Group psychological intervention for postnatal depression: a nested qualitative study with British South Asian women

Culturally Sensitive Perinatal Mental Health Care: Experiences of Women From Minority Ethnic Groups

BACKGROUND

Current research has identified how ethnic minority women experience poorer health outcomes during the perinatal period. In the United Kingdom, specialist perinatal mental health services provide mental health treatment for women throughout the perinatal period. Service users have previously highlighted that perinatal services are hard to access and lack cultural sensitivity, whereas healthcare professionals have described limited opportunities and resources for developing cultural competency.

OBJECTIVES

We explored the experiences of ethnic minority women with National Health Service (NHS) specialist perinatal teams and identified what culturally sensitive perinatal mental health care means to this group.

DESIGN

Individual semi-structured interviews were conducted, and an interpretative phenomenological analysis framework was used to analyse the interview transcripts.

SETTING AND PARTICIPANTS

Participants were recruited from NHS specialist perinatal teams and online via social media.

RESULTS

Six women were interviewed. Four group experiential themes central to the experiences of participants emerged: (1) strengthening community networks and peer support; (2) valuing cultural curiosity; (3) making sense of how culture, ethnicity, race and racism impact mental health; and (4) tailoring interventions to ethnic minority women and their families.

DISCUSSION AND CONCLUSIONS

The findings capture how ethnic minority women experience specialist perinatal teams and offer insights into practising culturally sensitive care. Perinatal mental health professionals can support ethnic minority women by strengthening their access to community resources and peer support; being curious about their culture; helping them to make sense of how culture, ethnicity, race and mental health interact; and applying cultural and practical adaptations to interventions.

PATIENT OR PUBLIC CONTRIBUTION

A Lived Experience Advisory Group (LEAG) of women from ethnic minority groups contributed to the design and conduct of this study. The LEAG had lived experience of perinatal mental health conditions and accessing specialist perinatal teams. The LEAG chose to co-produce specific aspects of the research they felt fit with their skills and available time throughout five group sessions. These aspects included developing the interview topic guide, a structure for debriefing participants and advising on the social media recruitment strategy.

Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis

Background

Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care.

Objectives

Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services.

Methods

Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders.

Data sources

Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews.

Review methods

In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway.

Results

Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels.

Limitations

In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English.

Conclusions

The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services.

Recommendations for health policy and practice

These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it.

Future work

Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries.

Trial registration

This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Women's experiences of psychological treatment and psychosocial interventions for postpartum depression: a qualitative systematic review and meta-synthesis

BACKGROUND

To provide a comprehensive, systematic evaluation of the literature on experiences of psychological interventions for postpartum depression (PPD) in women. Depression is one of the most common postpartum mental disorders. Studies have identified that psychological interventions reduce depressive symptoms. However, less is known about the experiences of women who have received such treatments.

METHODS

A systematic review of the literature was conducted by searching five databases (CINAHL, Cochrane Library, EMBASE, Medline, PsycINFO), in August 2022. Studies with qualitative methodology examining women's experiences of professional treatment for PPD were included and checked for methodological quality. Eight studies (total N = 255) contributed to the findings, which were synthesized using thematic synthesis. Confidence in the synthesized evidence was assessed with GRADE CERQual.

FINDINGS

The women had received cognitive behavioral therapy (5 studies) or supportive home visits (3 studies). Treatments were individual or group-based. Two main themes were identified: Circumstances and expectations, and Experiences of treatment, with six descriptive themes. Establishing a good relationship to their health professional was important for the women, regardless of treatment model. They also expressed that they wanted to be able to choose the type and format of treatment. The women were satisfied with the support and treatment received and expressed that their emotional well-being had been improved as well as the relationship to their infant.

CONCLUSION

The findings can be helpful to develop and tailor patient-centered care for women who are experiencing postnatal depression.

