Project:

Applied Epidemiology and Biostatistics

MSPH Second Semester

Al-Shifa School of Public Health

Prepared By: Dr Umer Farooq

Submitted to: Haleema Masud

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Table of Contents

Title Page................................................................................... 1
Table of Contents........................................................................ 2
Objectives.................................................................................. 3
Methodology
1 Method.................................................................................. 3
2 Study design..........................................................................3
3 RESULT..................................................................................4
ANNEXES:..................................................................................6

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Objectives

Primary objective
:
To estimate Anxiety and stress in the postpartum mother experiencing first time mother
Secondary objective:

To assess the variability of different stressors impacting women at later stages of infant development

Methodology

As part of a larger cross-sectional study (on first-time mothers' experiences of motherhood), a convenience sample
was obtained in Melbourne, Australia. The study was entitled "Factors associated with first-time mothers' experience
of motherhood".

Measure

Depression Anxiety Stress Scales (DASS-21)

The DASS consists of three self-report scales that have been designed to measure the negative emotional states of
depression, anxiety and stress .The DASS-21 is a brief 21 item version of the full DASS, which originally consisted
of 42 items. Each of the three DASS-21 scales contains seven items representing the dimensions of depression,
anxiety and stress. Participants are asked to rate the extent to which they experienced each state over the past
week on a 4-point likert rating scale. Sub-scale scores are derived by totaling the scores.
Edinburgh Postnatal Depression Scale (EPDS)

The EPDS has been designed to screen postnatal women for the likelihood of postnatal depression. The 10-item
scale assesses symptoms of anhedonia and reactivity, self-blame, anxiety, panic, coping, insomnia (due to
unhappiness), sadness, tearfulness and self-harm .The EPDS excludes somatic symptoms such as fatigue and
change in appetite, which may occur normally in the post-partum, and which may otherwise potentially not dis-
criminate depressed from non-depressed women.
This 10-item scale includes questions such as "I have been able to laugh and see the funny side of things" and "I
have blamed myself unnecessarily when things went wrong". Respondents indicate on a four-point likert scale, the
response that best describes the way they have been feeling over the past seven days. Items are scored from 0 to
3 with a maximum total score of 30.

Results

Prevalence of depression according to the EPDS and the DASS

A total of 325 women participated in this study ranging in age from 18 to 44 years, with a mean age of 32 years (SD
= 4.6).. In relation to educational level, 103 women (31.9%) reported having had no tertiary education, 107 women
(33.1%) reported having completed undergraduate university degrees, and 113 women (34.8%) reported having
completed postgraduate university degrees.

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In the present sample of postnatal women (N = 325), The EPDS identified 80 women (25%) as likely to be
depressed. Those women scoring 9 or less on the EPDS will be referred to as unlikely depressed.
In order to further interpret these findings, the DASS-21 severity categories (i.e., mild, moderate, severe, and
extremely severe) were explored for each defined group of women (i.e., depressed, anxious-depressed, anxious,
and stressed), with the corresponding number of women who received an EPDS classification (i.e., likely depressed
and unlikely depressed) (see Table 1).
Table 1: Numbers of women in each scoring category on DASS-21 depression, anxiety and stress scales for
each classified group (depressed, anxious-depressed, anxious, and stressed), and the number of women with
corresponding EPDS identifications
Mil No EPDS identification (i.e., unlikely
d Moderate Severe Extremely Severe depressed)

Depressed group (N = 38)

on DASS-depression 24 12 1 1
on EPDS-likely depressed 14 9 a 1 1 12
Anxious-depressed group (N =
23)
on DASS-depression 3 9 9 2
on EPDS-likely depressed 3 7 9 2 2b
on DASS-anxiety 5 8 3 7
on EPDS-likely depressed 4 8 2 7 2b
Anxious group (N = 18)
on DASS-anxiety 10 4 1 3
on EPDS-likely depressed 5 1 1 3 8
Stressed group (N = 15)
on DASS-stress 8 4 3
on EPDS-likely depressed 2 1 2 10

a Missing data for one woman who failed to complete the EPDS.

b The EPDS missed 4 classifications, 2 on depression and 2 on anxiety, which accounted for 2 cases of anxious-depression.

