Sociodemographic Differences in Perspectives on Postpartum Symptom Reporting

Abstract

Objective The overall goal of this work is to create a patient-reported outcome (PRO) and decision support system to help postpartum patients determine when to seek care for concerning symptoms. In this case study, we assessed differences in perspectives for application design needs based on race, ethnicity, and preferred language.

Methods A sample of 446 participants who reported giving birth in the past 12 months was recruited from an existing survey panel. We sampled participants from four self-reported demographic groups: (1) English-speaking panel, Black/African American race, non-Hispanic ethnicity; (2) Spanish-speaking panel, Hispanic-ethnicity; (3) English-speaking panel, Hispanic ethnicity; (4) English-speaking panel, non-Black race, non-Hispanic ethnicity. Participants provided survey-based feedback regarding interest in using the application, comfort reporting symptoms, desired frequency of reporting, reporting tool features, and preferred outreach pathway for concerning symptoms.

Results Fewer Black participants, compared with all other groups, stated that they had used an app for reporting symptoms (p = 0.02), were least interested in downloading the described application (p < 0.05), and found a feature for sharing warning sign information with friends and family least important (p < 0.01). Black and non-Hispanic Black participants also preferred reporting symptoms less frequently as compared with Hispanic participants (English and Spanish-speaking; all p < 0.05). Spanish-speaking Hispanic participants tended to prefer calling their professional regarding urgent warning signs, while Black and English-speaking Hispanic groups tended to express interest in using an online chat or patient portal (all p < 0.05)

Conclusion Different participant groups described distinct preferences for postpartum symptom reporting based on race, ethnicity, and preferred languages. Tools used to elicit PROs should consider how to be flexible for different preferences or tailored toward different groups.

Keywords

patient-reported outcomes - obstetrics - symptom information

Background and Significance

Maternal health organizations have developed solutions to address the high-rate pregnancy-related deaths (PRDs) in the United States.[1] [2] However, interventions rely on perinatal persons recognizing symptoms and contacting a provider.[3] [4] Professional associations have also created one-page summaries to help patients identify PRD warning signs,[5] [6] but these do not provide real-time, tailored support. The use of patient-reported outcomes (PROs) paired with simplified algorithms may bridge this gap by allowing patients to report symptoms and encouraging them to seek care when indicated.[7] [8] [9] [10]

It will be critical for PRO tools to prioritize the needs of minoritized groups.[11] In one 2020 study, Black/African American and Hispanic/Latino patients experienced severe maternal morbidity nearly three and two times more than White patients, respectively.[12] Postpartum depression is also significantly more common in Black perinatal patients and those who are non-English language preferring (NELP).[12] [13] Additional studies have indicated that NELP patients have significantly worse postpartum outcomes,[14] [15] [16] [17] [18] although recent reports focus solely on race/ethnicity and fail to break out the unique needs of NELP patients.

Objectives

The overall goal of this work is to create two versions of a PRO and patient decision support application, the maternal outcome monitoring support (MOMS) system. An English-language version will prioritize the needs of Black postpartum patients, and a Spanish-language version will prioritize the needs of NELP Hispanic postpartum patients. The goal of this case study is to understand differences in perspectives for the described tool among postpartum patients of (1) Black/African American race, (2) Spanish-speaking Hispanic ethnicity, (3) English-speaking Hispanic ethnicity, and (4) non-Black race and non-Hispanic ethnicity. Comparisons will allow us to determine both differential needs for the English and Spanish versions of the app, while also informing tailoring needs for future extension of the app to other groups.

Methods

Study Design

Survey sampling services (Qualtrics and Dynata) recruited 446 participants who had given birth within the past 12 months for a one-time, cross-sectional survey using standardized recruitment materials. Each panel included participants representative of the U.S. Census based on race, ethnicity, age, and gender.

