Nonspecialists providing perinatal depression services in China: a qualitative study^†

The research took place at a Maternity and Child Healthcare Center in Jiangsu Province, China. This facility is the first in the region to focus on maternal mental health care, and they have organized nurses to routinely screen prenatal and postnatal women for PND in the last 6 months. However, no management of screening results, such as prevention, treatment, referral, or follow-up, has been implemented. This study selected pregnant and postpartum women managed by the institution’s personnel and clinical nurses and those who tested positive for PND screening. Inclusion criteria for patients were as follows: women in the antenatal or postnatal period within 1 year; EPDS score ≥10; local residents; at least a junior high school education level; and voluntary participation. Exclusion criteria for patients were: inability to clearly express their feelings and noncooperation with interviewers. Inclusion criteria for service providers were: management personnel with at least 5 years of experience in obstetrics and gynecology management and clinical nurses with experience in managing PND patients, who voluntarily participated in the research. Exclusion criteria for service providers were: inability to clearly express their feelings and noncooperation with interviewers. The sample size was determined based on information saturation, i.e., when no new themes emerged.

Theories and predefined constructs can be used to find and predict factors that could affect or predict implementation success, guide how to change the plan and customize implementation strategies, and provide a foundation for developing high-order models and theories about implementation.¹² The Consolidated Framework for Implementation Research (CFIR), one of the most widely used influencing factor frameworks, guides the interview outline for stakeholders, which includes 39 factors in 5 domains (intervention characteristics, outer setting, inner setting, individual characteristics, and process).¹³ We conducted interviews excluding the domain “process” as part of the exploration before implementation (Supplementary File 1 of the List and Definition of CFIR constructs).

The study adhered steadfastly to the ethical precepts enshrined within the Declaration of Helsinki,¹⁴ and its orchestration received the imprimatur of the Hospital Research Ethics Committee. The tapestry of interviews unfurled betwixt the temporal confines of January and March in the annus mirabilis of 2022. Prior to engaging in substantive, semi-structured, and in-depth face-to-face interviews lasting between 20 min and 40 min, participants were kindly beseeched to complete a comprehensive sociodemographic questionnaire. This formality was enshrined in Supplementary File 2 of the Interview Guide for Nursing Managers and Clinical Nurses, as well as Supplementary File 3 of the Interview Guide designed for women suspected of grappling with despondency. Throughout the labyrinthine voyage of our research endeavor, the sanctity of privacy and the inviolability of confidentiality served as our unwavering lodestar. To immortalize the profound narratives shared by our respondents, we harnessed the capabilities of a digital voice recorder. In instances where the august preferences of our respondents did not align with the utilization of this auditory device, we diligently transcribed their insights by hand. In the spirit of gratitude for their candid participation, participants received modest tokens of appreciation upon the culmination of our interviews.

The authors analyzed a step-by-step participatory method, with any discrepancies resolved through discussion. The recordings were verbatim transcribed, and the original Chinese transcripts were kept. However, the data coding was done in English. Furthermore, the Chinese quotes we chose were translated into English and evaluated by researchers with foreign educational backgrounds in the research team to ensure language equivalency in terms of reporting and publishing. The transcripts were all entered into the NVivo® program. According to the existing CFIR framework and a codebook adapted from CFIR’s website, the transcripts were processed using content analysis technology,¹⁵ and the results were analyzed using a deductive approach.¹⁶ The first phase of the analysis was to create initial coding nodes and subnodes based on the CFIR framework’s domains and constructs; the second step was to examine, identify, and deductively code meaning units, such as sentences or longer semantic units, into the nodes and subnodes.¹³ Then, to support the findings, the best representative statements from each construct were chosen.

A total of 20 stakeholders were interviewed. Ten women with an EPDS score of ≥10 were involved in the study, with an average age of 26 ± 3.7 years. The interviews included 5 nursing managers and 5 clinical nurses with an average age of 34 ± 2.4 years and 32 ± 4.6 years, respectively. The socio-demographic characteristics of the subjects are shown in Table 1.

“Needs and Resources of Those Served By the Organization” is a commonly reported factor and is categorized under “Outer Setting” and defined as “The extent to which the needs of those served by the organization (e.g., patients) as well as barriers and facilitators to meet those needs are understood and prioritized.¹³” Stigma regarding people with mental illness is an issue in many cultures and ethnicities, mothers with postpartum depression (PPD) do not talk about it or ask for help due to these overwhelming feelings.¹⁷ Understanding how mothers feel about stigma may suggest how to communicate with struggling moms more effectively. Support from the husband, which includes caring for the newborn and providing emotional and material support, has also been linked to service entry.¹⁸ We found that trivial household tasks, heavy life loads, and husbands’ lack of understanding and approval limit women’s help-seeking behavior as well as escalate their negative emotions. In addition, women with a limited understanding of PPD are at a higher risk for PPD, Heh and Fu¹⁹ found that women with a higher risk for PND and who got formal information about PPD had a lower EPDS than those who did not. In our study, participants had personal experiences with PPD symptoms or had heard about them from friends or family. However, those sources of info were usually wrong, and few had details on PPD from professionals. For service receivers, the following approaches should be utilized: awareness-raising, literacy programs to improve knowledge about mental illnesses, and advocacy through education, training, mutual help, and counseling.^20,21

