Online Peer Support and Well-being of Mothers and Children: Systematic Scoping Review

Background Online peer support groups are common and can be an effective tool for mothers with young children. The purpose of this review is to examine the types of support that online-based peer groups establish, as well as its health effects on mothers and their children. Methods Systematic scoping review. Systematic review of existing literature was conducted using PubMed, CINAHL, Medline, Cochrane and Ichushi (Japanese language) database in December 2019. Results Based on the inclusion and exclusion criteria, a total of 1,475 articles were extracted by initial search. After the review of titles, abstracts and full texts, a total of 21 articles met the inclusion criteria. The types of support mothers received were mainly informational and emotional support. Mothers also felt a sense of connection and community. Some health effects of online-based peer support group were seen in the area of mothers’ mental well-being. Minimal effects were seen in behavioral modification for child nutrition and breastfeeding. Conclusion Due to the limited evidence in interventional studies, the effects of online-based peer support groups were inconclusive. Further studies with rigorous research designs would be helpful in future research.

Isolation of mothers, especially those with young children, in communities=societies has been a frequently discussed topic. 1,2 Shifts in family=community structure and change in workstyle for women contribute to social isolation among new mothers. 3,4 The geographic loss of a community network means fewer formal and informal safety nets for mothers. 2,3,5 Birthing and parenting can be physically and mentally demanding for mothers. Although the duration of postpartum hospitalization and the quality of postpartum care varies from country to country, the mothers with newborns are discharged soon after the delivery and are expected to know how to look after their infants. There used to be female family members and relatives who could share the wealth of wisdom for childbearing and childrearing at home or in the neighborhood; however, due to change in social structure, such as increases in the number of nuclear families, single-parent households, and pregnancies at advanced maternal age, it is more and more difficult for modern mothers to obtain readily available information and advice from their strong ties. [6][7][8] With this trend, internet appears to be filling the gap of mothers' needs for information and advice. Internet technology has spread dramatically over the past two decades and many parents utilize the Internet to seek information and support regarding health and parenting. 9,10 Numerous web-based mothers' communities have been established, formally and informally, and mothers use those sites for various reasons, including anonymity and immediate affirmation and support. 9,11 These online communities take various forms, such as bulletin boards, email threads, blogs and Social Networking Site (SNS) communities. SNS communities have grown significantly and many participate in one or more types of SNS. 12 In addition to the Internet, SNS has also become a critical source of information and support for parents. 9,11 Thus researchers have recently revealed how mothers of young children use the Internet and SNS, yet the effectiveness of online peer support groups on their well-being has not been well-examined.
Furthermore, it is important for health professionals including public health nurses to understand the effectiveness of online peer support groups because professional-led interventions were conducted online, sometimes in conjunction with online peer support groups. 13,14 Also, online peer support effects of general mothers are even less clear since many studies in this field were based on underline conditions and diseases. 4,15,16 By performing a review of currently available publications, the following questions are explored: 1. What kind of peer support are mothers providing and receiving from online parenting communities?
2. Are there any health effects to mothers and their children in relation to the use of online parenting communities?

Inclusion and exclusion criteria
With this scoping review, articles were searched for online peer support for infant and young children. Peer-reviewed journals in English and Japanese were included in the review. The inclusion criteria were as follows: 1. The study focused on online peer support group. 2. Online-based peer support was a part of interventions and= or focus of the study. 3. The target population included mothers with preschool children or younger. 4. The article assessed=examined the effect of online-based peer support group for mothers. Exclusion criteria were as follows: 1. The target online-based peer support groups were based on clinical conditions, diseases or prevention of specific clinical=health conditions. 2. The target online-based peer support groups have a major healthcare professional component (eg professional-led interventions) Literature selection processes are shown in Figure 1.

Search strategy
The literature search was conducted in December 2019. Pubmed, Medline, CINAHL, Cochrane and Ichushi (Japanese language) database were screened. Search terms used for the literature search is listed in Table 1. No limitation on years were applied. Some common clinical conditions related to online peer support, such as developmental disabilities, rare diseases, substance abuse, and neonatal intensive care (NICU) were applied as exclusion criteria. Elderly population was also applied as an exclusion term, since the target population was mothers of young children. With the database screening, a total of 1,475 articles were extracted for the review.
Among the selected articles, 238 articles were excluded due to duplication. Titles were screened for appropriateness for the review based on inclusion=exclusion criteria. Articles were excluded if the title included specific diseases names (ie, diabetes, autism), target population other than mothers with young children (ie, fathers, adolescents), terms that indicate specific treatment= intervention aims (ie, abuse, grief ), or terms that indicate types of research or intervention other than online peer support for parents (ie, systematic review, intervention for children). Then abstracts were examined based on inclusion=exclusion criteria (n = 96). The remaining 27 articles plus nine articles added from reference lists and other related systematic reviews were examined in full text based on the same criteria. After completion of the review with two researchers, a total of 21 articles were selected for this review ( Figure 1).