Table 1 Description of survey measure question and response text

Source	Topic	Question(s)	Response options
Background, general interest	Experience reporting symptoms	Have you ever used an app (i.e., on your phone) to enter information about your symptoms or how you were feeling?	Yes, no
		Have you ever used an app (i.e., on your phone) to enter information about things going on with your baby (e.g., feeding, changing)?
	Interest in MOMS	We now want you to imagine you are talking to researchers who are creating an app along with your health professional's office that would allow you to report symptoms you have after having a baby. The app could tell you if (1) the symptoms are normal and you do not need to take any action at this time OR (2) the symptoms are concerning and you should reach out to a health professional. The following questions are about this app. Would you download the described application?	Yes, no, I need more information
Qualitative interviews	Comfort reporting symptoms	How comfortable would you feel reporting physical health symptoms (e.g., headache, shortness of breath, and blurred vision) using the app (symptoms would only be seen by your health team and researchers studying the app)?	Very comfortable, somewhat comfortable, neutral, somewhat uncomfortable, and very uncomfortable
		How comfortable would you feel reporting mental health symptoms (e.g., extreme sadness, worry, or tiredness) using the app (symptoms would only be seen by your health team and researchers studying the app)?
	Desired frequency of reporting	How often would you be willing to report symptoms?	More than once per day, once per day, once per week, only when you are experiencing symptoms, other
	Reporting tool features	How important would it be to have reminders to enter your symptoms?	Very important, somewhat important, neutral, not important
		How important would it be that the app provides resources about what you may do at home related to the symptom(s) you have shared?
		We are also considering having an option where mothers could choose trusted friends or family members who may see the information in the app (but not report symptoms). How helpful would this feature be to you?	Very helpful, somewhat helpful, neutral, somewhat unhelpful, very unhelpful
	Preferred outreach pathway for concerning symptoms	What options would you like for contacting your health professional team?	Call yourself, schedule a call with a nurse for the current or next business day, use an online chat, send a secure message using your patient portal, other

Abbreviation: MOMS, maternal outcome monitoring support.

The study team designed the survey and provided anonymous links to the survey which was distributed by the survey sampling services to panels of their verified users. Participants consented and completed the study using the Qualtrics survey platform.

Participants

Eligible adult participants reported giving birth within the past 12 months and were able to read English or Spanish. Participants belonged to one of four self-identified demographic subgroups: (1) profile language of English, Black/African American race (B/NH-Eng), and non-Hispanic ethnicity; (2) profile language of Spanish and Hispanic ethnicity; (3) profile language of English with Hispanic ethnicity (Hisp-Eng); or (4) profile language of English, non-Black race, and non-Hispanic ethnicity (NB/NH-Eng).

Study Measures

The survey asked about the postpartum experience (symptoms experienced and actions taken), information use and sharing preferences, questions specific to PROs and the tool under development, patient activation,[19] knowledge of PRD symptoms, and sociodemographics ([Table 1]). This case study focuses on results related to PROs and the related PRO collection and patient decision support system under development (MOMS).

Table 2 Sociodemographic characteristics of the sample (n = 446), mean (SD) or n (%), and range as appropriate

Demographic subgroup	Overall (n = 446)	B/NH-Eng (n = 97)	Hisp-Eng (n = 116)	Hisp-Span (n = 171)	NB/NH-Eng (n = 62)	p-Value
Age–mean; range	33.6; range: 18–52	31.3; range: 18–52	32.9; range: 19–51	34.6; range: 19–53	35.7; range: 22–48	p < 0.01
Education
Less than a bachelor's degree	200 (44.8%)	55 (57.3%)	60 (51.7%)	69 (43.1%)	16 (25.8%)	p = 0.001
Bachelor's degree or higher	234 (52.4%)	41 (42.7%)	56 (48.3%)	91 (56.9%)	46 (74.2%)
Prefer not to answer	12 (2.7%)	1 (1.0%)	0 (0%)	11 (6.4%)	0 (0%)
Perceived financial resources
“Enough” or “more than enough”	353 (79.1%)	65 (69.1%)	97 (84.3%)	137 (80.6%)	54 (88.5%)	p = 0.011
“Not enough”	87 (19.5%)	29 (30.9%)	18 (15.7%)	33 (19.4%)	7 (11.5%)
Prefer not to answer	6 (1.3%)	3 (3.1%)	1 (0.9%)	1 (1 (0.6%)	1 (1.6%)
Number of children
One child	170 (38.1%)	27 (28.4%)	46 (39.6%)	88 (57.1%)	9 (14.5%)	p < 0.001
Two or more children	257 (57.6%)	68 (71.6%)	70 (60.4%)	66 (42.9%)	53 (85.5%)
Prefer not to answer	19 (4.3%)	2 (2.1%)	0 (0%)	17 (9.9%)	0 (0%)

Abbreviations: B/NH-Eng, Black, non-Hispanic, English-speaking; Hisp-Eng, Hispanic, English-speaking; Hisp-Span, Hispanic, Spanish-speaking; NB/NH-Eng, non-Black, non-Hispanic, English-speaking.

