1

2012: A newborn baby girl was

thrown from apartment

2

2012: Young mother beating her 10-

month old helpless baby

3

2014: Mother of 9 month old baby

dead of committing suicide

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5

POSTNATAL DEPRESSION (PND):

AN UNDERSTANDING FROM MALAYSIAN

PERSPECTIVES

Siti Roshaidai Binti Mohd Arifin

Supervisors: Prof. Helen Cheyne & Prof. Margaret Maxwell

NMAHP Research Unit, School of Nursing, Midwifery and Health, University of

Stirling

OUTLINES

INTRODUCTION

LITERATURE REVIEW

PROBLEM STATEMENT

RESEARCH OBJECTIVES & RESEARCH QUESTIONS

METHODOLOGY & METHODS

ETHICAL CONSIDERATIONS

PLAN FOR ANALYSIS

CONCLUSION

6

INTRODUCTIONImprovement in maternal health as one of the 8 Millennium Development Goals.

(United Nations Development Programme, 2014)

PND often remains underdiagnosed and undertreated in clinical practice.

(WHO, 2008)

Wide variation in reported rates of PND within and across countries and cultures.

(Halbreich and Karkun, 2006)

7

Systematic review of prevalence of PND

Continents Prevalence of PND

USA (Lobato, et al. 2011; Dennis,

Heaman and Vigod, 2012)

8.0-37.5%

Africa (Agoub, Moussaoui and Battas

2005; Kakyo et al., 2012)

5.6-43.0%

Australia (Brooks et a.l, 2009; Austin

et al., 2010)

6.0-32.8%

European (Grote et al. , 2010;

Meltzer-Brody et al. , 2013)

4.0-40.4%

Asia (Ekuklu, 2004; Ho-Yen et al.

2006)

4.9-40.4%

The prevalence of PND ranged from 4.9% to 40.4% with Nepal and

Turkey/Netherlands recording the lowest and highest rates of PND,

respectively (Ekuklu 2004; Ho-Yen et al, 2006; Meltzer-Brody et al, 2013)

8

Prevalence of PND in Malaysia

Years Cultural Setting Prevalence of PND (%)

Kit et al., 1997 Malay, Indian,

Chinese

3.9

Wan Mohd Rushidi et al., 2002 Malay 9.8

Wan Mohd Rushidi et al., 2003 Malay 14.1

Azidah et al., 2006 98% Malay 20.7

Wan Mohd Rushdi et al., 2006 Malay 16.38

Kadir et al., 2009 Not mentioned 27.3

Zainal et al., 2012 Malay, Indian,

Chinese

6.8

9

10

Women in different cultures and countries

interpreted PND in their own ways.

Cultural practices and beliefs would

somehow protect women from PND in some

cultures but could also associate with PND in

another community.

The experience of PND is not fully shared

experience.

(Rahman, 2007; Edwards and Timmons, 2005;

Oates et al, 2004; Rodrigues et al, 2003).

No published study on women’s experience

of PND in Malaysia.

Qualitative Synthesis of women’s experience of

PND

11

The women not only require validation of their feelings but also should be

offered a wide range of treatment options not fully dependent on the

medical model (Bilszta et al, 2012; Rush, 2012).

Need for culturally appropriate intervention

The professionals care towards women with PND was limited by

the use of different language

different cultural background

inadequate assessment tool

a lack of knowledge on PND

less experience in dealing directly with depressed women

(Teng, Blackmore and Stewart, 2007; Oliveira Santos Junior et al,

2012)

In Malaysia, more than 50% of nurse-midwives confused PND with

postnatal 'blues' (Keng, 2005)

Healthcare Professionals perceptions’ of PND

PROBLEM STATEMENT

12

A significant health

problem

Wide variation in

prevalence

Need for culturally

appropriate

intervention

Quantitative

descriptions

Cultural

understandings and

sensitivity is crucial

BUT underdiagnosed

and undertreated

BUT unclear

explanations

BUT based on the

Western culture

NOT nature experiences

of PND

BUT lack of cross

cultural study

(Chien et al, 2006; Rahman, 2007; Niemi et al, 2010; Davy 2013; Mamisachviliet

al, 2013)

RESEARCH AIMS & RESEARCH QUESTIONS

13

Research Aims Research Questions

1. Understand the

experience of women

with PND in Malaysia

• What are the experiences of

PND among Malaysian

women?

2. Explore women’s

perceptions of the

causes of PND in

Malaysia.

• Do women’s causal

explanations of PND differ

across different cultural

backgrounds within Malaysia?

If so, how does it differ?

RESEARCH AIMS & RESEARCH QUESTIONS

14

Research Aims Research Questions

3. Explore the knowledge

and perception of

Malaysian health care

professionals on PND

and its helpful strategies.

• What are the knowledge and perceptions

of health care professionals about PND

in Malaysia?

• How women suffered with PND were

supported in the healthcare systems?

• What are resources available in the

Malaysian healthcare systems for women

suffering from PND?

4. To explore potential

interventions for women

with PND in Malaysia.

• Postnatal Women: What are the

Malaysian women’s perceptions towards

the roles of healthcare professionals in

managing PND?

• HCPs: What are the experiences of care

and helpful strategies for Malaysian

women with PND?

