Clusters of maternal depressive symptoms in South Western Sydney, Australia

Critical Realism in Symptom Science - A Scoping Review

There has been an increasing interest in research positioned within critical realism (CR). This analysis aimed to determine how CR has been applied in symptom science through a scoping review of the literature. Fifty-two articles were identified through searches in seven databases and search engines, and grey literature. Quantitative and qualitative analyses were performed using Excel and ATLAS.ti 8.0. Review findings indicate that CR has been used to examine two key aspects of symptoms - symptom experiences and symptom interventions. The details of how CR was operationalized are presented. This first scoping review highlights how a critical realist lens would help examine individual and contextual factors that influence symptom experiences, response to interventions, and outcomes.

"You're a 'high-risk' customer": A qualitative study of women's experiences of receiving information from health professionals regarding health problems or complications in pregnancy

BACKGROUND

Experiencing complications in pregnancy is stressful for women and can impact on fetal and maternal outcomes. Supportive encounters with health professionals can reduce the worry women experience. Further research is needed to understand women's perspectives on communicating with their healthcare providers about their concerns.

AIM

This study explored women's experiences of receiving information about pregnancy complications from healthcare providers and their interactions with multiple professionals and services during pregnancy.

METHODS

This was a qualitative interpretive study. Semi-structured interviews were conducted with 20 women experiencing pregnancy complications recruited from antenatal services at two hospitals in Sydney. Inductive thematic analysis was used to analyse the data.

FINDINGS

Women had a range of reactions to their diagnoses, including concern for their baby, for themselves and for their labour. Most women reported that communication with healthcare providers was distressing, they were not listened to and staff used insensitive, abrupt language. Women were also distressed by delays in education, receiving contradictory information and having to repeatedly share their stories with different health professionals. In some cases, this damaged the therapeutic relationship and reduced trust towards healthcare providers. Midwives were generally preferred over doctors because they had a more woman-centred approach.

CONCLUSION

To improve women's experiences of care for pregnancy complications, it is critical to improve the communication skills of maternity service providers. Women's need for information, resources and support can best be provided by continuity of care with a named health professional, for example, a midwife working within an integrated multidisciplinary antenatal service model.

Using Geospatial Analysis to Inform Development of a Place-Based Integrated Care Initiative: The Healthy Homes and Neighbourhoods Experience

INTRODUCTION

Disadvantaged families experience many barriers to accessing health and social care. The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was developed to address these barriers, and ensure families have their complex needs met and are kept safe and connected to society.

DESCRIPTION

A spatial epidemiology approach was taken, as part of the HHAN feasibility phase, to identify the geographical distribution of the "most vulnerable" families in Sydney Local Health District (SLHD). A literature review was conducted to identify indicators of family stress and disadvantage, and cluster and hotspot analyses were undertaken. Hotspots of family stress and disadvantage were mapped for SLHD and used to identify areas for HHAN place-based delivery, and for collaborative co-design.

DISCUSSION

The HHAN initiative called for consideration of context and the undertaking of collaborative design with communities. The spatial analysis provided a more accurate picture of family stress and disadvantage than previously available and provided a tool that could be used during consultation and planning activities.

CONCLUSION

When planning place-based integrated care initiatives, spatial analysis of small geographic scales can allow identification of areas of concentrated or complex disadvantage that may be masked when analysis is performed on larger areas, allowing for targeted, place-based delivery of programs to those most in need.

Spatial and population drivers of persistent cholera transmission in rural Bangladesh: Implications for vaccine and intervention targeting

We identify high risk clusters and measure their persistence in time and analyze spatial and population drivers of small area incidence over time. The geographically linked population and cholera surveillance data in Matlab, Bangladesh for a 10-year period were used. Individual level data were aggregated by local 250 × 250 m communities. A retrospective space-time scan statistic was applied to detect high risk clusters. Generalized estimating equations were used to identify risk factors for cholera. We identified 10 high risk clusters, the largest of which was in the southern part of the study area where a smaller river flows into a large river. There is persistence of local spatial patterns of cholera and the patterns are related to both the population composition and ongoing spatial diffusion from nearby areas over time. This information suggests that targeting interventions to high risk areas would help eliminate locally persistent endemic areas.

Antenatal psychosocial risk status and Australian women's use of primary care and specialist mental health services in the year after birth: a prospective study

BACKGROUND

Poor mental health in the perinatal period can impact negatively on women, their infants and families. Australian State and Territory governments are investing in routine psychosocial assessment and depression screening with referral to services and support, however, little is known about how well these services are used. The aim of this paper is to report on the health services used by women for their physical and mental health needs from pregnancy to 12 months after birth and to compare service use for women who have been identified in pregnancy as having moderate-high psychosocial risk with those with low psychosocial risk.

METHODS

One hundred and six women were recruited to a prospective longitudinal study with five points of data collection (2-4 weeks after prenatal booking, 36 weeks gestation, 6 weeks postpartum, 6 months postpartum and 12 months postpartum) was undertaken. Data were collected via face-to-face and telephone interviews, relating to psychosocial risk factors, mental health and service use. The prenatal psychosocial risk status of women (data available for 83 of 106 women) was determined using the Antenatal Risk Questionnaire (ANRQ) and was used to compare socio-demographic characteristics and service use of women with 'low' and 'moderate to high' risk of perinatal mental health problems.