We developed de novo questions, given that the survey involved a novel tool. Question topics relevant to MOMS were derived from a qualitative interview study of 45 obstetric health professionals, mental health professionals, and representative patients.[20] Relevant topics included: (1) experience reporting symptoms, (2) interest in MOMS, (3) comfort reporting symptoms, (4) desired frequency of reporting, (5) reporting tool features, and (6) preferred outreach pathway for concerning symptoms ([Table 1]). The first two categories were included out of general interest to understand differences in experience using symptom reporting applications and perceptions of the MOMS tool. The latter categories were derived from the qualitative study. First, participants echoed previous studies that there may be sensitivities in reporting mental health symptoms compared with somatic symptoms due to stigma.[21] Second, participants expressed varied views about how often they would want to report symptoms with an emergent desire for “just-in-time” symptom reporting as opposed to set intervals. Third, participants described a potential role for additional features including reminders to report symptoms, resources for nonurgent symptom management, and the ability to have trusted care partners view urgent warning signs. Last, participants expressed interest in different options for outreach to health professionals when urgent symptoms were encountered, and these options were included as closed-ended answer options in the survey.

The study team has expertise in health literacy, consumer health informatics, PROs, reproductive psychiatry, and obstetrics. The study team iteratively reviewed the entire question battery to ensure construct and face validity. After several rounds of feedback from the study team, the questions were pilot tested with naive users in English to resolve any confusing wording or survey logic programming issues. The survey was then translated into Spanish by a certified translator. The translations were also reviewed by a native speaker not involved with the translation. See [Supplementary Material] (available in the online version) for the full survey battery.

Power Calculation

Assuming a moderate effect size, we calculated a minimum necessary sample size of 67 participants in each of the four demographic groups using GPower version 3.1 (Cohen's effect size = 0.5, two-sided α = 0.05, Power = 0.8).[22] We initially targeted outreach to 100 participants per group and worked with the survey sampling firm to reach these quotas within the time frame we had to complete the study.

Analysis

For proportions, we applied chi-squared tests, except in situations where cell sizes were too small when we instead used Fisher's exact test. Ages, the only non-proportional variable, were treated as raw continuous values, and differences in age between groups were evaluated by analysis of variance, followed by post-hoc tests using Bonferroni corrections. Those (n = 2) who reported under the age of 18 years or over 55 years were excluded from the analysis.

Missing data were mitigated by using Qualtrics built-in “force response” feature that did not allow participants to continue without responding to needed questions. We also included “other,” “neutral,” or “prefer not to answer” options for more sensitive questions so participants did not feel forced into unsuitable answer options.

Results

Participant Characteristics

[Table 2] presents the characteristics of the participants by group as well as the results of statistical testing to determine differences between groups.

Perspectives on Patient-Reported Outcomes and the Patient-Reported Outcome Tool (Maternal Outcome Monitoring Support)

[Table 3] reports participant perspectives regarding PROs and the MOMS system. We first asked participants if they had ever reported symptoms or how they were feeling in an app either for themselves or for their baby. Black participants were least likely to have reported symptoms about themselves (57.7% compared with over 70% in all other groups). There were no significant differences in having reported symptoms of their babies.

Table 3 Differences in participant perspectives related to outcome reporting and the MOMS system

