Mar 20, 2014 - AZIDAH, A.K., SHAIFUL, B.I., RUSLI, N. and JAMIL, M.Y., 2006. Postnatal depression and socio- cultural practices among postnatal mothers in ...
A QUALITATIVE STUDY OF WOMEN’S PERSPECTIVES ON POSTNATAL DEPRESSION IN MALAYSIA Siti Roshaidai Binti Mohd Arifin Supervisors: Prof. Helen Cheyne & Prof. Margaret Maxwell NMAHP Research Unit, School of Health Science
OUTLINES INTRODUCTION LITERATURE REVIEW PROBLEM STATEMENT RESEARCH AIMS & RESEARCH QUESTIONS METHODOLOGY & METHODS DATA ANALYSIS CONCLUSION
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INTRODUCTION Improvement in maternal health as one of the 8 Millennium Development Goals. (United Nations Development Programme, 2014) PND often remains underdiagnosed and undertreated in clinical practice. (WHO, 2008)
Wide variation in reported rates of PND within and across countries and cultures. (Halbreich and Karkun, 2006)
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INTRODUCTION Continents
Prevalence of PND
USA (Lobato, et al. 2011; Dennis, Heaman and Vigod, 2012)
8.0-37.5%
Africa (Agoub, Moussaoui and Battas 2005; Kakyo et al., 2012)
5.6-43.0%
Australia (Brooks et a.l, 2009; Austin et al., 2010)
6.0-32.8%
European (Grote et al. , 2010; Meltzer-Brody et al. , 2013)
4.0-40.4%
Asia (Ekuklu, 2004; Ho-Yen et al. 2006)
4.9-40.4%
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INTRODUCTION Prevalence of PND in Malaysia Years
Cultural Setting
Prevalence of PND (%)
Kit et al., 1997
Malay, Indian, Chinese
3.9
Wan Mohd Rushidi et al., 2002
Malay
9.8
Wan Mohd Rushidi et al., 2003
Malay
14.1
Azidah et al., 2006
98% Malay
20.7
Wan Mohd Rushdi et al., 2006
Malay
16.38
Kadir et al., 2009
Not mentioned
27.3
Zainal et al., 2012
Malay, Indian, Chinese
6.8 5
LITERATURE REVIEW: Qualitative synthesis on the experience of PND
No published qualitative study on the experience of PND in Malaysia.
Women shared similarities and differences in describing the experience of PNDcultural practice
The need for culturally appropriate care & intervention
(Rahman, 2007; Edwards and Timmons, 2005; Oates et al, 2004; Rodrigues et al, 2003). 6
PROBLEM STATEMENT A significant health problem
BUT underdiagnosed and undertreated
Wide variation in prevalence
BUT unclear explanations
Quantitative descriptions
NOT nature experiences of PND
Need for culturally appropriate intervention
BUT lack of cross cultural study
(Chien et al, 2006; Rahman, 2007; Niemi et al, 2010; Davy 2013; Mamisachviliet al, 2013)
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RESEARCH AIMS & RESEARCH QUESTIONS Research Aims
Research Questions
1. Understand the experience • What are the experiences of PND of women with PND in Malaysia among Malaysian women? 2. Explore women’s perceptions • Do women’s causal explanations of of the causes of PND in PND differ across different cultural Malaysia. backgrounds within Malaysia? If so, how does it differ? 3. Explore potential interventions for women with PND in Malaysia.
• What are the experiences of care and helpful strategies for Malaysian women with PND? • What are the Malaysian women’s perceptions towards the roles of healthcare professionals in managing PND? 8
METHODOLOGY AND METHODS Critical Realism Social constructivism
Positivism
(Pilgrim & Bentall, 1999)
Philosophical Framework 9
METHODOLOGY AND METHODS Study design
Exploratory qualitative design
Study setting
Eight Maternal and Child Health Clinics (MCH) under Health Department of Federal Territory Kuala Lumpur Malaysia.
329,847 square kilometres with a total population of over 28.3 million (Department of statistics, 2010; Khader, 2012) 10
METHODOLOGY AND METHODS Population
Women with different cultural backgrounds who attended postnatal or child health care at MCH Clinics in Kuala Lumpur.
Sample
30-36 women with depressive symptoms: • 10-12 of Malay, Chinese and Indian who have attended postnatal or child health care at MCH Clinics in Kuala Lumpur.
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METHODOLOGY AND METHODS Sampling
• Purposive sample: to ensure diversity in cultural beliefs and practices.
Inclusion criteria
• Age 18-45 years. • No more than 1 year postnatal at the time they enter the study. • Had been staying in Malaysia after the last childbirth and until the time of the interview. • PHQ-2 ≥ 3 and/or EPDS≥ 3 and/or self identified and/or being referred by HCP • Malaysian by nationality. • Sufficiently fluent in English or Malay Language to participate in the interview.
