Postpartum Depression and HelpSeeking Behaviors

JOGNN

RESEARCH

Postpartum Depression and Help-Seeking Behaviors in Immigrant Hispanic Women Lynn Clark Callister, Renea L. Beckstrand, and Cheryl Corbett

Correspondence Lynn Clark Callister, RN, PhD, College of Nursing, Bringham Young University, 136 SWKT, Provo, UT 84602. [email protected] Keywords postpartum depression Hispanic immigrant women mental health care barriers

ABSTRACT Objectives: To describe perceptions of immigrant Hispanic women experiencing symptoms of postpartum depression (PPD) and to identify barriers to seeking mental health services. Design: Qualitative descriptive. Setting: Community health clinic. Participants: Twenty immigrant Hispanic women scoring positive for symptoms of PPD receiving health care at a community health clinic who declined mental health services participated in audiotaped interviews held in their homes. Methods: Following Institutional Review Board approval and informed consent, interviews were conducted with study participants. Transcribed data were analyzed as appropriate for qualitative inquiry. Results: Some of the women did not recognize and/or denied their symptoms attributing their sadness to financial concerns, family relationships, and/or work stressors. Study participants articulately described their symptoms and identified personal barriers including beliefs about emotional health, the perceived stigma of mental illness, hesitancy to seek treatment for symptoms of PPD, and cultural beliefs about motherhood and the role of women. Social barriers included inadequate social support, immigration status, and limited English proficiency. Health care delivery barriers included financial and time constraints and lack of child care and transportation. Conclusion: Limited social networks and barriers to health care should be addressed to foster positive outcomes. Mental health services should be embedded with primary health care or obstetric care clinics to facilitate access. Personal and professional support can make a significant contribution to the reduction of symptoms of PPD.

JOGNN, 40, 440-449; 2011. DOI: 10.1111/j.1552-6909.2011.01254.x Accepted April 2011

Lynn Clark Callister, RN, PhD, is a professor in the College of Nursing, Bringham Young University, Provo, UT. Renea L. Beckstrand, CCRN, PhD, CNE, is an associate professor in the College of Nursing, Brigham Young University, Provo, UT.

(Continued)

ispanics are the largest and fastest growing minority group living in the United States, constituting more than 15% of the population and projected to constitute 30% of the population by 2050 (Bernstein & Edwards, 2008). Between 2000 and 2006, Hispanics accounted for 50% of the nation’s growth, and more than 18 million Hispanic women of childbearing age were living in the United States (U.S. Census Bureau, 2007). Immigrant Hispanic women have the highest fertility rate of all ethnic/racial groups, accounting for 24% of births in the United States (Pew Hispanic Center, 2010).

H

grants, more likely to be married, have lower levels of education, lower incomes, larger households, and higher poverty rates (Pew Hispanic Center, 2010). In a review of the mental health of undocumented Mexican immigrants, limited resources, marginalization/isolation, vulnerability, fear, stress, and depression compromised their health (Sullivan & Rehm, 2005). Postpartum depression (PPD) is pervasive in culturally diverse women (Callister, Beckstrand, & Corbett, 2010). It has been documented that though PPD is prevalent among disadvantaged Hispanic women, it is not readily detected by women or their health care providers, and these women were less likely to seek mental health treatment (Chaudron et al., 2005; Heilemann, Frutos, Lee, & Kury, 2004; Lara, Le, Letechipia, & Hochuhausen, 2008;

The authors report no conflict of interest or relevant financial relationships.

In 2008, more than 65% of foreign-born Hispanics were born in Mexico, with an estimated 12.7 million living in the United States. It is estimated that 55% are undocumented. Mexicans account for 32% of all immigrants and are younger than other immi-

440

& 2011 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

http://jognn.awhonn.org

RESEARCH

Callister, L. C., Beckstrand, R. L., and Corbett, C.

