From Idea to Implementation: Development of the Smart-e-Moms App to Reduce Postpartum Depressive Symptoms

Abstract

Introduction

Postpartum depression is the most common mental health disorder associated with the birth of a child. However, postpartum depression often remains untreated because there are not enough prevention and treatment options. Barriers such as lack of knowledge and fear of stigmatization also make it more difficult for affected women to start treatment. Digital interventions could be an option which might circumvent many of these barriers. This study describes the development process of the smartphone-based intervention Smart-e-Moms which aims to reduce postpartum depressive symptoms.

Material and Methods

The app was developed using a participatory and iterative approach. The three steps used for the formative evaluation were: (1) an analysis of needs and preferences (focus groups with 9 formerly affected women and 11 midwives), (2) an analysis of the barriers and facilitating factors to use the app (online survey of 37 mothers), and (3) testing of the app (online interviews with 10 acutely affected women). Qualitative data was analyzed with MAXQDA for content analysis.

Results

Step 1 identified numerous challenges after giving birth such as stress, negative thoughts and feelings, and lack of support, all of which flowed into the contents of the app. Ensuring that the units were short and the topics “self-care” and “relationship to the child” were also considered important. In step 2, barriers and facilitating factors were identified and incorporated into the design of the app. Step 3 consisted of a positive assessment of the first version of the app in terms of content and formal design as well as usability. The final app consisted of 10 behavioral units with written psychological guidance, constantly accessible exercises on self-care and the relationship to the child and permanently available information on common challenges after giving birth.

Conclusion

We present a new and innovative approach which aims to reach out more easily to women with postpartum depressive symptoms. The most important insights from the development process, the final design, and the elements of the program are described here.

 

MissingLinkText

Keywords

postpartum depression - app - smartphone-based intervention - formative evaluation

Introduction

Postpartum depression (PPD) is one of the most common disorders to affect women after giving birth and can have a significant impact on the health of the mother and the development of the child. The risk of developing PPD after giving birth is 8–19% [1] [2] [3] [4]; in Germany more than 77000 cases with PPD are reported every year [5]. The clinical presentation of postpartum depression resembles that of a depressive episode (ICD-10 F32) occurring at other times in life but is characterized by additional symptoms specifically related to motherhood [6]. They include ambivalent feelings about one’s own child and feelings of shame and guilt [7] [8]. The association of the depressive episode with the postpartum period can be reported using the additional ICD-10 code of O99.3 “mental disorders and diseases of the nervous system complicating pregnancy, childbirth and the puerperium” [6]. If PPD is not treated, there is a risk of recurrent depressive episodes [9]. At the same time, PPD does not only have a significant negative effect on the mother’s well-being but also has a long-term impact on the relationship between mother and child [10] [11] [12], the development of the child [9] [13], and the family dynamics [14] [15]. Various studies and review articles have described the negative impact on different aspects of infant development at emotional, cognitive, and behavioral levels [9] [14] [16]. Moreover, mothers with PPD appear to experience more difficulties with social relationships including in their partnerships [14] [15] [17].

Despite the high prevalence and wide-ranging impact of PPD, the majority of affected women are not treated [18]. Accessing appropriate treatment is complicated by a number of factors: on the one hand, affected mothers are often afraid of being stigmatized, they feel ashamed and do not have enough information about the available support [19] [20] [21] [22]. At the same time, the mothers face structural and logistical barriers such as reduced flexibility in terms of time and location because of their special situation after giving birth [20] [23]. A lack of treatment options and of time on the part of health care providers also makes it more difficult to start treatment [24] [25]. The result of these barriers is that many women with PPD do not receive the necessary support in time and only 15% of affected women receive treatment [18].

Internet-based interventions (IBIs) are a promising option to overcome some of the above-mentioned barriers and offer support to affected mothers [26] [27] [28]. IBIs can be used flexibly to fit in with the available time and location and therefore offer a low-threshold, timely opportunity to integrate therapeutic support into daily life [29]. The use of IBIs can be implemented to be anonymous, which can reduce feelings of shame and facilitate access to treatment [30]. IBIs for women with PPD have been found to be more accessible, leading to a significant reduction of depressive symptoms [31] [32]. As 57.4% of pregnant women and mothers already use health-related applications on their smartphones after giving birth [33], a smartphone-based intervention is especially suitable to reach this specific target group.

While smartphone-based interventions for mothers with postpartum depressive symptoms already exist in other countries [34] [35] [36] [37], similar provisions in Germany are lacking [38]. Currently, there is only one computer- and smartphone-based intervention available in Germany. However, the program already starts in pregnancy and aims to preventively reach pregnant women without requiring depressive symptoms to be present [39]. To close this gap, a German-language smartphone-based intervention specifically for mothers with postpartum depressive symptoms was developed and evaluated. The aim was to create an evidence-based, low-threshold, digital intervention to address the specific needs and challenges of the target user group and contribute to improving their mental health. This article describes the development process of the smartphone-based intervention Smart-e-Moms and presents the final version of the app.

 

MissingLinkText

Material and Methods

Study design

The stage model of behavioral therapy research [40] divides the development and evaluation of interventions into three phases: (I) Development and pilot testing, (II) Evaluation of efficacy in a randomized controlled study, and (III) Investigation into generalizability, implementation, cost-benefit ratio, and acceptance. The formative evaluation of Smart-e-Moms was based on the first phase (Ia) of this model and follows the methodological recommendations for internet-based interventions of Danaher and Seeley [41] and Whittaker et al. [42]. Based on the suggestions of Whittaker et al. [42], the intervention was initially roughly conceptualized by sifting the available evidence. The subsequent formative evaluation consisted of three steps which are described below.

Step 1: Analysis of needs and preferences

Three focus groups with women formerly affected by PPD (n = 9) and three focus groups with experts (midwives) (n = 11) were created to obtain an understanding of the specific challenges and needs of women after giving birth and adapt the initial content concept and the formal design. Qualitative evaluation used a multi-step deductive-inductive process.

Participants

Experts from different regions in Germany were selectively contacted by e-mail and telephone as well as through flyers distributed in maternity hospitals, midwife practices and birthing centers. Initial interviews by telephone were carried out to include the midwives in the study. Inclusion criteria were at least two years of professional experience working as a midwife as well as access to the internet and to a device with audio and video functions. A total of 11 midwives participated in the three focus groups (FG1, n = 3; FG2, n = 4, FG3, n = 4). The mean age of the participating midwives was 44.8 years and the mean duration of their professional experience was 19.1 years.