Exploratory RCT of a group psychological intervention for postnatal depression in British mothers of South Asian origin - ROSHNI-D

BACKGROUND

Postnatal depression (PND) is a global public health problem. There is a high prevalence of PND amongst ethnic minority women and major ethnic inequalities in mental health care in the U.K. Language and cultural barriers pose a significant challenge for access to timely treatment and interventions for British South Asian (BSA) women with PND.

METHODS

The study, carried out in Manchester and Lancashire, England, was a two-arm single-blind exploratory randomised controlled trial. BSA women (N = 83) having a baby <12 months were randomised either to the group receiving the culturally adapted Positive Health Programme (PHP) (n = 42) or to the group receiving treatment as usual (TAU) (n = 41). Follow-up assessments were at 3 months (end of intervention) and 6 months after randomisation.

RESULTS

Using an intention to treat analysis, there was no significant difference between PHP intervention and TAU groups in depression measured using Hamilton Depression Rating Scale both at 3 and 6 months follow up. Using modified intention to treat analysis, women who attended four or more sessions showed significant reduction in depression in the PHP group compared to the TAU group and the greater number of sessions attended was associated with greater reductions in depression scores.

LIMITATIONS

The sample was relatively small and the study was conducted in one geographical area in Northwest England; hence, these results may not be generalizable to other regions and populations.

CONCLUSION

The recruitment and trial retention figures highlighted the ability of the research team to engage with BSA women, having implications in planning services for this group.

TRIAL REGISTRATION

Clinicaltrials.govNCT01838889.

Postnatal experiences of South Asian immigrant women in Australia, Canada, the United Kingdom, and the United States of America: a qualitative systematic review protocol

OBJECTIVE

The goal of this review is to gain an understanding of the postnatal experiences of South Asian immigrant women in 4 English-speaking countries: Australia, Canada, the United Kingdom, and the United States of America.

INTRODUCTION

The postnatal period is an important time in the lives of women and their families. Major changes take place during this time as a woman's body gradually returns to its pre-pregnancy state. The postnatal period is also a time for women to adapt and transition into their new role as a mother. Immigrant women experience many challenges in accessing quality postnatal care in comparison to non-migrant populations. South Asian immigrant women, specifically, encounter unique postnatal experiences and face a myriad of hardships in accessing proper postnatal care. The presence of cultural factors and traditional norms largely influence postnatal experiences of South Asian immigrant women. Cultural factors include, but are not limited to, relationships with family and in-laws, gender-specific roles, newborn gender, mental health stigma, language barriers, acculturative stress, and expression of depression.

INCLUSION CRITERIA

Qualitative studies in English reporting postnatal experiences of South Asian immigrant women published after January 2000 will be considered for this review. Research designs may include, but are not limited to, feminist research, exploratory descriptive design, or ethnography. Gray literature will be limited to theses and dissertations only.

METHODS

MEDLINE, Embase, CINAHL, EthOS, and ProQuest Dissertations and Theses will be searched. Disagreement resolution, data extraction, and meta-aggregation will be completed through discussion between 2 reviewers. Studies will be critically appraised and assigned a level of credibility.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022354306.

A meta-ethnography investigating relational influences on mental health and cancer-related health care interventions for racially minoritised people in the UK

OBJECTIVE

Despite calls to increase the 'cultural competence' of health care providers, racially minoritised people continue to experience a range of problems when it comes to health care, including discrimination. While relevant qualitative meta-syntheses have suggested better ways forward for health care for racialised minorities, many have lacked conceptual depth, and none have specifically investigated the relational dimensions involved in care. We set out to investigate the social and cultural influences on health care interventions, focusing on psychological approaches and/or cancer care to inform the trial of a new psychological therapy for those living with or beyond cancer.

METHOD

A meta-ethnography approach was used to examine the relevant qualitative studies, following Noblit and Hare, and guided by patient involvement throughout. Papers were analysed between September 2018 and February 2023, with some interruptions caused by the Covid pandemic. The following databases were searched: Ovid MEDLINE, EBSCO CINAHL, Ovid Embase, EBSCO PsycINFO, Proquest Sociology Collection (including Applied Social Sciences Index & Abstracts (ASSIA), Sociological Abstracts and Sociology Database), EBSCO SocINDEX, Ovid AMED, and Web of Science. The systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42018107695), and reporting follows the eMERGe Reporting Guidance for meta-ethnographies (France et al. 2019).

