Immigrant Women and Mental Health Care: Findings

Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20

Immigrant Women and Mental Health Care: Findings from an Environmental Scan Joyce O’Mahony & Nancy Clark To cite this article: Joyce O’Mahony & Nancy Clark (2018): Immigrant Women and Mental Health Care: Findings from an Environmental Scan, Issues in Mental Health Nursing, DOI: 10.1080/01612840.2018.1479903 To link to this article: https://doi.org/10.1080/01612840.2018.1479903

Published online: 01 Oct 2018.

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ISSUES IN MENTAL HEALTH NURSING https://doi.org/10.1080/01612840.2018.1479903

Immigrant Women and Mental Health Care: Findings from an Environmental Scan Joyce O’Mahony, RN, PhDa and Nancy Clark, RN, PhDb a School of Nursing, Thompson Rivers University, Kamloops, BC, Canada; bFaculty of Human and Social Development, School of Nursing, University of Victoria, Victoria, BC, Canada

ABSTRACT

Immigrant women’s mental health is a growing public health policy issue. New immigrant mothers may be particularly vulnerable to less than optimal mental health following childbirth given the cultural and geographic isolation, socioeconomic factors, gender roles, and language difficulties that influence their postpartum experiences. The purpose of this environmental scan was to increase understanding of immigrant women’s perinatal mental health care services within the interior of a western Canadian province. Four interrelated themes emerged to impact postpartum health of immigrant women: (i) community capacity building, (ii) facilitators of mental health support and care, (iii) barriers of mental health promotion and support, and (iv) public policy and postpartum depression. Knowledge gained from this study contributes to healthy public policy and practices that promote mental health and support among immigrant women.

Background The context of equitable public health and primary health care provision is increasingly affected by diversity of population groups and disjuncture between policies and practices that are incongruent with the complexity of immigrant women’s health care needs. Immigrant groups make up a rapidly changing multicultural context in all Canadian provinces and territories. For example, since 2015 Canada received approximately 40,000 refugees from Syria (Immigration, Refugees, and Citizenship Canada [IRCC], 2017). Highlights of the 2006 census report 20% of Canada’s population is foreign born, and approximately 16%, of the 1.1 million immigrants who arrived since 2013 settled in British Columbia (BC) (Statistics Canada, 2006). Canada has a long history of public health achievements in the past century; however, immigrant mental health remains a public health priority linked with poverty, social exclusion, and structural racism (Williams & Meadows, 2017). By structural racism, we refer to the policies and practices that institutional actors have on (re)producing social exclusion based on multiple intersections of race, class, immigrant status, and gender (Viruell-Fuentes, Miranda, & Abdulrahim, (2012). This critique stems from the attention to cultural difference as key factors related to poorer immigrant mental health outcomes but which masks the social dimensions of mental health, e.g. poverty, education, and gender as well as institutional responsibility for redressing inequities in healthcare (Clark, 2018; Viruell-Fuentes et al., 2012). Research suggests that immigrant groups experience worse health outcomes longitudinally when compared with

native born Canadians, known as the healthy immigrant effect (Beiser, 2005; Kirmayer, et al., 2011). This trend is often correlated by poorer health outcomes that match Canadian born citizens with length of time in Canada. However, this may not be true for immigrants that arrive under various national immigration categories, e.g. asylum seeker, government, or privately sponsored refugee. Various contexts and intersections may determine base line health. Across immigrant categories, immigrant women experience significant mental health challenges due to precarious employment, poverty, gender roles, language, and literacy barriers during resettlement (Clark & Vissandjee, in press; Guruge & Khanlou, 2004; Hankivsky & Christoffersen, 2008; O’Mahony & Donnelly, 2013). The most prevalent barriers reported about immigrant health care access in Canada include linguistic barriers, lack of information how to navigate health services and cultural difference (Kalich, Heinemann, & Ghahari, 2016). In addition to systemic barriers, rates of mental disorders vary across migrant groups but are linked to post-migration factors which moderate effects of pre-migration stress (Kirmayer et al., 2011). Gender and maternal mental health is less understood. Some research suggests that immigrant women experience two to three times the risk of Canadian born counter parts for postpartum depression (Kirmayer et al., 2011). Definitions Perinatal mental health is defined as women’s mental health during pregnancy up to 1 year postpartum (Higgins,

CONTACT Joyce O’Mahony [email protected] School of Nursing, Thompson Rivers University, 805 TRU Way, Kamloops, BC V2C0C8, Canada. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/imhn ß 2018 Taylor & Francis Group, LLC