Study interests
There were several studies focused on first-time mothers. 20,21,23,24,28,32,33 Some targeted vulnerable populations such as adolescent and=or single mothers. 17,20,35 Among the intervention-based studies, outcome measures extended to various areas such as nutrition of children, 28 initiation and duration of breastfeeding 22 and parental stress level 29 as well as social support. 17,35 For non-interventional quantitative studies, research data was mainly retrieved from cross-sectional questionnaires= surveys. 8,[30][31][32][33] For qualitative studies, interviews, questionnaires and focus group meetings were the main data sources. Three studies retrieved data from online contents. 2,17,18 The majority of studies had outcomes measures with mental health related topics including empowerment, 21,30 depression, 31,32 self-esteem, 31 self-confidence, 20,25 parental stress level, 20,32,33,35 social support, 2,18,21,30-33 and loneliness. 8 Outcomes and emerging themes Mothers' mental well-being: feeling of support from online groups The majority of articles discussed direct or indirect effects of social support (informational, emotional and instrumental). 2,17,18,21,[30][31][32][33]35 Social capital was examined by Jang 34 by conducting path analysis among mothers of pre-school children in the United States. This study found that frequency of SNS use had a positive association with bonding social capital and bridging social capital. Drentea et al 2 analyzed contents of mothers' online bulletin boards threads and concluded that online community increased social capital by exchanging information and emotional support as well as community protection. Others suggested that mothers felt connectedness. 20 Yet, some studies also acknowledged negative support such as criticism, disagreement, polarized debate, and judgement, were seen in online communities. 2,17,27,35 Mothers' mental well-being: parental stress level and maternal depression There were three studies that examined relationships between online peer support and parental stress. 32,33,35 Nolan 20 conducted a qualitative research targeting adolescent mothers and found parental stress reduction with utilization of web discussion. Those mothers felt the effect of stress reduction by sharing problems and receiving positive feedback and empathetic responses. With the study conducted by Dunham, 35 Parenting Stress Index (PSI) was measured before and after the participation of web moderated social network platform for 6 months. The result showed that active participants were more likely to have decreased stress level post-intervention. Another study assessed parenting stress in relation to participation in blogging and online social networking among first time mothers. 32 There was no direct significant association between parenting stress and blogging=social networking. However, the author pointed out that blogging frequency predicted feelings of connectedness and connectedness predicted the social support when the variables were fitted to structural equation model (SEM). Parental stress had an intervening effect between social support and maternal depression. Miyata 31 explored depression and found that "non-posting" mothers in online peer groups initially had higher depression score, but the score lowered after three months. Meantime, depression score for "posting" group remained relatively same. When fitted into SEM, it was suggested that internet support may have indirectly reduced depression among online group users. A study done with Chinese mothers; however, did not support a hypothesis of negative relationship between mothers' online activities and perceived stress level. 