Demographic subgroup	Overall	B/NH-Eng (n = 97)	Hisp-Eng (n = 116)	Hisp-Span (n = 171)	NB/NH-Eng (n = 62)	p-Value
Symptom reporting using an app
For self (yes)	323 (72.4%)	56 (57.7%)	84 (72.4%)	136 (79.5%)	47 (75.8%)	p = 0.02[a]
For baby (yes)	226 (75.3%)	69 (71.1%)	88 (75.9%)	132 (77.2%)	47 (75.8%)	p = 0.74
Download MOMS app (yes)	390 (87.4%)	76 (78.3%)	106 (91.4%)	156 (91.2%)	52 (83.9%)	p = 0.046[a]
Comfort with symptom reporting (very comfortable or somewhat comfortable)
Physical symptoms	380 (85.3%)	79 (81.4%)	101 (87.1%)	148 (86.6%)	52 (83.9%)	p = 0.64
Mental health symptoms	365 (81.8%)	72 (74. %2)	98 (84.5%)	146 (85.4%)	49 (79.0%)	p = 0.11
Preferred symptom reporting frequency
More than once per day	149 (33.4%)	25 (25.8%)	28 (24.1%)	82 (47.9%)	14 (22.6%)	p < 0.001[a]
Once per day	161 (33.6%)	34 (35.1%)	55 (47.4%)	49 (28.7%)	23 (37.1%)	p = 0.014[a]
Once per week	67 (15.0%)	18 (18.6%)	16 (13.8%)	22 (12.9%)	11 (17.7%)	p = 0.56
Only when experiencing symptoms	66 (14.7%)	19 (19.6%)	17 (14.7%)	16 (9.4%)	14 (22.6%)	p = 0.033[a]
Other	87 (19.5%)	29 (30.9%)	18 (15.7%)	33 (19.4%)	7 (11.5%)	NA
Importance of app features (very/somewhat important, very/somewhat helpful)
Reminders to enter symptoms	390 (87.4%)	80 (82.4%)	101 (87.1%)	158 (92.4%)	51 (82.3%)	p = 0.056
Resources for symptom self-management	406 (91.0%)	85 (87.6%)	104 (89.7%)	162 (94.7%)	55 (88.7%)	p = 0.177
Symptom information sharing with trusted significant others	360 (80.7%)	65 (67.0%)	100 (86.2%)	148 (86.6%)	47 (75.8%)	p < 0.001[a]
Preferred outreach pathway for outreach to health professional (for severe symptoms)
Call health professional them self	259 (58.0%)	44 (45.4%)	68 (58.6%)	115 (67.3%)	32 (51.6%)	p < 0.01[a]
Schedule a call with nurse (same or next day)	195 (43.7%)	56 (57.7%)	58 (50.0%)	53 (31.0%)	28 (45.1%)	p < 0.001[a]
Online chat	151 (33.9%)	39 (40.2%)	50 (43.1%)	45 (26.3%)	17 (27.4%)	p < 0.01[a]
Patient portal secure message	90 (20.2%)	26 (26.8%)	32 (27.6%)	22 (12.9%)	10 (16.1%)	p < 0.001[a]

Abbreviations: B/NH-Eng, Black, non-Hispanic, English-speaking; Hisp-Eng, Hispanic, English-speaking; Hisp-Span, Hispanic, Spanish-speaking; MOMS, maternal outcome monitoring support; NA, not available; NB/NH-Eng, non-Black, non-Hispanic, English-speaking.

^a p-Value significant < 0.05.

We provided participants with the following description of the MOMS system and asked if they would download the app, “We now want you to imagine you are talking to researchers who are creating an app along with your health professional's office that would allow you to report symptoms you have after having a baby. The app could tell you if 1) the symptoms are normal and you do not need to take any action at this time OR 2) the symptoms are concerning and you should reach out to a health professional.”

Black participants were least likely to report that they would download the app (78.3%) with non-Black/non-Hispanic participants being the next least likely (83.9%) and over 90% of both Hispanic participant groups reporting that they would download the app.

Participants then provided their level of comfort reporting physical (85.3% very or somewhat comfortable) and mental health symptoms (81.8% very or somewhat comfortable); we found no significant differences across groups comparing those who stated they would be “very comfortable” or “somewhat comfortable” versus those who would be “neutral,” “somewhat uncomfortable,” or “very uncomfortable.”

Next, participants selected how often they would be willing to report their symptoms. Spanish-speaking Hispanic participants were most likely to prefer reporting symptoms more than once per day (47.9%; p < 0.001), with English-speaking Hispanics most frequently selecting once per day (47.4%; p = 0.014). A plurality of Black (35.1%) and non-Black/non-Hispanic (37.1%) participants also selected once-per-day reporting but at lower rates. Black (14.7%) and non-Black/non-Hispanic (22.6%) participants preferred only reporting symptoms as they were experiencing them at a higher rate than the two Hispanic groups (p = 0.033).

Participants then rated the importance of app features mentioned in the semistructured interviews (i.e., reminders to enter symptoms, resources for nonurgent symptom management, and sharing symptom information with care partners). Black and non-Black/non-Hispanic participant groups found a feature that would allow them to share educational symptom information (but not symptom reports) with trusted others of their choice less important than the two Hispanic groups. No other comparisons were significant.