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J. O’MAHONY AND N. CLARK

Downes, Carroll, Gill, & Monahan, 2017). Reproductive mental health is a broader term which includes pre-pregnancy, pregnancy, postpartum, pregnancy loss, infertility, and premenstrual syndrome. In this research, both terms are used to describe mental health challenges experienced by immigrant women that include both migratory factors and post-migratory stressors. Risk factors Approximately, 10–20% of women suffer from mental health problems during the perinatal period (Ayers & Shakespeare, 2015; Vigod, et al., 2017). A Canadian systematic review on immigrant women’s experiences of postpartum depression (PPD) in Canada, found that women who are born outside of Canada and who have recently immigrated (within a 5year period) have a five times greater risk of depression (Kirmayer et al., 2011). Despite this prevalence, Higgins, Carroll, Gill, Downes, and Monahan (2017) maintain that women’s mental health issues often go unrecognized by maternity and health care providers. Immigrant women that experience depression, posttraumatic stress disorder, and psychosis, often do not access public health and primary health care services due to intersecting factors including disruption of social networks and lack of culturally appropriate care (Ahmed, Bowen, & Xin Feng, 2017; Mengesha, Perz, Dune, & Ussher, 2017; Merry, Gagnon, Kalim, & Bouris, 2011). There is a substantial body of evidence showing that maternal depression and subsequent poor maternal–infant interactions adversely affect the developing child (Ayers & Shakespeare, 2015; Schmied, Black, Naidoo, Dahlen, & Liamputtong, 2017). These adverse mental health effects can have long lasting effects on both maternal and child health. Risk factors for mental ill health for immigrant women during the perinatal period are related to contextual factors such as immigrant status, social isolation, culture, systemic discrimination, poverty, and gender relations (Ayers & Shakespeare, 2015; Higginbottom et al., 2015; O’Mahony & Donnelly, 2010; Vissandjee, Thurston, Apale, & Nahar, 2008). Key challenges Individual risk factors have a relationship with public policy. Immigrant groups experience multiple barriers related to accessible mental health care resources, implicated by broader political, social, and health care structures (DeSouza, 2013; Hansson, Tuck, Lurie, & McKenzie, 2010; Raphael, 2016; Viruell-Fuentes et al., 2012). In addition to systemic processes which impact immigrant mental health, public policy on immigrant women’s maternal mental health has focused on screening for PPD. For example, a public health policy initiative was introduced to screen for PPD using the Edinburgh Postnatal Depression Scale (EPDS) in interior BC (Cox, Holden, & Sagovsky, 1987). Despite the validity and reliability of the 10-item self-rating scale, there are critiques regarding the appropriateness of using the screening tool with diverse cultural groups. Ethnocentric

assumptions underpinning the EPDS items and diverse range of cross-cultural understandings about maternal child health may need further examination (Stapleton, Murphy, & Kildea, 2013; Tobin, Di Napoli, & Wood-Gauthier, 2015). Studies that explore the public health nurses (PHNs) role in screening and assessing mental health, show that while PHNs are involved in screening and use tools to aid in best practice decision making, there is a lack of consistent approach, even when guidelines and protocols are available (Borglin, Hentzel, & Bohman, 2015; Jomeen, Glover, Jones, Garg, & Marshall, 2013; Rollans, Schmied, Kemp, & Meade, 2013). As part of public health policy and practice, PHNs are reported to lack the knowledge and skills required to provide comprehensive perinatal mental health care to women (Higgins, Downes, et al., 2017). With linking nursing, midwifery, and immigrant women’s maternal care, DeSouza’s (2013) findings suggest that immigrant mothers experience multiple forms of structural racism embedded in culturalist discourses where nurses continue to promote neoliberal approaches to mothering. These findings reflect assimilation practices abdicating institutional responsibility and potentially causing psychological harm. Primary health care services deliver most of mental health care treatment which includes family physicians, and nurse practitioners (NPs), yet are not prepared to deliver mental health care due to lack of adequate education and collaboration with specialized mental health services (Wener & Woodgate, 2017). In the United Kingdom, an overview of health system response to immigrant women’s perinatal health suggests there is an overall lack of identification of women at risk for mental health, lack of training in perinatal health and dominance of biomedical model with emphasis on pharmacotherapy (Ayers & Shakespeare, 2015). Australia also receives a high number of immigrant groups that experience significant barriers related to accessible sexual and reproductive health care (Mengesha et al., 2017). Similarly, in Canada, accessible and culturally congruent care is underpinned by language and trained interpreters, and lack of cultural understanding and gender sensitive responses. Importantly, immigrant women do not actively seek care for PPD (Hansson et al., 2010; Kirmayer et al., 2011; O’Mahony & Donnelly, 2010). Challenges to immigrant women’s perinatal care and mental health are compounded during the resettlement period. For example, resettlement policies have shifted toward integration and settlement of immigrant groups further away from metropolitan centers and into rural and remote communities across BC and other provinces (Racine & Lu, 2015; Sherrell, Friesen, Hyndman, & Shrestha, 2011). Although some research has focused on PPD as important in understanding immigrant women’s mental health, and the impacts of social and environmental factors, little is known about how current policy and practice respond to immigrant women’s mental health related to reproductive health and/or during the perinatal period especially immigrant women who live in smaller mid-size towns and remote communities. Moreover, the role of public health nurses and midwives in provision of mental health care access and