Lara-Cinisomo, Gri⁄n, & Daugherty, 2009; Martinez & Carter-Pokras, 2006; Nadeem et al., 2007). This is of concern because of deleterious e¡ects not only to the mother, but also to the infant and the entire family (Fitelson, Kim, Baker, & Leight, 2011). Le, Munoz, Soto, Delucchi, and Ippen (2004) suggested that PPD is often ‘‘under-reported, underrecognized, and under-treated’’ (p. 160). Providing holistic care to vulnerable and underserved populations is congruent with Institute of Medicine (2010) recommendations. The Utah Pregnancy Risk Assessment Monitoring System (PRAMS) data set identi¢ed demographic di¡erences in Utah women who report symptoms of PPD and seek help versus those who are symptomatic but do not seek help. There was a 14.7% prevalence rate of symptoms of PPD, and 60% of these women did not seek help. Seeking help for prenatal depression was associated with seeking help for postpartum depression. Hispanic women (odds ratio [OR] 5 3.2; 95% con¢dence intervals [CI], [1.3, 8.1]) were more likely not to seek help (McGarry, Kim, Sheng, Egger, & Baksh, 2009). In a 2010 report,15.2% of Hispanic women living in Utah reported symptoms of PPD (Utah Department of Health Center for Multicultural Health, 2010). In an outcomes evaluation of the Hispanic Labor Friends Initiative conducted at a Utah community health center (Hazard, Callister, Birkhead, & Nichols, 2009), immigrant Hispanic women were screened using the Beck PPDS^Spanish version (Beck & Gable, 2003). Four of the 21 women had signi¢cant symptoms of PPD. Three were at high risk for PPD and were referred to a mental health professional for further evaluation and treatment. Because many of these women did not return for their 6-week maternal postpartum checkup and were not assessed for PPD, the need was identi¢ed to determine the incidence of PPD in this population of vulnerable women. A second study documented the incidence of PPD in immigrant Hispanic women receiving services at another Utah clinic (Lucero, Beckstrand, Callister, & Sanchez-Birkhead, in press). The incidence of PPD symptoms was 54% in the 96 women tested using the Beck PDSS^Spanish version. Women who scored higher than the cuto¡ score of 60 were referred for mental health services. The Cronbach’s a on the PDSS^Spanish version was .96. Many declined to make an appointment for such services and shared with the researchers the multiple stressors they were experiencing in their lives. Many became very emotional about their potential

JOGNN 2011; Vol. 40, Issue 4

diagnosis of PPD, and others denied that they had symptoms of PPD.

Problem Statement and Purpose Based on the above-cited studies, especially the one conducted by Lucero and associates, the need was identi¢ed to determine why women with symptoms of PPD declined to seek mental health services.The purposes of this qualitative descriptive study were to describe the perceptions of having symptoms of PPD in immigrant Hispanic women and to identify the barriers to accessing mental health services. Lack of data regarding the health needs of immigrants has been identi¢ed as a factor associated with health disparities in vulnerable populations (Edberg, Cleary, & Vyas, 2010). The current study contributes to overcoming this paucity of data.

Literature Review Depression in Hispanics Heilemann, Co¡ey-Love, and Frutos (2004) identi¢ed the reasons for depression in low-income women of Mexican descent as partner and family issues, feelings of being alone, ¢nancial concerns, and somatic symptomatology. However, this study did not speci¢cally target PPD, and the Center for Epidemiologic Studies Depression Scale (CES-D) was used for screening. Heilemann and Copeland (2005) identi¢ed help-seeking sources in depressed low-income women of Mexican descent and found that these women seek help only from their families rather than from professionals and may continue to experience symptoms of depression. Often Hispanic women do not disclose information to health care providers because they don’t feel safe unless they sense compassion, caring and genuine interest from their caregivers (Julliard et al., 2008).

Barriers to Accessing Mental Health Services Barriers to help-seeking behaviors for depression in Hispanics include stigma, ¢nancial/insurance concerns, transportation, immigration status, lack of knowledge of available resources, linguistic and cultural barriers, ‘‘coldness’’ of health care providers, and lack of understanding of mental health services. Study participants in two studies were not accustomed to the provision of mental health treatment in their countries of origin (Pincay & Guarnaccia, 2007; Shobe, Co¡man, & Dmochowski, 2009). In a study of low-income immigrant women and U.S.-born Black and Latina women, Nadeem et al. (2007) concluded that stigma related to depression

Cheryl Corbett, APRN, MSN, FNP-c, is an assisant teaching professor, in the College of Nursing, Brigham Young University, Provo, UT.