RESULTS

Twenty-nine journal papers were included in the final review. Themes (third-order constructs) developed in the paper include the centrality of the patient-practitioner relationship; how participants give meaning to their illness in connection to others; how families (rather than individuals) may make health decisions; how links with a higher power and spiritual/religious others can play a role in coping; and the ways in which a hierarchy of help-seeking develops, frequently with the first port of call being the resources of oneself. Participants in studies had a need to avoid being 'othered' in their care, valuing practitioners that connected with them, and who were able to recognise them as whole and complex (sometimes described in relational languages like 'love'). Complex family-based health decision-making and/or the importance of relations with non-human interactants (e.g. God, spiritual beings) were frequently uncovered, not to mention the profoundly emergent nature of stigma, whereby families could be relatively safe havens for containing and dealing with health challenges. A conceptual framework of 'animated via (frequently hidden) affective relationality' emerged in the final synthesis, bringing all themes together, and drawing attention to the emergent nature of the salient issues facing minoritised patients in health care interactions.

CONCLUSION

Our analysis is important because it sheds light on the hitherto buried relational forces animating and producing the specific issues facing racially minoritised patients, which study participants thought were largely overlooked, but to which professionals can readily relate (given the universal nature of human relations). Thus, training around the affective relationality of consultations could be a fruitful avenue to explore to improve care of diverse patients.

Patient-Centered Care Experiences of First-Generation, South Asian Migrants with Chronic Diseases Living in High-Income, Western Countries: Systematic Review

BACKGROUND

First-generation migrants from South Asia account for a considerable proportion of the immigrant populations in high-income, western countries and are at a high risk of developing complex, chronic diseases such as cardiovascular disease and diabetes. Yet, previous systematic reviews have not synthesized information about the healthcare needs and preferences of such migrants and the best ways for health services to provide them with appropriate, culturally sensitive, patient-centered care. The aim of this study is to systematically review the international evidence about first-generation, South Asian migrants' healthcare experiences from the patients' perspectives.

METHODS

Five databases were searched for qualitative, quantitative, and mixed methods studies published between January 1990 and April 2020. Fourteen thousand, six hundred and forty-four papers were retrieved and screened using pre-determined eligibility criteria. Sixty-one papers were included in this narrative synthesis. Relevant qualitative findings from the included papers were thematically analyzed, and quantitative findings were summarized.

RESULTS

Five themes emerged from findings: 1) Healthcare services engaged; 2) the language barrier; 3) experiences and perceptions of healthcare advice; 4) the doctor-patient relationship; and 5) the role of patients' families in supporting access and delivery of healthcare.

CONCLUSION

The findings indicate that communication barriers reduce the cultural and linguistic appropriateness of healthcare. Potential solutions include employing healthcare staff from the same cultural background, training healthcare professionals in cultural competence, and proactively including first-generation, South Asian migrants in decision-making about their healthcare. Future research should explore South Asian migrants' experiences of multimorbidity management, continuity of care, interdisciplinary collaboration, the formation of treatment plans and goals as little to no data were available about these issues.

Treatment of maternal depression in low-income women: A feasibility study from Kilifi, Kenya

AIMS OF THE STUDY

To test the feasibility and acceptability of a group psychosocial intervention called Learning Through Play (LTP) plus Culturally adapted Cognitive Behaviour Therapy (CaCBT) for depressed Kenyan mothers with children aged 0-36 months.