15

PHILOSOPHICAL FRAMEWORK

Positivism Social

constructivis

m

Critical

Realism

(Pilgrim & Bentall, 1999)

STUDY DESIGN AND STUDY SETTING

16

Study

design

Exploratory qualitative design

Study

setting

Five Maternal and Child Health Clinics (MCH)

under Health Department of Federal Territory

Kuala Lumpur Malaysia.

Female Psychiatric Ward, Hospital Kuala Lumpur

17

Populatio

n

Postnatal women with different cultural backgrounds including

Malay, Chinese and Indian women who attend for postnatal or

child health care at MCH Clinics in Kuala Lumpur and

Putrajaya, and their healthcare professionals.

Sample 30 women with PND:

• Comprised of Malay, Chinese and Indian who attend for

postnatal care or child health at MCH Clinics in Kuala

Lumpur.

15-20 Healthcare Professionals:

• Comprised of nurse manager, head nurses, nurse-midwives,

public nurses and medical doctors who involve with

postnatal care in the selected clinics.

SAMPLING STRATEGY

RECRUITMENT OF POSTNATAL WOMEN

Approach the potential participant during postnatal / child health visit

Screening stage:PHQ-2 ≥ 3

and/or Self identified

and/or Being referred by HCP

Provide an invitation letter and a Patient’s

Information Sheet

Contact the potential participant through phone after at least 24 hours-

for interview session

Interview stage:

Home/private room in the clinic

Post-interview stage: EPDS

NOTES: Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionairre-2

(PHQ-2)

RECRUITMENT OF POSTNATAL WOMEN

19

Sampling • Purposive sample: to ensure diversity in cultural beliefs and practices.

Inclusion

criteria

• Age 18-45 years.

• No more than 1 year postnatal at the time they enter the

study.

• Had been staying in Malaysia after the last childbirth and

until the time of the interview.

• PHQ-2 ≥ 3 and/or self identified and/or being referred by

HCP

• Malaysian by nationality.

• Sufficiently fluent in English or Malay Language to

participate in the interview.

Exclusion

criteria

• Not fluent in English or Malay Language

• Severely depressed to the extent that participation in the

interview might worsened their condition.

• Non-Malaysian by nationality.

RECRUITMENT OF HEALTHCARE

PROFESSIONALS

Identify potential participant through organization chart and clinic manager

Approach potential participant by invitation letter

Explain about the research aims and process- provide

Participant’s Information Sheet

Contact the potential

participant through phone/ approach face to face in the clinic after at least

24 hours

Arrange for interview session

and seek for inform consent

prior to interview session

RECRUITMENT OF HEALTHCARE

PROFESSIONALS

21

Inclusion

criteria

• Caring for postnatal women

• Work for not less 6 months in the MCH clinic.

Exclusion

criteria

• Work in MCH clinic for less than 6 months.

RESEARCH INSTRUMENT FOR DATA

COLLECTION Screening Tools

Patient Health Questionairre-2 (PHQ-2)

Face to face Semi-structured interview

Interview guide:

Two different set:

Women with experience of PND

Healthcare professionals

Post interview stage

Edinburgh Postnatal Depression Scale (EPDS)22

PLAN FOR ANALYSIS

23

Data collection and data

analysis will be

conducted concurrently

NvivoThematic analysis

Conducted by only

one researche

r

All themes will be cross-

checked by two PhD

supervisors

Informed consent

Anonymity and

Confidentiality

Data Protection

Cultural and Linguistic Barriers

Ethical Approval Process

Potential Distress

Researcher Skills

Resources

ETHICAL CONSIDERATIONS

24

Ethical Approval Process

25

Upon the approval the researcher has visited the clinics on an agreed date and time.

An application letter has been sent to the respective Director, Health Department of Federal Territory Kuala Lumpur and the Clinic Managers in

the respective clinics.

Malaysian government: online registration with the Malaysian National Medical Research Register (NMRR) – to get approval from The Malaysian

National Institute of Health Research (NIHR) and Malaysian Research Ethics Committee (MREC).

University’s Ethical approval: School Research Ethics Committee (SREC)

CONTRIBUTION OF THE STUDY

26

Academic contribution Add on the theoretical understandings of

PND in relation to cultural differences.

Encourage further high quality research to provide effective, relevant and culturally sensitive intervention for PND.

Clinical contribution The findings of this study will be the

foundation of developing preventative intervention for PND in Malaysia.

GANTT CHART

27

Year First Year: 2013/ 2014 Second Year: 2014/2015 Third Year: 2015/2016

Months Sep-

Dec

Jan-

Mac

Apr-

Jun

Jul-

Aug

Sep-

Dec

Jan-

Mac

Apr-

Jun

Jul-

Aug

Sep-

Dec

Jan-

Mac

Apr-

Jun

Jul-

Aug

Tasks

Initial thesis planning with supervisors

×Refinement of topic with aims and

methodology ×

Submission of proposal draft to supervisors

×Refinement of proposal for 10th month panel

review ×

Submission for10th month panel review

×Presentation for 10th month panel review

×Submission of study protocol to

University Ethics committee ×

Submission of study proposal to Malaysian

ethics committee (NIHR and MREC) ×

Data collection

×Data analysis

×Writing final report

Submission of final report

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