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A Sudanese Perinatal Mental Health Support Group: 24-month Evaluation Report
WA Perinatal Mental Health Unit
August 2011
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Citation The citation below should be used when referencing this work: WA Perinatal Mental Health Unit, Women and Newborn Health Service (2011). A Sudanese Perinatal Mental Health Support Group: Final Evaluation Report. Perth, WA: Department of Health. © Department of Health, State of Western Australia (2011). Copyright to this material produced by the Western Australian Department of Health belongs to the State of Western Australia, under the provisions of the Copyright Act 1968 (C’wth Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the WA Perinatal Mental Health Unit and the Department of Psychological Medicine, King Edward Memorial Hospital for Women, Western Australian Department of Health. The Department of Health is under no obligation to grant this permission. Please acknowledge the WA Department of Health when reproducing or quoting material from this source. Important Disclaimer All information and content in this Material is provided in good faith by the WA Department of Health, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents, do not accept legal liability or responsibility for the Material, or any consequences arising from its use.
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Acknowledgments
This report is the culmination of several years of effort by a diverse team of
dedicated and generous people, and their organisations. The WA Perinatal
Mental Health Unit expresses sincere thanks to all involved.
In particular, the project would not have been possible without the dedicated
efforts of the staff at Ishar, Multicultural Women’s Health Centre. We would
also like to thank the Sudanese women who had the courage to participate in
the group, the generosity to complete the interviews and questionnaires, and
then the trust to consent for this information to be used for evaluation
purposes.
For further information contact:
Dr Janette Brooks, Senior Research Psychologist
Miriam Maclean, Research Officer
WA Perinatal Mental Health Unit
15 Loretto Street, Subiaco, WA. 6008
Phone: (08) 9340 1795
Fax: (08) 9340 1782
Email: Janette.Brooks@health.wa.gov.au
or Miriam.Maclean@health.wa.gov.au
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Contents
EXECUTIVE SUMMARY ..............................................................................1
INTRODUCTION ..........................................................................................3
BACKGROUND ..............................................................................................5 EXPECTED OUTCOMES .................................................................................6 KEY PERFORMANCE INDICATORS (KPI) ..........................................................7
EVALUATION FRAMEWORK / RESEARCH DESIGN............. ...................7
INTERVIEWS .................................................................................................8 RIGOUR .......................................................................................................8 INSTRUMENTS ............................................................................................11 PROCEDURE ..............................................................................................13 PARTICIPANTS............................................................................................14
ANALYSIS........................................... .......................................................17
EPDS DATA ..............................................................................................17 INTERVIEW DATA ........................................................................................17
RESULTS ...................................................................................................19
QUANTITATIVE RESULTS - EPDS DATA ........................................................19 QUALITATIVE RESULTS - INTERVIEW DATA ....................................................20
DISCUSSION..............................................................................................37
RECOMMENDATIONS ..............................................................................43
REFERENCES ...........................................................................................44
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Executive Summary Immigrant and refugee status has been identified as a risk factor for
mental illness during the perinatal period, with numerous factors postulated
that may predispose these women to suffer from mental health problems,
including social isolation, separation from family, financial difficulties,
experiences of discrimination, and a lack of familiarity with health care
practices in the host country. For women migrating from Sudan to Australia,
exposure to violence or trauma in Sudan, prior to migration, may also
increase risk of mental health problems during the perinatal period.
Acknowledging these issues, the WA Perinatal Mental Health Unit
(WAPMHU) and State Perinatal Mental Health Reference Group (SPMHRG)
endorsed the provision of funding to establish and trial a support group for
Sudanese women in the perinatal period based on a psycho-educational
group format. In May 2008 a Service Agreement was made between the
Women and Newborn Health Service, Department of Health and Ishar
Multicultural Women’s Health Centre Inc. to carry out this project. This
report presents the evaluation framework and results of the 2 years of data
collection and analyses conducted under the auspices of that framework by
Ishar and WAPMHU.
Evaluation is based on a pre and post-group design using both
quantitative and qualitative data collection methods. Five groups were
conducted during the evaluation period. Both qualitative and quantitative
data were collected from the first two groups. Twenty-six Sudanese mothers
completed pre-group assessments, including an interview, a demographic
questionnaire and an Edinburgh Postnatal Depression Scale (EPDS).
Seventeen of these women completed post-group assessments and were
thus included in data analyses. To reduce the burden of data collection, only
the EPDS data was collected from participants in subsequent groups (i.e.
three of the five groups run during the evaluation period). Pre and post-
intervention EPDS data was collected from a further 30 women in the final
three groups, resulting in a total of 47 participants.
Quantitative data collected via the EPDS was used to assess
changes in depressive symptomatology over the course of the 8-week
group term. Interview transcripts were thematically content analysed in nine
sections - corresponding to the questions posed during the interviews.
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Eligibility for participation in the perinatal mental health support group
was based upon Sudanese ethnicity and motherhood status, irrespective of
the presence or absence of depressive symptomatology. In light of this,
the level of depressive symptomatology found pre and post-group in this
sample of Sudanese mothers is concerning. Eighty-nine percent of the
Sudanese women participating in the support group (42 out of 47) scored
above cut-off (≥10) on the EPDS pre-group, suggesting that the prevalence
of perinatal depression may be significantly higher in this population of
childbearing women than general community samples. The percentage of
women scoring above the cut-off decreased to 43% post-group (20 out of
47). Although still higher than the general community, the reduction in
depression risk as indicated by the EPDS was both statistically and clinically
significant.
Overall, the evaluation results indicate that the key performance
indicators were met. Local Sudanese women are attending the support
groups, and showing a number of positive outcomes. In addition to the large
decrease in depressive symptomatology, the participants’ awareness of
perinatal mental health issues improved post-group and the importance of
accessing services if/when needed was apparent. There was an increase in
level of perceived psychosocial support by the participants, with support
networks expanding from family and friends to incorporate health
professionals and community services. Moreover, the participants indicated
that they would be more comfortable asking for help from a range of health
professionals post-group. Based on the results of this evaluation, continued
funding of the service has been recommended.
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Introduction
The perinatal period1 is associated with major biological, psychological
and social changes for women. Subsequently, it comes as no surprise that
mood disorders (which include depression and bipolar disorder) have been
found to peak in onset during the childbearing years (Australian Bureau of
Statistics, 2008) and there is now increasing evidence that anxiety may be
just as prevalent (Austin, 2004).
Postnatal depression (PND) or anxiety affects approximately 10% of
women during pregnancy and approximately 15% of women during the year
after birth (beyondblue, 2011). Research has linked depression during
pregnancy and postpartum to chronic depression, marital difficulties and
behavioural and cognitive delays in children (Pope, Watts, Evans,
McDonald, & Henderson, 2000), yet despite the prevalence and
consequences, many women living in Australia still remain unidentified and
untreated.
Women from culturally and linguistically diverse (CALD) backgrounds
(i.e. non-English speaking background and born overseas or with at least
one parent born overseas) make up 12% of the Australian female
population, and Australia’s shifting immigration policies are leading to
greater inflows of women (Gwatirisa, 2009). The acculturation or
resettlement experiences of refugee women are often compounded by
harsh pre-migration experiences that can make the transition difficult
(Gwatirisa, 2009). A meta-analysis combining the results from 67,294
participants in 56 published studies found poorer mental health outcomes
among refugees than non-refugees (Porter & Haslam, 2005). Very high
rates of mental distress and mental health disorders have been observed
among refugees who have experienced war/conflict (Roberts, Damundu,
Lomoro, & Sondorp, 2009).
The civil conflict in Sudan, between the Government of Sudan in the
north and rebels in southern Sudan, lasted over 20 years. The signing of the
Comprehensive Peace Agreement in January 2005 marked a tenuous end
to 21 years of conflict. During the conflict approximately 1.9 million people
were killed by violence, disease and starvation, up to 4 million people were
1 For the purposes of this project the perinatal period is defined as pregnancy to three years following birth.
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forcibly displaced from their homes (as internally displaced persons), and
there were up to 1 million refugees living in countries throughout the world,
including Australia (Roberts, et al., 2009). There have been escalations of
conflict in recent years (Refugees International, 2010; Tempany, 2009), and
in July 2011, South Sudan declared its independence and became a
sovereign state (Australian Broadcasting Company, 2011).