RESULTS

The findings indicate high use of postnatal universal health services (child and family health nurses, general practitioners) by both groups of women, with limited use of specialist mental health services by women identified with moderate to high risk of mental health problems. While almost all respondents indicated that they would seek help for mental health concerns most had a preference to seek help from partners and family before accessing health professionals.

CONCLUSION

These preliminary data support local and international studies that highlight the poor uptake of specialist services for mental health problems in postnatal women, where this may be required. Further research comparing larger samples of women (with low and psychosocial high risk) are needed to explore the extent of any differences and the reasons why women do not access these specialist services.

Realist theory construction for a mixed method multilevel study of neighbourhood context and postnatal depression

BACKGROUND

We have recently described a protocol for a study that aims to build a theory of neighbourhood context and postnatal depression. That protocol proposed a critical realist Explanatory Theory Building Method comprising of an: (1) emergent phase, (2) construction phase, and (3) confirmatory phase. A concurrent triangulated mixed method multilevel cross-sectional study design was described. The protocol also described in detail the Theory Construction Phase which will be presented here.

METHODS

The Theory Construction Phase will include: (1) defining stratified levels; (2) analytic resolution; (3) abductive reasoning; (4) comparative analysis (triangulation); (5) retroduction; (6) postulate and proposition development; (7) comparison and assessment of theories; and (8) conceptual frameworks and model development.

THEORY CONSTRUCTION

The stratified levels of analysis in this study were predominantly social and psychological. The abductive analysis used the theoretical frames of: Stress Process; Social Isolation; Social Exclusion; Social Services; Social Capital, Acculturation Theory and Global-economic level mechanisms. Realist propositions are presented for each analysis of triangulated data. Inference to best explanation is used to assess and compare theories. A conceptual framework of maternal depression, stress and context is presented that includes examples of mechanisms at psychological, social, cultural and global-economic levels. Stress was identified as a necessary mechanism that has the tendency to cause several outcomes including depression, anxiety, and health harming behaviours. The conceptual framework subsequently included conditional mechanisms identified through the retroduction including the stressors of isolation and expectations and buffers of social support and trust.

CONCLUSION

The meta-theory of critical realism is used here to generate and construct social epidemiological theory using stratified ontology and both abductive and retroductive analysis. The findings will be applied to the development of a middle range theory and subsequent programme theory for local perinatal child and family interventions.

Realist identification of group-level latent variables for perinatal social epidemiology theory building

We have previously reported in this journal on an ecological study of perinatal depressive symptoms in South Western Sydney. In that article, we briefly reported on a factor analysis that was utilized to identify empirical indicators for analysis. In this article, we report on the mixed method approach that was used to identify those latent variables. Social epidemiology has been slow to embrace a latent variable approach to the study of social, political, economic, and cultural structures and mechanisms, partly for philosophical reasons. Critical realist ontology and epistemology have been advocated as an appropriate methodological approach to both theory building and theory testing in the health sciences. We describe here an emergent mixed method approach that uses qualitative methods to identify latent constructs followed by factor analysis using empirical indicators chosen to measure identified qualitative codes. Comparative analysis of the findings is reported together with a limited description of realist approaches to abstract reasoning.

Spatial analysis of suicide mortality in Québec: spatial clustering and area factor correlates

Understanding the spatial distribution of suicide can inform the planning, implementation and evaluation of suicide prevention actions. No previous study has assessed spatial clustering of the different methods of suicide in Quebec. The aim of this study was to assess spatial clustering of suicide in Quebec between 2004 and 2007 and neighborhood level predictors of the clusters. Scan statistics was applied to detect clusters of suicides by method and by sex. Smoothed standardized mortality ratios (SMRs) for suicide for each neighborhood were also estimated and their association with neighborhood characteristics was investigated using the Bayesian hierarchical spatial model. The pattern of suicide rate was different among men and women; men showed higher standardized mortality rates. The most likely clusters of suicide were found in remote rural areas. However, some neighborhoods in urban areas also had noticeable suicide clusters. Firearms suicide was most likely found in remote rural areas while poisoning and hanging suicide methods clustered in urban areas. These findings suggest that it is important to take geographical variations into account in national policy and health services planning.

Disentangling the influence of neighborhood and individual characteristics on early residential mobility among newly diagnosed patients with schizophrenia: a multilevel analysis

PURPOSE

Early residential mobility of schizophrenic patients may relate to discontinuity of treatment and adverse outcome. However, factors influencing early residential mobility of these patients are still poorly examined. The aim of this study was to disentangle the influence of individual and neighborhood characteristics on early residential mobility of schizophrenic patients.

METHODS

The study used administrative data of 13, 400 individuals newly diagnosed with schizophrenia in Quebec between 2001 and 2002. These individuals were nested in 163 different health territories. Multilevel analyses were used to assess the contribution of individual and neighborhood characteristics on early residential mobility.