ISSUES IN MENTAL HEALTH NURSING

support has been under reported. This study addresses a gap in knowledge about the experiences of public health nurses, immigrant service providers as well as mental health specialist perspectives on the impact of perinatal screening (EPDS) and mental health care of immigrant women in the interior region of BC.

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part of the analysis. Open ended interview guides were used with ten key informants to address research questions 1 and 2. Lastly, a fluid survey was conducted with n ¼ 100 participants that included PHNs and mental health professionals. The specific aim of the survey was to learn more about health care professionals’ thoughts and opinions concerning the EPDS and referral process.

Purpose and research questions The purpose of this environmental scan was to increase understanding of immigrant women’s reproductive mental health care services within rural settings and to inform the implementation of a cross regional research program. Three research questions guided the study: (1) What are the reproductive and mental health care services within the Interior Health Region? (2) How are immigrant women screened for and referred to follow-up care and treatment of PPD? and (3) What policies influence the reproductive mental health care of immigrant women in rural settings? Methodology Our research was underpinned by critical social theoretical perspectives which aim to mitigate social inequities and work toward positive social change (Crotty, 1998; Kincheloe & McLaren, 2005). An important dimension of our approach was to use different sources of evidence regarding distribution of geographical resources, the determinants of immigrant women’s maternal mental health, their interrelatedness, and the usefulness of interventions to improve maternal health of immigrant women in a western Canadian province. Given the critical theoretical orientation the aims of this research are to support all related mental health nursing, including public health and other practitioners in promoting mental health and wellbeing of immigrant women during the postpartum and perinatal period. Recruitment of participants Networking with healthcare professionals in Public Health and Mental Health provided a diverse sample of mental health, community/public health practitioners, policy makers, and managers who best informed the research priorities, questions, and future direction of the next phase of the research program. The environmental scan recruitment, data collection, and analysis were conducted from July 2016 to June 2017. The study received research ethics board approval from Thompson Rivers University and Interior Health Authority. Data collection Data collection activities included document analysis of hospital and community profiles, regional health policies, and grey literature search. Review of literature pertaining to immigrant reproductive mental health care services (geographic distribution of services, as well as current culturally tailored approaches used) was conducted and included as

Data analysis Drawing from Carspecken (1996) Sandelowski (1995), and Denzin (1994), a thematic analysis was conducted across the three data collection activities. This process was iterative and interpretative and included initial data coding, categorization of concepts and development of themes. A cross-thematic analysis was done which included both authors’ review of grey literature (online websites), individual transcripts and fluid survey responses individually and together. As analysis findings became more refined we consulted with one of the key informants (a public health nurse) to provide feedback on emerging themes.

Findings In the following, we describe findings of web and internet resources, individual interviews, and a fluid survey. To help answer part of our first research question, an internet search was conducted focusing on the community perinatal resources across interior health region of BC. Search terms used included mental health, postpartum depression, and reproductive mental health. The web search showed less resources to specialists such as reproductive/perinatal mental health and mental health services. However, some web-based resources provided information in lay language as well as translation services through Health Link BC, and Healthy Families BC. In some cases, these web-based resources such as the one found on Health Link BC provided an app which could assist immigrant women and families to locate services near them. Access to mental health support for immigrant women experiencing reproductive mental health issues and or during perinatal period required health literacy in being able to access a computer and other technologies such as smart phones, iPad, iPhone and/or telephone. There were no specific services identified that provided resources for immigrant fathers. Three resources specific for immigrant families where identified include the Refugee Clinical Care Package for Interior Health; New Comer Care Pathway, and the Affiliation of Multicultural Societies and Service Agencies of BC in one mid-size city. Most of the web resources were geared toward health care professionals to help navigate resources including health care coverage. Following the internet searches, we were interested to know how women are screened for PPD and what mental health services are provided for women during the perinatal period. Ten key informant interviews were conducted with immigrant service providers, public health administrators, public health nurses, policy experts, and primary health care providers across BC. The impact of universal screening