METHODS USED TO CONDUCT THE STUDY

This study was a single-arm mixed methods feasibility study to test an integrated parenting intervention for postnatal depression in a low-income rural area of Fumbini village in Kilifi District of Kenya. Women between the ages of 18 and 45 years with children up to 3 years were screened for depression using the Patient Health Questionnaire (PHQ-9). Those scoring above 10 on PHQ-9 were interviewed using the Revised Clinical Interview Schedule (CIS-R) to confirm the diagnosis of depression. Assessments were carried out at baseline and at the end of the intervention (3 months), followed by qualitative interviews with 12 women. Qualitative interviews were analysed using thematic analysis from a socio-constructionist theoretical lens.

RESULTS OF THE STUDY

The LTP Plus was both feasible and acceptable with high satisfaction among the participants. Qualitative results showed that the women perceived the intervention as beneficial in reducing the symptoms of depression, coping with stress and negative emotions. The results also indicated a reduction in scores on PHQ-9, GAD-7 with an increase in perceived social support, health-related quality of life and an improvement in mothers' knowledge about child development at the end of the intervention.

CONCLUSIONS DRAWN FROM THE STUDY AND CLINICAL IMPLICATIONS

This study represents the first feasibility research on integrated parenting intervention in Kenya. The results indicated that culturally adapted LTP plus CaCBT is feasible and acceptable in a low-income setting of Kenya. There is now a need to study the clinical and cost-effectiveness of LTP plus CaCBT in an appropriately powered larger randomised control trial, with a longer follow-up period.

Multicentre randomised controlled trial of a group psychological intervention for postnatal depression in British mothers of South Asian origin (ROSHNI-2): study protocol

Background

In the UK, postnatal depression is more common in British South Asian women than White Caucasion women. Cognitive–behavioural therapy (CBT) is recommended as a first-line treatment, but there is little evidence for the adaptation of CBT for postnatal depression to ensure its applicability to different ethnic groups.

Aims

To evaluate the clinical and cost-effectiveness of a CBT-based positive health programme group intervention in British South Asian women with postnatal depression.

Method

We have designed a multicentre, two-arm, partially nested, randomised controlled trial with 4- and 12-month follow-up, comparing a 12-session group CBT-based intervention (positive health programme) plus treatment as usual with treatment as usual alone, for British South Asian women with postnatal depression. Participants will be recruited from primary care and appropriate community venues in areas of high South Asian density across the UK. It has been estimated that randomising 720 participants (360 into each group) will be sufficient to detect a clinically important difference between a 55% recovery rate in the intervention group and a 40% recovery rate in the treatment-as-usual group. An economic analysis will estimate the cost-effectiveness of the positive health programme. A qualitative process evaluation will explore barriers and enablers to study participation and examine the acceptability and impact of the programme from the perspective of British South Asian women and other key stakeholders.

Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review

The improvement of perinatal mental health formed part of WHO's Millennium Development Goals. Research suggests that the implementation of perinatal mental health care is variable. To ensure successful implementation, barriers and facilitators to implementing perinatal mental health services need to be identified. Therefore, we aimed to identify the barriers and facilitators to implementing assessment, care, referral, and treatment for perinatal mental health into health and social care services. In this systematic review, we searched CINAHL, Embase, MEDLINE, and PsycINFO with no language restrictions for primary research articles published between database inception and Dec 11, 2019. Forward and backward searches of included studies were completed by March 31, 2020. Studies were eligible if they made statements about factors that either facilitated or impeded the implementation of perinatal mental health assessment, care, referral, or treatment. Partial (10%) dual screening was done. Data were extracted with EPPI-Reviewer 4 and analysed by use of a thematic synthesis. The protocol is registered on PROSPERO, CRD42019142854. Database searching identified 21 535 citations, of which 46 studies were included. Implementation occurred in a wide range of settings and was affected by individual (eg, an inability to attend treatment), health-care professional (eg, training), interpersonal (eg, trusting relationships), organisational (eg, clear referral pathways), political (eg, funding), and societal factors (eg, stigma and culture). A complex range of barriers and facilitators affect the implementation of perinatal mental health policy and practice. Perinatal mental health services should be flexible and women-centred, and delivered by well trained health-care professionals working within a structure that facilitates continuity of carer. Strategies that can be used to improve implementation include, but are not limited to, co-production of services, implementation team meetings, funding, and coalition building. Future research should focus on implementation barriers and facilitators dependent on illness severity, the health-care setting, and inpatient care.