The most commonly researched mental health disorders in refugee
and conflict affected populations appear to be post-traumatic stress disorder
(PTSD) and depression (de Jong, Komproe, & Van Ommeren, 2003; de
Jong et al., 2001). Although mental health research with Sudanese
populations is scarce, PTSD rates of 46% have been recorded amongst
Sudanese refugees living in Uganda during the conflict (Karunakara et al.,
2004). In post-war Southern Sudan 36.2% prevalence rates of PTSD and
49.9% prevalence rates of depression have been reported (Roberts, et al.,
2009). A recent review of research on the mental health of Sudanese
refugees found evidence of high rates of PTSD and depression, as well as
concerns about current stressors such as family problems (Tempany, 2009).
Immigrant and refugee status has been identified as a risk factor for
depression during pregnancy and in the postpartum period (Dankner,
Goldberg, Fisch, & Crum, 2000; Glasser et al., 1998; Onozawa, Kumar,
Adams, Dore, & Glover, 2003; R. Small, Lumley, & Yelland, 2003; Goyal,
Murphy, & Cohen, 2006; Rubertsson, Wickberg, Gustavsson, & Radestad,
2005; Zelkowitz et al., 2008). Numerous factors have been postulated that
may predispose immigrant and refugee women to suffer from mental health
problems, including social isolation, separation from family, financial
difficulties, experiences of discrimination, and a lack of familiarity with health
care practices in the host country (Mulvihill, Mailloux, & Atkin, 2001).
For women migrating from Sudan to Australia, exposure to violence
or trauma in Sudan, prior to migration, may also increase the risk of mental
health problems during the perinatal period. Results of recent research
conducted in post-war Sudan reported that 44% of female respondents had
witnessed the murder of family or friends, 48% had directly experienced a
combat situation, 22% had been forcefully separated from family and
friends, 15% beaten or tortured, 10% imprisoned, and 8% raped (Roberts,
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et al., 2009). The same study found a PTSD rate of 42.5% and a depression
rate of 58.7% amongst female respondents (Roberts, et al., 2009)
So, although research into the perinatal mental health status of
Sudanese women is unavailable at this time, statistics such as these,
together with the extensive knowledge regarding the risks of psychological
distress during the perinatal period for the general population, leave no
question that Sudanese women can be regarded as a high-risk population in
need of culturally appropriate support during the transition to Australia and
motherhood.
Background In 2004, a state-wide mapping of perinatal mental health services
was conducted and consultations with a range of community health workers
undertaken. The resulting report (State Perinatal Mental Health Reference
Group, 2005) highlighted significant gaps in health professionals’ cultural
awareness when addressing the perinatal mental health needs of women
from culturally and linguistically diverse (CALD) backgrounds. Adding to the
difficulties was a lack of culturally or linguistically appropriate perinatal
mental health resources.
Subsequent to this report, a series of focus groups were conducted
with women from Iraq, Sudan and Ethiopia, with the objective of gathering
information on their experiences and thus mental health requirements
during the perinatal period. The selection of these three CALD communities
was based on a number of factors, including population size, percentage of
child-bearing women, family size, and levels of education and literacy.
The results of the focus groups, as well as a literature review, are
presented in “Social and emotional experience of the perinatal period for
women from three culturally and linguistically diverse (CALD) communities”
(State Perinatal Mental Health Reference Group, 2008). Recommendations
from this report highlighted the importance of linking together pregnant
women and new mothers within the community. It was proposed that ethnic-
specific cultural liaison workers could co-ordinate self-help or support
groups from within the community. It was envisaged that these groups could
be used as forums for women to share their experiences and develop
culturally appropriate coping strategies.
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On the basis of these results, the State Perinatal Mental Health
Reference Group (SPMHRG) endorsed the provision of funding to establish
and trial a support group for Sudanese women in the perinatal period based
on a psycho-educational group format. In May 2008 a Service Agreement
was made between the Women and Newborn Health Service (WNHS),
Department of Health and Ishar Multicultural Women’s Health Centre Inc.
to carry out this project.
Over the 2 year evaluation period, five groups were conducted. Each
group met for two hours a week over eight weeks. The program was
designed to incorporate informational/educational sessions, discussion of
personal issues and time for networking/socialising. The
informational/educational sessions included topics such as healthy lifestyle
and parenting skills, dealing with government and non government services,
and self responsibility.
An interim evaluation report presented the results from the first 12
months of data collection, with the evaluation framework and results from
the first group. The present report builds upon the 12-month evaluation to
include results from all five groups conducted during the 24-month
evaluation period.
Expected Outcomes It was hoped that as a result of attending the support group,
Sudanese women living in the Perth metropolitan area would become more
comfortable engaging with community and mental health services.
Subsequently, the level of psychosocial support perceived by Sudanese
women was expected to increase. A raised awareness of perinatal mental
health issues within the Perth Sudanese community and increased perinatal
specific knowledge by local service providers were also objectives of the
project. These outcomes were expected to assist in facilitating early
identification and intervention for women at high psychological risk,
potentially leading to an increase in engagement with mental health and
community services.
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Key Performance Indicators (KPI) 1. Participation in support groups by local Sudanese women (i.e.
interest and attendance)
2. Increase in level of perceived psychosocial support by Sudanese
women in the local area
3. Decrease in depressive symptomatology, as assessed by the
Edinburgh Postnatal Depression Scale
4. Increased perinatal specific knowledge by participants and local
service providers
5. Increase in reported levels of ‘comfort’ during engagement with
obstetric services during pregnancy by local Sudanese women
6. Increase in reported levels of ‘comfort’ during engagement with
community services during pregnancy and postpartum by local
Sudanese women
7. Increase in reported levels of ‘comfort’ during engagement with
mental health services in pregnancy and postpartum by local
Sudanese women
8. Increased capacity within local communities for bicultural community
worker to facilitate support groups (independent of original facilitator).
Evaluation Framework / Research Design
The evaluation was based on a pre and post-group design using both
quantitative and qualitative data collection methods. Awareness of cultural
sensitivity and literacy issues led to greater emphasis placed upon collection
of qualitative data in the initial stages of the evaluation. For the first two
groups, demographics, background information and interview data were
collected from participants along with EPDS scores. Analysis of the data
from Group 1 suggested that the EPDS was effectively detecting changes
within the target population. Therefore, to reduce the burden associated with
data collection, only the EPDS scores were collected for Groups 3, 4 and 5.
The results for all five groups are included in this report.
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Interviews Specifically designed semi-structured interviews were employed to
collect the qualitative data for this evaluation. The research interview is one
form of a conversational approach to qualitative analysis (Kvale, 1996). The
interview allows the researcher to gather vast amounts of data and to use
that data to understand the experiences of the participants and the meaning
they make of their experiences. Interviewing provides a powerful and
flexible way to gain insight into people’s experiences and allows
unanticipated responses to be expressed and analysed. An exploratory
semi-structured interview technique was employed, providing a framework
within which respondents could express their own personal perspectives.
The interview questions served as a checklist to ensure all pertinent issues
were raised but allowed for unexpected lines of enquiry to emerge.
Rigour Five main, somewhat overlapping issues have been addressed in the
design, implementation and analysis of the present study to obtain the
highest quality conclusions: (1) Objectivity/Confirmability, (2)
Reliability/Transferability, (3) Internal Validity/Credibility, (4) External
Validity/Credibility, and (5) Utilisation/Application.
Objectivity/Confirmability.
The question of whether conclusions depend on the subjects and
conditions of the enquiry rather than on the inquirer (Guba & Lincoln, 1989)
is sometimes labelled as ‘external reliability’ with emphasis on the
replicability of the study by others (Le-Compte & Goetz, 1982). Objectivity or
confirmability of the current findings was strengthened by numerous
strategies, including: methods and procedures were described in detail and
presented explicitly, the actual sequence of data collection and analyses
that lead to the conclusions can be followed, conclusions were explicitly
linked with exhibits of condensed/displayed data, and study data has been
retained and is available for re-analysis by others (Miles & Huberman,
1994).