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through EPDS increased awareness and referrals for women at risk. However, lack of provider education, increased need for collaboration across primary care and mental health and public health as well as a framework for cultural safe services were identified as gaps in service for immigrant women. Building community capacity, facilitators of mental health support, barriers for mental health promotion and public policy for PPD emerged as key interrelated themes. Building community capacity Consistent with the initial internet search, use of information technologies such as mobile apps/social media, tele health were viewed by providers as building capacity for mental health awareness and accessible services and supports. In the following excerpts, service providers highlight how technologies can enhance capacity for education on perinatal care for immigrant women in interior health regions: P802-0078: “I think it’s a matter of … education of healthcare providers … about the importance of screening and referral … and being able to offer support … PHNs have been fantastic in BC … we have telehealth’s that are held [and] therapists in community or psychiatrists … who can attend the telehealth”

Technologies were also viewed as a way to build social connection and awareness across women from different cultural groups: DMP00-0052: “ … social media is playing a big part … you know sort of promoting and helping … there’s a Latino face book group, there’s a Filipino face book group.”

Other community and public health initiatives to enhance local capacities included PHN’s collaboration among immigrant service agencies and church or faith-based organizations. Front line providers viewed strategies such as potluck lunches, walking groups, cooking classes as effective to not only increase social support, and networking, but also to access immigrant friendly health promoting activities. An extension of collaboration included what several participants defined as ‘shared care work’ across service sectors (public health, mental health and immigrant services). P16-005 “ … tried to map maternity patients’ experience as they moved through different services … because some of them are rural patients and they need to see maternity providers in a different community. So that was one of our efforts and then a virtual clinic where we shared information between physician offices.”

Local geographies impacted PHN’s ability to support immigrant women and families timely access to specialized support but capacities where virtual clinics are established helped assessment and referral processes. Local communities across Interior Health Regions enhanced their resources through networking and sharing information and this was viewed as a collective responsibility across health professions. P16-004 “ … one thing that really helped … to build relationships and understanding support capacity … shared care committee for perinatal mental health and substance use”

In addition to the capacity building strategy of shared care work was the development of community champions and peer mentors to build competencies for mental health during the perinatal period. Community ‘champions’ were perceived to be beneficial in acting as mentors for providing education for rural health care professionals in smaller communities. There was an overwhelming response to support training and education of service providers across interior regions. Participants spoke about ‘building bridges,’ capacities, and competencies between mainstream mental health and public health. These strategies were viewed as enhancing clinical competencies and important for developing a clear pathway to care for immigrant women. Similarly, peer mentorship was viewed by service providers as linking immigrant women with mental health and social service supports. P16-005: “ … immigrant women who maybe don’t feel comfortable in participating in groups … … peer mentoring model … offers variety of settings and personal support … if we had a different model that would incorporate outreach … tapping into volunteers”

Many providers spoke about how immigrant women would be unlikely to attend mainstream mental health clinics either due to cultural factors, lack of knowledge and/or distance and location of services. Issues of trust and safety were raised as integral to supporting immigrant women’s access to perinatal and reproductive mental health care. Provision of peer support was also viewed by providers as enhancing support for women and their families so that issues around cultural stigma, trust and safety could be enhanced. Excerpts from a health care provider recommended the following approaches to peer support: 802-0074 “ … a community clinic where they would have different kinds of services … peer support and they also had like fathers come in … ” P16-005: “ … immigrant women who maybe don’t feel comfortable in participating in groups … … peer mentoring model … offers variety of settings and personal support … if we had a different model that would incorporate outreach … tapping into volunteers”

The above excerpts highlighted the need for increased family centered resources and support for immigrants during the perinatal period. In these contexts, both immigrant service providers and nurses spoke about peer support as a strategy to enhance capacity for supporting immigrant women’s perinatal mental health in small towns and metropolitan areas. These findings are fitting with other research suggesting a reorientation to mental health services toward a shift in mainstream cultural policies and practices (DeSouza, 2013; Guruge, Thomson, George, & Chaze, 2015). Facilitators of mental health support and care Participants highlighted community capacity building strategies for supporting immigrant women’s mental health and identified key facilitators for provision of accessible mental health support. The notion of using ‘lay language’ and


making services friendlier, by having familiar faces and perinatal services closer to home. As primary health care services may be distrusted across greater geographic distances in the interior regions, ensuring support that is closer to home was identified as a community strength: 802-0078: “Yeah … making sure people are trained … so it’s all about getting it closer to home and making it free of charge”