More to lose? Longitudinal evidence that women whose social support declines following childbirth are at increased risk of depression

OBJECTIVE

We examined the dynamic relationship between life changes (pregnancy and childbirth) and social support during the postpartum period.

METHODS

A large, nationally representative sample of Australian women (N=806) who completed the Household Income and Labour Dynamics in Australia Survey (HILDA) in the year immediately before and immediately after giving birth to a child reported on measures of perceived social support and mental health.

RESULTS

Analyses indicated a decrease in both social support and mental health after having a baby. Social support during the postpartum period - controlling for social support and mental health prior to the birth of a baby - predicted better mental health in women. However, for women who experienced a decline in social support, prenatal social support was a risk factor for a decline in mental wellbeing rather than a protective factor.

CONCLUSIONS

Women who have 'more to lose' are at increased risk of mental ill-health if they cannot maintain existing sources of social support. Implications for public health: Loss of social support during pregnancy and the postpartum period should be considered as a significant risk factor for postpartum depression in its own right and one that warrants screening and intervention.

Psychological interventions for maternal depression among women of African and Caribbean origin: a systematic review

BACKGROUND

Maternal depression is a leading cause of disease burden for women worldwide; however, there are ethnic inequalities in access to psychological interventions in high-income countries (HICs). Culturally appropriate interventions might prove beneficial for African and Caribbean women living in HICs as ethnic minorities.

METHODS

The review strategy was formulated using the PICo (Population, phenomenon of Interest, and Context) framework with Boolean operators (AND/OR/NOT) to ensure rigour in the use of search terms ("postpartum depression", "maternal depression", "postnatal depression", "perinatal depression" "mental health", "psychotherapy" "intervention", "treatment", "black Caribbean", "black African", "mothers" and "women"). Five databases, including Scopus, PsycINFO, Applied Social Science Index and Abstracts (ASSIA), ProQuest Central and Web of Science, were searched for published articles between 2000 and July 2020. 13 studies met the inclusion criteria, and the relevant data extracted were synthesised and thematically analysed.

RESULTS

Data syntheses and analyses of included studies produced four themes, including (1) enhance parenting confidence and self-care; (2) effective mother-child interpersonal relationship; (3) culturally appropriate maternal care; and (4) internet-mediated care for maternal depression.

CONCLUSION

In the quest to address maternal mental health disparities among mothers of African and Caribbean origin in HICs, the authors recommend culturally adapted psychological interventions to be tested in randomised control trials.

Beyond the barriers: South Asian women’s experience of accessing and receiving psychological therapy in primary care

Purpose

A number of initiatives have been developed to ensure easy access to mental health services for Black and Asian Minority Ethnic (BAME) communities. Improving Access to Psychological Therapies (IAPT) is a service that delivers first line interventions for South Asian women; however, little is known about what makes IAPT accessible for this population. This paper aims to explore South Asian women’s experiences of accessing psychological therapy and whether therapy within IAPT helps individuals to re-frame their experiences within their own cultural context.

Design/methodology/approach

A qualitative approach was used. Semi-structured interviews were carried out with South Asian women who accessed an IAPT service. Ten participants took part in the study and interviews were analysed using thematic analysis.

Findings

Six themes were identified; access, experience, cultural framework, therapist characteristics, expectations and “sticking with it”. Having a good therapeutic relationship with the therapist was key. While cognitive behavioural therapy (CBT) enabled clients to manage their symptoms, manualised CBT led to a sense of dissatisfaction for some. Clients spoke of having to make a forced choice to either deny their culture or leave their culture at the door to access therapy. Cultural and religious exclusion had a negative impact on therapy particularly for those whose difficulties were related to their cultural or religious context.