Last, participants selected options they would like for reaching out to a health professional if the app determined the symptoms they had reported required additional assistance. Participants could select multiple options. Spanish-speaking Hispanics preferred calling the health professionals themselves (67.3%), followed by English-speaking Hispanics (58.6%), non-Black/non-Hispanics (51.6%), and then Blacks (45.4%). Fifty-eight percent of Black participants preferred the option to schedule a call, which was the least preferred option among Spanish-speaking Hispanic participants. A relatively higher percentage of Black and English-speaking Hispanic participants preferred online chat and patient portal secure message options as compared with the Spanish-speaking Hispanic and non-Black/non-Hispanic participants.

Discussion

Our case study report found nuanced differences in preferences and priorities for a PRO and decision support system for the postpartum period based on race, ethnicity, and language. Several studies have addressed presenting PROs back to patients and possible inclusive tailoring approaches.[23] [24] [25] [26] However, fewer focus on how the PROs are collected, and our results serve as a starting point for addressing this gap.

Black participants described less experience using apps to report symptoms about themselves, though they did not report significant differences in tracking information about their babies. As outcome reporting often occurs through the patient portal, previously described disparities in portal use may be one driver of this difference.[27] However, Black participants (along with English-speaking Hispanic participants) were relatively more interested in using an online chat or the patient portal for reaching out to health professionals. This finding aligns with previous research indicating that access to eHealth tools may not be offered equitably, due to assumptions by care teams in who may use these tools or disparities in technology access,[28] and strategies such as universal signups may mitigate disparities in use.[29]

Black participants also had significantly less interest in downloading the described PRO and decision support application compared with other groups, although interest was still relatively high, with more than three-quarters reporting interest in downloading the app. The description app provided did not indicate that the tool had been designed exclusively with Black postpartum people for Black postpartum people. Given the known disparities and distrust among Black patients driven by systemic racism, indicating when PRO and other tools have been tailored toward them may be an important feature for outreach.[30] Relatedly, another study involving a tool for perinatal symptom support for Black patients highlighted the importance of participants feeling like the content was written for them.[31] Black participants further expressed less interest in a feature that would allow them to share warning sign information with trusted others of their choosing. This may be driven by lower levels of interest in the tool but could also be impacted by phenomena such as stigma or the Black superwoman syndrome, which involves “perceived obligations to project strength, resist feelings of vulnerability and dependence…and prioritize caregiving over self-care.”[32]

Spanish-speaking Hispanic participants expressed a willingness to report symptoms most frequently (more than once per day), followed by English-speaking Latina participants who most often selected that they would prefer to report symptoms once per day. This may indicate, for example, a preference to provide health professionals with information more frequently to allow them to support decisions or an increased perceived need for help with symptoms they experience.

Spanish-speaking Latina participants also preferred calling their health professional as a means for outreach for concerning symptoms, which may require a language-concordant health professional or interpreter support. They reported less interest in online chat options which may facilitate automated translation support, so future work should explore if there may be ways to make this option more appealing when linguistically concordant services may be in short supply.

This study had several limitations. First, as a case study, it focuses on a specific PRO and decision support application designed for severe postpartum symptoms. Second, Spanish-speaking Latina participants were chosen from Spanish-speaking panels, which may include persons who can speak English in addition to Spanish. Hispanic ethnicity patients also reporting their race as Black were included in the Hispanic ethnicity group. Future studies may determine if there are differences in need based on race among those of Hispanic ethnicity.[33] While panels used for recruitment were representative of the U.S. Census based on certain demographic variables, it is unclear if issues regarding representation in our sample (e.g., somewhat higher average education) are due to the panel sample or those who elected to participate in this study. Future designs may consider approaches that allow for more complex modeling to understand differences in perspectives, as in our study, there were significant demographic differences between groups. Specifically, previous studies have indicated that self-reporting may also be impacted by sociodemographic factors such as education or financial resources. This should be further explored. In our work, we will conduct iterative usability assessments of MOMS with target end user groups prior to evaluation and use to ensure appropriate implementation of findings. Lastly, we may be slightly underpowered after exclusion to detect differences among the non-Black/non-Hispanic group.

Conclusion

Our case study indicated that participants may have different tailoring needs for applications that elicit PROs and provide related decision support to patients. While this finding requires further assessment in other clinical domains, it suggests that the flexibility of interaction pathways in applications that allow for PRO entry may help support inclusive design for different groups of participants. Flexible designs within a single system may also support users with intersectional identities and the complexities of changing needs within individual participants.[34] [35]

Clinical Relevance Statement

PROs and associated decision support may help perinatal patients better understand how they are feeling, promote education, increase confidence in self-care abilities, and help them determine when to seek care for concerning symptoms. It is important that these tools be inclusively designed to mitigate disparities in use. Inclusive design may require flexible interfaces or tailoring to meet the needs of different patient groups based on race, ethnicity, and preferred language.