Closer to home also included tapping into community resources such as faith-based organizations as a source of mental health support and social capital for new comer immigrant families. There is a general belief amongst care providers that immigrant women keep to themselves and gain support through family networks. As this service provider explained, these are community strengths: DMP 0052: “ … there are quite a number of cultural groups in Kelowna, with the number of churches and faith groups … and I think that is a real strength … ”

Public health collaborations across service sectors including nontraditional health resources such as faith-based organizations were viewed as community strengths and facilitators for mental health promotion. Enhancing social support during resettlement and post-migration has been identified as an important protecting factor in mental health (Guruge et al., 2015). While providers spoke about innovative strategies to promote and facilitate access to mental health care they also experienced significant barriers to mental health promotion of immigrant women during the perinatal context. Barriers of mental health promotion and support Key barriers for mental health care and support for immigrant women included intersections of language of culture, and gender, safety/trust, lack of health care provider education, and accessible clear pathways to mental health care and support. Health care providers felt that language, culture, and gender could not be easily separated and that immigrant women’s access to services was not culturally congruent due to lack of interpreters and often related to gender roles. In the following excerpt, an immigrant service provider discusses this challenge: P17-0015: “The husband came out, got work … and then helped his wife immigrate. So, the woman … was not working outside the home so she didn’t have the interaction with the community. So often it was the father who had more fluent English … so I was relying on him to help with translation”

Immigrant women’s gendered experiences may be invisible due to gender roles and education, i.e. literacy. In some cases, having family act in the role of interpreter maybe a cultural risk for women due to stigma of mental illness or lack of knowledge about perinatal and reproductive mental health. In addition, participants spoke about the cultural stigma around mental illness which may prevent immigrant families from accessing mainstream mental health services and supports. Similarly, another provider highlighted the need for gender sensitive translators:

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P802-0083: “Even if you had a very sensitive translator – first of all you can’t always guarantee they are the same gender”

Providers viewed gender sensitivity as a barrier to immigrant women’s screening and referral particularly for women who lacked access to resources based on their education and who may experience further stigmatization by a translator not of the same gender. Gender sensitive screening and support was also viewed to enhance safety and trust as some providers noted that immigrant women may experience stigma. P0052: “And women tend to fall through the cracks, because of all the things that happen to women … don’t follow up – fear of authority … ”

P17-0014: “I think there is some stereotypes that are out there, … not trusting government agencies … ” Trust of authority and fear could be related to negative experiences with health care providers, as well as pre-migration experiences and trauma. Participants identified that counselling services in particular have less access or integration of language interpreters than public health or immigrant services. This may be related to the fact that many immigrant families do not view psychological counselling as a first line health intervention. Almost all participants discussed a need for more training and education related to immigrant health and perinatal health. Gender sensitivity and enhanced support for immigrant families, screening of male partners and provision of female interpreters were suggested to enhance family support during the perinatal period. Health care provider education and accessible pathways for mental health support for immigrant women during the perinatal period were identified as the most significant barriers. Providers were unanimous in the need to develop better competencies and knowledge related to clinical pathways and referrals. Some PHNs identified the fear and anxiety related to limited knowledge about mental health risk factors and the referral process. P16-004: “ … in our perinatal working group and what we have been looking [at] in reproductive mental health is “how do we support that rural clinician in [southern BC] to be able to provide services to someone who is depressed and has a baby … ?”

With recent universal screening roll out, most participants found the EPDS helpful in identifying women who might be at risk of PPD and other mental health problems. Some participants felt it supported the overall assessment and built trust as this often could be the first access into the health care system. However, it was also viewed that provider education includes not only factors related to screening of risk but also issues related to culturally safe care practices across community groups. P 802-0083 “nurses could definitely be resourced to know what are the settlement agencies? … extra training around trauma informed care and cultural humility … ”

Health care professionals also had concerns regarding the cultural sensitivity/meanings, and or misinterpretation of the EPDS questions. Some felt it was not as simple as translating the EPDS into another language and would require

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Figure 1. Has the Edinburgh Postnatal Depression Scale (EPDS) helped you to identify women at high risk for postpartum depression (PPD)?

validation by their ethnic community. Health care professionals identified timely access to care and treatment for PPD as a ‘priority’ for all women in the postpartum period. Although screening universally for PPD is now a ministry directive in BC, there are identified gaps in accessible pathways to care between mental health and public health. P16-004: “Really worried about how mental health will respond with – well we don’t have anybody in the office today or we don’t have anybody who’s trained, we do not do this, and is not part of our mandate. We are not comfortable with these kinds of referrals … ”

It was viewed that mainstream mental health services may not have enough training related to factors impacting immigrant women’s mental health in the perinatal context. Likewise, a health care provider adds: P161012-005 “Family physicians, public health and the community organization do not have the capacity to do mental health support. [ … ] so, if the mom actually made it to the door … If they were low risk they were basically given self-help guides that’s the formula.”