33 Mothers' mental well-being: feeling of empowerment, self-esteem, and confidence Some also suggested that mothers not only accessed online communities to obtain knowledge, but also to seek validation for normality. 18,23,26 Empowerment was another topic examined in relation to mothers' online activities. One study showed online Pubmed (((("internet" OR "web" OR "online" OR "world wide web" OR "blog" OR "world wide web applications" OR "online system" OR "social media" OR "facebook" OR "chat" OR "social network site" OR "sns"[MeSH Major Topic])) AND ("psychosocial support" OR "peer counseling" OR "peer support" OR "peer support group" OR "peer group" OR "social support"[MeSH Major Topic])) AND (parent* OR "family" OR "mother/infant" OR "mother/child" OR "mother"[MeSH Major Topic])) NOT ("developmental disabilities" OR "rare disease" OR "substance abuse" OR "substance use" OR "drug abuse" OR "drug use" OR "drug addiction" OR "aged" OR "elderly" OR "senior" OR "older adult" OR "nicu") CINAHL and MEDLINE ( MH internet OR AB internet OR AB web OR online OR MH world wide web OR MH ( blog) OR MH "world wide web applications" OR MH (online system) OR AB "social media" OR AB facebook OR AB chat OR AB ( sns or social networking site ) ) AND ( MH support, psychosocial OR MH peer counseling OR MH peer support OR MH peer support groups OR MH peer group OR MH social support ) AND ( MH ( parents or parental or parenting ) OR MH ( mother and child ) OR MH family ) NOT ( MH (developmental disabilities) OR MH (rare diseases) OR MH ( substance abuse or substance use or drug abuse or drug addiction or drug use ) OR MH ( aged or elderly or senior or older people ) OR MH ( nicu or neonatal intensive care unit ) ) Cochrane database (internet OR web OR online OR world wide web OR blog OR world wide web applications OR online system OR social media OR facebook OR chat OR social network site OR sns) AND (psychosocial support OR peer counseling OR peer support OR peer support group OR peer group OR social support) AND (parent OR family OR mother/infant OR mother/child OR mother) NOT (developmental disabilities OR rare disease OR substance abuse OR substance use OR drug abuse OR drug use OR drug addiction OR aged OR elderly OR senior OR older adult OR nicu) in Title Abstract Ichushi (Japanese Database) ((インターネット/TH or internet/AL) or (インターネット/TH or インターネット/AL) or "web"/AL or "online"/AL or ("インターネット"/TH or "world wide web"/AL) or ("ブ ログ"/TH or "blog"/AL) or "world wide web applications"/AL or ("オンラインシステム"/TH or "online system"/AL) or ("ソーシャルメディア"/TH or "social media"/AL) or ((ソーシャルメディア/TH or "facebook"/AL) or (オンライン社会的ネットワーク形成/TH or "facebook"/AL)) or "chat"/AL/AL or "social network site"/AL or ((ソーシャルメ ディア/TH or "sns"/AL) or (オンライン社会的ネットワーク形成/TH or "sns"/AL)) AND (psychosocial/AL and support/AL or (心理社会的支援システム/TH or 心理社会的支 援システム/AL) or peer/AL and (カウンセリング/TH or counseling/AL) or (ピアカウンセリング/TH or ピアカウンセリング/AL) or peer/AL and support/AL or peer/AL and support/AL and group/AL or peer/AL and group/AL or (ピアグループ/TH or ピアグループ/AL) or social/AL and support/AL or (社会的支援/TH or 社会的支援/AL) or (心理 社会的支援システム/TH or 心理社会的支援システム/AL)) AND ((親らしさ/TH or parenting/AL) or (育児/TH or 育児/AL) or ("家族"/TH or "family"/AL) or (家族/TH or 家族 /AL) or (母/TH or mother/AL) or (母/TH or 母/AL) or (母子関係/TH or 母子関係/AL)) AND (PT=会議録除く) NOT ((developmental/AL and disabilities/AL or (発達障害/TH or 発達障害/AL) or rare/AL and (疾患/TH or diseases/AL) or (希少疾患/TH or 希少疾患/AL) or substance/AL and abuse/AL or substance/AL and use/AL or (薬物/TH or drug/AL) and abuse/AL or (薬物/TH or drug/AL) and use/AL or (薬物/TH or drug/AL) and (嗜癖行動/TH or addiction/AL) or (物質関連障害/TH or 物質関連障害/AL) or (薬物 乱用者/TH or 薬物乱用者/AL) or (高齢者/TH or 高齢者/AL) or (高齢者/TH or aged/AL) or (高齢者/TH or elderly/AL) or senior/AL or older/AL and (成人/TH or adult/AL) or (新生児 ICU/TH or nicu/AL) or (新生児 ICU/TH or 新生児 ICU/AL))) Yamashita A, et al.