Reflexivity was used to identify areas of potential bias. “The ability to
put aside personal feelings and preconceptions is more a function of how
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reflexive one is than how objective one is because it is not possible to set
aside things about which they are not aware” (Ahern, 1999).
Reliability/Transferability.
Reliability or transferability, that is, stability of observations over time
and across researchers and methods was sought through the development
of clear key performance indicators (KPIs) and congruence between these
KPIs and the evaluation design.
The researcher’s role within the research context was explicitly
described, and a ‘meaningful parallelism’ was sought across data sources
by maintaining parameters with respect to participants, contexts and times
(Miles & Huberman, 1994). That is, for each of the groups, one researcher
conducted all pre and post interviews in the participant’s homes and this
same researcher was responsible for transcribing all interviews, and then a
different researcher was allocated to the collation and analysis of the data.
Internal validity/Credibility.
Unlike the classic, measurement-oriented view which differentiates
face, content, convergent, discriminant, and predictive validity,
for the purposes of the current study a more qualitative approach was taken,
thus the inclusion of the term ‘credibility’. Maxwell (1992) distinguishes
among the types of understanding that may emerge from a qualitative study:
descriptive (what happened in specific situations); interpretive (what it
meant to the people involved); theoretical (concepts, and their relationships,
used to explain actions and meanings); and evaluative (judgments of the
worth or value of actions and meanings). Warner (as cited by Miles &
Huberman, 1994) also refers to ‘natural’ validity – the idea that the events
and settings studied are not modified by the researcher’s presence and
behaviours.
Unfortunately there are often issues in gathering data from non-
English speaking participants in Australia. For example, the use of
interpreters is sometimes necessary, however within a small community the
interpreter may be known to participants which can raise concerns about
privacy and confidentiality. However having an unfamiliar interviewer can
also result in a lack of openness as they may not have had the opportunity
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to develop the required level of trust from the participants (Tempany, 2009).
To this end, interviews were conducted by a person from the service who
was familiar to the participant in the participant’s home. Although this can
also raise issues such as the potential to provide more positive comments
about the service, on balance a familiar and trusted interviewer was deemed
preferable. The inclusion of more ‘objective’ measures in the form of the
EPDS scores provides a complementary form of evaluation against which to
consider the qualitative responses.
Triangulation of data sources (i.e., Edinburgh Postnatal Depression
Scale, interviews and research literature) were used in an effort to produce
converging conclusions and give support for adequate validity/credibility
within the present study.
External Validity/Credibility.
Maxwell (1992) speaks of ‘theoretical’ validity, the presence of a
more abstract explanation of described actions and interpreted meanings.
Maxwell suggests that generalisability requires connections to be made,
either to unstudied parts of the original case or to other cases. Although
such an explanation could be considered as ‘internal’ validity, it gains added
power if connected to theoretical networks beyond the immediate study.
With this in mind the present evaluation employed ‘multiple case sampling’
(Miles & Huberman, 1994), that is, 17 Sudanese mothers living in the Perth
metropolitan area and attending the perinatal support group were
interviewed prior to group commencement and again at the end of the
group. A literature review was then used to ‘connect’ the conclusions to
existing theory. The characteristics of the current sample of mothers are
described in enough detail to permit adequate comparisons with future
samples and the boundaries and limitations of this sample are also
discussed.
Utilisation/Application.
‘Pragmatic validity’ (Kvale, 1996) is an essential addition to more
traditional views of ‘goodness’. In addition to informing future funding
decisions, the present study ultimately aimed to provide useful information
to people working with and providing support and information to Sudanese
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mothers living in Australia. Whether those people were health professionals,
policy makers or volunteer mothers working within organisations concerned
with providing services to CALD mothers was unimportant. What was
important was the identification of positive strategies, techniques and
information that could be passed on to expectant or new mothers to ease
their transition and enhance their parenting experience.
Instruments The evaluation instruments included the Edinburgh Postnatal
Depression Scale (EPDS; (Cox, Holden, & Sagovsky, 1987), an interview
schedule and a demographic questionnaire.
Interview schedule
A semi-structured interview schedule was developed by the
WAPMHU Project Officer, in consultation with the WAPMHU Senior
Research Psychologist, to guide the face-to-face interviews with
participants. Questions included in the interview schedule were guided by
the KPIs, that is, questions were included to elicit discussion of perinatal
mental health issues, ascertain current levels of support and assess comfort
levels whilst engaging with available services. The establishment of rapport,
cultural sensitivity and flexibility were considered in the design of the
schedule.
The following nine questions were included in the interview schedule
and prompts were suggested for use as required to elicit elaboration and/or
clarification:
1. How do you feel about the amount of support you have at the
moment? Do you have enough support from your family, friends,
community, community services?
2. Do you think a woman’s emotional health is important when she
becomes a mother? Why?
3. Can you think of any emotional problems a mother might experience
while she is pregnant or after she’s given birth? Have you heard of
mothers who have depression? Anxiety?
4. For a woman who may be pregnant, or has a baby, what kinds of
things do you think are helpful to ensure good emotional health?
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When you feel like you’re not coping / sad what kinds of things do
you do or could you do to make yourself feel better?
5. What kinds of services have you visited during your pregnancy or
since you’ve had the baby? Where do you go if you need help with
your health or your baby’s health?
6. How comfortable do you feel using/going/visiting these services?
7. Where would you go to get help if you felt like you’re not coping?
8. (Group 1 Only) How would you feel about asking for this kind of help?
(Group 2 Only) Would you ask for help from family, friends, your
community, child health nurse or doctor or counsellor? And would
you feel comfortable to ask for help?
9. How comfortable would you feel about using a counselling service?
Demographic Questionnaire
The demographic questionnaire was purpose designed for this
evaluation to gather information on basic demographic variables. It was a
structured questionnaire containing 10 questions to be completed by the
interviewer at the time of interviewing the participant. These questions
provided information on the participant’s age, parity, number of children,
woman’s country of origin, whether the children were born in Australia,
marital status, primary spoken language, other language/s, EPDS version
used, and whether the EPDS and interview were completed with the
assistance of an interpreter. There were also spaces provided to record the
total EPDS score before the group began and at the end of the 8-week
term. For Group 2, a slightly shortened version was used, excluding
information on assisted completion of the questionnaire, country of origin
and referral source. Recording of marital status was also altered.
Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden &
Sagovsky, 1987)
The EPDS was used to measure depressive symptomatology. This
10-item screening questionnaire takes about 5 minutes to complete and
pertains to the women’s feelings during the past 7 days. The items refer to
depressed mood, anhedonia, guilt, anxiety, and thoughts of self harm.
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The EPDS has been widely used in cross-cultural work to measure
depressive symptoms during the perinatal period and appears to be a
reliable measure for both immigrant and non-immigrant respondents
(Rhonda Small, Lumley, Yelland, & Brown, 2007). The EPDS has been
translated into many languages and validated in many countries, including
Africa.
In the present study, an EPDS score of 10 or more was considered
‘high risk’ or indicative of depressive symptomatology, as recommended for
use when screening migrant women during the antenatal and postnatal
period in Western Australia (Department of Health - Government of Western
Australia, 2006).
Procedure Eligibility for participation in the perinatal mental health support group
was based upon Sudanese ethnicity and motherhood status, irrespective of
the presence or absence of depressive symptomatology. As such, group
participants varied in terms of current mental health status/psychosocial
well-being, as well as age, education, whether English was spoken,
occupation, marital status, and parity.
Once informed consent was obtained from group participants
(i.e., to use de-identified data for evaluation purposes), the Project
Coordinator, employed by Ishar, administered an EPDS. For Groups 1 and
2 the Project Coordinator also completed the demographic questionnaire
and conducted a semi-structured interview with each participant prior to
commencement of the group.
Interviews and questionnaire completion took place in the women’s
homes. After introductions and cultural formalities the interviews took place
in an area in the home where the women felt comfortable (e.g., bedroom,
kitchen or lounge room). The reason for the interviews was explained to the
women and a written program outline was given to them. It was made clear
to the women that the information was confidential and would not be
identifiable when analysed and reported.