In summary, participant interviews revealed the need for increased education, culture and gender sensitive training and support as necessary for promoting mental health and accessible pathways to care for immigrant women. In the following, we link the findings with the fluid survey results.

Fluid survey findings After completing the initial interviews, we developed further interview questions that could specifically address public health and mental health care providers’ perspectives regarding the EPDS and explore impacts of the tool for immigrant women requiring mental health support for PPD. Findings showed that 93% of health care professionals in this survey provided mental health services and support for postpartum women (Figure 1).

Seventy-nine percent (79%) of participants reported that the EPDS helped screen for postpartum depression and 21% stated it was not helpful. PHNs used the EPDS screening tool at two months postpartum at community health centers (immunization clinics) whereas mental health clinicians usually received referrals once initial screening was done. Participants who found the EPDS helpful, stated the tool was quick, easy to use and helped identify women potentially at risk for PPD. Some clinicians may have found the EPDS not helpful due to their experience in working with immigrant women and/or increased skills in mental health assessments. Public Health Nurses (PHNs) viewed the EPDS as a tool to help initiate conversation about psychological issues and found it was easier to facilitate follow up care. This may be related to overall lack of perceived training related to mental health identified by key informant interviews (Figure 2). Both mental health care professionals and PHNs identified the EPDS as a facilitator to increase inter-professional collaboration and timely access for women at risk during the postpartum period. However, PHNs also identified that the policy initiative of the EPDS increased their case load. Similar findings are reported in our key informant interviews whereby many participants wanted increased education and training concerning mental health and addictions related to women in the postpartum period. These data complement our qualitative interview findings whereby increased community capacity for supporting immigrant women postpartum was related to better integration of community-based organizations, public health, and mental health. In rural locations, the notion of ‘shared care work’ and having increased networks of collaboration enhanced capacity but not necessarily individual level competencies. In smaller communities ‘champions and/or community leaders’ were viewed as having increased knowledge, competency and passion for mental health and substance use problems for women in the postpartum period (Figure 3).


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Figure 2. What has supported your competencies in providing mental health care services and supports for high risk women during the postpartum period?

Figure 3. Have you experienced any challenges in providing postpartum mental health care and services for immigrant women?

Not all participants experienced barriers in providing postpartum mental health care and services for immigrant women. Approximately, 44% did not experience barriers or challenges in comparison to 56% who did. This difference may be related to the fact that many organizations have not had a large influx of immigrant families in their communities and/or immigrant women and families do not seek mainstream mental health supports and resources. However cultural incongruence was described as language and interpretation barriers related to identification of risk factors within the EPDS. For example, ambiguous questions such as “do you ever feel like harming yourself?” were not easily translatable questions that could be confusing for immigrant women. PHNs reported that the EPDS might potentially hinder relationships with the decline of home visits. Likewise, many participants suggested immigrant women may not want to disclose their experiences due to privacy and sharing concerns with strangers. Perspectives from

health care professionals suggested that gender relations also prevented some women from accessing support. Overall decreased resources for immigrant women’s health were found to be a major barrier for support services postpartum. Similarly, to the interviews, PHNs and mental health practitioners raised concern over EPDS impact on caseloads and that a ‘threshold’ for mental health and addictions is often reached in terms of referrals. Lastly, communication and awareness of cultural stigma were identified as important factors which need to be addressed for preventing and promoting mental health and well-being for immigrant women and their families (Figure 4). These findings are fitting with provider interviews which recommend the need for ‘friendlier’ services and inclusive of families. Future policy directives which promote cultural safe training could be implemented across public health policy and with immigrant services to increase practitioner knowledge, mitigate stigma and distrust of the health care system.

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Figure 4. Which factors have contributed to promoting mental health and well-being for immigrant women during the postpartum period?

