Background
Perinatal mental illness is a significant global problem, with postnatal depression prevalence ranging from 13 to 20% [
1,
2]. Of women with postnatal depression, almost 40% are estimated to have developed symptoms during pregnancy [
3]. Perinatal anxiety disorders may be as prevalent as depression [
4], and higher levels of antenatal anxiety increase the risk of postnatal depression [
5].
Pregnancy is a time of heightened vulnerability for the development or recurrence of mental illness [
6] and women of refugee background are likely to be at greater risk than the general population given pre- and post-settlement stressors [
6,
7]. Estimates of mental illness prevalence in general refugee populations vary, with systematic reviews reporting depression prevalence of 5–31% and post-traumatic stress disorder (PTSD) 9–31%, with evidence of significant comorbidity [
8,
9]. The prevalence of
perinatal mental illness in this demographic is poorly documented. Throughout this paper, the term ‘refugee background’ refers to women who self-report either a refugee or asylum seeker background. Refugees are persons with a well-founded fear of persecution, who are outside of their country of origin and unable or unwilling to return, while asylum seekers are persons seeking protection whose refugee status is unconfirmed [
10].
Perinatal mental illness presents a major public health challenge, given its contribution to maternal morbidity and indirect mortality [
6], adverse obstetric outcomes [
11], and impaired psychological and physical development of infants and children [
12,
13]. Partners’ quality of life and mental health may also be affected, and other children in the family may experience a greater risk of mental illness and adverse social and behavioural outcomes [
6,
14,
15]. Thus, there is a clear rationale for antenatal screening to identify early symptoms and provide appropriate follow-up and management to prevent exacerbation of symptoms and improve outcomes. Moreover, the regular contact between health professionals (HPs) and women during pregnancy supports the rationale for integrating screening into routine antenatal care [
16].
Australian clinical practice guidelines recommend routine antenatal assessment of (i) psychosocial risk factors and (ii) depression and anxiety symptoms using the Edinburgh Postnatal Depression Scale (EPDS), an extensively used and validated perinatal screening tool [
6,
17].
However, antenatal screening is not routinely implemented at many hospitals [
18], and little is known about how to integrate mental health screening into antenatal care. Barriers include lack of time, funding or follow-up infrastructure and inadequate training [
6,
19]. Few enablers have been identified but include raising awareness amongst HPs, support from hospital management and development of follow-up pathways [
19,
20].
Implementation is likely to be more complex for women of refugee background given their vulnerability and barriers to accessing health services such as lack of interpreters or healthcare literacy, Western medical models and stigma associated with mental illness [
7,
21‐
23]. Previous studies of maternity care models with women of refugee background have not explored mental health screening [
21,
22], system challenges or factors critical to success in rolling out a comprehensive screening and referral programme [
24,
25].
Monash Health is located in south-east Melbourne in the Australian state of Victoria. It is one of the largest maternity service providers in Australia and also services a region with one of the largest resettled refugee populations in the country, up to 8.7% of the regional population [
10,
26]. Importantly, a large proportion—40% over the last 10 years—of persons resettled under Australia’s Humanitarian Programme were women of child-bearing age [
27]. Women self-reporting a refugee background are preferentially allocated to the Monash Health refugee antenatal clinic where possible. Psychosocial risk factor assessment, which aims to identify risk factors associated with perinatal mental illness such as past history of mental illness, current or past abuse, substance abuse and lack of social support [
6], is routinely undertaken at Monash Health. However, screening for anxiety and depression symptoms is not undertaken at all, which is likely to lead to considerable under-recognition of women at risk of perinatal mental illness. This evidence-practice gap in antenatal care is widespread, with under a third of state public maternity hospitals reporting use of a psychosocial risk factor assessment tool and a quarter of hospitals reporting use of the EPDS [
18]. This study aimed to (i) investigate barriers and enablers to implementing evidence-based, nationally recommended perinatal mental health screening and (ii) inform sustainable implementation of a screening and referral programme, in women of refugee background.
Discussion
Summary of key findings
This study systematically defines barriers and enablers to implementation of perinatal mental health screening and referral for women of refugee background. Participants overwhelmingly recognised the need for mental health screening and PTSD screening. Factors affecting implementation identified by HPs included staff training needs, inter-disciplinary roles to support referral and clearly communicated, robust referral pathways. CRs prioritised continuity of care, female interpreters and HPs, social support and useful follow-up care. Key environmental considerations included availability of in-person interpreters, rigorously translated EPDS versions, time constraints and capacity of MHS.
Effective behaviour change techniques for each of the eight domains (i.e. behavioural determinants) were identified from Michie et al.’s matrix, which maps theoretical domains to behaviour change techniques. The multidisciplinary research team, including members from the Monash Women’s Maternity and Monash Health Refugee Health and Wellbeing services, then selected the most relevant techniques to this setting, developed recommendations (Table
3) and compared these recommendations with the current literature.