Depending on the woman’s level of English and feelings of
competence either she would be asked the interview questions in English or
through an interpreter. Probes and prompts were used when required to
14
assist the women in understanding the questions, especially because of the
language barrier. The questions were asked and their answers written as
closely as possible to verbatim by the interviewer at the time of interview in
the woman’s home. The answers were interpreted back into English if
required by the interpreter present at the interview. Each interview took
between 60 and 120 minutes to complete.
The typing of the handwritten answers to the interview questions was
done by the Project Coordinator, who had also conducted the interviews.
This de-identified pre-group data was then submitted to the WAPMHU
Research Officer in hard copy and electronic format.
Post-group evaluation data, was collected and submitted via the
same process and using the same questionnaires, at the completion of the
8-week support group term by the Project Coordinator. The WAPMHU
Research Officer was responsible for collating and analysing pre and post-
group data and preparing this evaluation report in consultation with the
Project Coordinator.
Appropriate ethical clearance, and registration, for this Quality
Improvement activity was obtained from the King Edward Memorial Hospital
for Women Ethics Committee.
Participants Participants were females born in Sudan and now living in the Perth
metropolitan area, who had been referred to Ishar, were pregnant or had
given birth in the last 36 months, and were subsequently attending a
perinatal mental health support group being run by Ishar. Developed as a
‘universal’ service, that is, by recognising that all women born in Sudan and
currently in the perinatal period could potentially benefit from the support
group (Williams & Berry, 1991), mothers who scored above or below the
recommended cut-off on the EPDS (i.e., ≥10; Department of Health, 2006)
were eligible for group attendance and were thus included in this evaluation
sample.
The demographics of Group 1 participants are shown in Table 1.
Although 14 women in total were interviewed and completed questionnaires
pre-group, 10 women attended for the entire 8-week term and were thus
interviewed again post-group and included in the pre-group / post-group
15
analysis. Mothers’ ages ranged from 17 to 31, with a mean age of 22. Three
of the women were primiparous and six of the women had an infant less
than 1 month of age at the commencement of the group. Six of the women
attending the group were unmarried.
The demographics of Group 2 participants are shown in Table 2.
Pre-group questionnaires and interviews were completed by 11 women,
with post-group data collected from 7 women. On average, participants in
Group 2 were older than those in Group 1. Mothers’ ages ranged from 17 to
34 with a mean age of 26. They were also more likely to be married.
The evaluation did not attempt to gather information about the
participants’ prior circumstances, such as exposure to violence or trauma
that may have been experienced in Sudan. However, a number of the
participants faced difficulties during the time the groups were run. These
included deaths in the family, serious health concerns for themselves or
family members, caring for a child or relative with disabilities, crowded
accommodation with relatives, isolation and language barriers, and family
conflict or violence. Such circumstances could make it more difficult for the
effects of the support group to reach statistical significance, as a stressful
life event occurring partway through the eight weeks could significantly
reduce well-being. However, difficult circumstances are part of the everyday
reality for many of these families and serve to highlight the need for support
groups.
Table 1 Profile of Participants in Group One
Age Parity Infants age (months)
Marital status
17 Primiparous 1 Traditional marriage
17 Multiparous 2 Unmarried
18 Primiparous 1 Unmarried
20 Primiparous 0.5 Traditional marriage
20 Primiparous 0.5 Unmarried
23 Primiparous 15 Unmarried
23 Primiparous 0.5 Unmarried
27 Primiparous 0 Unmarried
27 Multiparous (4+) 3 Married
31 Multiparous (4+) 15 Married
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Table 2 Profile of Participants in Group Two
Demographic data and drop-out rates were not collected for Groups
3-5. The total number of participants who completed post-group EPDS
questionnaires in each of these groups was 10, 11 and 9, respectively.
Several participants attended more than one group, and additional data was
collected in these instances. However, in order to maintain consistency in
the analysis, where data has been identified as being from a second or
subsequent group, it was not included in the main analysis. Pre and post-
group EPDS scores were collected from 47 participants in total.
Attrition of participants
In Group 1, a total of four women who were interviewed pre-group did
not complete the 8-week term and did not complete post-group interviews.
One of these women decided not to attend the group prior to session one,
whilst the remaining three women had attended a number of sessions but
had then ceased attending prior to end of term. Reasons for non-attendance
were not sought from two of these three group members. Due to unfortunate
personal circumstances, the third mother was unable to complete the group
(despite regular attendance for most of the term), and it was deemed
inappropriate for her to be interviewed post-group.
Of the five women from Group 2 that did not complete post-group
interviews and questionnaires, two had not commenced the program, while
three had only attended a few sessions. As they had not completed the
program they were not asked to provide post-group data. Attrition data was
not collected for subsequent groups.
Age Parity Infants age (months)
Marital status 2
17 Primiparous 0 Defacto
20 Primiparous 1 Married
24 Multiparous 0.5 Married
26 Primiparous 0 Married
28 Multiparous (4+) 2 Married
31 Primiparous 2 Married
34 Multiparous (4+) 1 Married
17
Analysis
EPDS Data The EPDS (Cox, Holden & Sagovsky, 1987) was used to assess
depressive symptomatology among the mothers that participated in the
group. Data from 47 participants was available for the analysis. Data was
coded and entered into PASW version 18.0 (formerly known as SPSS) for
data analyses. Frequency distributions, graphs and descriptive statistics
were generated for initial data exploration. A score of 10 or higher was used
as the cut-off score to indicate the presence of depressive symptoms in this
population of migrant women, as recommended by the Department of
Health, Government of Western Australia (2006).
Interview Data Thematic content analysis of the qualitative interview data involved
three phases: coding, pattern coding, and reporting of findings and
interpretations.
Coding
The initial coding phase involved the development of a question-
ordered matrix using Microsoft Excel for the participants’ responses to each
of the interview questions. Each transcript was divided into nine sections,
according to the participants’ responses to the nine interview questions.
The sections were then read and speech units of varying lengths, typically 7
to 10 words, were coded and transferred into the matrix.
Pattern Coding
Pattern coding is a method for grouping initial codes into a smaller
number of themes, sets or constructs (Miles and Huberman, 1994).
To facilitate pattern coding and enhance transparency of the process, a new
matrix was constructed for each of the interview questions: 1) current
support, 2) importance of emotional health, 3) knowledge of depression and
anxiety, 4) helpful ideas, 5) service usage, 6) service comfort, 7) future
service seeking, 8) comfort asking for help, and 9) mental health service
comfort. Coded text was transferred from the question ordered matrix to the
18
corresponding new matrix and then searched for key words/phrases, which
were entered into two separate columns – one for pre-group and one for
post-group responses.
The number of times each of the key words/phrases was repeated
across cases/participants was then counted and entered into the matrix,
maintaining separate columns for pre and post-group data. This process
was repeated within each of the 9 matrices, identifying the most common
responses to each of the focus group questions.
With the repetition of key words/phrases across cases clearly
displayed within each matrix, the most ‘dominant’ or ‘prevalent’ patterns
could be identified – and analysis of pre-group and post-group themes was
facilitated. Colour coding was then applied to identify similarities and
differences between key words/phrases and as a result themes emerged.
Appropriate precautions were undertaken in the development and revision
of themes (i.e., ensuring all themes were distinct from each other in
meaningful ways and keeping them as semantically close to the terms they
represent) as recommended by Miles and Huberman (1994).
The use of matrices facilitates transparency of the research
methodology – from initial coded data to themes, strengthening objectivity or
confirmability of the current findings (Miles & Huberman, 1994). The
participants own words were used within matrices and refinement (i.e.,
development of themes) was made explicit, leaving a clear ‘audit trail’ so
that ‘lower levels’ of analysis could be referred to easily.
19
Results The results of the analysis are presented in two sections: quantitative
and qualitative. The quantitative section contains results from participants in
all five groups, while the qualitative section provides additional rich
information from the interviews conducted with Groups 1 and 2. The
qualitative section is divided into nine sections, corresponding to the
questions posed during the interviews. Each of these qualitative sections
begins with a diagrammatic presentation of themes generated from the
responses to that question and the text that epitomised these themes (in
italics) is then discussed.