Multiple-Choice Questions

1. Which of the following is NOT a reason cultural tailoring may be helpful for patient-reported outcomes reporting tools?

   • So participants feel the language in the tool is written for them.

   • To reduce disparities in utilization of patient-reported outcomes.

   • To discourage certain groups of people from using them.

   • To be respectful and inclusive of different cultural identities.

   Correct Answer: The correct answer is option c. To discourage certain groups of people from using them.

2. Which of the following may present challenges to cultural tailoring?

   • There may be many relevant groups that need to use the tool.

   • People may identify with more than one group.

   • Group identities and needs can change over time.

   • All of the above.

   Correct Answer: The correct answer is option d. All of the above.

Conflict of Interest

L.E.R. is an up-to-date contributor and an advisory board member for the New English Journal of Medicine, and Contemporary OB/GYN. She has also been a speaker for Medscape and is an expert reviewer for Pfizer on the RSV Vaccine. A.H. is an up-to-date contributor, a co-founder and medical consultant for Iris Ob Health, and a consultant for Progyny.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by the Weill Cornell Medicine Institutional Review Board.

• References

• 1 Pregnancy-related deaths in the United States. Published September 26, 2023 . Accessed September 27, 2023 at: https://www.cdc.gov/hearher/pregnancy-related-deaths/index.html
• 2 Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States,. 2017–2019 \textbar CDC. Accessed November 10, 2022 at: https://www.cdc.gov/maternal-mortality/php/data-research/mmrc-2017-2019.html?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html
• 3 Troiano NH, Witcher PM. Maternal mortality and morbidity in the united states: classification, causes, preventability, and critical care obstetric implications. J Perinat Neonatal Nurs 2018; 32 (03) 222-231
• 4 Bingham D, Suplee PD, Morris MH, McBride M. Healthcare strategies for reducing pregnancy-related morbidity and mortality in the postpartum period. J Perinat Neonatal Nurs 2018; 32 (03) 241-249
• 5 Suplee PD, Kleppel L, Santa-Donato A, Bingham D. Improving postpartum education about warning signs of maternal morbidity and mortality. Nurs Womens Health 2017; 20 (06) 552-567
• 6 Urgent Maternal Warning Signs \textbar CDC. Accessed November 11, 2022 at: https://www.cdc.gov/hearher/maternal-warning-signs/index.html
• 7 Chen H, Chai Y, Dong L, Niu W, Zhang P. Effectiveness and appropriateness of mhealth interventions for maternal and child health: systematic review. JMIR Mhealth Uhealth 2018; 6 (01) e7
• 8 Ngai FW, Chan SWC, Ip WY. The effects of a childbirth psychoeducation program on learned resourcefulness, maternal role competence and perinatal depression: a quasi-experiment. Int J Nurs Stud 2009; 46 (10) 1298-1306
• 9 Guo Y, Chen Y, Lane DA, Liu L, Wang Y, Lip GYH. Mobile health technology for atrial fibrillation management integrating decision support, education, and patient involvement: mAF app trial. Am J Med 2017; 130 (12) 1388-1396.e6
• 10 Denis F, Basch E, Septans AL. et al. Two-year survival comparing web-based symptom monitoring vs routine surveillance following treatment for lung cancer. JAMA 2019; 321 (03) 306-307
• 11 Krishnamurti T, Birru Talabi M, Callegari LS, Kazmerski TM, Borrero S. A framework for Femtech: guiding principles for developing digital reproductive health tools in the United States. J Med Internet Res 2022; 24 (04) e36338
• 12 Howell EA, Egorova NN, Janevic T. et al. Race and ethnicity, medical insurance, and within-hospital severe maternal morbidity disparities. Obstet Gynecol 2020; 135 (02) 285-293
• 13 Wisner KL, Sit DKY, McShea MC. et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry 2013; 70 (05) 490-498
• 14 Hayes I, Enohumah K, McCaul C. Care of the migrant obstetric population. Int J Obstet Anesth 2011; 20 (04) 321-329