Context and implications for clinical practice
Perceived need for perinatal mental health and PTSD screening
The perceived necessity of perinatal mental health screening is an indicator of system readiness for change and is associated with a greater likelihood of effective implementation [
37]. The perceived need to screen for PTSD symptoms in routine antenatal care of women of refugee background has not previously been reported, and specific PTSD screening may address the concern of a few HPs that the EPDS overlooks trauma. The varied opinions as to
how to execute PTSD screening may reflect participants’ concerns about exacerbation of symptoms if screening is inappropriately administered or differing success with screening methods. This highlights the need for careful selection of appropriate perinatal mental health and PTSD screening methods and training for HPs in sensitive administration (
Beliefs about capabilities, Table
3).
Table 3
Recommendations for implementation of perinatal mental health screening in women of refugee background
Knowledge | Information regarding behaviour, outcome | Provide information for HPs regarding rationale for screening; clinical guidelines and evidence-practice gap; appropriate EPDS administration, scoring and actions; and PTSD screening | Provide information (e.g. culturally appropriate group sessions, translated printed materials) at earlier appointments about perinatal mental illness, routine screening, and MHS |
Skills | Goal/target specified: behaviour or outcome Increasing skills: problem solving, decision making, goal setting Rehearsal of relevant skills | Organisation to set target of routine screening; individual HPs to set targets for skills attainment Provide training for HPs regarding identification and prioritisation of refugee health needs; appropriate use, scoring and actions to EPDS; and cultural competence (including approach to mental health and managing family members) Provide opportunities to practise skills | |
Social/professional role and identity | Social processes of encouragement, pressure, support | Involve refugee health nurse, bicultural worker, perinatal mental health nurse and senior staff to support referral Balance inter-disciplinary approach with clear delineation of roles Ensure clear communication between antenatal and postnatal services and identify women already receiving mental health care | |
Beliefs about capabilities | Increasing skills: problem solving, decision making, goal setting Social processes of encouragement, pressure, support | Provide training for HPs (i.e. sensitive administration of trauma screening tool, management of women at risk of suicide or self-harm) Engage staff by communicating the rationale for screening and benefits for women | |
Beliefs about consequences | Persuasive communication Information regarding behaviour, outcome | Provide information for mental HPs regarding the provision of refugee appropriate mental health care (e.g. practical advice about managing symptoms) | HPs to normalise screening; provide culturally appropriate mental health information at earlier appointments; manage expectations regarding referrals; and communicate professionalism of interpreters and usefulness of follow-up mental health care |
Environmental context and resources | Environmental changes (e.g. objects to facilitate behaviour) | Select the most appropriate time(s) to screen with input from HPs administering the EPDS (e.g. second antenatal visit and again in third trimester). Allow HPs discretion to screen earlier or later or to forgo screening if guided by MHS already involved in care Management to work with HPs to allow appropriate appointment length and flexibility to manage disclosures and make immediate referrals Map MHS in the area and confirm capacity and sustainability of services prior to implementation | Incorporate rigorously translated screening tools into routine maternity care Provide skilled, onsite, female interpreters for common refugee languages and standardised instructions for appropriate EPDS translation Screen in a private setting Provide advice around transport |
Social influences | Social processes of encouragement, pressure, support | Ensure a ‘go-to’ or support person for HPs (e.g. refugee health nurse, senior staff, psychiatry liaison), regular team meetings and debrief opportunities | Ensure continuity of care Include referral pathways to social work, women’s groups and language services HPs to explain to family members what screening and potential follow-up involves; however screening to be undertaken privately |
Behavioural regulationb | Planning, implementation Prompts, triggers, cues | Establish robust referral pathways, feedback mechanisms to confirm receipt of referrals, communication channels between services, and clear documentation at all stages of pathways Clearly communicate pathways (e.g. flowcharts) and contact numbers for to HPs | Establish various pathways for different needs while minimising referral points Use on-site services where possible (e.g. social worker) |
Inter-disciplinary approach
The clear differences in roles attributed to each HP group and the recognised importance of refugee health nurse and perinatal mental health nurse roles uniquely highlight inter-professional relationships as important support structures for HPs involved in implementation [
38] (
Social/professional role and identity, Table
3). The perceived role of bicultural workers in educating and supporting women of refugee background is supported by the literature [
21,
25] and by the CCCF, which asserts that individuals’ awareness and knowledge alone are insufficient to result in culturally competent environments and organisations must also adapt services to be accessible to culturally and linguistically diverse patients [
32]. That all HPs asserted a role at one or more stages of screening, referral and management confirms the need for an inter-disciplinary approach in this setting.