Women formerly affected by PPD were recruited via Facebook groups and through posters in doctorʼs offices. Inclusion criteria were a knowledge of German, access to a device with audio and video functions, and postpartum depressive symptoms within the last five years (self-reported). One participant whose depressive episode had occurred 10 years ago was also included because she still vividly recalled the symptoms. Nine women (mean age 34.9 years; average number of children 1.4) participated online in two focus groups (FG1: n = 4; FG2: n = 3) or through a focused interview (paired depth interview; PDI; n = 2). Four women had a university degree, four had passed their school-leaving examination (Abitur) and one participant had attended school up to grade 10. According to the stratification of class index [43], one of the participants had a low socioeconomic status (SES), one participant had a high socioeconomic status, and the remaining participants had a medium SES. The duration of depressive symptoms ranged from two months to four years. All participants gave their written consent to participating in the study.

Implementation

The focus group sessions were held in the months from August to November 2020. All discussions were recorded using an audio recorder. The platform Senfcall was used for the sessions, as it complies with the requirements of the German General Data Protection Regulation (DGPR). Each focus group was moderated by two people and followed a previously determined interview guideline, with topics grouped under one of three headings: (a) challenges after giving birth, (b) feedback on the first concept of the Smart-e-Moms app, and (c) the formal design of the app. The results of topics (b) and (c) have been summarized together and are presented as target group-specific wishes.

Evaluation

MAXQDA 2020 [44] was used to analyze the focus groups. The audio recordings of the focus group sessions were imported into the software, which was then used to transcribe them. Transcription was based on Kuckartz [45]. Coding was based on content-structuring qualitative content analysis [46]. A multi-step deductive-inductive approach was selected, whereby the first step consisted of deductively generating main categories based on the questions in the guideline. The main categories were then assigned to relevant passages in the transcripts. In a second step, the text passages assigned to the different main categories were organized thematically into inductively generated subcategories. This created a category system which was tested using a transcript and adjusted. The results were summarized and presented, depending on how often they were coded across all focus groups. The number of times the topic was coded served as an orientation to show which of the discussed topics might be relevant [47].

 

MissingLinkText

Step 2: Barriers and facilitating factors

Possible barriers to and factors facilitating the use of the app were analyzed to ensure that the app would meet the needs and expectations of its users. To do this, the first session of the app was prototyped and presented to 37 mothers in an online survey.

Participants

Participants were recruited via an event “The long night of science (Lange Nacht der Wissenschaft)” held at the Free University of Berlin and through social media. Mothers could participate if their youngest child was not older than five years of age at the time of the survey. The surveyed mothers did not have to have depressive symptoms to take part in the survey. The mean age of the mothers was 32 years. The mean age of their children was 26 months. Analysis of the highest educational level of the participants showed that 11% had attended secondary school (n = 4), 16% had attended high school (n = 6), 51% (n = 19) had gone to university, and 22% (n = 8) had gone to university of applied sciences.

Implementation

The online survey was carried out using the Unipark program of the software QuestBack. All participants consented to participating in the survey after reading the participation information online. The survey began by describing the project and presenting the first design suggestions online via a QR code, followed by questions about socio-demographics as well as barriers to using an app and factors facilitating the use of an app to cope with postpartum depressive symptoms. The following questions were asked to identify potential barriers and facilitating factors:

1. What could prevent women from using the app?

2. What could motivate more women to use the app?

Evaluation

A multi-step deductive-inductive approach was chosen to evaluate the answers. The main categories “barriers and facilitating factors” were determined in advance, while the individual subcategories were inductively extrapolated from the available material. In contrast to the focus groups, the focus here was on the number of participants who mentioned specific aspects. Similar answers were grouped and the number of participants who had mentioned each aspect was recorded.

 

MissingLinkText

Step 3: Testing the app

The insights obtained from Steps 1 and 2 were used to continue to develop the contents and design of the app and were included in the development of the first beta version of the app. Online interviews with 10 women currently suffering from PPD were carried out to review the contents and formal design of the app along with its usability. The participants were additionally asked again about barriers and facilitating factors, but this time with a specific focus on the newly developed beta version of the app.

Participants

Participants were recruited through the German self-help organization “Schatten & Licht e. V.” [Shadows and Light]. Women received information about the study from an anonymous online survey (Unipark; Questback) and could consent to participating in the study. Participants were adult women who had given birth in the last year, had a computer or laptop with a camera, and currently suffered from postpartum depressive symptoms (EPDS ≥ 10). The Edinburgh Postpartum Depression Scale (EPDS) [48] is one of the most common screening tools used to assess postpartum depression. The EPDS is a self-report questionnaire consisting of 10 items which must be rated from zero to three. A total score of 10 or higher is an indication of probable postpartum depression [49]. The German version of the EPDS has good psychometric properties [49]. Ten women with a mean age of 32.8 years (SD = 4.6) participated in the interviews. The mean age of their children was 6.7 months (SD = 2.4). Nine of the women had one child and one woman had three children. Eight of the women had passed their school-leaving examination [Abitur], one had completed a degree at a university of applied sciences, and one woman had a secondary school certificate.

Implementation

The interviews were carried out online and followed a semi-structured interview guideline. The participants were asked to complete the first session of the app in its entirety. Afterwards, they were able to move freely through the other areas of the app. As they did so, they were encouraged to freely express their thoughts (“think-aloud method” [50]) and provide feedback about the app. The moderators were allowed to ask additional questions. In addition, the following standardized questions, based on Burchert et al., 2018 [51], were asked:

1. Do you think that this app could be helpful for women who feel down or depressed after giving birth?

2. What do you think is good about the app?

3. What, in your opinion, is not so good or even bad about the app?

4. What could be done to improve the app?

The following questions were asked to identify specific barriers and facilitating factors:

1. What would put you off using this particular app?

2. What would motivate you to use this particular app?

The interviews were carried out in November and December 2023 and the reimbursement for time and expenses incurred was 100 Euros. All interviews were recorded and transcribed after the interview had concluded.

Evaluation

The usability requirements were reviewed deductively based on five categories from the Health IT Usability Evaluation Model (Health-ITUEM; [52]): Information Needs, Learnability, Performance Speed, Flexibility/Customizability, plus the category Health Impact from the adaptation by Househ et al. [53]) and two additional categories from the User Version of the Mobile Application Rating Scale (uMARS; [54] – Aesthetics und Motivation & Engagement). Every dimension was divided into positive and negative codes, with no neutral codes awarded [53]. Ideas for improvement were coded [51]. Answers which could not be captured deductively with the relevant dimensions were analyzed inductively. Analysis was done in MAXQDA 2024 [55]. 20% of the transcripts were coded twice for consistency. All disagreements were resolved by discussions and a final category system was created.

 

MissingLinkText

 

MissingLinkText

 

MissingLinkText

Results

Step 1: Analysis of needs and preferences

Focus group surveys of formerly affected women (n = 9) and midwives (n = 11) were carried out to analyze the specific challenges and needs of users.

Challenges facing women after giving birth

Formerly affected women

The challenges after giving birth reported by women formerly affected by PPD were usually assigned to the subcategory stressful thoughts and feelings. Mothers reported feeling completely overwhelmed. They described it as feeling powerless and overwhelmed when dealing with their children, together with strong feelings of failure. They constantly felt themselves to be on the edge of complete exhaustion.