Discussion Most respondents found the education and roll out of the EPDS helpful in identifying women who may be at risk of PPD and or other mental health problems. However, significant challenges exist related to service delivery for perinatal and reproductive mental health support for immigrant women in context where social determinants of mental health intersect, such as local geography, gender roles, education, and health literacy. In short, the policy implications for the EPDS suggest through enhancement of the referral process there is greater impact on mental health clinicians and PHNs regarding resources, time, and clinical expertise. This may reflect broader discourses of neoliberalism at the intersections of migration and resettlement of immigrant families in western states (DeSouza, 2013) as well as a need for more public policy analysis on multi-level impacts and responses to supporting immigrant mental health (Clark & Vissandjee, in press). Importantly more education is needed to support service providers across various geographic locations in the interior region concerning mental health and cultural competencies. For example, while most service providers, particularly PHNs have found the EPDS useful as a screening tool they recommended that it be available in other languages. There is a need for development of clearer pathways to care which include gender sensitive immigrant services and language translators. Many community-based organizations lack sustained funding and are services not offered in other languages. Thus the redistribution of health resources are not equitable in the context of resettlement policies and where immigrant families experience multiple barriers to integration (Viruell-Fuentes et al., 2012). Both the individual interviews as well as the fluid survey support previous research showing that linguistic barriers and cultural difference are significant barriers for accessible, equitable and competent health care (Kalich et al., 2016). This finding is consistent with literature suggesting that immigrant knowledge is best translated by word of mouth or by local community organizations in which

trust and language services are integrated (O’Mahony & Donnelly, 2013). Situating our findings in broader discourses of structural racism and cultural discourses, our findings suggest that there is a need to critically reflect on ethnocentric practices and policies which attend to intersecting dimensions of maternal care of immigrant women. As DeSouza (2013) has argued “there is a need to critique the single subject of maternity” (p. 299). This would include attention to migration, post-migration and settlement structures which impact mental health and well-being of women and families. Few studies have explored PHN experiences or perspectives on mental health care services for immigrant women in the perinatal context. Other research which focuses on primary care services has focused on family physicians and the role of nurse practitioners in providing mental health services and the need for increased collaboration across services and professions (Wener & Woodgate, 2017). While provision of mental health services and supports in the perinatal period can be a significant barrier for immigrant woman this research also highlights the existing capacities in smaller towns and remote regions. The recommendations for emotional safe care, multidisciplinary working groups, enhanced education, and informed decision making are supported by best practice principles outlined by Higgins, Carroll, et al. (2017). An important finding is the need for destigmatizing mental health across services and inclusion of mental health training within public health nursing. There is strong need for communication among community service providers and agencies to promote immigrant women’s mental health. PHNs and other service providers recognized the need to learn more about the diverse mental health perinatal resources and services offered throughout the Interior Health region. Yet unlike mental health clinicians, PHNs felt overburdened by the increased responsibility for providing formal mental health support in remote areas. This finding is well supported in past research suggesting PHNs lack the knowledge and skills required to provide comprehensive perinatal mental health care to women (Borglin et al., 2015; Higgins, Downes, et al., 2017; Jomeen et al., 2013; Rollans et al., 2013).


Equity oriented pathways to care for immigrant women during postpartum within interior BC require re-structuring of services to meet the needs of immigrant women and their families. As previously noted, this argument stems from a critical analysis of existing policy and practice which considers the culture of societal institutions (Viruell-Fuentes et al., 2012). In addition, health service providers have reported they want more training and education related to culturally safe care practices and mental health as well as integration of shared resources. This will also require a self-led attention to ethnocentrism as it is embedded within institutions governing public health. There is an under representation of peer led or immigrant support for women which may impact the way in which health care practices are delivered. For example, women who are in smaller communities may not have access to transportation or social networks which could increase access and promote better health. Peer navigators have been recognized as mitigating health disparities across various population groups including women with cancer, HIV and Indigenous groups and more recently as best practices for reducing racial and ethnic disparities (Chin et al., 2012). Inclusion of peers and immigrant women with lived experience are required in shaping policies and practices that directly impact them (Clark & Vissandjee, in press). Some respondents indicated that immigration is not a policy issue for their communities. This is not surprising given the fact that many immigrant groups relocate due to economic reasons. However, refugees (a subset of immigrants) e.g. the Syrian crisis has significantly impacted the resettlement and health sector across provinces and territories across Canada. In view of changes to Canadian immigration policy and provincial destining policies, BC interior regions may experience significant impact to communities and their abilities to meet the health needs of immigrant groups (Ahmed et al., 2017). Innovative knowledge about community capacity strengths as well as mitigating barriers to accessible mental health services and supports are priority public policy issues.