441

RESEARCH

Postpartum Depression and Help-Seeking Behaviors in Immigrant Hispanic Women

and treatment may account for the underutilization of mental health services. Huang, Wong, Ronzio, and Yu (2007) found that minorities and foreignborn mothers were less likely to seek services, suggesting that ‘‘more e¡orts are needed to overcome barriers in mental health services access and utilization, especially in minority and foreign-born populations’’ (p. 266). The perceptions of community leaders regarding the needs, concerns, social support, and interactions with health care services by Hispanic socially disadvantaged single mothers have been described (Campbell-Grossman, Hudson, Keating-Le£er, Yank, & Obafunwa, 2009). Limited social networks and barriers to health care should be addressed to promote positive outcomes in these vulnerable women.

Postpartum Depression in Hispanics The risks of experiencing major depressive episodes in socially disadvantaged Mexican women have been identi¢ed and screening for perinatal mood disorders across the childbearing year was recommended (Le et al., 2004). In a sample of 69 immigrant Hispanic women, Diaz, Le, Cooper, and Munoz (2007) found a signi¢cant linear change in depressive symptoms from pregnancy through postpartum, with quality interpersonal relationships and adequate social support contributing to a steeper decline in symptoms of PPD. Sheng, Le, and Perry (2010) also found that there was a relationship between symptoms of PPD and lack of social support. A qualitative systematic review of PPD help-seeking barriers and maternal treatment preferences identi¢ed help-seeking and health service barriers (Dennis & Chung-Lee, 2006) but did not include any studies of Hispanic women. A quantitative study of 509 women (26.5% Hispanic) identi¢ed women’s attitudes, preferences, and perceived barriers to treatment for PPD. The greatest barriers were lack of time, stigma, and child care issues. However, few were recent immigrants to the United States, only 12.8% spoke Spanish as their primary language, and interviews were not conducted (Goodman, 2009). A framework of patient decision-making behavior for the current study includes the problem (choices, complexity, outcomes), the context (risk, urgency, woman-provider interaction, cognitive demands, environmental stressors, time frame, education), and the individual woman (cultural values, decision styles, participation preference, psychological and physical statements, and perceptions of risk (Pierce & Hicks, 2001; Figure 1).

442

The relationship between protective strength factors, resources such as social support, and risks, and depressive symptoms in Hispanic childbearing women has been identi¢ed (Mann, Mannan, Quinones, Palmers, & Torres, 2010). Sense of mastery and life satisfaction had protective e¡ects on mental health (Heilemann et al., 2004). No qualitative descriptive studies were found about help seeking in Hispanic immigrant women experiencing symptoms of PPD; thus the need to conduct the current study was identi¢ed.

Method Study Design and Data Collection This qualitative descriptive study was conducted following Institutional Review Board approval. Twenty women were recruited from a sample of 96 immigrant Hispanic women who participated in the previous study (Lucero et al., in press). These women received services at a community health center in a western state. Recommendations for recruiting Hispanic women as study participants in perinatal mental health research were followed (Brandon, Shivakumar, Lee, Inrig, & Sadler, 2009; Shedlin, Decena, Mangadu, & Martinez, 2009). The Postpartum Depression Screening Scale^Spanish Version had been used in the previous study (Lucero et al.). This tool had a total score a reliability of .96 with a recommended cuto¡ score of 60 for a positive screen for PPD. This cuto¡ point had a sensitivity of 84% and a speci¢city of 84% (Beck & Gable, 2005). Reuland et al. (2009) con¢rmed the suitability of the use of this instrument with Spanish speaking populations. Inclusion criteria for the current study included a cuto¡ score greater than 60 on the PDSS^Spanish Version. The Cronbach’s a on this tool for the above cited study was .96 (Lucero et al., in press).The purposive sample included Hispanic immigrant women of varying ages, educational levels, and parity. The women were approached by the same researcher who had invited them to complete the PDSS^Spanish Version instrument in the earlier study (Lucero et al.).They were not screened for depression during their pregnancies but received prenatal care at the clinic. Services at the clinic do not routinely include screening for PPD. Their familiarity with and trust of this investigator increased their willingness to participate in the current study because the cultural value of personalismo was respected. In addition, embedding research recruitment in the clinic proved helpful in recruiting study participants (Le, Lara, & Perry, 2008). Following informed consent, the women participated in an audiotaped interview of approximately