“Totally overwhelmed. By even the smallest things.”

(formerly affected woman, participant no. 9, PDI)

Ambivalent feelings towards their own child were also described as stressful. Different participants reported they found it difficult to build an emotional connection to their newborn baby or that motherhood did not trigger any feelings of happiness. Many regretted becoming a mother or were convinced that they should give away their child. A feeling of isolation was also described as stressful. Some women described feeling “isolated at home,” not working any more, and no longer leaving the house every day as very stressful. The interviewees also suffered from feelings of guilt. These feelings were connected to not being able to breastfeed, not being happy about motherhood, regretting becoming a mother, or that they had not given birth “naturally” [vaginal/spontaneous birth]. Feelings of inferiority and disappointment with themselves were also reported. Anxieties and worries were also reported, including the fear of making mistakes, of simply not managing, and worries about the health of their child. A feeling of hopelessness was reported. When in crisis, participants believed that things would never change. The conviction that from now on they would always be depressed and would “never be free again” weighed heavily on them. Participants also reported vividly about feeling that they were no longer themselves and that they felt “stupid.”

Other identified challenges were a lack of support (from their partner, the care system, and their social network), stress (e.g., due to problems sleeping, comparisons with other mothers, aftereffects of the birth) and breastfeeding. [Fig. 1] provides an overview of the various subcategories, the hierarchy of these subcategories, and how often they were coded across all focus groups of formerly affected women and midwives.

“I should also add that I always tried to look good, to keep up appearances and always go grinning through life, and it is so exhausting, it is so incredibly exhausting, to pretend to be feeling so differently at that moment.”

(formerly affected woman, participant no. 6, FG2)

Fig. 1 Hierarchical categories: subcategories model of the biggest challenges after giving birth together with how often they were coded for in the groups of affected women and midwives. The image presents the biggest challenges after giving birth as reported by the focus groups from the perspective of formerly affected women and midwives. Among the formerly affected women, “stress,” “stressful thoughts and feelings,” “breastfeeding,” and “lack of support” were identified as the core challenges. The challenges listed by the midwives were classified under the categories “stress,” “anxiety,” “breastfeeding,” and “lack of support.”

Midwives

The surveyed midwives also emphasized that anxiety played an important role in the postpartum period. Women worried about the well-being of their infant and were afraid of being unable to cope with the situation. A lack of support was also mentioned as a further challenge. What was emphasized most often was that women needed to have a functioning social network after they had given birth. The participants reported that support was often limited and that the women found it difficult to ask for help. In contrast to the surveyed women, the challenges reported by the midwives were most often summarized under the subcategory stress. It appeared to be especially associated with “high expectations” and “lack of calm/relaxation.” In the period after giving birth women had high expectations of themselves und put themselves under a lot of pressure. Many women, for example, had the expectation that they should “always be happy” after the birth and that parenting would be intuitive and natural and would work out well right from the start. Efforts to meet the presumed demands of others put women under additional pressure. Many of the women had huge expectations of what they needed to do to be a good mother.

“[…] a very big problem is the very, very high standards the women set themselves […]”

(midwife, participant no. 8, FG3)

Midwives also reported breastfeeding as a challenge after giving birth. They particularly emphasized difficulties with breastfeeding and the pressure that “it should work straightaway.”

 

MissingLinkText

Target group-specific needs

Content development of the app

Women formerly affected by PPD considered the topic self-care to be especially important. They emphasized that it was paramount to also look after oneself to recover. In times of crisis, they had often neglected their own needs. The midwives also considered this to be important. At the same time, they mentioned that highlighting this topic at an early stage during the intervention was difficult and could demand too much of affected women. Women formerly affected by PPD also described their relationship to their child as very relevant for an intervention. They requested exercises to promote bonding with their child and reported that talking to their child about their thoughts, actions, and feelings had a calming effect. The participating midwives also assessed the topic as relevant for the intervention. At the same time, they noted that it might reinforce the issue of feeling guilty, as many women with PPD suffered because they were unable to create the desired connection to their child. Another important topic mentioned both by formerly affected women and by midwives was dealing with the experience of giving birth. Here too, women would have very much wanted support to help them deal with their emotions. Overall, midwives considered the topic of support to be especially important. They emphasized that specifically planning support could provide relief for women in the postpartum period. The midwives also felt it was important for the app to provide sufficient information about additional forms of support after the birth. Women formerly affected with PPD wished for comprehensive information on various topics such as dealing with the child or the different developmental stages of infants. They also emphasized the need to have an opportunity to exchange experiences. Exchanging experiences with other affected women and integrating experience reports were mentioned as key aspects which could help reduce feelings of isolation. When dealing with any topic, the important thing was to ensure that no pressure was exerted, in accordance with the slogan: “Don’t stress.” This particularly applied to contents which were supposed to activate certain behaviors. Any activities proposed by the app had to be easily implemented and not cause any additional stress. A summary of the evaluation of the first content concept of Smart-e-Moms and the proposed changes is given in Appendix 1.

“[…] the relationship to the child is also very important, I didn’t have one in the early stages.”

(formerly affected woman, participant no. 8, PDI)

Formal design of the app

Formerly affected women had different opinions about the appropriate time frame for the different units and homework tasks, ranging from five minutes to 30 minutes. When they evaluated the set homework, the focus had to be on integrating the tasks into daily life. A wish to have daily modules was mentioned, but without any pressure for it to be a daily obligation. The focus had to be on avoiding stress as “stress is toxic for health.” The majority of midwives proposed a time frame of ten minutes per session and suggested a flexible structure for the different units. Opinions about the right length of time for the homework tasks varied, with times between five and 15 minutes considered appropriate. When asked about the number of units they should work through every week, participants noted that doing a session every day or one session two or three days per week would be useful. Women who had formerly been affected with PPD also preferred being addressed informally in the app (i.e., by using the informal “Du” rather than the formal “Sie”). The option to receive reminders to do a module was welcomed by both formerly affected women and midwives. The midwives additionally felt that it was important that users could interrupt their work on a session at any time and continue with it at another time.

“Well, I think it would depend on the exercises. […]. [Difficult exercises] would have been too much for me at the time.”