Quantitative Results - EPDS Data On average, participants attending the Sudanese Perinatal Mental
Health Support Groups during the 24-month evaluation period reported a
significant reduction in depressive symptomatology from admission (M
=13.81, SE = 0.52) to discharge (M = 9.17, SE = 0.52, t(46) = 8.10, p <
0.001, r = 0.77)3. Importantly, this reduction moved the average EPDS score
from over 13 which was above the recommended cut-off of ≥10 indicating
the likelihood of depression was considered high at admission, to below 10,
indicating the likelihood of depression was reduced.
Furthermore, in considering what these results mean for the
participants, 68% of women showed an improvement of at least four points
on the EPDS, which has been recommended as a useful criteria for
determining clinically significant change using the EPDS (Matthey, 2004).
The percentage of participants scoring above the cut-off on the EPDS
reduced from 89% (42 out of 47 women) pre-group to 42% (20 out of 47
women) post-group.
As can be seen in Table 3, most of the groups began with an
average EPDS score of approximately 14, reducing to just over 9 after
3 Note: As the links between research and policy strengthen (Watson & Tully, 2008); it is important to make findings transparent with regard to the actual effect on the lives of women and their families. Subsequently, researchers have adopted a more standardised method of reporting results in which they use effect sizes (or change expressed in terms of a percent of standard deviation) instead of, or as well as, the more traditional alpha values (such as, p < 0.05). Rules of thumb used in evaluations of social service programs define effect sizes of up to 0.2 as small, 0.5 as moderate and 0.8 as large (Cohen, 1983; McCartney & Rosenthal, 2000). Effect sizes were calculated for statistically significant results, as reported above. The effect size of 0.77 for the pre-post comparison of the EPDS represents a substantive finding.
20
participating in the groups. Group 2 showed a different pattern, with a
notably lower pre-group EPDS score and a smaller improvement at post-
group.
Table 3 Mean Pre and Post-Group EPDS Scores by Group
Group 1 Group 2 Group 3 Group 4 Group 5 Combined
Pre-Group 14.3 9.7 14.9 14.4 14.6 13.8
Post-Group 10.5 7.1 9.0 9.4 9.2 9.2
Qualitative Results - Interview Data There are a number of similarities, but also differences between
Group 1 and Group 2. As noted previously, Group 2 members were typically
older, more likely to be married and started with a lower level of depression
than Group 1. The qualitative comments showed that Group 2 was more
familiar and comfortable with a range of services, and their pre-group
responses were often similar to the post-group responses of Group 1. In
addition, the prompts may have been used more routinely in Group 2, with
separate answers recorded for first and prompted responses. Consequently,
the responses from Groups 1 and 2 were analysed separately. For each
question, thematic results graphs for Group 1 are presented, followed by
discussion and comparisons with Group 2. As noted above, Group 2
showed a different profile of depression scores to the other groups.
Therefore, it seems reasonable to speculate that the Group 1 results may
be more representative of the participants in subsequent groups.
Participants’ comments are shown in italics. To maintain the privacy
of participants, they have been assigned an identifying number that is used
in this report. P1.2 indicates participant number 2 from Group 1. This
numbering system is not aligned with the demographics details in Table 1
and Table 2 due to the small number of participants.
21
Question 1: How do you feel about the amount of sup port you have at the moment?
Figure 1. Themes generated pre-group from question 1: Current support (Group 1)
Figure 2. Themes generated post-group from question 1: Current support (Group 1)
Responses about current support were similar for Group 1 and 2.
Three themes emerged in response to this first question regarding the level
of support the women believed they had before the group began:
‘Insufficient support’, ‘Adequate support’ and ‘Support from family and
friends’. It should be noted that although family support was a common
theme, in a number of cases available family members were in-laws or
extended family, and some women reported they missed family members in
Sudan. Thus, even when family members living locally or overseas are
supportive, there can still be important gaps in the support available.
Support from family and friends
Good level of support
Insufficient
support
Community services and group support
CURRENT SUPPORT
Improving
Support from family and friends Adequate
support
Insufficient
support
CURRENT SUPPORT
22
Of the pre-group themes, ‘Insufficient support’ and ‘Support from
family and friends’ remained post-group, but ‘Adequate support’ improved to
become ‘Good level of support’. For example, P1.8 pre-group said “I live
with my brother and sister in law and their children. They support
sometimes”. P1.8 post-group then said “It is good. I am getting support from
Ishar and I am getting support from Anglicare and from family and friends
and the community.” In addition to the three pre-group themes, two new
themes emerged post-group: ‘Improving’ and ‘Community and group
support’, both conveying a positive shift in support networks available to
participants. The ‘Improving’ theme was built from women talking about the
support they felt from participating in the group as well as from information
they had gained about other community supports they could utilise. For
instance P1.2 spoke about the group itself: “I am very happy about the
amount of support, for example the program that has been running here
every Friday has been very helpful for me”. P2.8 noted some improvement
in the support she received, commenting pre-group “I feel good about the
emotional support I received although sometimes it is ok or not. Social
support is ok. Practical support is very hard to come and it is too much for
me and sometimes I nearly cry. I have no relatives.” And post-group
“Emotional support is good; social support is also good. Practical support –
half-half – not much. Practical support from my husband is improved. He is
supportive now since I started the women’s group - perinatal training at
Ishar”.
There was a noticeable broadening in the sources of support
mentioned post-group, with more women mentioning receiving good support
from the community and community groups, as well as family or friends.
This is the “Community services and groups” theme.
The women in Group 2 were asked a further probing question “do
you have enough support from your family, friends, community services?”,
and were therefore more likely to mention community services pre-group.
Some indicated they received enough support from community services,
whereas others indicated they did not. In both Groups 1 and 2, the
‘Community services and groups theme’ appeared unprompted post-group.
The knowledge and empowerment gained from attending the groups
was commented on by participants from both groups. For example P1.1
23
stated: “The support was really good because we learn a lot of things about
babies and myself; and how to manage things for the family. I also learnt
what to do when my baby is sick.” An important part of the knowledge
gained was learning how to access support when it is needed. For example
P1.10 commented “I feel good at the moment, because I know where to go
and there are many people who support me on what I don’t know”. P2.5
stated “I have good support socially, emotionally, practically through the
programme provided by Ishar. It taught me how I can get support.” P2.1 felt
more able to help herself because of the support provided by Ishar: “I am
very happy with the support I get from Ishar, because I am able to help
myself now because of their support… I have never got support from
anybody like Ishar, and the friends I have from Ishar during the program”.
Interestingly, the interview transcripts indicated that more support
was needed by the women whose English was limited (i.e., the women who
had required an interpreter for the interviews). These women appeared to
be the group members who had not made such a noticeable positive shift
post-group with regard to accessing support in the community.
For example P1.3 said pre-group: “I am missing my mother a lot who
is back in Sudan. I live with my brother and my sister in law and their
children. I don’t speak English so find it very difficult. All my other family is
back in Sudan. I have no friends here.” Post-group she still spoke of feeling
lonely: “I have a bit of support at home, but I feel very alone outside the
house”. Given this woman has left her family behind in Sudan, has moved to
a country where she cannot speak the language, and has given birth to an
infant by caesarean section 6 weeks prior to beginning the group, it is not
surprising that she may be struggling emotionally or that it may take longer
than 8 weeks for positive changes to occur.
Nevertheless, for those women whose English is limited, attending
the group has given them a much-needed opportunity to connect with a
community service and other Sudanese speaking women that would not
otherwise have been available. Their willingness to make this connection
and attend the group can thus be seen as an important step in the right
direction.
24
Question 2: Do you think a woman’s emotional health is important
when she becomes a mother? Why?
Figure 3. Themes generated pre-group from question 2: Emotional health (Group 1)
Figure 4. Themes generated post-group from question 2: Emotional health (Group 1)
Within Group 1, two strong themes emerged from analyses of the
pre-group transcripts: ‘Don’t know’ and ‘Yes, for baby’. Both of these themes
indicated that the women were largely unaware of the many psychosocial
and biological changes that occur during the perinatal period and how these
changes can affect them emotionally. P1.1: “I don't really know…”
For those women who did acknowledge that emotional health is
important, the pre-group discussion was very limited, with the focus being
placed solely upon the woman’s role as the carer for the infant rather than
as an individual with her own needs for emotional health and well-being. For
example P1.8 pre-group said: “Yes, because she is a mother.” And P1.14
pre-group said: "Yes, because she has to look after her children.”