Reference Number
Online group created by researchers • Data was obtained from prenatal (32-38 weeks) and postnatal interviews (when infants are 3 to 7 months). • Value experiential knowledge and practical advice. • No specific targeting online group selected • Mothers who delivered within 12 months (n = 6).
Samples were collected from face-to-face parenting group.
• Children <1 year-old • Data was collected via observation and interview • Improving confidence as a mother: seeking advice. Mothers' Online Peer Support Systematic Scoping Review group participation was correlated with feelings of empowerment among mothers. 30 O'Connor et al 21 also pointed out that virtual community provided an additional source of advice and increased mothers' sense of empowerment. In this study, association between online group engagement and feeling of empowerment was positive. As for self-esteem, Miyata suggested an indirect effect on self-esteem with internet community participation and this was also true with the participants who did not actively participate. 31 Some qualitative studies indicated that online community helped to increase mother's confidence as a parent. 20,25 Mothers' mental well-being: loneliness Mandai et al 8 conducted cohort cross-sectional study of Japanese mothers and found that higher loneliness was significantly related to smaller SNS (social network sites) network as well as real social network.

Behavioral change facilitation with online-based peer group
Some studies assessed behavioral outcomes with online-based peer group interventions. Those included child nutritional intake 28 and breastfeeding. 29 Family=social network related outcomes were also measured and those included marital satisfaction= conflict 32 and family support. 33 Behavioral change facilitation: nutritional intake of children Downing et al 28 examined Facebook peer group support effects after a series of nutrition classes (face-to-face). In this study, primary outcomes were children's physical measurements, physical activities and various food intakes. The amount of fruit intake was the only significant difference noted between mothers with online peer support and non-peer group support. Fruit intake was increased among children with mothers who joined online peer support group.

Behavioral change facilitation: breastfeeding
A nested interventional study was conducted to assess exclusive breastfeeding. 29 Intervention group had access to other members, and they had significantly higher exclusive breastfeeding rate at 26 weeks after delivery though no significance was noted in any other weeks.

DISCUSSION
Online peer support in form of informational, emotional supports were consistently present in the reviewed studies. Online peer support communities seem to influence mothers' mental well-being directly and indirectly. Yet, interventions related to behavioral change focusing on feeding did not seem to have significant effects. Price et al 23 concluded that online peer support would complement face-to-face interaction, but not as a substitution. Yet, others valued the nature of online anonymity and this particular environment provided safe spaces for mothers and facilitated disclosure of their true feelings and concerns. 20,21,24,27 One of the benefits of online support is its accessibility. Mothers can have a better sense of control and peace of mind by obtaining information, advice and reassurance in timely manner. There are "lurkers" who do not actively participate in the online communities but follow and obtain information as needed by browsing online sites. Miyata 31 and Johnson 24 suggested that those passive participants could also receive some benefits from online communities.
Accuracy of online information often becomes a focus of discussion, but the trend of online information usage among mothers may be slightly different from the information provided by healthcare professionals. Mothers use online information for validation or as an additional information source. Johnson 24 suggested that mothers did not take all the information they received online. They rather filtered the information according to their needs. Price et al 23 also suggested mothers gather information they need and follow their intuition for their decision making. Mothers may be asking questions online not because they want to get the right answers, but to gather heterogeneous opinions. It can also play a role of safety nets for mothers who have common questions which can be answered by other mothers who went through the same situation. However, online information can be misleading, unhelpful, or even wrong in some cases, 9,10 and mothers' information literacy skills may play a critical role for online information to be effective. Also, it is reported that mothers' problematic use of the Internet or=and SNS (ie, addiction) has a detrimental impact on their interpersonal relationships and emotional stability, which could possibly lead to child maltreatment. 36 In addition to understanding these negative aspects online peer support may have, it is especially important for healthcare professionals to consider when promoting maternal health through peer-support channels.

Limitations
There were limited numbers of interventional studies evaluating effectiveness of online peer support. Because of this, the review took the scoping review to explore what was already known in this field of research, and comparison by country or year the research was conducted was not made. Given that culture and social systems can be different depending on countries and the environment of parents, especially their usage of the Internet and SNS, can change over time, future studies should consider them in examining effectiveness of online peer support groups. Due to the nature of the review, no critical appraisal or bias assessment was conducted.

Conclusion
Effects of online-based peer support groups for mothers were explored. The review suggested some positive effects on maternal mental well-being, but the evidence was very limited to properly evaluate effectiveness of online peer group among the mothers of young children. When healthcare professionals consider health promotion of mothers through an online-based peer support group approach, the unique needs of mothers-to-mother support should be considered to maximize the support efforts.
Internet continues to be one of the major information sources for parenting mothers. Online peer support can be an easy and convenient way to increase maternal mental well-being. It gives mothers a unique opportunity to connect with others and exchange opinions. It can be particularly helpful in the circumstance where in-person social networks are limited, including the situation of COVID-19 pandemic. More structured interventional study designs to evaluate the effectiveness of online peer support are needed.