(formerly affected woman, participant no. 8, PDI)

 

MissingLinkText

 

MissingLinkText

Step 2: Barriers and facilitating factors

The first prototype of the app was developed based on the above discussed results and presented to 37 mothers as part of an online survey. Participants in this survey were asked about barriers which would prevent users from using the app if they had postpartum depression and factors which would facilitate using the app. Lack of time was reported most often as a barrier to using the app. This included the everyday stresses “of a very new mother” and texts and homework tasks which took up too much time. One mother stated: “To-do lists can be so incredibly long, there may not be much time left.” (participant no. 26, online survey). Lack of acceptance of apps as a medium and having to confront and deal with one’s own feelings were identified as barriers almost as often. Some of the women considered apps as a format to be generally unsuitable or mentioned concerns about using the app in front of their child. Some women pointed to the difficulty of accepting their own problems and confronting them. The fact that the app was generally unknown was also considered a barrier to use. It was felt that an “overabundance” of apps already existed and women would have to know that this app was not just “one of many.” The participants in the online survey also listed severity of depression and shame and fear of stigmatization as potential barriers. One participant reported that she was afraid that she would “be stigmatized as a bad mother if you admit to yourself that you are having such thoughts.” (participant no. 23, online survey). Trust with respect to data security and potential cost were also mentioned.

Advertising was considered the most important facilitating factor, whether through advertising in general or more specifically through promoting the app on social media or through recommendations by experts (e.g., midwives, gynecologists, advertising in hospital) or by handing out flyers. Moreover, it was thought to be important that the app would already be made available at an early stage. The general opinion was that disseminating information about what is available at an early stage, i.e., during antenatal classes, prior to giving birth, or at discharge from hospital, would promote more general use of the app. Other facilitating factors mentioned by the participants were low or no cost, increasing trust in the app through testimonials or the publication of results, and offering anonymous access to the app. One woman stated: “[…] I think that if it is anonymous, many more women will let themselves be helped.” (participant no. 13, online survey). [Table 1] provides an overview of identified barriers and facilitating factors.

Table 1 Overview of identified barriers and facilitating factors from an online survey of 37 mothers.

	Barriers	Online survey (n = 37)			Facilitating factors	Online survey (n = 37)
1	Lack of time/feeling overwhelmed	10	27.0%	1	Advertising in general	9	24.3%
2	Unknown	7	18.9%	1a	Recommended by experts/flyers	11	29.7%
3	Lack of acceptance	9	24.3%	1b	Recommended via social media	4	10.8%
4	Cost	2	5.4%	2	Low cost	3	8.1%
5	Severity of depression	3	8.1%	3	Time point	4	10.8%
6	Shame and fear of being stigmatized	4	10.8%	4	Anonymity	2	5.4%
7	Trust	1	2.7%	5	Trustworthiness	2	5.4%
				6	Other (e.g., offer preventively, provide contact points)	2	5.4%

 

MissingLinkText

Step 3: Testing the app

A beta version of the app was developed using the insights obtained from Steps 1 and 2. Ten women were asked in online interviews about the contents and formal design as well as the usability of the app. In addition, questions were asked again about barriers and facilitating factors which would specifically affect using this app. In the beta version, the first five out of 10 units were made available for testing by the women. In addition to the units, the app also included self-care exercises (relaxation and mindfulness exercises, mindfulness exercises with the infant) and information modules about different topics which concerned women after giving birth (e.g., sleep, other forms of support available), which were already available in the beta version. The app also integrated a writing task in the form of a recurrent exercise also already included in the beta version. After the writing exercise, users would receive a written individualized response from a psychologically trained counsellor (see [Table 3]). In the online interviews, all 10 women stated that they could imagine using an app to cope with depressive feelings after giving birth or having “looked for something that like.”

“Yes, I think I could have really used that at the time.”

(participant no. 8, online interview)

[Table 2] provides an overview of the usability dimensions identified using Health-ITUEM [52] and uMars [54], with examples. In addition to the prescribed Usability dimension, inductive analysis was able to identify more dimensions. The resulting categories were assigned to the dimensions “Impact,” “Usability,” and “User Experience.”

Of the 227 assigned codes, 121 were assigned to the dimension “Impact,” 58 to the dimension “Usability” and 48 to the dimension “User Experience.” The category “Information Needs” was coded most often (54 times), followed by “Intervention Components” (coded 48 times), “Learnability & Ease of Use” (coded 38 times) and “Aesthetics” (coded 29 times).

Table 2 Usability dimensions based on Health-ITUEM and uMARS with sample answers which were coded as positive (+), negative (−) or as suggestions (s).

Usability dimensions	Definition	Examples (coding)
1 Dimensions based on Health-ITUEM [47] and uMars [49]. 2 Categories based on inductive analysis. (+) positive codes, (−) negative codes, (s) suggestions
Impact
Health Impact1	Expected changes to the mental health of mothers with postpartum depressive distress caused by the Smart-e-Moms app.	(+) Yes, I absolutely believe that because it can be used directly and there are no obstacles to overcome. One doesn’t have to first gather twenty different types of information and have to ring around everywhere and really say that I’m not doing so well and then have to explain oneself.
Information Needs1	Describes how much the information provided in the app meets the needs of users (e.g., overarching topics, experience reports).	(+) myths about motherhood. (…) well I find that exciting. (+) I think it’s cool that it also included a woman who has also experienced it and talks a bit about herself. It means you are not so alone.
Intervention Components2	Describes how much specific exercises and interactive elements meet the needs of the users (e.g., mindfulness exercises)	(s) So yes, I would actually also include ideas on playing with the child, because that is one of those things when if it is your first child, you don’t have a clue, suddenly the child is wriggling around and is awake – what should I do with it?
Usability
Performance Speed1	Efficiency in terms of time required to complete the tasks in the app (e.g., reading the texts).	(+) I find that the different sections are very good in terms of length. I don’t find it too long or too much at once.
Learnability & Ease of Use1	The Smart-e-Moms app is easy to understand and use by first-time users.	(−) I did need just a moment to find my way around.
Flexibility/Customizability1	Provision of alternative options to carry out tasks which would allow different users to use the app according to their preferences.	(s) […] I think it would be cool if one could somehow shift the mindfulness exercises one really likes and does a lot to the start page […].
User Experience; UX
Aesthetics1	Statements about the design of the app	(−) I don’t really like these pictures in this form.
Text Composition2	Statements about the style of writing	(+) Well, I thought that the texts were written very respectfully.
Flexibility of Use2	Perceived flexibility in terms of times and locations to use the app	(+) […] just being able to do it sometime, at a time when I want to do it.
Anonymity2	Statements relating to the anonymity of an app compared to a face-to-face approach.	(+) […] I think that is a good step to start with, to start off by being more anonymous.
Motivation & Engagement1	The users stated that they were interested, enthusiastic, or generally motivated to use the app.	(+) Yes, well, like I said, I think it’s good and I think that it would be very helpful and I would also use the app.

Impact

Health Impact

Ten women commented about the impact of the app on health (n = 10, 100%); all of them appreciated the app as helpful for women with postpartum depressive symptoms. One reason for this which almost all the women mentioned was the low-threshold access to the app (n = 8, 80%). One participant emphasized that the app was “immediately usable […] and you don’t have to overcome any obstacles.” (participant no. 4, online interview). Some of the women (n = 4, 40%) considered the app to be helpful as it contributed to destigmatizing PPD and normalized difficult feelings after giving birth. It was felt to be helpful to know that one was not alone with those feelings and that other women felt the same way. The app was also considered to be helpful because of therapeutic support it offered (n = 3, 30%) and the exercises included in the app (n = 2, 20%). One woman reported: “Above all, you are getting support and you always get a response and that is just really great.” (participant no. 7, online interview).