Yes, for self
Yes, for baby
EMOTIONAL
HEALTH
Don’t know
Yes, for baby
EMOTIONAL
HEALTH
25
Whilst the ‘Yes, for baby’ theme persisted post-group it was counter-
balanced with a new second theme: ‘Yes, for self’. The replacement of the
‘Don’t know’ theme with this new theme indicated that more of the women
were aware post-group of the importance of not only being able to care for
their child/ren but for themselves also. An example of this positive shift pre
to post-group can be seen in the responses of participant P1.2, who pre-
group was not able to answer this question and then post-group answered:
“Yes, because when you become a mother you have a lot of responsibility
such as taking care of yourself and your baby.”
Pre-group, the participants in Group 2 were already aware of the
importance of good emotional health for mothers and children. For example
P2.4 answered ”Yes. It is important, because a woman’s emotional health
helps her to be a good mother and take care of herself and her baby. The
woman will be happy with herself and baby”. P2.6 said “Yes, because a
woman’s emotional health is important for her own good and the good of the
child”.
Question 3: Can you think of any emotional problems a mother might
experience while she is pregnant or after she’s giv en birth? Have you
heard of mothers who have Depression? Anxiety?
Figure 5. Themes generated pre-group from question 3: Perinatal mental health knowledge (Group 1)
Don’t know
Lonely
Sad
PERINATAL
MENTAL HEALTH KNOWLEDGE
26
Figure 6. Themes generated post-group from question 3: Perinatal mental health knowledge (Group 1)
In contrast to the previous questions, completely different themes
emerged pre to post-group in the Group 1 response to this question
regarding participants’ knowledge of perinatal mental health. It should be
noted that although the question was intended to assess perinatal mental
health knowledge, it was worded in terms of emotional problems to make
the question more accessible. Pre-group themes included: ‘Don’t know’,
‘Sad’ and ‘Lonely’, indicating limited knowledge of perinatal mental health,
even when probed more specifically about depression and anxiety. For
example P1.5 pre-group answered this question with: “When you are not
with your family and they are not happy with you it makes me feel sad.”
The shift in post-group themes reflected a greater level of understanding,
with discussion of the causes of maternal mental illness and how they may
present. For example, pre-group P1.1 said: “I think a mother might be sad
and feel lonely. I don't know what depression is.”, whilst post-group this
same participant described some of the possible causes of postnatal
depression.
Although levels of understanding of this complex topic remained
basic and at times confused post-group, overall there appeared to be an
increase in awareness that women during the perinatal period may
experience various forms of mental illness. This positive change was
illustrated by participant P1.2 who pre-group did not answer this question
PERINATAL
MENTAL HEALTH KNOWLEDGE
Causes of depression and anxiety
Descriptions of mothers with
depression and anxiety
27
and post-group responded: “A mother might experience being stressed,
depressed and even be depressed when she is pregnant”.
Moreover, there appeared to be an important post-group realisation
by numerous participants that mothers could become depressed. For
instance, despite one of the participant’s brother’s apparently suffering from
depression in Sudan, P1.6 stated pre-group: “I haven’t heard about mothers
who have depression”. In contrast, P1.6 spoke at length post-group about
what she believed could be causes and symptoms of maternal depression
and anxiety.
Group 2 began with a higher level of understanding of emotional
health. They discussed a number of issues that can lead to distress, such
as sickness during pregnancy; worries during pregnancy about the baby’s
health and a safe delivery; relationship conflict or an unwanted pregnancy;
or having a baby that cries a lot, lack of help and insufficient rest. They
commented on a range of feelings that can accompany pregnancy and the
postnatal period including frustration, loneliness, sadness, anxiousness and
stress. For example, P2.1 listed a number of concerns and situations that
can impact on mothers’ emotional health: “About having a safe delivery for
both mother and the child; if parents are not happy about the pregnancy;
when the woman and the husband are having problems in the family; after
delivery – when the baby is sick and cries a lot; when you don’t have
someone to assist you; anxious to go back to school – this brings me some
emotional problems”.
In total, 4 of the 7 participants stated pre-group that they had heard of
depression and anxiety, and 2 others mentioned anxiousness or emotional
problems. As a result of this higher level of prior knowledge, there was little
change in the responses from Group 2 participants from pre-group to post-
group.
28
Question 4: For a woman who may be pregnant, or has a baby, what
kinds of things do you think are helpful to ensure good emotional
health? When you feel like you’re not coping / sad what sort of things
do you do or could you do to make yourself feel bet ter?
Figure 7. Themes generated pre-group from question 4: Helpful ideas (Group 1)
Figure 8. Themes generated post-group from question 4: Helpful ideas (Group 1)
The pre-group responses to this question, which asked for
suggestions to help a mother achieve and maintain positive emotional
health, were limited to one major theme: ‘Talking’. As beneficial as talking
can be, this result did indicate a very limited awareness of the variety of
support services, medical and non-medical treatments, and self-help
strategies available to help women during this challenging time of their lives.
The variety and depth of responses increased post-group, the
outcome of which was four themes: ‘Talk – to family and friends’, ‘Talk – to
Importance of support
Talk – to health professionals
HELPFUL IDEAS
Physical health care
Talk – to friends
(or family)
HELPFUL IDEAS
Talk
29
health professionals’, ‘Importance of support’, and ‘Physical health care’.
The increase in awareness of options was illustrated well by participant P1.6
who only spoke of the bible pre-group, but post-group said: “She should go
to a Counsellor or a friend of hers to counsel her or she could go out for a
walk or watch TV or read the bible...She can see community nurses or her
doctor.”
Although talking still featured heavily post-group, the introduction of
health professionals as an alternative person to talk to indicated that the
participants were now aware of this option and its benefits. For example,
although pre-group P1.8 spoke of visiting friends or speaking to her mother,
post-group she also spoke of accessing community supports: “The things
that are important are getting support from different people. When I feel I am
not coping I will communicate with Ishar or the Child Health Nurse”.
Group 2 participants tended to have a range of helpful ideas at pre-
group including talking, exercise, eating well, getting enough sleep and
thinking positively. Several mentioned talking to professionals. Similar to the
previous question, there was relatively little change in Group 2 responses
before and after attending the group.
Question 5: What kinds of services have you visited during your
pregnancy or since you’ve had the baby? Where do yo u go if you need
help with your health or your baby’s health?
Figure 9. Themes generated pre-group from question 5: Service usage (Group 1)
Doctor/GP
Child Health
Nurse
Ishar Midwife
SERVICE USAGE
Hospital –
OPH/KEMH
30
Figure 10. Themes generated post-group from question 5: Service usage (Group 1)
For both Group 1 and Group 2 the major services accessed by
participants did not change significantly from pre to post-group. For Group
1, Princess Margaret Hospital (PMH) was added post-group to the obstetric
hospitals, King Edward Memorial Hospital and Osborne Park Hospital. The
only other minor change in Group 1 was that reference to Ishar expanded
from the midwife pre-group to the service as a whole post-group. Group 2
had a small increase in the number of participants that mentioned Ishar and
child health nurses at post-group.
Doctor/GP
Child Health
Nurse
Ishar
SERVICE USAGE
Hospital –
OPH/KEMH/PMH
31
Question 6: How comfortable do you feel using/going /visiting these
services? (those visited in question 5).
Figure 11. Themes generated pre-group from question 6: Service comfort (Group 1)
Figure 12. Themes generated post-group from question 6: Service comfort (Group 1)
Similar to the findings of the previous question, no significant
changes were noted pre to post-group in regard to comfort levels whilst
accessing services. However, as the majority of participants stated that they
were already comfortable utilising these services pre-group, there was not
much room for improvement. Subsequently, the only shift observed was the
addition of “Very” in front of “Comfortable”, that is, from stating that they
were “Comfortable” pre-group to “Very comfortable” post-group. Many of the
Group 2 participants indicated pre-group they were very comfortable with
accessing services.
Very comfortable
Good
SERVICE
COMFORT
Comfortable
Good
SERVICE
COMFORT
32
Question 7: Where would you go to get help if you f elt like you’re not
coping?