“Cosmopolitanism” is identified as another frequently reported factor and is categorized under the domain “Outer Setting” and defined as “The degree to which an organization is networked with other external organizations.”¹³ A lack of multisectoral collaboration models has also been identified as a major barrier to establishing integrated mental health treatment in LMICs.²² Collaborative care and consultation models improve outcomes in primary care settings by providing mental health support. Consultation models could be adapted for the obstetric setting through structured mental health telephonic or online consultations for perinatal health care professionals. Spedding et al.²² propose an on-site model, where a psychiatrist provides care at an obstetrics and gynecology hospital, to improve connections with patients, simplify referrals, and keep patients away from stigmas. Improved collaboration and liaison relationships could increase feelings of self-efficacy among perinatal health care professionals, enabling them to manage simple cases and refer to more complex ones, thereby improving access to care.²³

“Structural characteristics” is identified as another frequently reported factor and are categorized under the domain “Inner Setting” and defined as “Social architecture, age, maturity, and size of an organization.”¹³ Obstetricians and perinatal women find screening to be futile without trained providers who can refer them to mental health resources. Although perinatal women have a high acceptance of depression screening, screening for PND remains controversial since many women do not wish to be contacted by a mental health provider.²⁴ Among women who test positive for depression, fewer than 30%^24,25 attend a first or subsequent mental health visit, and as few as 0%–6%^25,26 attend an entire course of treatment. The lack of adherence is most likely caused by the lack of systems to ensure depression evaluation, treatment, and referral.²⁷ One systematic review²⁸ found that broken referral pathways and unclear work structures are important structural barriers to perinatal mental health care. Another study found that perinatal mental health implementation was hindered by complex and unclear pathways, such as unlinked services, lack of continuity, lack of referral resources, and complicated bureaucratic procedures.²⁸ In order to integrate maternal mental health care into routine maternal health care, the mental health care system must be strengthened and the governance system must produce clear mental health policies, programs, strategies, and structures.

“Available Resources” is identified as another frequently reported factor and is categorized under the construct “Readiness for implementation” (domain “Inner Setting”) and defined as “The level of resources organizational dedicated for implementation and ongoing operations including physical space and time.”¹³ Limited resources affect universal health coverage and the quality of treatment. Long wait times, lack of training, and inadequate resources are caused by a lack of government readiness, capacity, and priority. Other systematic reviews^29,30 have also mentioned them as barriers to identifying and treating perinatal mental disorders. Consequently, perceptions and established barriers associated with service providers should be addressed in order to create an environment conducive to implementing and maintaining mental health continuity of care in health facilities.^31,32 Especially nurses need to be educated about PND since they have the most contact with perinatal women. Improving their mental health literacy and providing supervisory support is crucial to health systems and should be a top priority for administrative health professionals.³³ There should be potential solutions to facilitate quality-assured interventions by fully utilizing information technology, such as regulation through effective digital platforms, or provision of training and supervision.

“Knowledge and beliefs” is identified as another frequently reported factor and is categorized under the domain “Characteristics of individuals” and defined as “Individuals’ attitudes toward the innovation, familiarity with facts, truths, and principles related to the innovation.”¹³ An Israeli study³⁴ of 224 family practitioners and pediatricians suggests that 98% consider it essential to recognize PND symptoms, with 89.8% declaring that they would be involved in diagnosis and treatment or refer to another professional and 76.5% indicating that they would use a brief questionnaire to identify PND. However, due to limited knowledge, providers were less confident and willing to address PND. According to our study, many health care providers lacked knowledge about PND and avoided discussing the topic, which made perinatal women feel uncomfortable speaking about these sensitive issues and may not disclose the most severe symptoms of mental illness. In Other systematic reviews and meta-synthesis,^35,36 high-income countries identified a lack of mental health knowledge and attitudes among intervention staff as barriers to implementing PND management. It is more efficient and effective for nonpsychiatric professionals to establish good communication with patients to guide and promote mental health behaviors, and a key factor in PND management is improving the mental health literacy and beliefs of service providers.

The notion of “Access to Knowledge and Information” surfaces as a recurrently cited determinant, aligning itself within the construct of “Readiness for Implementation” amidst the expansive realm of the “Inner Setting.” Its eloquent characterization delineates it as “the ease with which one can acquire comprehensible information and enlightenment regarding the innovation, along with the adeptness to seamlessly integrate it into one’s occupational endeavors.”¹³ Esteemed researchers have extolled the virtues of comprehensive intervention compendiums, replete with meticulous referral flow charts, rigorously standardized operating procedures, and didactic health education manuals. These seminal works assume the role of guiding luminaries, imparting direct guidance to clinical endeavors, upholding the sacrosanct mantle of quality assurance, and inscribing the edicts of best practices.^37,38 The blueprint, hence, beckons for further refinement, as it endeavors to carve a path toward a standardized and pragmatic trajectory, as perceived from the vantage point of the provider. Additionally, it seeks to bestow upon both online and offline domains a veritable treasure trove of informational promotion manuals, serving as a beacon for consumers in their quest for knowledge and enlightenment.

The study is not devoid of its imperfections, as 3 notable shortcomings come to the fore. Foremost among these is the imperative acknowledgment of the singular socio-cultural milieu in which the research was nestled, thereby underscoring the need for judicious caution when extrapolating the findings to dissimilar geographical and cultural domains. Second, a modicum of meaning inherent in the respondents’ experiential narratives and perspectives may have been inadvertently forfeited in the intricate process of transcription, during the delicate transmutation from the vernacular of Chinese to the lyrical tapestry of English. Lastly, the study, as it currently stands, finds itself in its formative stages, rendering the facets linked to the “process” construct within the ambit of the Consolidated Framework for Implementation Research (CFIR) an elusive terrain, yet to be meticulously charted. Despite these acknowledged limitations, it is noteworthy that subsequent investigations, encompassing diverse demographic strata and varying sample sizes, have yielded corroborative outcomes, thus lending credence to the overarching veracity of the research findings.