Practical implications

Culture and religion continues to be excluded from psychological therapy for South Asian Women. A cultural shift is required from within IAPT services to maintain engagement for this group. Further clinical implications are discussed.

Originality/value

While the experiences of Black and Asian ethnic minority groups accessing secondary mental health services has been explored, this study explores and highlights the experiences of South Asian Women accessing therapy in primary care, and uniquely identifies the processes that enable women to engage in therapy.

Reducing loneliness among migrant and ethnic minority people: a participatory evidence synthesis

Background

To date, there has been little research into the causes of, and solutions to, loneliness among migrant and ethnic minority people.

Objectives

The objectives were to synthesise available evidence and produce new insights relating to initiatives that aim to address loneliness among these populations, plus the logic, functioning and effects of such initiatives.

Data sources

Electronic database searches (MEDLINE, Applied Social Sciences Index and Abstracts and Social Science Citation Index via Web of Science – no date restrictions were applied), grey literature searches, and citation and reference searching were conducted. Data were generated via nine workshops with three consultation panels involving 34 public contributors, and one practitioner workshop involving 50 participants.

Review methods

Guided by ‘systems thinking’, a theory-driven synthesis was combined with an effectiveness review to integrate evidence on the nature and causes of loneliness, interventional types and programme theory, and intervention implementation and effectiveness.

Results

The theory review indicated that common conceptualisations of ‘loneliness’ can be usefully extended to recognise four proximate determinants when focusing on migrant and ethnic minority populations: positive social ties and interactions, negative social ties and interactions, self-worth, and appraisal of existing ties. A total of 170 interventions were included. A typology of eight interventions was developed. Detailed logic models were developed for three common types of intervention: befriending, shared-identity social support groups and intercultural encounters. The models for the first two types were generally well supported by empirical data; the third was more tentative. Evaluation of intervention processes and outcomes was limited by study content and quality. Evidence from 19 qualitative and six quantitative studies suggested that social support groups have a positive impact on dimensions of loneliness for participants. Evidence from nine qualitative and three quantitative studies suggested that befriending can have positive impacts on loneliness. However, inconsistent achievements of the befriending model meant that some initiatives were ineffective. Few studies on intercultural encounters reported relevant outcomes, although four provided some qualitative evidence and three provided quantitative evidence of improvement. Looking across intervention types, evidence suggests that initiatives targeting the proximate determinants – particularly boosting self-worth – are more effective than those that do not. No evidence was available on the long-term effects of any initiatives. UK intervention (n = 41) and non-intervention (n = 65) studies, together with consultation panel workshop data, contributed to a narrative synthesis of system processes. Interlocking factors operating at individual, family, community, organisational and wider societal levels increase risk of loneliness, and undermine access to, and the impact of, interventions. Racism operates in various ways throughout the system to increase risk of loneliness.

Limitations

There was a lack of high-quality quantitative studies, and there were no studies with longer-term follow-up. UK evidence was very limited. Studies addressing upstream determinants operating at the community and societal levels did not link through to individual outcome measures. Some elements of the search approach may mean that relevant literature was overlooked.

Conclusions

Theory regarding the causes of loneliness, and functioning of interventions, among migrant and ethnic minority populations was usefully developed. Evidence of positive impact on loneliness was strongest for shared-identity social support groups. Quantitative evidence was inadequate. The UK evidence base was extremely limited.

Future work

UK research in this area is desperately needed. Co-production of interventional approaches with migrant and ethnic minority people and evaluation of existing community-based initiatives are priorities.

Study registration

This study is registered as PROSPERO CRD42017077378.

Funding

This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 10. See the NIHR Journals Library website for further project information.

A systematic review of ethnic minority women's experiences of perinatal mental health conditions and services in Europe

Background

Women from ethnic minority groups are at greater risk of developing mental health problems. Poor perinatal mental health impacts on maternal morbidity and mortality and can have a devastating impact on child and family wellbeing. It is important to ensure that services are designed to meet the unique needs of women from diverse backgrounds.

