Depression women in developing countries (Shidhaye & Giri, 2014).

Depression is a major public health issue, affecting 300 million people worldwide. It is more common among women than men (World Health Organization WHO, 2017). Postpartum depression is the most common complication of childbirth and maternal mental health issues are regarded as a public health concern all over the world (Shidhaye & Giri, 2014). The paper first seeks to understand postpartum depression from the public health perspective. It then describes the health belief model of behavior change and its constructs. Finally, the paper examines the use of health belief model in assessing beliefs of women at the risk of or suffering from postpartum depression.

 Postpartum Depression- a public health concern According to WHO (2017) worldwide about 10% of pregnant women and 13% women post childbirth suffer from mental disorders primarily, depression. The percentages are even higher for women in developing countries (Shidhaye & Giri, 2014). Postpartum depression is diagnosed between 2 and 6 weeks post childbirth and may last up to 2 years (Atkins, 2010).

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Pregnancy, labor and childbirth have a great influence on the physical and emotional well-being of a woman. Women suffering from postpartum depression may feel overwhelmed, exhausted, worried, guilty, irritable, have difficulty eating or sleeping and have little or no interest in activities (Shidhaye & Giri, 2014). Depression has an adverse impact on the quality-of-life and functional capacity of these women and also for the entire family. By disrupting the mother child bonding, depression may have long term implications for the child, including impaired motor, & mental development, low self-esteem, poor self-regulation and difficult temperament (Wisner, Chambers & Sit, 2006). Postpartum depression can be effectively managed with individual and group counseling, and medications in severe cases. Public health interventions during routine antenatal and postpartum health checks provide an opportunity for early identification of maternal depression and providing coordinated care following a diagnosis (Shidhaye & Giri, 2014). Commonly identified social determinants for postpartum depression are age, socio-economic status, ethnicity, family support, family history, family dynamics, unplanned pregnancies, lack of knowledge, substance abuse, etc. Shidhaye & Giri (2014) reported preference for male child, low status accorded to women/girl child and family & relationship problems as the key determinants of postpartum depression in developing countries.

Zauderer (2009) mentioned that women are reluctant to seek help for postpartum depression, and may suffer in silence. Some are influenced by societal stigma related to mental health disorders, while others may feel shameful about feeling depressed at a time which is considered a joyful milestone (Werner, Miller, Osborne, Kuzava & Monk, 2015). The use of health behavior theory in the planning and implementation of health interventions is known to improve their effectiveness. There is a need for comprehensive approach which takes into account social and environmental factors in treating postpartum depression. Social ecological model and stigma theory may prove to be an effective approach in rehabilitating women with postpartum depression.   Following sections describe the social ecological model and stigma theory and explore the possibility of using the theories for treating women with postpartum depression.

Social Ecological Model Social Ecological model provides a framework to understand the dynamic interplay between individuals and their environment. The social ecological model has its origin in the field of psychology, in the 20th century when the work of Lewin, Skinner, Barker and other eminent researchers began to recognize the influence of environment on human behavior (Sallis & Owen, 2015). The model demonstrates that human behavior is a result of knowledge, attitudes, beliefs of individuals as well as social influences including the people with whom they interact, organizations & communities to which they belong and national policies and laws (Sallis & Owen, 2015). The Social Ecological model by addressing multiple levels of influence gives a comprehensive approach to behavior change. There are no constructs of the model per se, but the internal and external factors influencing behavior are presented as levels. There exists an interplay between and among the levels.

Ecological model is most useful as a guiding framework for planning behavior specific interventions. The model recognizes that health behavior change is maximized and sustained for longer, when supported with environment and policy efforts (Sallis & Owen, 2015).  Perceptually, the different levels are organized as concentric circles with the innermost representing intrapersonal or individual level, moving to the external levels which include interpersonal, institutional, community and finally the policy level (Jaonna Hayden). This multilevel perspective is the basis for all ecological models, however specific terms used for each level may differ. The five levels of the ecological model used in health education and promotion as described by Joanna Hayden are as follows:Intrapersonal/Individual level- Includes individual characteristics like knowledge, attitude, skills, and beliefs which influence behavior.

Other contributing factors at this level are biology (genetics), gender, age, education, employment, motivation, etc. An example of individual factors affecting behavior is when personal history of abuse increases the likelihood of an individual becoming a victim or perpetrator of violence. Interventions at this level may include strategies like peer counseling, support groups and are aimed at changing the individual perceptions and beliefs.Interpersonal level- This level includes external factors which influence behavior of an individual.

Relationship of an individual with peer, family members, relatives, and acquaintances has a significant impact on health. Cultural factors like traditions also are also included in this level. The social relationships are an important source of emotional support, social identity and also define an individual’s role in the social structure. Interpersonal relationships play an important role in deciding whether or not an individual will engage in a behavior. For example An individual’s likelihood of smoking increases when his parents, siblings, or friends smoke.

Interventions at this level should focus on changing the social norms which encourage undesirable behavior. Institutional/ Organizational level- The third level of ecological framework concerns organizations which include workplaces, churches, schools, universities, local neighborhood organizations etc. Structures and processes at the organizations can have both positive and negative effect on health of individuals. Organizations are also a source of social support and propagate social norms and values. In the workplace, for example access to onsite gyms, wellness centers, cafetarias provide opportunities for promoting health.

Whereas, excessive workload, constant pressure to meet deadlines, targets, outwork competition, etc. can lead to stress and consequent health problems.  Community level- At the community level, contributing factors include availability and location of resources that promote health, social networks, and social norms that exist among individuals, groups, and organizations. Social norms in the community can be health promoting or not. Violence in a community is more likely when there is high population density, drug trafficking, high turnover of people, and great diversity.