Figure 13. Themes generated pre-group from question 7: Future service seeking (Group 1)
Figure 14. Themes generated post-group from question 7: Future service seeking (Group 1)
The responses from Group 1 and Group 2 differed markedly for this
question. Among Group 1 participants, pre-group responses to this question
indicated that help would only be sought from ‘Family’ or ‘Friends’ or the
‘Midwife at Ishar’, whom had referred many of the participants to the group.
In contrast, post-group themes indicated that participants would also now
consult their ‘Doctor’ (i.e., GP), ‘Child Health Nurse’ or a ‘Counselor/Social
Worker’. The expansion in awareness of possible sources of support/help
and apparent willingness to access such services if the need arose can be
seen as one of numerous positive outcomes of the group.
Informal – friends, community
Ishar
Child Health
Nurse
FUTURE SERVICE SEEKING
Counselor/ Social Worker
Doctor
Friends
Ishar midwife
Family
FUTURE SERVICE SEEKING
33
This small but positive shift is demonstrated by participant P1.3 who
pre-group responded: “I don’t have anywhere to go. I don’t know anyone
from my community. I only have my brother and sister-in-law here who don’t
speak English.” and then post-group responded: “I found out through the
program that I could ask for help from Ishar.”
Themes from Group 2 are presented below. Whereas Group 1
focussed on informal social supports, such as family or friends, Group 2
responses all related to formal support systems such as health
professionals and community services. Most participants (six of the seven)
mentioned a GP or Doctor at pre-group. Hospitals (N=4), Child Health
Nurses (N=3) and Ishar (N=2) were also mentioned by participants pre-
group. Although the majority of Group 2 participants did not increase the list
of services they would access between pre and post-group, P2.10
commented pre-group “I would not go anywhere for help, I would try to work
it out myself”, and post-group answered “I will call or go to Ishar;
Counselling services; GP; Community Child Health Nurse”. This is a positive
change as it is important for women to recognise that help is available and
that it is acceptable to seek help if they are not coping.
Figure 15. Themes generated pre-group from question 7: Future service seeking (Group 2).
Child Health Nurse
Hospital Doctor/GP
FUTURE SERVICE SEEKING
Ishar
34
Figure 16. Themes generated post-group from question 7: Future service seeking (Group 2)
Question 8: How would you feel about asking for hel p?
Figure 17. Themes generated pre-group from question 8: Comfort asking for help (Group 1)
Figure 18. Themes generated post-group from question 8: Comfort asking for help (Group 1)
Child Health Nurse
Hospital Doctor/GP
FUTURE SERVICE SEEKING
Ishar
Comfortable
COMFORT
ASKING FOR HELP
Specific Health
Professionals
Comfortable
Uncomfortable
COMFORT
ASKING FOR HELP
35
When questioned how they would feel about asking for help before the
group began, the majority of participants in both groups stated that they
would be ‘Comfortable’. Nevertheless, there were also pre-group responses
indicating a level of discomfort with the prospect of asking for help from
people they did not know. For example, participant P1.13 said “I wouldn’t
feel comfortable asking someone for help if I didn’t know them”.
However, the ‘Uncomfortable’ theme did not emerge post-group,
indicating a positive shift for those women who had expressed discomfort
pre-group. For example, post-group participant P1.13 said that she would
now feel comfortable asking for help: “I would feel comfortable”.
The new theme ‘Specific Health Professionals’ that emerged post-
group for Group 1 was due to many of the participants mentioning the health
professionals that they would go to for help (which they had not done pre-
group). The professionals included their GP, Child Health Nurse, Ishar and
a Counsellor. Compared to Group 1, Group 2 participants were more likely
to mention specific health professionals they would feel comfortable to ask
for help at pre-group.
Question 9: How comfortable would you feel about us ing a counselling
service?
Figure 19. Themes generated pre-group from question 9: Mental health service comfort (Group 1)
Comfortable
Unknown
Uncomfortable
MH SERVICE
COMFORT
36
Figure 20. Themes generated post-group from question 9: Mental health service comfort (Group 1)
Among Group 1 participants, there was a noticeable positive change
in responses to this question from pre to post-group, with the pre-group
themes ‘Uncomfortable’ and ‘Unknown’ not present post-group, and the new
theme ‘Benefits’ emerging post-group. Prior to participating in the group, all
Group 2 participants knew what a counselling service was and most felt
comfortable or very comfortable using one.
The observed increased level of comfort when presented with the
idea of accessing mental health services was illustrated well by participant
P1.1 who said pre-group: “I don’t think I would feel comfortable because I
don’t know what they do.” The response of participant P1.1 post-group
included possible benefits of going to a mental health service “It is ok to use
counselling services because they help you when you feel sad. They will
talk with you what to do for yourself.” A similar improvement in comfort with
accessing counselling services was expressed by one of the participants in
Group 2. Pre-group, P2.10 answered “Not comfortable”, however at post-
group she responded “Yes I feel good to talk problem with someone; and
then I don’t feel stress about it any longer”.
Very comfortable
MH SERVICE
COMFORT
Benefits
37
Discussion The concept of acculturation is widely used in research with migrant
groups, and refers to the changes that an individual undergoes when they
come into contact with another culture, such as when migrating to a new
country. This acculturation entails numerous psychological changes,
including adjustments in behaviour, values, attitudes and identity (Williams
& Berry, 1991). Despite earlier views to the contrary, acculturation does not
inevitably lead to psychological distress, with the level of distress dependent
upon numerous factors. One of the most influential of these factors is the
presence of social and cultural groups that may provide support for the
person entering into the experience of acculturation (i.e., a protective
cacoon). With a lack of social support also identified in ‘mainstream’
research as an important risk factor for postnatal depression (Dennis, 2004;
Pope, et al., 2000; Robertson, Grace, Wallington, & Stewart, 2004) this
perinatal mental health support group, facilitated by Ishar and funded by
WAPMHU, was intended to provide such a ‘cacoon’ for Sudanese mothers
living in the Perth metropolitan area.
Research suggests that migrants tend to fare better emotionally
when they adopt an ‘integrative’ approach to acculturation, which involves
maintaining valued aspects of one’s own culture and heritage while also
connecting with and selectively adopting aspects of the new culture (Berry,
2005). In assessing participants’ knowledge related to perinatal mental
health, and providing education and information through the support groups,
it is important to be mindful that ‘knowledge’ and understandings of health
are never culture-free. The view of perinatal mental health and help-
seeking promoted through this program were based on the scientific
research literature, and typically ‘Western’ views of health. However, the
aim has been to create a positive and culturally appropriate forum for
sharing information, through the involvement of bi-cultural project members
and placement of the service within Ishar (a multicultural women’s health
service) as well as the use of a community and strengths-building approach.
It was hoped that the information provided would support Sudanese women
to understand and access local services. The interview data suggests the
program was effective and a positive experience for participants.
38
Despite immigrant status being identified as a risk factor for
depression during the perinatal period (Dankner, et al., 2000; Glasser, et al.,
1998; Onozawa, et al., 2003; Rubertsson, et al., 2005; R. Small, et al.,
2003) (Goyal, et al., 2006), there is limited research available on specific
risk factors for immigrant women. From the research available the risk
factors for postpartum depression appear to include: a lack of social
support, stressful life events, physical health problems, and an inability to
speak the language of the host country (Small, et al., 2003;(Parvin, Jones, &
Hull, 2004). For example, a Quebec study that used language spoken at
home as an index of acculturation, found that women who spoke neither of
the ‘native’ languages (i.e., English or French) at home were at twice the
risk for postnatal depression compared with those women who did (P.
Zelkowitz & Milet, 1995). Such research findings are noteworthy given that
only one of the 14 women initially participating in the first support group
nominated English as their primary (i.e., spoken at home) language, and 6
women required an interpreter during the evaluation assessments (this
information was not recorded for the subsequent groups). Moreover, it was
the women without fluent English speaking skills who did not appear to
make a noticeable improvement with regard to accessing support services
in the community.
Under the Government Settlement Program, any newly arrived
immigrant in Australia may be eligible for a range of settlement services,
such as assistance in accessing medical services (Gwatirisi, 2009). Despite
this, immigrants and refugees continue to face challenges, such as health
providers and other service providers’ inadequate understanding of their
needs and challenges. This is particularly the case when it comes to mental
health service provision, with high costs, misunderstanding, stigma and
shame in addition to the cultural and language differences. An extensive
body of literature can be found on the barriers to mental health care
utilisation amongst refugees and immigrants (Wong et al., 2006).