Information Needs

Ten women commented on the contents of the information provided in the app. Nine women reported on positive aspects (n = 9, 90%), including the overarching topics (n = 7, 70%), the sequence of the units (n = 3, 30%) and the integrated experience reports (n = 3, 30%). One woman stated: “[I] think the units are very good because those are definitely the biggest problem areas.” (participant no. 6, online interview). The majority of the participants (n = 7, 70%) reported that the information relieved the burden of PPD and normalized the issue: “What I also thought was especially good was that it just mentioned that you are not to blame. That fact that that was clarified immediately and that many people have it.” (participant no. 1, online interview). There were also some criticisms about the information provided. Two of the women stated that they already knew all the information in the app about the symptoms and the development of postpartum depression (n = 2, 20%). One of them commented: “[…] I already knew a lot of the info because I had already looked into it.” (participant no. 7, online interview). Five women had suggestions for improvement (n = 5, 50%) which included changes to the structure (n = 2, 20%), the option to skip information (n = 1, 10%), and a request for more information and tips on sleeping (n = 2, 20%) and about antidepressants (n = 1, 10%).

Intervention Components

Nine of the 10 women commented on the integrated exercises and interactive elements. Most comments were positive (n = 8, 80%) especially with respect to the mindfulness exercises (n = 5, 50%) and the exercises with the child (n = 7, 70%). One of the women commented on the exercise “Mindfully observing my child” as follows: “[…] but just simply this observing and looking and also just enjoying the moment, I think it is great.” (participant no. 3, online interview). Two of the women considered the exercise “Setting goals” to be too challenging (n = 2, 20%). The 8 (80%) proposed suggestions for improvement were mainly about wanting additional exercises and functions (n = 7, 70%). The most common suggestions were requests for a bigger choice of exercises to do with their child (n = 2, 20%), a body scan (n = 2, 20%), and the option to exchange experiences with other affected women (n = 2, 20%).

 

MissingLinkText

Usability

Learnability & Ease of Use

Many of the women commented about the learnability of the app and how easy it was to use (n = 9, 90%) and mentioned positive aspects (n = 9, 90%). They considered that the app had a “simple design,” was “arranged clearly” and that the exercises were explained well. Other positive assessments were that the contents were only unlocked gradually, that the units could be paused at any time, and that progress in the app was shown visually. At the same time, there were also a number of criticisms (n = 6, 60%) which included difficulties in finding one’s way around the app, and problems with the navigation functions (clicking to continue, scrolling) and the presentation of the contents. One woman commented: “[you don’t see] that you can continue scrolling here.” (participant no. 9, online interview). The proposed suggestions for improvements (n = 5, 50%) included differentiating the units visually by means of different pictures and headings, showing the time needed to complete the mindfulness exercises, a simplified interactive layout without boxes, and the option to navigate the app by “swiping” rather than clicking to continue.

Performance Speed

Four of the women commented about the performance speed of the app (n = 4, 40%). All of them mentioned positive aspects. Several women commented positively on the short texts and units (n = 4, 40%). One woman stated: “Yes, I think […] you don’t need that much time to get through a unit.” (Participant no. 8, online interview). However, one woman considered some of the text passages to be too long (n = 1, 10%).

Flexibility & Customizability

Four of the women made comments about flexibility and customizability (n = 4, 40%); all of them put forward suggestions for improvement. Most of them were related to the mindfulness exercises (n = 3, 30%). It was suggested that it would be nice to be able to individually adjust the play speed and the voice-over of the mindfulness exercises. And that there should be an option to drag exercises onto the start screen. One woman would also have preferred an individually adjustable profile (n = 1, 10%).

 

MissingLinkText

User experience

Four of the women commented about the texts of the app (n = 4, 40%). Three women (n = 3, 30%) commented that the texts had been written “empathetically” and “lovingly” and “straightaway, you [feel] safe to open yourself up there.” (participant no. 6, online interview). One woman criticized that the app only talked about women and therefore excluded other people with children (n = 1, 10%). Some of the women commented positively on the fact that the app could be used anonymously (n = 5, 50%) and flexibly in terms of time (n = 5, 50%). Eight of the women also commented on their motivation to use the app (n = 8, 80%). Six of the women said that they could imagine themselves using the app. But two of the women were critical about using the app. One of the women said: “It’s too much for me. I would put it aside now.” (participant no. 10, online interview). All the women commented on the design of the app (n = 10, 100%); almost all of them mentioned almost all positive aspects (n = 8, 80%). Many of the women made positive comments about the chosen colors, the font, and the integrated graphics. Five of the women had criticisms (n = 5, 50%), especially with respect to the color scheme. Some described it as “chilly” and “too clean.” Suggestions for improvement (n = 4, 40%) included a “friendlier” color scheme and adjustments to specific graphics.

 

MissingLinkText

Specific barriers and facilitating factors

The identified barriers and facilitating factors largely concurred with the results of Step 2. However, the most common barrier mentioned at this point was that the app was unknown (n = 5, 50%). Lack of time, problems with acceptance, potential cost, severity of depression, and lack of trust were also mentioned as barriers. The most important facilitating factor mentioned to promote use of the app was advertising, mainly through recommendations from experts and self-help organizations (n = 7, 70%). In addition, as in Step 2, advertising through social media, low cost, receiving information about the app earlier, and the app’s anonymity were listed as facilitating factors. One woman stated: “[it is important] that you can get hold of it without first having to, sort of, say anything about it to anyone.” (participant no. 1, online interview).

 

MissingLinkText

 

MissingLinkText

Finalizing the app

[Table 3] presents and summarizes the most important insights obtained from Steps 1, 2 and 3. The obtained insights were incorporated into the final version of the app.

Table 3 Most important insights obtained from the development process of the Smart-e-Moms app.

Step 1: Analysis of needs and preferences

Offer target group-specific support: The app should focus on the greatest challenges after giving birth. Stresses and pressures, ambivalent feelings towards the child, anxieties and worries, feelings of guilt and shame, and difficulties with sleeping and breastfeeding should be addressed and validated. Contents about self-care and on the relationship to the infant as well as additional options for support should be integrated in the app. The motto for all the units should be “don’t put yourself under pressure.” The app should contain structured units of up to 30 minutes and simple exercises which can be paused at any time so as not to generate any pressure and avoid creating feelings of being overwhelmed. Make it possible to exchange experiences: The app should integrate experience reports The app should offer the opportunity to exchange experiences or refer the user to a site where such exchanges are possible. Promote user engagement: Addressing users of the app using the informal “du” could improve its accessibility. The app should include the option to receive reminders.