JOGNN, 40, 440-449; 2011. DOI: 10.1111/j.1552-6909.2011.01254.x


RESEARCH


CONTEXT

PROBLEM •

Choices

•

Complexity

•

Outcomes

•

Risk

•

Urgency

•

Women-provider interaction

•

Cognitive demands

•

Environmental stressors

•

Time frame

•

Education

INDIVIDUAL WOMAN •

Cultural values

•

Decision styles

•

Participation preference

•

Psychological and physical states

•

Perceptions of risk

Figure 1. Framework of patient decision-making behavior. Pierce and Hicks (2001).

60 minutes conducted by a multilingual and bicultural member of the research team at a site that was mutually convenient, usually the homes of the study participants. They were informed that the information they provided would be presented and published to professional audiences but assured that con¢dentiality would be maintained and data would not identify them speci¢cally. Questions were not asked about immigrant status. Verbal consent was obtained to alleviate the fear of signing any documents. Interviews were characterized with a warm and personal (personalismo and simpatia) yet professional and respectful approach. Women were given a $20 gift certi¢cate as an expression of appreciation for their participation. A semistructured interview guide adapted from the work of Pincay and Guarnaccia (2007) was used to guide the discussion (Table 1).

Data Analysis Demographic data were analyzed using statistical software, and data collection and analysis proceeded concurrently. Data collection continued until saturation was reached. Audiotaped interviews were transcribed and translated verbatim by the multilingual interviewer, with transcripts proofread for accuracy. Emerging themes were identi¢ed individually by members of the research team engaging in re£ection, with important data bits highlighted and labeled with tentative themes in the margins of the transcript. Following individual analysis, collaborative analysis with the entire research team occurred to verify themes. Sharing insights helped to establish con¢rmability as the


researchers asked,‘‘What is the woman saying’’? Final consensus regarding themes was generated. It was not feasible to contact study participants to conduct member checks. Field notes were kept to help ensure the trustworthiness of the data as themes were clari¢ed. These ¢eld notes helped to establish the sociocultural context of the women who participated in the study. In the Findings section, the voices of the women who participated in the study are shared to make the data transparent (Marshall & Rossman, 2006; Tobin & Begley, 2004).

Table 1: Interview Guide 1. For you, what is emotional or mental health? 2. What is PPD? 3. What should a woman do if she su¡ers from PPD? 4. What can the family of a woman with PPD do for them? 5. What problems does a woman with PPD encounter when seeking help? 6. What problems does a woman with PPD have in ¢nding appropriate services? 7. What type of problems do you think make it hard for women to access treatment? 8. What recommendations do you have for solving these problems? 9. Is there anything else that you would like to say about this topic?

443

RESEARCH


Women identified personal, social, and health care delivery barriers to accessing treatment for symptoms of postpartum depression.

Findings Maternal age ranged from17 to 39 years, with a mean of 24 years. Scores on the PPDS^Spanish Version ranged from 62 to 141, with a mean of 75. Seven were primiparas and 13 multiparas having a range of two to six children ranging in age from 6 months to 1 year. One woman had twins; the rest were singleton births. Nineteen of the women were from Mexico and one from Argentina. Four women were single, seven were in committed relationships, and nine were married. The women had been educated about PPD when they completed the screening tool and referred for mental health services available in the clinic. Some of the women did not recognize and/or denied their symptoms of PPD, attributing them to sadness related to other factors in their lives, such as ¢nancial concerns, family relationships, or work stressors. This lack of recognition is supported in the literature (Nadeem et al., 2007). On the other hand, study participants clearly described their symptoms. One single mother said, ‘‘I felt something di¡erent, something sad. Whenever she started to cry, I felt desperate, with a desire to run away.’’ Another woman reported the following: Some women feel like crying for no reason. For example, when the baby starts crying, you feel lonely. When I had my baby I felt like