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of identified ‘at risk’ population groups. Increased education for immigrant women concerning Canadian laws/policies and mental health could be offered at a community level that is non-health service specific. This may decrease stigma and increase gender sensitivity. Community based organizations can provide support for new mothers on a variety of issues including breast feeding and mutual support. Workshops could also be offered in different languages, peer led and include various language groups of the communities represented in rural and mid-size towns/cities. Importantly, ‘shared care’ could include education and training delivered by service experts as well as peers to more formal perinatal and mental health services. Enhanced community capacity to support immigrant women’s mental health There is endorsement for sustainability in community capacity supports which integrate services across systems of care which includes community-based organizations, mental health services, community support such as new baby support groups and public health care services for immigrant women and families. In addition, immigrant service organizations could collaborate with local public health agencies and mental health services. Development of pathways to care can provide service providers more explicit approaches to care for immigrant women in rural communities. Use of peer navigators could strengthen existing community resources to decrease barriers to public health and mainstream mental health services and supports. Findings of this environmental scan reveal that each community has different resources and innovative pathways for enhancing and promoting mental health. As part of enhancing capacities, communities of practice will also require increased cultural training on socio-historical context of migration and racialization of immigrants, particularly as they resettle into postcolonial contexts in Canada. Culturally safe and gender sensitive policy

Limitations The environmental scan was conducted within an interior region of BC and may not be generalizable in other contexts. Due to the scope of the research aims, diverse immigrant women were not included, however, this environmental scan serves as a pragmatic first step in the development and advancement of policies and programs that affect the availability of and access to mental health care supports and services for immigrant women.

Recommendations and implications for policy and practice Increased education and training Cultural safety and competency training can increase health care professionals’ knowledge about the broader processes of social exclusion which impact mental health and well-being

More research is needed to guide the development and evaluation of policy and programs designed to improve culturally appropriate health care for immigrant women. As increased numbers of immigrant families settling into the interior region of BC, health care professionals recommended that language, gender, geography, and culture must be integrated with enhancing access for immigrant women and their families. There is a recognized need for cultural safety and trauma and violence informed care practices and policies within provincial health authorities across communities. Gender intersects with cultural practices as many PHNs identified immigrant women may be more at risk for postpartum mental health (Kirmayer et al., 2011). However, social dimensions of gender, post-migration and during resettlement also impact immigrant women’s child care responsibilities, limited knowledge about services and women’s rights in the Canadian context. Interpreters from various languages need to reflect gender sensitivity and be accessible across primary

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care and specialized services to support screening tools such as the EPDS. This could include gender sensitive, e.g. female interpreters, cultural brokers and/or peer mentors. More work is being conducted on the role of cultural brokers and language interpreters in the field of mental health (Miklavcic & LeBlanc, 2014). These advances may mitigate the tendencies to racialize and mask social inequities produced by the lack of critical attention to intersecting dimensions of immigrant women’s perinatal mental health.

Smrek, Regional Knowledge Coordinator, Maternal Child Health within Interior Health, and a 4th year TRU undergraduate nursing student. The research team acknowledges that the research took place on the traditional and unceded lands of the Secwepemc Nation.

Disclosure statement No potential conflict of interest was reported by the authors.

Funding Evaluation of EPDS universal screening While the EPDS is being used as a prevention strategy, health promotion must also be fostered with wrap around supports for immigrant women postpartum. Many PHNs have already started to develop clearer pathways to care so that women do not fall through the cracks. This may also facilitate some anxiety and work load issues that PHNs raised. Professional practice standards must be linked with clearly developed clinical care pathways to serve the most vulnerable. It is recommended that screening needs to be family centered and initiated in the prenatal period in order to move away from neoliberal policies which unwittingly frame motherhood of immigrant women as ‘other’ (DeSouza, 2013). While many women could benefit from women specific resources and community-based support services, family centered approaches could reach new fathers and provide increased education about mental health issues.

Conclusion Lack of professional practice standards based on cultural safe, trauma, and violence informed policy impact immigrant women’s perinatal and reproductive mental health. The policy impact of the EPDS has raised the issue of better clinical care pathways and need for a more transparent and critically reflexive referral process and practice for health care professionals. Moreover, there is a need for establishing provincial universal protocols and standards of practice related to perinatal and postpartum mental health for all women and families. Without sufficient knowledge and skill among nurses in perinatal mental health, women may be without the available evidence-based interventions and supports. Increased collaboration across services including public health, can enhance primary care support for mental health and wellbeing of immigrant women in perinatal context. Outreach, advocacy, and community support require community capacity building including information technologies as well as increased funding and improved public policy. Health care provider education and training needs to be integrated with key intersecting barriers identified by practitioners to redress health and health care inequities and support Canada’s leadership in building healthy public policy for all.

Acknowledgments The investigators that worked together on this research study were faculty from Thompson Rivers University, University of Victoria, Joanne

This study was funded by a TRU Internal Research Fund and in-kind support from the TRU School of Nursing.

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