Step 2: Analysis of barriers and facilitating factors

Take account of the lack of time and problems with acceptance: The app should allow flexible use and be easy to integrate into a daily life which has “time pressures and stresses.” Exercises which can be used flexibly, and asynchronous written responses could make it easier to use the app. The app should provide scientifically based content and be recommended by specialists to increase its acceptance by users. Cost and publicity: Make it possible for users to use the app free of charge Call attention to the app with targeted advertising (by specialists and via social media)

Step 3: Testing the app

Provide an inviting and supportive atmosphere: Ensure destigmatization and normalization of all contents. Provide friendly and appreciative texts. The design of the app should create an inviting atmosphere (e.g., by using warm colors). Provide additional content: Additional mindfulness exercises to be done with the child and a treasure trove of games for low-threshold accessibility to promote mother–child bonding. Make the app user-friendly: simple to use and navigate short texts and units Use visual markers: progress within the app, contents which are not yet available

 

MissingLinkText

Final Smart e-Moms app

The final Smart-e-Moms app consists of linear cognitive-behavioral therapeutic interventions, constantly available information, and self-care exercises. Under the heading “Information” users can access articles on Sleep, Breastfeeding, Depression, Partnership and Sexuality, Getting to Know My Baby, Stressful Birth Experiences und other forms of available support (e.g., local professional support, self-help groups). The exercises for “self-care” include relaxation and mindfulness exercises, an option to collect happy moments which means being able to record nice moments, and exercises to strengthen the mother–child bond (e.g., mindfulness exercises with the baby, playful activities for mother and child).

Apart from the introductory welcome session and the final concluding session, the intervention is divided into four thematic blocks, each of which consists of 2 units: (1) Myths about Motherhood, (2) Well-being Activities, (3) Stress, and (4) Relationship with the Child. The intervention is subdivided into 10 sessions of about 20 minutes each. It was envisaged that users would work through two units per week over a period of five weeks. Each session includes psychoeducation, different exercises, audio files with experience reports, and suggestions on how to integrate exercises into daily life. Based on the identified main problem areas, the exercises make use of elements which have already been found to be effective in the context treating depression in both face-to-face and internet-based interventions (e.g., planning positive activities, cognitive restructuring, mindfulness exercises) [56] [57] [58] [59]. The intervention also includes a recurrent exercise in the form of asynchronous writing tasks. Each written exercise will receive a written response from a psychological counsellor within two days. This allows users to be flexible when using the app as there are no time constraints and the user does not have to forego the personal contact. Research findings have shown that IBIs are more effective, especially for participants with high levels of distress, when the intervention is guided [60]. Depending on their progress through the app, the user will be asked either to report about their current life situation, to reflect on the past week or to provide a retrospective review of the program.

An overview of the contents of the individual units and the integrated exercises and the design of Smart-e-Moms is given in [Table 4] and [Fig. 2].

Table 4 Contents, integrated exercises, and goals of the individual modules of Smart-e-Moms.

No.	Name	Content	Exercises	Goals
Note. * After the introductory module, the user can access these functions continuously
1	Welcome	Introduction to the intervention and setting individual goals, psycho-education on PPD	Mood tracker*, writing exercise	To increase awareness of own symptoms and normalize negative emotions; motivate user to engage with the program
Individualized feedback from a counsellor
2+3	Myths about motherhood	Myths about motherhood, connection between thoughts and feelings	Collection of happy moments*, cognitive restructuring, writing exercise	To dispel the myths about motherhood, reduce feelings of shame, increase focus on positive moments
Individualized feedback from a counsellor
4+5	Well-being activities	Connection between well-being activities and mood, how to cope with challenges	Activity planner*, writing exercise	To activate behaviors and include well-being activities in daily life with the child
Individualized feedback from a counsellor
6+7	Stress management	Dealing with stress, self-care as a mother	Mindfulness exercises and exercises to learn self-compassion*, writing exercise	To deal with stressful situations, carry out mindfulness exercises and self-care in daily life, increase self-acceptance and self-compassion
Individualized feedback from a counsellor
8+9	You and your baby	Relationship with the baby. Challenges in mother–child relationships	Mindfulness exercises and ideas on how to play for mother and baby*, writing exercise	To normalize ambivalent feelings, strengthen the mother–child bond
Individualized feedback from a counsellor
10	Final session	Summary of the most important components of the intervention; Helpful strategies for later	Writing exercise (review of the last few weeks), emergency kit*	To maintain positive changes, relapse prevention
Individualized feedback from a counsellor

Fig. 2 Overview of the design of the Smart-e-Moms app. The image shows the design of the Smart-e-Moms app and provides an overview of the start screen with the icons for “Units,” “Self-care” and “Information.” Typical contents, exercises, and a writing task are shown.

 

MissingLinkText

 

MissingLinkText

Discussion

This study describes the development of the Smart-e-Moms app, a smartphone-based intervention to reduce postpartum depressive symptoms. The app was developed using a participatory approach and the aim was to include the needs and preferences of the target group as much as possible and to overcome potential barriers.

The insights obtained were directly incorporated in the design and final aspect of the app. The final Smart-e-Moms app consists of 10 behavioral therapy units which require a maximum of 20 minutes each to work through, self-care exercises which can be carried out when the user has time, and various information modules. The limited time required for each session and the integration of simple exercises are consistent with research findings which show that in the postpartum period women prefer short exercises which can be carried out easily [61]. Moreover, cognitive performance in this period is often reduced, making it more difficult to carry out lengthy and demanding tasks [62]. Structuring the app into 10 units corresponds to the standard scope of self-help programs for women in the peripartum period [27].

The development of the Smart-e-Moms app has provided several important insights and suggestions which can be used to develop internet-based interventions (IBIs). The development process described above emphasizes the importance of using a participatory approach. Without the participatory inclusion of the target group, it is possible that many important aspects might have been overlooked. The analysis of the needs and preferences made it possible to identify specific challenges and user requirements. The focus on self-care and the relationship to the child is especially important in this context, as the inclusion of both areas go back to direct requests and needs expressed by formerly affected women. The frequency with which the categories “Information Needs” and “Intervention Components” were coded in the subsequent testing of the app also highlights the importance ensuring that target groups are involved early when developing the contents of IBIs. Many of the women evaluated the contents and exercises as suitable: the app covered the “biggest problem areas,” normalized difficult feelings and took the pressure off users. The emphasis that affected women placed on their feelings of shame and guilt led to a greater focus on normalizing such feelings and destigmatizing postpartum depression in all stages of developing the app. It is possible that they would not have been accorded quite so much importance without the feedback of the target group. The option to use the app flexibly and needs-based, including receiving written asynchronous psychological counselling, was developed in response to the limited time available to users. Without a participatory approach, these flexible options might not have been given so much weight.