Acknowledging all these issues (e.g., immigrant status as a risk
factor for depression, importance of social support to acculturation and
mental well-being, barriers to accessing mental health services), qualitative
techniques were applied to gather information on Sudanese mothers’
knowledge of perinatal mental health issues, the amount of support
39
Sudanese mothers believe is available for them in the Perth metropolitan
area, and their experiences whilst accessing services.
All Sudanese women living in the Perth metropolitan area who were
pregnant or had given birth in the last 3 years were eligible to participate in
the support group, being facilitated by Ishar and funded by the WAPMHU.
Twenty-six women completed full pre-group assessments, including an
interview, a demographic questionnaire and an EPDS. Seventeen of these
women completed post-group assessments and were thus included in
qualitative data analyses. Interview transcripts were thematically content-
analysed in nine sections - corresponding to the questions posed during the
interviews.
The expansion of support networks from informal sources, such as
family and friends, to health professionals, was a theme repeated during
interviews. Women participating in the group appeared to not only increase
their knowledge regarding alternative sources of support, but also became
more comfortable with the idea of accessing such supports if/when needed.
Women’s responses also indicated that their knowledge of perinatal mental
health issues had increased, that is, that mothers can become depressed or
anxious and what may cause these feelings. Moreover, women’s responses
post-group indicated that they knew talking to others and accessing support
was an important step to feeling better. Women also appeared to have an
increased awareness that emotional health is important for the sake of the
mother as well as the child.
The changes in knowledge and attitudes were particularly apparent in
Group 1 compared to Group 2, indicating that the greatest improvements
occurred where levels of knowledge and comfort with service provision were
lower to begin with. However, the support and information was also well-
received in Group 2, with some increases in knowledge, and a greater
sense of being able to help themselves using the knowledge and social
networks gained through the service.
As stated previously, eligibility for participation in the perinatal mental
health support group was based upon Sudanese ethnicity and motherhood
status, irrespective of the presence or absence of depressive
symptomatology. In light of this, the level of depressive symptomatology
40
found pre and post-group in this sample of Sudanese mothers is
concerning.
Quantitative data collected via the EPDS was used to assess
changes in depressive symptomatology over the course of the 8-week
group term. The majority of the participants had a score indicating an
elevated risk of depression: 42 of the 47 Sudanese women (89%) that
completed the support group and assessments scored above cut-off (≥10)
on the EPDS pre-group. Including the EPDS scores of women who only
completed the pre-group questionnaires, 88% of the Sudanese women had
EPDS scores above the cut-off. Compared to a prevalence rate of 13%
established via a meta-analysis of 59 studies with nearly 13,000 participants
(O'Hara & Swain, 1996), these results suggest that the prevalence of
perinatal depression may be significantly higher in this population of
childbearing women. Although prevalence estimates have varied from 3% to
30%, depending on the period of time under consideration (i.e., symptoms
in the past week or past year), the length of postnatal follow-up
assessments, and the type of measurement being utilised (Pope, et al.,
2000) the difference with this childbearing population is still significant.
If this finding is then compared to prevalence rates obtained via
research with immigrant populations, the difference is still present, although
not quite as large. It appears that the majority of perinatal mental health
research conducted with immigrant populations has been Canadian. For
example, in a community sample of pregnant immigrant women in Canada,
42% indicated high risk of depression on the EPDS (Zelkowitz, Schinazi,
Katofsky, Saucier, & Valenzuela, 2004). Furthermore, women who had lived
in Canada for less than 5 years were found to be at greatest risk. In another
large sample (N = 1250) of pregnant Canadian women assessed for
depressive symptomatolgy using the EPDS, 15% of the immigrant women
in the sample scored in the high risk range compared to 7% of women
born in Canada (Sword, Watt, & Krueger, 2006).
Postpartum research on the mental health of immigrant women is just
as scarce as that available during pregnancy, with Canada once again
being the site of the majority of study. Nevertheless, as found with
depression during pregnancy, women born outside of Canada or having
41
lived in Canada for less than 5 years have been found to be at greatest risk
of postnatal depression (Dennis & Ross, 2006).
A longitudinal study in Canada (Zelkowitz, et al., 2008) investigated
stability and change in postnatal depression in 106 childbearing immigrant
women. They reported that 37.7% of these immigrant women scored in the
high risk category of the EPDS at 2 months postpartum. Based on a
comparison to the prevalence rate of 3.4% found in a sample of over 1500
postpartum women from the same catchment area, the authors concluded
that their results “provide further evidence that immigrant women are at risk
for postpartum depression” (Zelkowitz, et al., 2008, p. 8).
The current findings (i.e., 88% scoring ≥10 on the EPDS) add support
to the Canadian research, and indicate that Sudanese immigrant women
giving birth in Australia may be at high risk of depression. Given the
traumatic and complex case histories of the women participating in this
support group, these results are not completely unexpected.
Although only one psychological study has been conducted in post-
war Southern Sudan to date (Roberts, et al., 2009), its results put the
current findings into context. The objective of this collaborative study
conducted by researchers from the Department of Public Health and Policy,
London, and the Ministry of Health, Southern Sudan, was to measure PTSD
and depression in the town of Juba, Southern Sudan and to investigate the
association of demographic, displacement, and past and recent trauma
exposure variables on PTSD and depression (Roberts, et al., 2009).
The results showed a strong association of gender on mental distress, with
women more than twice as likely as men to exhibit symptoms of PTSD
(odds ratio 2.01) and depression (odds ratio 2.37). The PTSD rates were
42.5% and the depression rates were 58.7% amongst women (Roberts, et
al., 2009).
With 92.4% of respondents experiencing one or more of the 16
trauma events covered in the Harvard Trauma Questionnaire used in the
study, and trauma being closely associated with psychological distress, it is
not surprising that prevalence of these disorders in post-war Sudan is so
high. Women and refugees were found to be two of four subgroups who
were significantly more likely to have experienced eight or more traumatic
events. For instance, 63% of women respondents had ever lacked food or
42
water, 48% had been seriously ill without access to medical care, 44% had
witnessed the murder of family or friends, 48% had directly experienced a
combat situation, 22% had been forcefully separated from family and
friends, 15% beaten or tortured, 10% imprisoned, and 8% raped.
Given the severity of these traumas, it was noteworthy that being
forcefully separated from family was one of three trauma events with
significant associations with PTSD and depression. For the women
participating in this perinatal mental health support group, who had recently
given birth and are now raising their children in a foreign land, away from
family, the impact of this separation on their mental health was tangible, with
many participants speaking of missing family and feeling lonely.
Acknowledging that there are no quick fixes that will address the level
of trauma and complex life histories that these women present with, the
current evaluation results do indicate that the key performance indicators for
this project are being met. Local Sudanese women are attending the
support groups and there was an increase in level of perceived
psychosocial support by the participants, with support networks expanding
from family and friends to incorporate health professional and community
services. The participants’ awareness of perinatal mental health issues had
improved post-group and the importance of accessing services if/when
needed for the sake of themselves and their children was apparent.
Moreover, the participants indicated that they would be more comfortable
asking for help from a range of health professionals post-group.
There was a statistically significant decrease in average depressive
symptomatology scores from pre to post-group. In addition, the percentage
of participants scoring above the cut-off on the EPDS reduced from 89%
pre-group to 42% post-group. This is a very positive change, particularly
given the complex case histories of the participants and relatively short
provision of service (one 8-week term). With continued group attendance
and the associated improvements in mental health knowledge and
awareness of support services available it is hoped that further
improvements would be made by women.
43
Recommendations The number of women reporting depressive symptomatology in the
evaluation sample was higher than both the general population and that
reported in the literature for immigrant mothers, and confirms the need for
perinatal mental health strategies for Sudanese mothers in WA.
The evaluation results indicate that there has been a significant and
meaningful change for participants. The social support, information and
exposure to community services afforded by this group appear to have had
a positive effect and can be built upon for future and extended benefits.
Depressive symptomatology decreased significantly from pre to post-group.
Based on the results of this evaluation, continued funding of the service has
been recommended.
44
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