Title: Positive Intervention Effect of Mobile Health Application Based on Mindfulness and
Social Support Theory on Postpartum Depression Symptoms of puerperae
Version: 3 Date: 20 Mar 2022
Reviewer:  Melania Severo
Reviewer's report:
Dear Editor,
first thank you for asking me to review this interesting contribution. The article titled "The Effect
of “We’ll App” Consist of Mindfulness and Social Support to Puerperae’ Maternal Parental
Self-Efficacy and Postpartum Depression" represents an interesting article on efficacy of “We
'll App” in improving social support and maternal self-efficacy and in reducing postpartum
depression symptoms. The aspects of the novelty are defined. I am reporting some comments
as follows in order to recommend some implementations.
- The Authors could improve the title. It does not appear of clear and immediate meaning to the
reader, while it could be made simpler and more explanatory from a linguistic point of view.
Thus, they should improve also “Objective” section in abstract.
- In line 7 of the introduction, the Authors wrote "Depression can occur and develop during the
perinatal period". They should cite recent literature to support this statement, including incidence
and prevalence rates.
- In paragraph 1.1 titled “Social support and postpartum depression”, Authors described the lack
of social support as a significant risk factor for postpartum depression. However, despite Authors
described social support “as the physical, cognitive and emotional support and assistance
provided by members or experts in a social network” (line 4) they use Perceived Social Support
Scale (MSPSS) that measure perceived social support focusing on “individual self understanding
and self feelings of the degree of social support”, as the Authors themselves wrote (line 8
of paragraph 2.2. titled “Instruments”). This implies that Authors should argue the construct
of perceived social support in the introduction. Perceived social support is a concept that
implies something different from the social support actually received, e.g., it is possible to
receive practical and emotional support and help and at the same time perceive loneliness and
poor support. This deepening is mandatory to provide consistency between the introduction,
the instrument used, and the variable evaluated. Moreover, Authors named the instrument
“Perceived Social Support Scale (MSPSS)”, but likely they refer to the Multidimensional Scale
for Perceived Social Support (MSPSS), that themselves cited in references 36, 37 and 38. If it
is, correct the name of the rating scale in text.
- In line 10 of section 1.3 named "Mobile health and postpartum depression," the Authors
wrote “mHealth" without having used this abbreviation before. Insert "mHealth" in the text after
"mobile health" in parentheses before using it alone for the first time.
- In lines 3 and 4 of the "Participants" section, the Authors wrote "The demographic
characteristics of the two groups are shown in Table 1, and the two groups were not significantly
different in terms of these demographic characteristics". However, they did not report a
statistical analysis to confirm this statement. Therefore, the Authors should necessarily include
the statistical analysis performed to demonstrate the absence of significant differences in the
characteristics of the two groups. Student's t test or chi-square (#2) test should be performed
to compare between-group differences in sociodemographic and clinical variables for the
experimental and control group. The results of these analysis should be reported in Table 1.
- Replace the term "postpartum depression" with the expression "risk of developing postpartum
depression" or "postpartum depressive symptoms" in the title, abstract, hypotheses, description
of instruments, results, and discussion. The Edinburgh Postnatal Depression Scale (EPDS)
is a widely used screening tool to detect depression in the perinatal period. However, the
diagnosis of postnatal depression should be made using a validated DSM-based structured or
semistructured interview administered within 2 weeks of the administration of the depression
screening tool (such as the EPDS). As a matter of fact, DSM-5 criteria for depression consider
symptoms that have occurred within the last 2 weeks. In addition, although there is no separate
diagnosis in the DSM-5 for depression during pregnancy or postpartum, there is specification
for cases of major depression with "peripartum onset," the period including pregnancy and
postpartum. Thus, due to the exclusive use of the EPDS, Authors throughout the text should
refer to "postpartum depressive symptoms" or "risk of postpartum depression," and not use the
term "postpartum depression" loosely (e.g., they could write "APP reduces risk of developing
postpartum depression, or postpartum depression symptoms").
- In line 4 of section 2.4, "Procedure and Design," the Authors wrote that the women enrolled
were those between 10 and 28 weeks' gestation; however, the timing of the intervention needs
to be clarified. Exactly what needs to be clarified is:
1) at what point in the peripartum did the first assessment occur (eg, before or after delivery)
2) at what point in the peripartum the use of the APP began (e.g., at how many weeks of gestation
or after delivery)
3) the exact time in the peripartum when the post assessment was performed.
- Very importantly, Authors should indicate whether there were any women within the study who
achieved a clinically significant score on the EPDS (9 or higher). The number and percentage
for each of the two groups should be indicated. In Table 2, the scores on the EPDS are very
low in all groups (eg, mean 2.308 and standard deviation 0.569 in the APP group). If the mean
scores on the EPDS were so low within the sample (considering that the EPDS scores from 0
to 30), the efficacy results of the APP cannot be generalized to women experiencing clinically
significant postpartum depressive symptomatology (e.g., with an EPDS score greater than or
equal to 9), as they are not representative of them. In my opinion, this is an important point to
develop in the limitations section of the study.
- In addition, even for the MSPSS, the means and standard deviations shown in Table 2 seem
too low. This seems odd, unless the Authors considered a score range other than 12-84 for the
MSPSS. A clarification is due to facilitate readers' understanding of the data.
- Regarding references, DOIs have to be indicated after each reference (when possible in
hyperlink form).
In conclusion, just a few additional suggestions and minor corrections.
- In section 2.4. (Procedure and Design) it would be helpful to indicate the adherence rate and
the total number of women who were asked to participate in the study.
- For clarity, the Authors could write t0 and t1 in the text and tables to refer to the pre-test and
post-test, respectively.
- It would be better if the Authors made explicit the total sample number and the number of
patients in each group in Tables 1 and 2 and Figure 2.
- As a future perspective, the Authors could add the need for longitudinal studies with repeated
follow-up to test the durability of APP efficacy over time.
- In line 4 of section 2.4 "Procedure and design" maybe there is a typo: "proletarian omen", if
it is a typo, delete it.
- In line 4 of section 2.4 "Procedure and Design", the word “attriation” appears to be a typo that
should be replaced with “attrition”.
- In line 6 of section 1.4 “Research gaps, research objectives and hypotheses," correct "reduced"
to "reduce".
- Line 15 of section 2.2 " Instruments," correct “behaviou” with “behavior”.