Exclusion criteria
• Not fluent in English or Malay Language • Severely depressed to the extent that participation in the interview might worsened their condition. • Non-Malaysian by nationality. 12
METHODOLOGY AND METHODS Approach the potential participant during postnatal / child health visit
Provide an invitation letter and a PIS
Screening stage: PHQ-2 ≥ 3 and/or EPDS ≥ 12
Contact the potential participant at least 24H
Interview stage: Home/private room in the clinic/ preferred venue
Recruitment of Women with PND NOTES: Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionairre-2 (PHQ-2)
METHODOLOGY AND METHODS School Research Ethics Committee (SREC)
Economic Planning Unit, Malaysia
- Director, Health Department of Federal Territory Kuala Lumpur and Putrajaya - Clinic Managers in the respective clinics
- Malaysian National Institute of Health Research (NIHR) - Malaysian Research Ethics Committee (MREC)
Ethical Approval Process
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DATA ANALYSIS
Data collection and data analysis were conducted concurrently
Nvivo
Framework analysis
All themes were crosschecked by two PhD supervisors
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DATA ANALYSIS Transcription Interpreting the data
Familiarizati on with the interview
Charting data into the framework matrix
Coding
Applying the analytical framework
Developing a working analytical framework
Framework Analysis
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RESULT 318 approached 240 scored < 3 in PHQ and < 12 in EPDS
24.5% 78 qualified for interview
33 interviewed 10 Malay (30.3%)
12 Chinese (36.4)
35 not interviewed (15 refused to participate, 5 uncontactable, 13 not contacted, 1 cannot converse in Malay/ English, 1 was not fit to be interviewed)
11 Indian 33.3%
Figure1: Summary of Recruitment Strategy
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RESULT Demographic characteristics
Frequency
Percentage (%)
Age 21-30 31-40 > 40
18 13 2
54.5 39.5 6.0
Employment status Housewife Working
19 14
57.6 42.4
Parity Primid Multiparous (2-5)
11 22
33.3 66.7
Duration after childbirth ≤ 6 months 6- 12 months
21 12
63.6 36.4
RESULT It just a disturbance. I think it just a temporary disturbance…I don’t think it is very severe, right? (PT7, Malay)
My mother in law follows the traditional practices strictly. So I was stressful. That’s why I was stressful (PT7, Malay)
I cannot hold myself. I cannot control my emotion (PT28, Chinese)
I’m thinking of blending the mosquito coil, feed it to my kids and myself (PT6, Malay) 19
RESULT Barriers in seeking help
Desired care
Emotional
Coping Strategies
Physiological
Coping strategies and help seeking
Signs and Symptoms Women’s perspectives on postnatal depression
Perceived impacts Being judged
Behavioural
Causal explanations
Pregnancy-related stressors
Dual identity
Exacerbating factors Transition of motherhood
Themes and subthemes ** Based on analysis of the first 10 transcripts
EARLY INTERPRETATION OF THE DATA Signs and symptoms:
• Even PND has found to affect the maternal physiology and behaviours after childbirth, not surprisingly the emotional imbalance is one of the key indicator for PND.
Causal explanations:
• Traditional postnatal practices found to be one of the contributing factors to PND among Malay and Chinese women but none of Indian women seems to be affected by the practices. • Tradition-modernity conflict is one of the main contributing factors in Chinese women.
Perceived impact:
• Claim of dual identity and being judged by their community network. 21
EARLY INTERPRETATION OF THE DATA
Coping strategies and help seeking:
• None of the interviewed women being diagnosed with postnatal depression • More attention given to the baby ~ almost no information given on maternal emotional status after giving birth. • Perceived the roles of HCP are more on medical/physical care but not on emotional/ psychological health. • Malay women ~ religious practices is one of the major helpful strategies but not being highlighted very much among Indian and Chinese women. • They need for care from HCP including counselling, education on postnatal care and telephone-based peer support intervention. 22
CONCLUSION Academic contribution • Explored the women’s experience of PND, the causal explanation, and potential intervention for PND (objectives are achieved) • Add on the theoretical understandings of PND in relation to cultural differences. Clinical contribution
• The findings of this study will be the foundation of developing preventative intervention for PND in Malaysia. 23
GANTT CHART Year Months
First Year: 2013/ 2014 SepDec
JanMac
AprJun
JulAug
Second Year: 2014/2015 SepDec
JanMac
AprJun
JulAug
Third Year: 2015/2016 SepDec
JanMac
AprJun
Tasks Initial thesis planning with supervisors Refinement of topic with aims and methodology Submission of proposal draft to supervisors Refinement of proposal for 10th month panel review Submission for10th month panel review Presentation for 10th month panel review Submission of study protocol to University Ethics committee Submission of study proposal to Malaysian ethics committee (NIHR and MREC) Data collection Data analysis Writing final report Submission of final report
× × × × × × × × × ×
× 24
JulAug
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