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Table 2 Summary of key themes related to conceptualization of mood and factors related to depressive symptoms

From: Cognitive testing of the PHQ-9 for depression screening among pregnant and postpartum women in Kenya

Key theme

Representative quotations

“Depression” is described with specific cultural idioms including “thinking too much”, “feeling moodless”, and “feeling like your head will burst”

“You feel like your head is going to burst, you are thinking about a lot of issues. You are feeling so depressed.” Pregnant, HIV-uninfected, spoke in Kiswahili and English, PHQ-9 score of 8

“Depression is when you are having a lot of disturbing thoughts.” Postpartum, HIV-infected, spoke in Kiswahili and English, had a PHQ-9 score of 2

Depressive symptoms are common but transient during pregnancy and postpartum periods

“If you find that for two days you don’t feel the same way you were a few days ago, you get a counselor to talk to you because we women, we feel so moodless when we are pregnant and it’s not intentional. Sometimes you will find your husband asking for food and you tell him to go and get for himself the food and this is just because you are moodless, it’s not because you want to. But tomorrow you will find that your mind is stable and you are back to normal.” Pregnant, HIV-uninfected, spoke in Kiswahili and English, PHQ-9 score of 8

Depressive symptoms are related to external stressors including responsibilities as a wife and mother, relationship with a partner, and one’s HIV status

“Sometimes one feels they are down because you want to do that thing but you don’t make it. Like you can see I want to wash dishes but I don’t feel like it so I will feel like I am down. Yes, the house is dirty, what the husband will think, you see?” Pregnant, HIV-uninfected, spoke in Kikuyu, Kiswahili, and English, PHQ-9 score of 4

“Sometimes you find that you are quarrelling with your husband. You find that the children have been chased away from school for school fees, no food is in your house. You feel you are so stressed…if it’s eating, there is no mood to eat. When people talk to you, you feel that today you have no mood.” Pregnant, HIV-uninfected, spoke in Kiswahili and English, PHQ-9 score of 8

“I might wake up and sit with my husband, we might start chatting and then you find we have disagreed over a small issue, or he asks me to do something and then I tell him that I will not be able to do it but he insists. That issue affects me and I see as if he is forcing me to do something that I don’t want to do. I feel bad about it…I keep getting depressed because of these issues. Sometimes I lose hope as to whether we will stay together or if he will leave me at some point. There was a time when we had a disagreement and I found myself going to get poison to take. Luckily he came home and so I did not take it. I find myself thinking about it [still].” Pregnant, HIV-infected, spoke in Kiswahili and English, PHQ-9 score of 9

“Most of the time, the way I am (HIV-positive), you keep thinking about your child’s results…My child has already been tested for [HIV] and I had a lot in my mind about the results. Something else that can bother my mind is when you live discordant, I think about my husband leaving me because he probably sees me differently.” Postpartum, HIV-infected, spoke in Kiswahili and English, PHQ-9 score of 5

“Mostly what can make a person die is not using [HIV] medication wrongly, it is lack of counseling and stigma from HIV negative people because they can be using medicine well but those around them stigmatize them or society stigmatizes them so they get depression or stress. It is mainly about feeling like a failure especially when you look at your age mates, when you compare your life and see that their lives are better.” Postpartum, HIV-infected, spoke in Kiswahili, PHQ-9 score of 17

Unintended pregnancy and HIV diagnosis can cause women to feel they’ve let their families down

“I can use an example, whereby we have a family, they had a girl child, so the girl child fails to finish her education, she gets pregnant. For me that can be a failure. Disappointing the family.” Postpartum, HIV-uninfected, spoke in Kiswahili and English, PHQ-9 score of 3

“Mostly it’s about being HIV positive so it makes me think I have let people down, so I feel like even if I do something good, I doubt that anyone will see as if I have achieved anything.” Postpartum, HIV-infected, spoke in Kiswahili, PHQ-9 score of 17

Religious coping is important for participants who experience depressive symptoms, feelings of hopelessness, or suicidal ideation

“[Depression] is when you say that you have lost hope. What can I say, like I had said earlier, you should just thank God…When I experience the things I have told you and I am not able to eat, I ask God to help me. If I face any difficulty, God will help me.” Pregnant, HIV-uninfected, spoke in Kikuyu, PHQ-9 score of 8

“With depression it’s something that has really gotten to you, that’s weighing heavily on the mind and you feel that thing might bring harm to your body. However, after some days you can get into a state of acceptance, you begin to see that God is there, you pray, you tell God that He’s in control, that He’s the one that can intervene and you begin to feel peace.” Pregnant, HIV-uninfected, spoke in Kiswahili, PHQ-9 score of 8

“[When talking to someone with suicidal intent], I would comfort them and tell them because it was God who created you let Him take you when the time comes, instead of doing yourself harm which could mean that you are correcting God”. Pregnant, HIV-infected, spoke in Kiswahili and Kikuyu, PHQ-9 score of 2