• 15 Pope C. Addressing limited English proficiency and disparities for Hispanic postpartum women. J Obstet Gynecol Neonatal Nurs 2005; 34 (04) 512-520
• 16 Campbell-Grossman C, Brage Hudson D, Keating-Lefler R, Ofe Fleck M. Community leaders' perceptions of single, low-income mothers' needs and concerns for social support. J Community Health Nurs 2005; 22 (04) 241-257
• 17 Bennett IM, Culhane JF, McCollum KF, Mathew L, Elo IT. Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency. Am J Orthopsychiatry 2007; 77 (02) 243-248
• 18 Webb DA, Bloch JR, Coyne JC, Chung EK, Bennett IM, Culhane JF. Postpartum physical symptoms in new mothers: their relationship to functional limitations and emotional well-being. Birth 2008; 35 (03) 179-187
• 19 Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004; 39 (4 Pt 1): 1005-1026
• 20 Benda N, Woode S, Niño de Rivera S. et al. Understanding symptom self-monitoring needs among postpartum black patients: qualitative interview study. J Med Internet Res 2024; 26: e47484
• 21 Bodnar-Deren S, Benn EKT, Balbierz A, Howell EA. Stigma and postpartum depression treatment acceptability among black and white women in the first six-months postpartum. Matern Child Health J 2017; 21 (07) 1457-1468
• 22 Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 2009; 41 (04) 1149-1160
• 23 Lor M, Koleck TA, Bakken S. Information visualizations of symptom information for patients and providers: a systematic review. J Am Med Inform Assoc 2019; 26 (02) 162-171
• 24 Arcia A, George M, Lor M, Mangal S, Bruzzese JM. Design and comprehension testing of tailored asthma control infographics for adults with persistent asthma. Appl Clin Inform 2019; 10 (04) 643-654
• 25 Arcia A, Merrill JA, Bakken S. Consumer engagement and empowerment through visualization of consumer-generated health data. In: Edmunds M, Hass C, Holve E. eds. Consumer Informatics and Digital Health: Solutions for Health and Health Care. Switzerland:: Springer International Publishing;; 2019: 183-203
• 26 Turchioe MR, Myers A, Isaac S. et al. A systematic review of patient-facing visualizations of personal health data. Appl Clin Inform 2019; 10 (04) 751-770
• 27 Grossman LV, Creber RMM, Benda NC, Wright D, Vawdrey DK, Ancker JS. Interventions to increase patient portal use in vulnerable populations: a systematic review. J Am Med Inform Assoc 2019; 26 (8–9) 855-870
• 28 Internet, broadband fact sheet. Pew Research Center. Published January 31, 2024 . Accessed May 1, 2024 at: https://www.pewresearch.org/internet/fact-sheet/internet-broadband/
• 29 Ancker JS, Nosal S, Hauser D, Way C, Calman N. Access policy and the digital divide in patient access to medical records. Health Policy Technol 2017; 6 (01) 3-11
• 30 Alexander K, Clary-Muronda V. A scoping review of interventions seeking to improve aspects of patient-provider relationships involving Black pregnant and post-partum people. J Adv Nurs 2023; 79 (05) 2014-2024
• 31 Bryant AS, Coleman J, Shi X. et al. The power and promise of postpartum self care: evaluation of a web-based tool for underserved women. Matern Child Health J 2023; 27 (03) 548-555
• 32 Woods-Giscombe C, Robinson MN, Carthon D, Devane-Johnson S, Corbie-Smith G. Superwoman schema, stigma, spirituality, and culturally sensitive providers: factors influencing African American women's use of mental health services. J Best Pract Health Prof Divers 2016; 9 (01) 1124-1144
• 33 Torres-Ruiz M, Robinson-Ector K, Attinson D, Trotter J, Anise A, Clauser S. A portfolio analysis of culturally tailored trials to address health and healthcare disparities. Int J Environ Res Public Health 2018; 15 (09) 1859
• 34 Valdez RS, Brennan PF. Embracing complexity: rethinking culturally informed design in human factors/ergonomics and consumer health informatics. Int J Hum Comput Interact 2017; 33 (04) 322-332
• 35 Kim MT, Heitkemper EM, Hébert ET. et al. Redesigning culturally tailored intervention in the precision health era: self-management science context. Nurs Outlook 2022; 70 (05) 710-724

Publication History

Received: 14 March 2024

Accepted: 11 June 2024

Article published online:
21 August 2024