Aim

The aim of the review was to explore ethnic minority women's experiences of perinatal mental ill health, help-seeking and perinatal mental health services in Europe.

Data sources

Searches included CINAHL, Maternity and Infant Care, MEDLINE and PsycINFO with no language or date restrictions. Additional literature was identified by searching reference lists of relevant studies.

Design

This was a mixed method systematic review. Study selection, appraisal and data extraction were conducted by two researchers independently. A convergent approach was adopted for the analysis and the data were synthesised thematically.

Results

The 15 eligible studies included women from a range of minority ethnic backgrounds and were all undertaken in the United Kingdom (UK). Seven overarching themes were identified; awareness and beliefs about mental health, isolation and seeking support, influence of culture, symptoms and coping strategies, accessing mental health services, experiences of mental health services and what women want.

Conclusion

Lack of awareness about mental ill health, cultural expectations, ongoing stigma, culturally insensitive and fragmented health services and interactions with culturally incompetent and dismissive health providers all impact on ethnic minority women's ability to receive adequate perinatal mental health support in the UK. Future research should focus on in-depth exploration of the experiences of these women across multiple European settings and interventions to reduce health inequalities among vulnerable mothers and families affected by perinatal mental ill health.

Barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the UK

OBJECTIVE

Lack of access to mental health services during the perinatal period is a significant public health concern in the UK. Barriers to accessing services may occur at multiple points in the care pathway. However, no previous reviews have investigated multilevel system barriers or how they might interact to prevent women from accessing services. This review examines women, their family members' and healthcare providers' perspectives of barriers to accessing mental health services for women with perinatal mental illness in the UK.

DESIGN

A systematic review and meta-synthesis of qualitative studies.

DATA SOURCES

Qualitative studies, published between January 2007 and September 2018, were identified in MEDLINE, PsycINFO, EMBASE and CINAHL electronic databases, handsearching of reference lists and citation tracking of included studies. Papers eligible for inclusion were conducted in the UK, used qualitative methods and were focused on women, family or healthcare providers working with/or at risk of perinatal mental health conditions. Quality assessment was conducted using the Critical Appraisal Skills Programme for qualitative studies.

RESULTS

Of 9882 papers identified, 35 studies met the inclusion criteria. Reporting of emergent themes was informed by an existing multilevel conceptual model. Barriers to accessing mental health services for women with perinatal mental illness were identified at four levels: Individual (eg, stigma, poor awareness), organisational (eg, resource inadequacies, service fragmentation), sociocultural (eg, language/cultural barriers) and structural (eg, unclear policy) levels.

CONCLUSIONS

Complex, interlinking, multilevel barriers to accessing mental health services for women with perinatal mental illness exist. To improve access to mental healthcare for women with perinatal mental illness multilevel strategies are recommended which address individual, organisational, sociocultural and structural-level barriers at different stages of the care pathway.

PROSPERO REGISTRATION NUMBER

CRD42017060389.

Women's Experiences of Seeking and Receiving Psychological and Psychosocial Interventions for Postpartum Depression: A Systematic Review and Thematic Synthesis of the Qualitative Literature

INTRODUCTION

Postpartum depression (PPD) is a serious maternal disorder that can have adverse effects on maternal and infant health. The importance of offering effective and acceptable treatments is well recognized, particularly given the numerous barriers women in many settings face in accessing interventions for PPD. The aim of this systematic review was to synthesize qualitative research exploring women's experiences of professional psychological and psychosocial support for PPD.

METHODS

A systematic review of the literature was conducted in April 2017 by searching 5 electronic databases (CINAHL, MEDLINE, PubMed, Ovid, and Web of Science). Qualitative research studies published in English that explored women's experiences of professional psychosocial support for PPD were included, whereas studies exploring women's experiences of antidepressant medication only were excluded. Seventeen articles met inclusion criteria and were appraised for methodologic quality. Data were synthesized using the interpretive thematic synthesis method.