crying, nostalgic. I called for my mother but she could not come to help. My mother was here in my heart because she could not come. The women identi¢ed personal, social, and health care delivery barriers to seeking care. Personal barriers included beliefs about emotional health, the perceived stigma of mental illness and hesitancy to seek treatment of symptoms of PPD, and cultural beliefs about motherhood and the role of women. Social barriers included lack of social support, immigration status, and limited English pro¢ciency. Health care delivery barriers to seeking mental health services included ¢nancial constraints, time constraints, and lack of child care and transportation (Figure 2).

Personal Barriers Beliefs About Emotional Health, the Perceived Stigma of Mental Health, and Hesitancy to Seek Treatment for Symptoms of PPD. The women frequently noted that they should be able to handle everything, and when they couldn’t, they were embarrassed and felt guilty about their feelings. They were hesitant to share their feelings with family members or professionals and reluctant to seek mental health services. A 35-year-old mother with ¢ve children said, ‘‘We might not accept that we have depression and say, ‘No, I’m ¢ne.’ It is di¡erent from other diseases. Depression is very silent. This cannot be easily accepted.’’ Another reported that, ‘‘[A woman] might feel locked into her own depression [and] not look for help. She might feel guilty. She wonders what she is going to do. People might

PERSONAL BARRIERS •

•

Beliefs about emotional health and the perceived stigma of mental illness and the treatment of postpartum depression Cultural belief’s about motherhood and the role of women

SOCIAL BARRIERS • • •

Lack of social support Limited English proficiency Immigration status

HEALTH CARE DELIVERY BARRIERS • • • •

Financial cost Lack of child care Lack of transportation Lack of time

Figure 2. Barriers to seeking mental health services.

444

JOGNN, 40, 440-449; 2011. DOI: 10.1111/j.1552-6909.2011.01254.x


RESEARCH


think that she is crazy.’’ Another woman said, ‘‘I was afraid. I felt ashamed,’’ and also reported being worried that her children would be taken from her if health care providers knew that she was depressed. Study participants stated it was not culturally appropriate in their countries of origin for women to seek mental health services. This was described by one Mexican mother of two: In the Hispanic culture, the mothers always do everything, like taking care of the children, cleaning the house. They are expected to do everything. And people really think less of them when they have expression. Some women [may] think they cannot take it anymore, and that she is going to explode her emotions, because she simply cannot do everything. There are many women that simply won’t say anything.

Cultural Beliefs About Motherhood and the Role of Women. In the Hispanic culture, motherhood is viewed as a valued and respected role and Hispanic women enjoy a special social status, seen as ‘‘essential to the integrity of the family unit’’ (Lagana, 2003, p. 119). A 32-year-old mother of twins said, ‘‘Hispanic women are very strong. It is di⁄cult to say that we are sick. The family relies on the Hispanic mother and not the man. It is hard to accept that we need help.’’ Respecto is an important cultural value, especially a respect for and valuing of motherhood. Such values often con£ict with the role of women within the mainstream culture in the United States, where motherhood is less valued and women often assume multiple roles, including the obligation to contribute to household income. This puts extraordinary pressure on these women. Some study participants had left children with extended family in their countries of origin, and when they had another child they grieved for the children they left behind. This may have contributed to feelings of depression.