RESULTS

The final model indicates that at the individual level, being men, wonder patients and physical comorbidity increased the likelihood of early residential mobility whereas older patients were less likely to migrate earlier. The health territory level explains about 7 % of the variation of early residential mobility and variables influencing residential mobility at this level are the fourth and the third quartiles of the population density.

CONCLUSIONS

Factors influencing early residential mobility of schizophrenic patients are located at both individual and neighborhood levels. This suggests that policies targeting only one-level factors are unlikely to significantly delays early residential mobility.

Bayesian hierarchical spatial regression of maternal depressive symptoms in South Western Sydney, Australia

Background

There is increasing interest in the role played by maternal depression in mediating the effects of adversity during pregnancy and poor infant outcomes. There is also increasing evidence from multilevel regression studies for an association of area-level economic deprivation and poor individual mental health. The purpose of the study reported here is to explore the spatial distribution of postnatal depressive symptoms in South Western Sydney, Australia, and to identify covariate associations that could inform subsequent multilevel studies.

Methods

Mothers (n = 15,389) delivering in 2002 and 2003 were assessed at 2–3 weeks after delivery for risk factors for depressive symptoms. The individual-level binary outcome variables were Edinburgh Depression Scale (EDS) >9 and >12. The association between social, demographic and ecological factors and aggregated outcome variables were investigated using exploratory factor analysis and multivariate hierarchical Bayesian spatial regression. Relative risks from the final EDS >12 regression model were mapped to visualise the contribution from explanatory covariates and residual components.

Results

The exploratory factor analysis identified six factors: neighbourhood adversity, social cohesion, health behaviours, housing quality, social services, and support networks. Variables associated with neighbourhood adversity, social cohesion, social networks, and ethnic diversity were consistently associated with aggregated depressive symptoms. Measures of social disadvantage, lack of social cohesion and lack of social capital were associated with increased depressive symptoms. The association with social disadvantage was not significant when controlling for ethnic diversity and social capital.

Conclusions

The findings support the theoretical proposition that neighbourhood adversity causes maternal psychological distress and depression within the context of social buffers including social networks, social cohesion, and social services. The finding have implications for the distribution of health services including early nurse home visiting which has recently been confirmed to be effective in preventing postnatal depression.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-3-55) contains supplementary material, which is available to authorized users.

Explaining ecological clusters of maternal depression in South Western Sydney

BACKGROUND

The aim of the qualitative study reported here was to: 1) explain the observed clustering of postnatal depressive symptoms in South Western Sydney; and 2) identify group-level mechanisms that would add to our understanding of the social determinants of maternal depression.

METHODS

Critical realism provided the methodological underpinning for the study. The setting was four local government areas in South Western Sydney, Australia. Child and Family practitioners and mothers in naturally occurring mothers groups were interviewed.

RESULTS

Using an open coding approach to maximise emergence of patterns and relationships we have identified seven theoretical concepts that might explain the observed spatial clustering of maternal depression. The theoretical concepts identified were: Community-level social networks; Social Capital and Social Cohesion; "Depressed community"; Access to services at the group level; Ethnic segregation and diversity; Supportive social policy; and Big business.

CONCLUSIONS

We postulate that these regional structural, economic, social and cultural mechanisms partially explain the pattern of maternal depression observed in families and communities within South Western Sydney. We further observe that powerful global economic and political forces are having an impact on the local situation. The challenge for policy and practice is to support mothers and their families within this adverse regional and global-economic context.

Spatio-temporal clustering of the incidence of schizophrenia in Quebec, Canada from 2004 to 2007

Exploring spatio-temporal patterns of disease incidence can help to identify areas of significantly elevated or decreased risk, providing potential etiologic clues. In this study, we present a spatio-temporal analysis of the incidence of schizophrenia in Quebec from 2004 to 2007 using administrative databases from the Régie de l'Assurance Maladie du Quebec and the hospital discharge database. We conducted purely spatial analyses for each age group adjusted by sex for the whole period using SatScan (version 9.1.1). Findings from the study indicated variations in the spatial clustering of schizophrenia according to sex and age. In term of incidence rate, there are high differences between urban and rural-remote areas, as well as between the two main metropolitan areas of the province of Quebec (Island of Montreal and Quebec-City).

Immigrant maternal depression and social networks. A multilevel Bayesian spatial logistic regression in South Western Sydney, Australia

The purpose is to explore the multilevel spatial distribution of depressive symptoms among migrant mothers in South Western Sydney and to identify any group level associations that could inform subsequent theory building and local public health interventions. Migrant mothers (n=7256) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were Edinburgh Postnatal Depression Scale scores (EPDS) of >9 and >12. Individual level variables included were: financial income, self-reported maternal health, social support network, emotional support, practical support, baby trouble sleeping, baby demanding and baby not content. The group level variable reported here is aggregated social support networks. We used Bayesian hierarchical multilevel spatial modelling with conditional autoregression. Migrant mothers were at higher risk of having depressive symptoms if they lived in a community with predominantly Australian-born mothers and strong social capital as measured by aggregated social networks. These findings suggest that migrant mothers are socially isolated and current home visiting services should be strengthened for migrant mothers living in communities where they may have poor social networks.