Another important aspect which became clear during the development process was the commonalities and differences between the perspectives of midwives and those of the affected women. Both groups identified similar challenges after giving birth, including stress, ambivalent feelings towards the baby, and feelings of guilt. However, the midwives also emphasized the high expectations women had of themselves and the stresses associated with these expectations as well as the importance of providing detailed information. This led to the integration of more comprehensive information sections in the app which covered topics such as sleep, breastfeeding, partnership, and other forms of support. The affected women wanted more focus on normalizing and destigmatizing feelings of guilt and shame, while the midwives placed a greater emphasis on practical support and everyday solutions. These insights led to the development of contents which combined emotional support with practical tips. These examples show how important it is to integrate different perspectives into a development process to create suitable forms of support.

The insights obtaining from developing the Smart-e-Moms app could also be transferred to other IBIs developed for target groups with limited resources. Putting the users center stage, enabling flexible use of the app, and ensuring low-threshold access are key factors which should also be incorporated in other IBIs. Aspects such as asynchronous written guidance allows users to be flexible about when and how they use the app, which is essential especially for groups with limited resources (e.g., pregnant women, parents, family caregivers). It was also suggested that targeted advertising and recommendations by specialists could increase acceptance and awareness of such forms of support, which is particularly important in contexts where resources are limited.

In summary, the participatory development of the Smart-e-Moms app shows how important it is to actively involve the target group in the development process. The obtained insights offer valuable pointers for the design of IBIs and other supportive measures in areas with limited resources. The involvement of both specialists and the target group ensures that the developed interventions cover the most important aspects. Future research and practice could benefit from this approach when developing other digital solutions to support and implement mental health interventions.

 

MissingLinkText

Conclusion

The Smart-e-Moms app is an innovative approach which uses digital technology to address the lack of care available to deal with postpartum depression. The effectiveness of Smart-e-Moms is currently being tested in a randomized controlled study (for an overview of the evaluation, see [63]). Overall, the Smart-e-Moms app could make a significant contribution to the health care of mothers who have recently given birth by providing them with anonymous, low-threshold psychological support tailored to their individual needs.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

Our grateful thanks go to Philine Schell for her valuable support in compiling the manuscript and the images as well as to Louisa Huschke for her support with data collection. We would also like to thank all of the participants whose commitment made the development of the Smart-e-Moms app possible.