Inter-disciplinary collaboration involves pursuing common goals, shared decision-making and planning and open communication between HPs and services [
38] to ensure clarity around roles and appropriate, timely referrals and to prevent fragmentation of care. An example of shared planning is liaison with psychiatry departments and community MHS to assess their capacity to absorb referrals in the long-term (
Environmental context and resources). Low rates of referral to specialist MHS have been found in the UK (1–3% of women screened) and New South Wales, Australia, [
6,
39] with women requiring less extensive care managed by general practitioners; however, referral rates may be higher for women of refugee background. Evaluation of local implementation efforts including referral rates would inform scaling-up of implementation. Shared decision-making is vital in determining optimal timing of screening administration, which is poorly covered in the literature. If midwives are to administer screening, recognising their perception of when it is practical to screen is likely to facilitate ownership and adoption of screening (
Environmental context and resources, Table
3). In keeping with the ‘organisational support’ domain of the CCCF [
32], health service managers need to work with HPs to allow flexibility to manage disclosures and make immediate referrals.
Inter-disciplinary collaboration also requires flexibility in sharing professional responsibilities to improve clinical care [
38]. Not all HPs volunteered a direct role in screening. For instance, obstetricians recommended that midwives administer screening while they supported the referral and follow-up process; however, all HPs involved in antenatal care should receive training to appropriately fulfil their role whether they are directly involved in administering screening or not (
Skills, Table
3).
Effective communication with women
Achieving cultural equivalence in EPDS translations and having accurate, female interpreters is consistent with the literature [
21,
24,
40,
41]. Results from this study add that female interpreters are a priority specifically for mental health conversations to encourage disclosure from women with traumatic backgrounds. Translations of the EPDS are freely available for most refugee languages spoken in the local area [
42]. Institutional investment, such as incorporating translated screening tools into routine maternity care and ensuring availability of onsite interpreters for common languages of resettled refugees, reflects the organisation’s commitment to sustainable implementation [
37] and is essential to a culturally competent service [
32] (
Environmental context and resources, Table
3).
Beliefs about consequences are known to affect implementation success [
37] and persuasive communication and provision of information to HPs, and women are required to enhance and address these positive and negative beliefs respectively (
Beliefs about consequences, Table
3). Some HP concerns regarding EPDS administration in this population are consistent with other research [
24]. However, the positive perceptions of the EPDS by CRs and interpreters and their understanding of the impacts of perinatal mental illness contrast with a recent study, which described women’s lack of understanding of EPDS items and concepts, and postulated that women of refugee background lacked a framework for understanding the rationale behind EPDS administration [
24].
These differences may be attributed to greater exploration of CR understanding of the rationale for screening in this study; some CRs having experienced symptoms of mental illness or mental health care or differences in participant demographics (predominantly African compared with mostly Asian countries in this study), study design (focus groups and surveys compared with interviews) or familiarity with the EPDS. Further research is needed to investigate cross-cultural understandings of each EPDS item with women from key refugee communities.
Consistent with the literature [
23,
40], there was some evidence that women of refugee background may use different words to articulate perinatal depressive symptoms or may misunderstand the ‘perinatal onset’ qualifier. Thus, when explaining the EPDS and undertaking diagnostic assessment, HPs need to consider women’s different expressions for perinatal depression. However, many CRs also noted their own accepting attitudes towards mental illness differed from their communities’, possibly stemming from personal experiences of mental illness and MHS, education or supportive family and friends. This challenges the notion of stigma and different cross-cultural understandings as insurmountable barriers. Along with CR understanding of the rationale, this supports the provision of culturally appropriate information about mental health and routine screening at earlier appointments to increase acceptance of later screening and follow-up (
Knowledge and
Beliefs about consequences, Table
3).
Normalising screening, managing expectations regarding referral(s) and communicating the professionalism of interpreters and usefulness of follow-up care are recommended to allay women’s concerns and encourage engagement with services (
Beliefs about consequences, Table
3). This study contributes to an under-researched area [
43] and suggests that women of refugee background perceive ‘useful’ MHS to offer practical advice and opportunities to express emotions, thus providing valuable feedback for mental HPs.
Limitations and strengths
While indistinct boundaries between some TDF domains may be considered a limitation, this reflects the often multiple determinants of behaviours and confirms that behaviour change requires a multi-faceted approach. A smaller number of CRs were recruited compared with HPs; however, data saturation was achieved to fulfil the study aims. While many of the CRs had accessed maternity services since coming to Australia (some of whom were currently pregnant) and these experiences informed their responses, this study did not specifically recruit CRs currently attending a maternity service. Current service users may identify additional barriers or enablers from their experience. To address this, recommendations from this study have informed a pilot programme designed by a broad steering committee and evaluation will include focus groups with women and health professionals. Strengths of this study include the range of participants interviewed, community consultation, rigorous study design and use of two generalizable, applied theoretical frameworks.
Acknowledgements
The researchers wish to acknowledge the staff at the Monash Health Refugee Health and Wellbeing service and Monash Women’s Clinic (Dandenong) for supporting this research, with particular thanks to Razia Ali, Maggie Lynch and Jackie McAsey for their assistance recruiting community representatives.