Women as likely depressed, although according to the DASS-21, 15 of these women were not depressed, but were
rather anxious and/or stressed. As is common practice with the use of the EPDS as a screening tool, an index of the
severity of depression is required. However, in practice, if a depression scale (in this case the DASS-21 depression
scale) had been the only measure used to assess the severity of the 80 EPDS-identified women, these 15 non-
depressedbut clearly, distressedwomen would have potentially been overlooked for further investigation and
assistance

Interpretation of output from Kappa

The main piece of information we are interested in is the table Symmetric Measures, which shows that the Kappa
Measure of Agreement value is .56, with a significance of p < .0005. According to Peat (2001, p. 228), a value of .5
for Kappa represents moderate agreement, above .7 represents good agreement, and above .8 represents
very good agreement. So in this example the level of agreement between the classification of cases as depressed
using the EPDS and the DASS-Dep is good.
Sensitivity and specificity

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The frequencies and percentages provided in the Cross tabulation table can also be used to calculate the
sensitivity and specificity of a measure or test. This is commonly used in the medical literature to assess the
accuracy of a diagnostic test in detecting the presence or absence of disease, or to assess the accuracy of a new
test against some existing gold standard. Sensitivity reflects the proportion of cases with the disease or condition
that were correctly diagnosed, while the specificity represents the proportion of cases without the condition that
were correctly classified. In this example, we can test the consistency of the classification of the DASS-Dep against
the commonly used screening test, the EPDS.

The sensitivity of the DASS-Dep can be determined by reading down the second column of the table. Out of the 80
cases identified as depressed by the EPDS (our acting gold standard), 46 were also classified depressed on the
DASS-Dep. This represents a sensitivity value of 57.5 per cent (46/80).The specificity is determined by reading
down the first column of people who were classified as not depressed by the EPDS. The DASS-Dep correctly
classified 225 out of the 239, representing a specificity rate of 94.1 per cent. The two scales are quite consistent in
terms of the cases classified as not depressed; however, there is some inconsistency between the cases that each
scale considers depressed. For further details of this study see the Appendix

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Annexure 1 Code Book

Full Variable Name SPSS Variable Name Coding instructions

Identification number id Subject identification number
Age Age Age in years
Age group 2 categories Under and over 35s 1= under 35 , 2=35 and over
Levels of education Education 1=Primary, 2=some secondary, 3=
complete secondary, 4=additional
training,5=under-graduation
university,6=post-graduation
university
Education group 2 categories Education groups 1=non-tertiary, 2=tertiary
Depression anxiety stress scale DASS Depression gps 0=not depressed,1= mild to severe
depressed
EPDS gps 0=not depressed, 1=likely
Edinburgh Postnatal Depression
depressed
Scale (EPDS)

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Annexure 2 SPSS Output tables

Frequencies
Statistics

DASS depress EPDS gps

gps

Valid 323 320

N
Missing 2 5

Frequency Table
DASS depress gps

Frequency Percent Valid Percent Cumulative

Percent

not depressed 262 80.6 81.1 81.1

Valid mild to severe depression 61 18.8 18.9 100.0

Total 323 99.4 100.0

Missing System 2 .6
Total 325 100.0

EPDS gps

Frequency Percent Valid Percent Cumulative Percent

not depressed 240 73.8 75.0 75.0

Valid likely depressed 80 24.6 25.0 100.0

Total 320 98.5 100.0
Missing System 5 1.5
Total 325 100.0

Crosstabs
Case Processing Summary

Cases

Valid Missing Total

N Percent N Percent N Percent

DASS depress gps * EPDS

319 98.2% 6 1.8% 325 100.0%
gps

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 DASS depress gps * EPDS gps Crosstabulation

EPDS gps To

not depressed likely depressed

Count 225 34
not depressed
% within DASS depress gps 86.9% 13.1% 1
DASS depress gps
Count 14 46
mild to severe depression
% within DASS depress gps 23.3% 76.7% 1
Count 239 80
Total
% within DASS depress gps 74.9% 25.1% 1

Symmetric Measures

Value Asymp. Std. Errora Approx. Tb Approx. Sig.

Measure of Agreement Kappa .563 .055 10.231 .000

N of Valid Cases 319

a. Not assuming the null hypothesis.

b. Using the asymptotic standard error assuming the null hypothesis.