• References/Literatur

• 1 Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 2006; 91: 97-111
• 2 Howard LM, Megnin-Viggars O, Symington I. et al. Antenatal and postnatal mental health: summary of updated NICE guidance. BMJ 2014; 349
• 3 O’hara MW, Swain AM. Rates and risk of postpartum depression—a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54
• 4 Shorey S, Chee C, Chong Y-S. et al. Evaluation of Technology-Based Peer Support Intervention Program for Preventing Postnatal Depression: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7: e81
• 5 Döring KJ. Postpartale Depression – Versorgungssituation in der hausärztlichen Praxis. Hamburg: Universitätsklinikum Hamburg-Eppendorf; 2021
• 6 Dorsch VM, Rohde A. Postpartale psychische Störungen – Update 2016. Frauenheilkunde up2date 2016; 10: 355-374
• 7 American Psychiatric Association. Diagnostic and statistical Manual of mental Disorders. 5. Washington, DC: American Psychiatric Association; 2013
• 8 Stewart DE, Vigod S. Postpartum depression. N Engl J Med 2016; 375: 2177-2186
• 9 Netsi E, Pearson RM, Murray L. et al. Association of Persistent and Severe Postnatal Depression With Child Outcomes. JAMA Psychiatry 2018; 75: 247-253
• 10 Reck C. Postpartale Depression: Mögliche Auswirkungen auf die frühe Mutter-Kind-Interaktion und Ansätze zur psychotherapeutischen Behandlung. Prax Kinderpsychol Kinderpsychiatr 2007; 56: 234-244
• 11 Brummelte S, Galea LAM. Postpartum depression: Etiology, treatment and consequences for maternal care. Horm Behav 2016; 77: 153-166
• 12 Field T. Postpartum depression effects on early interactions, parenting, and safety practices: a review. Infant Behav Dev 2010; 33: 1-6
• 13 Kingston D, Kehler H, Austin M-P. et al. Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at three years. PLoS One 2018; 13: e0195365
• 14 Slomian J, Honvo G, Emonts P. et al. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond Engl) 2019; 15: 174550651984404
• 15 Reinhart M, Patton C, Chawla A. et al. The Humanistic Burden of Postpartum Depression: A Systematic Literature Review. Value Health 2018; 21: S187
• 16 O’Hara MW, McCabe JE. Postpartum Depression: Current Status and Future Directions. Annu Rev Clin Psychol 2013; 9: 379-407
• 17 Małus A, Szyluk J, Galińska-Skok B. et al. Incidence of postpartum depression and couple relationship quality. Psychiatr Pol 2016; 50: 1135-1146
• 18 Byatt N, Levin LL, Ziedonis D. et al. Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review. Obstet Gynecol 2015; 126: 1048-1058
• 19 Dennis C, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: A qualitative systematic review. Birth 2006; 33: 323-331
• 20 Goodman JH. Women’s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth 2009; 36: 60-69
• 21 McLoughlin J. Stigma associated with postnatal depression: A literature review. Br J Midwifery 2013; 21: 784-791
• 22 Werner E, Miller M, Osborne LM. et al. Preventing postpartum depression: review and recommendations. Arch Womens Ment Health 2015; 18: 41-60
• 23 O’Mahen HA, Flynn HA. Preferences and Perceived Barriers to Treatment for Depression during the Perinatal Period. J Womens Health (Larchmt) 2008; 17: 1301-1309
• 24 Nübling R, Jeschke K, Ochs M. et al. Zur ambulanten psychotherapeutischen Versorgung in Deutschland – Eine Befragung von Psychotherapeutinnen und Psychotherapeuten in fünf Bundesländern als ein Beitrag zur psychotherapeutischen Versorgungsforschung. Stuttgart: Landespsychotherapeutenkammer Baden-Württemberg; 2014
• 25 Pawils S, Kochen E, Weinbrenner N. et al. Postpartale Depression – wer kümmert sich? Versorgungszugänge über Hebammen, Gynäkologie, Pädiatrie und Allgemeinmedizin. Bundesgesundheitsbl 2022; 65: 658-667
• 26 Miura Y, Ogawa Y, Shibata A. et al. App-based interventions for the prevention of postpartum depression: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23: 441
• 27 Roman M, Constantin T, Bostan CM. The efficiency of online cognitive-behavioral therapy for postpartum depressive symptomatology: a systematic review and meta-analysis. Women Health 2020; 60: 99-112
• 28 Zhou C, Hu H, Wang C. et al. The effectiveness of mHealth interventions on postpartum depression: A systematic review and meta-analysis. J Telemed Telecare 2022; 28: 83-95
• 29 Schröder J, Berger T, Westermann S. et al. Internet interventions for depression: new developments. Dialogues Clin Neurosci 2016; 18: 203-212
• 30 Pugh NE, Hadjistavropoulos HD, Hampton AJD. et al. Client experiences of guided internet cognitive behavior therapy for postpartum depression: a qualitative study. Arch Womens Ment Health 2015; 18: 209-219
• 31 Fernandes DV, Monteiro F, Canavarro MC. et al. A Web-Based, Mindful, and Compassionate Parenting Training for Mothers Experiencing Parenting Stress: Results from a Pilot Randomized Controlled Trial of the Mindful Moment Program. Mindfulness (N Y) 2022; 13: 3091-3108
• 32 Zhao L, Chen J, Lan L. et al. Effectiveness of Telehealth Interventions for Women With Postpartum Depression: Systematic Review and Meta-analysis. JMIR Mhealth Uhealth 2021; 9: e32544
• 33 Osma J, Barrera AZ, Ramphos E. Are Pregnant and Postpartum Women Interested in Health-Related Apps? Implications for the Prevention of Perinatal Depression. Cyberpsychol Behav Soc Netw 2016; 19: 412-415
• 34 Franco P, Olhaberry M, Kelders S. et al. Guided web app intervention for reducing symptoms of depression in postpartum women: Results of a feasibility randomized controlled trial. Internet Interv 2024; 36: 100744
• 35 Jannati N, Mazhari S, Ahmadian L. et al. Effectiveness of an app-based cognitive behavioral therapy program for postpartum depression in primary care: A randomized controlled trial. Int J Med Inform 2020; 141: 104145
• 36 Fonseca A, Monteiro F, Alves S. et al. Be a Mom, a Web-Based Intervention to Prevent Postpartum Depression: The Enhancement of Self-Regulatory Skills and Its Association With Postpartum Depressive Symptoms. Front Psychol 2019; 10: 265
• 37 Danaher BG, Milgrom J, Seeley JR. et al. MomMoodBooster Web-Based Intervention for Postpartum Depression: Feasibility Trial Results. J Med Internet Res 2013; 15: e242
• 38 Westerhoff B, Trösken A, Renneberg B. about:blank? Online Interventions for Postpartum Depression. Verhaltenstherapie 2022; 32: 54-63
• 39 Schmidt-Hantke J, Vollert B, Nacke B. et al. PandaMom – Feasibility and acceptability of an internet- and mobile-based intervention to enhance peripartum mental well-being and to prevent postpartum depression. Internet Interv 2024; 37: 100765
• 40 Rounsaville BJ, Carroll KM, Onken LS. A stage model of behavioral therapies research: Getting started and moving on from stage I. Clin Psychol (New York) 2001; 8: 133-142
• 41 Danaher BG, Seeley JR. Methodological Issues in Research on Web-Based Behavioral Interventions. Ann Behav Med 2009; 38: 28-39
• 42 Whittaker R, Merry S, Dorey E. et al. A Development and Evaluation Process for mHealth Interventions: Examples From New Zealand. J Health Commun 2012; 17: 11-21
• 43 Hoffmeister H, Hüttner H, Stolzenberg H. et al. Sozialer Status und Gesundheit. Unterschiede in der Verteilung von Herz-Kreislauf-Krankheiten und ihre Risikofaktoren in der Bevölkerung der Bundesrepublik Deutschland nach Schichten und Gruppen. München: MMV Medizin Verlag; 1992
• 44 VERBI Software. MAXQDA 2020 [Computersoftware]. Berlin: VERBI Software; 2019
• 45 Kuckartz U. Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterstützung. 4. Weinheim: Beltz Juventa; 2018
• 46 Rädiker S, Kuckartz U. Analyse qualitativer Daten mit MAXQDA. Heidelberg: Springer; 2019
• 47 Schulz M, Mack B, Renn O. Fokusgruppen in der empirischen Sozialwissenschaft: Von der Konzeption bis zur Auswertung. Heidelberg: Springer; 2012
• 48 Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782-786
• 49 Herz E, Thoma M, Umek W. et al. Nicht-psychotische postpartale Depression. Geburtshilfe Frauenheilkd 1997; 57: 282-288
• 50 Jaspers MWM, Steen T, van den Bos C. et al. The think aloud method: a guide to user interface design. Int J Med Inform 2004; 73: 781-795
• 51 Burchert S, Alkneme MS, Bird M. et al. User-Centered App Adaptation of a Low-Intensity E-Mental Health Intervention for Syrian Refugees. Front Psychiatry 2019; 9: 663
• 52 Brown W, Yen P-Y, Rojas M. et al. Assessment of the Health IT Usability Evaluation Model (Health-ITUEM) for evaluating mobile health (mHealth) technology. J Biomed Inform 2013; 46: 1080-1087
• 53 Househ MS, Shubair MM, Yunus F. et al. The Use of an Adapted Health IT Usability Evaluation Model (Health-ITUEM) for Evaluating Consumer Reported Ratings of Diabetes mHealth Applications: Implications for Diabetes Care and Management. Acta Inform Med 2015; 23: 290-295
• 54 Stoyanov SR, Hides L, Kavanagh DJ. et al. Development and Validation of the User Version of the Mobile Application Rating Scale (uMARS). JMIR Mhealth Uhealth 2016; 4: e72
• 55 VERBI Software. MAXQDA 2024 [Computersoftware]. Berlin: VERBI Software; 2024
• 56 Hautzinger M. Kognitive Verhaltenstherapie bei Depressionen. 7. Weinheim: Beltz; 2013
• 57 Wolkenstein L. Postpartale Depression. Göttingen: Hogrefe; 2023
• 58 Zagorscak P, Heinrich M, Sommer D. et al. Benefits of Individualized Feedback in Internet-Based Interventions for Depression: A Randomized Controlled Trial. Psychother Psychosom 2018; 87: 32-45
• 59 Hofmann SG, Gómez AF. Mindfulness-Based Interventions for Anxiety and Depression. Psychiatr Clin North Am 2017; 40: 739
• 60 Karyotaki E, Efthimiou O, Miguel C. et al. Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry 2021; 78: 361-371
• 61 Ramphos ES, Kelman AR, Stanley ML. et al. Responding to women’s needs and preferences in an online program to prevent postpartum depression. Internet Interv 2019; 18: 100275
• 62 Wilkerson AK. Cognitive Performance as a Function of Sleep Disturbance in the postpartum Period. Denton: University of North Texas; 2015
• 63 Daehn D, Meyer C, Loew V. et al. Smartphone-based intervention for postpartum depressive symptoms (Smart-e-Moms): study protocol for a randomized controlled trial. Trials 2024; 25: 469

Publikationsverlauf

Eingereicht: 08. November 2024

Angenommen nach Revision: 01. März 2025

Artikel online veröffentlicht:
12. Juni 2025