mother of four who had been in the United States for 8 years but spoke only Spanish said the following of her experience: It is hard because there is only us here, my husband and I. It is hard if you don’t have family with you and not having someone to help you out. I didn’t have anyone to support me. What am I supposed to do? I had to press forward. On the other hand, a 20-year-old study participant described the help she received from her mother and grandmother: I did not want to admit that I had this problem, but I talked to my grandma and with my mom, who are my best friends. They helped me go on. I told them I felt depressed and they helped me. My mom said, ‘‘Having two children is not easy. You are doing the best you can.’’ Your own family needs to give you strength, to give you support. Some of these study participants turned to other supportive Hispanic women (compadre system) living in the United States. One Mexican mother expressed her appreciation for help she received from other Hispanic compadres: Even if they were not my direct family, they [said they] loved me and were going to help me with whatever I needed, that I should not feel alone. I needed that. They gave me a lot of support and love, and helped me with the children. They never left me alone. This helped me a lot. Familism is a powerful cultural value, and family social networks ameliorate stress. According to a traditional Mexican dicho, El que parte y comparte, se queda con la major parte or in other words, ‘‘‘He who divides and shares is left with the best part.’ The strength of the family is often greater than the sum of its parts’’ (Lagana, 2003, p.123).

Health Care Delivery System Barriers Social Barriers Lack of Support. Women sought help from their families rather than health care providers, but many felt isolated and lacked social support. They described a sense of social isolation and reported feeling very much alone. Traditional social networks are often compromised for these immigrant women because of family separation. Some reported a longing for home and family to provide help when they had a new baby. A 27-year-old Mexican


Barriers to accessing mental health services that study participants identi¢ed con¢rmed ¢ndings in the literature, including ¢nancial and time constraints as well as lack of child care and transportation. A 21-year-old already pregnant with another child said, ‘‘If she has no money, how is she going to ¢nd help [with her symptoms of PPD]’’? A 31-year-old mother of two described systems barriers, ‘‘As Hispanics we do not have insurance and money is what really counts.’’ She also spoke of being shuttled from service to service:

445

RESEARCH


Limited social support networks and barriers to care, including mental health services, should be addressed to foster positive outcomes in vulnerable women.

They send you to another person who is not aware of how to take care of the Hispanic culture. Then they say that this woman is getting crazy over nothing, and then we do not receive the care that we really need. The appointments are set many months after. They do not help when it is needed, which may lead to more serious problems. She also spoke of the need for additional education on PPD: Sometimes we simply lack information. In the prenatal classes they talk about our exams, food, appropriate weight, but they do not really ask about your mental health and how you are feeling emotionally. We really need classes [about] the symptoms of depression, and that if we have these feelings we should be encouraged to call someone and not be ashamed, to look for help, but they do not say anything. And at the hospital they teach you how to feed your baby, but they never ask you how you are feeling. Then you leave the hospital on your own.

Discussion and Implications for Clinical Practice Data obtained from interviews with women with symptoms of PPD should inform the provision of health care (Morrow, Smith, Lai, & Jaswal, 2008) as ¢ndings are translated into clinical practice guidelines (Brod, Tesler, & Christensen, 2009; Hinds et al., 2003; Sandelowski, 2004). The National Healthcare Disparities report identi¢ed the importance of improving the health of populations and reducing health disparities (Institute of Medicine, 2010). Further research is indicated which focuses on the relationship between social support and symptoms of PPD in Hispanic women. Continued testing of screening tools measuring symptoms of PPD is also indicated (Boyd & Worley, 2007). The blueprint for action to enhance care for childbearing women includes improving the quality and outcomes of care for vulnerable populations in primary health care settings (Loureiro et al., 2009; Transforming Maternity Care Symposium Steering Committee, 2010). It has been recommended that