RESULTS

Four main themes were identified: the process of help-seeking, barriers to seeking and accepting support, valued aspects of support, and outcomes. Women found the process of seeking help difficult, with several barriers preventing them from both seeking and accepting professional support. Despite this, women described the support received as beneficial and particularly valued the therapeutic relationship. Women reported 1) feeling more positive and confident after receiving a psychological and/or psychosocial intervention and 2) experiencing better relationships with their infant and other family members.

DISCUSSION

Although seeking and accepting professional support for PPD was a difficult process, women highly valued mental health care support and perceived it as beneficial. Clinical services should aim to address the barriers women face in accessing mental health care and empower women to feel in control throughout the process, offering interventions appropriate to each woman's personal circumstance.

Treatment of maternal depression in urban slums of Karachi, Pakistan: A randomized controlled trial (RCT) of an integrated maternal psychological and early child development intervention

BACKGROUND

Maternal depression is a major public health problem. This may affect a mother's ability to provide adequate care for the child. The objective of this study was to evaluate the effectiveness of the Learning through Play Plus program (LTP Plus) - a parenting program integrated with Cognitive Behaviour Therapy (CBT).

METHODS

A total of 247 women with symptoms of depression in Karachi, Pakistan were assigned randomly to either LTP Plus or routine care (Clinical Trials Identifier: NCT00835016). Symptoms of maternal depression were measured using the Edinburgh Postnatal Depression Scale (EPDS) at 3 and 6 months after baseline.

RESULTS

At 3 months, there was a significant reduction in the EPDS scores in the intervention group compared to the routine group (adjusted mean difference [AMD] -3.65, 95% CI -6.14 to -1.15, p <0.004). This effect was sustained at 6 months (AMD -2.62, 95% CI -4.43 to -0.81, p<0.005). These women also reported less parental distress and disability. There was also a significant improvement in maternal knowledge about child development at 6 months.

CONCLUSION

There was a significant reduction in depression among women who received the group parenting program LTP Plus. This intervention has the potential to be scaled up and integrated with mother and child health programs.

Pilot study of a culturally adapted psychoeducation (CaPE) intervention for bipolar disorder in Pakistan

BACKGROUND

Despite the use of maintenance medication, recurrence rates in bipolar affective disorder (BPAD) are high. To date, there are no clinical trials that have investigated the use of psychological interventions in bipolar disorder in Pakistan.

AIM

The purpose of the study was to assess the feasibility and acceptability of a culturally adapted bipolar psychoeducation programme (CaPE) in Pakistan.

METHODS

Thirty-four euthymic bipolar I and II outpatients were randomized to either 12 weekly sessions of individual psychoeducation plus Treatment As Usual (Intervention) or Treatment As Usual (TAU) (Control). Outcomes were assessed using the Young Mania Rating Scale (YMRS), Beck Depression Inventory (BDI), EuroQoL (EQ-5D), Bipolar Knowledge and Attitudes and Questionnaire (BKAQ), and a self-reported measure of medication adherence (Morisky Medication Adherence Scale-4 items, MMAS-4). Effect sizes were derived from baseline adjusted standardized regression coefficients.

RESULTS

Retention in the study was good, 80% of patients in the TAU follow-up assessment and 100% of patients in the CaPE group attended all 12 sessions. Patient satisfaction was higher in the CaPE group relative to control (ES = 1.41). Further, there were large effect sizes shown for CaPE versus TAU for medication adherence (MMAS-4: ES = 0.81), knowledge and attitudes towards bipolar (BKAQ: ES = 0.68), mania (YMRS: ES = 1.18), depression (BDI: ES = 1.17) and quality of life measures (EQ-5D: ES ⇒ 0.88).

CONCLUSIONS

Culturally adapted psychoeducation intervention is acceptable and feasible, and can be effective in improving mood symptoms and knowledge and attitudes to BPAD when compared with TAU. Larger scale studies are needed to confirm our findings.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02210390.