had a Cronbach's alpha coefficient of 0.72, and
Section 2 (Part B) had a Cronbach's alpha [29]”. This sentence looks hanging.
Validity and reliability: “After the pre-testing, the supervisor and co-supervisor examined the
questionnaire's content validity”. The process of content validation was not described here,
is there any meetings hold? Usually content validity was established before pre-testing. Also,
authors should state what is the qualifications or designation of the person who performed
content validation, which can replace the word “supervisor”.
Data Analysis: Authors mentioned that “More and more medical journals are using GLMMs
for modelling qualitative data or counts in recent years.” But since this is a quantitative study,
would this be relevant?
Results: Please check English for the phrase: “with most answers collected by Malay (75.1%).”
Results: In Table 1, I think the term older adults >40 years old is not very appropriate. Because
in a wider context, it refers to those above 60. Perhaps authors can just mention what the age
group, and remove the term young adults and older adults throughout the manuscript.
Knowledge, attitude and beliefs on postpartum depression awareness: Authors should try not to
repeat every results already made available in the Tables. Instead, they should summarize and
highlight the important/significant findings.
Results: The statement “According to item 10, it was difficult to receive adequate medical
treatment for postpartum depression during the COVID-19 epidemic. There were relatively
minor disparities between the indifferent (n = 147, 37.3%) and agreeing (n = 192, 48.7%) groups
of responders” is confusing and could be simplified and rephrased.
Results: Please check on the statement “As many as 78.4% and 60.9% of respondents believed
that postpartum depression is not genuine but merely fiction and is not deadly.” Because this
contradicts with what is stated in the Table 4.
The term Analytical Statistics did not seem appropriate. Do you mean inferential statistics?
Under the generalized liner mixed model, authors should describe how do they derive the
awareness level based on the knowledge, attitudes and belief, because it was not mentioned
inside the method.
Discussion- I believe the first paragraph of the discussion should also include the primary
findings from this study. At current, the first paragraph looks more like an Introduction.
Discussion: This sentence was not clear: “However, the woman's and her social support
network's failure to identify PPD symptoms is a barrier to properly treating this disease with
specialists' assistance”. What specialists does the author refers to?
Discussion: I can’t see the 85.2% under results. “However, most respondents (85.2%) said they
trusted their physician/obstetrician for information and avoided misconceptions about postnatal
depression, especially among the mother's social support network.”
Discussion: Please check whether the term “non-childless counterparts” is correct.
Discussion: “Results of GLMM analysis showed that educational levels were a significant
predictor of a good understanding of postpartum depression” I can’t see this under Results, nor
Table 8.
Discussion: “We also found no connection between age group and educational level and a final
score on attitudes.” Please indicate what is meant by final score.
Discussion: Association between Sociodemographic Factors with Belief-authors should attempt
to explain why is there no correlation between sociodemographic factors, which other studies
shows a lot of correlations. Sample size might be one reasons, but other factors should also be
provided.
Discussion: GLMM also revealed a lower attitude towards PPD among individuals who were
not exposed to the drug. I am not sure why drug was being mentioned here.
Discussion: “Because of the limited travel during pandemics, our findings differed from those
of the other studies. This, in turn, limited the research participants' exposure to mental health
problems.” I am not sure about what the authors want to highlight in these 2 sentences.
Limitation: Authors should discuss about the generalizability of their findings instead,
considering the characteristics of participants such as young age and higher level of education
may not represent those not included in the study. Non-response bias should be addressed as
well.
Conclusion: I could not understand this statement. “Public understanding about PPD had a
substantial impact on participants' attitudes and knowledge about the disease.  ”