446

‘‘Each woman has adequate help to cope with the challenges of the period after birth, including . . . postpartum depression’’ (Transforming Maternity Care Vision Team, 2010, p. S13). It is essential that nurses assess whether a woman will have adequate support after giving birth. Limited social networks and barriers to health care, including mental health services, should be addressed to foster positive outcomes in these vulnerable women (Sheng et al., 2010). Health care should include opportunities to ‘‘connect with people and services through innovative mechanisms and delivery models that emphasize community and social networking’’ (Transforming Maternity Care Vision Team, 2010, p. S13). Women should be encouraged to join support groups, church groups, and neighborhood networks. It is helpful for nurses to facilitate opportunities for women with limited social opportunities to network. The CenteringPregnancy model of group care for childbearing women is proving helpful in fostering connectedness among childbearing women (Carlson & Lowe, 2006; Massey, Rising, & Ickovics, 2006) which may ameliorate symptoms of depression. Focusing on the protective strength factors in these women, including resiliency, strong family networks, and a spiritual lifestyle satisfaction in designing interventions is essential. The childbearing year is an opportunity to intervene, because women are often motivated to become educated and to access health services demonstrating help-seeking behaviors (Edge & Mackian, 2010). Mental health services should be embedded with primary health care or obstetric care clinics to facilitate access (Le et al., 2008). Education should be provided across the childbearing year in ‘‘booster doses’’ with each health care encounter. Constant assessment for symptoms of PPD and referral as appropriate should be part of interactions with Hispanic immigrant women. Such encounters between childbearing/rearing women and their providers are referred to as ‘‘help seekers’’ and ‘‘help givers’’ by Edge and MacKian. A recent survey of nurses and postpartum women in the United States showed support for nurse-provided screening and counseling (Segre, O’Hara, Arndt, & Beck, 2010a, 2010b). The U.K. model utilizes nurses to screen and treat postpartum depression, including ‘‘listening visits’’ that combine active listening and problem solving. Nurses refer women to additional mental health services when necessary (Morrell et al., 2009). A similar intervention has been tested in Norway, and supportive counseling by public health nurses was associated with signi¢cantly lower depression scores (Glavin, Smith, Sorum, & Ellefsen, 2010).

JOGNN, 40, 440-449; 2011. DOI: 10.1111/j.1552-6909.2011.01254.x


RESEARCH


Personal and professional support including emotional, informational, and appraisal components makes a signi¢cant contribution to the reduction of symptoms of PPD (D’Angelo et al., 2009; Dennis, 2010; Leis, Mendelson, Darius, & Perry, 2009). A randomized trial demonstrated that a nursecommunity health worker (CHW) team was also e¡ective with socially disadvantaged women (Roman et al., 2009). A review of the literature on the use of maternal/child health services by Hispanic women demonstrated that community-based, promotora (lay health worker) based, primary-care based interventions is associated with positive outcomes (Wasserman, Bender, & Lee, 2007). A focus on prevention is essential. It is essential to educate women about depression across the childbearing years, during provider visits, in childbirth education o¡erings, and other encounters. One exemplary intervention, Mamas y Bebes, was designed to prevent the onset of perinatal mood disorders in childbearing women (Munoz et al., 2007). In an evaluation of the program, the prevalence of major depressive episodes during pregnancy and postpartum was 14% in the intervention group, signi¢cantly lower than 25% in the comparison group (Munoz et al.). Our state has a strong tertiary care system for perinatal health care under the leadership of the state Department of Health Center for Multi-Cultural Health. However, ¢nancial constraints to seeking mental health services should be addressed by health policy makers. Health disparities should be reduced through the provision of ¢nancial resources for disadvantaged and vulnerable women.

Proposed Primary Care-Based Management Model The stepped care model has demonstrated positive mental health outcomes for socially and socioeconomically disadvantaged women (Gjerdingen, Katon, & Rich, 2008). Maternal screening needs to occur during prenatal visits, the maternal postpartum visit or during pediatric well-child appointments in a primary care clinic, with consistent screening measures used (Lancaster et al., 2010). Some of the study participants said they never would have brought up their concerns about perinatal mood disorders themselves, but if a health care provider asked them directly they would be more likely to discuss their feelings. This emphasizes the importance of proactively screening and discussing this often sensitive topic.

Personal and professional support can make a significant contribution in the reduction of symptoms of postpartum depression.

Mental Disorders (4th ed.; DSM-IV) based depression interview. If symptoms do not meet the DSM threshold, rescreening should occur at a later date if symptoms continue. Step 3 follows con¢rmatory diagnosis of PPD, with active treatment initiated with a mental health specialist in the clinic, including the use of promotoras, support groups, nurse home visits, and cognitive behavioral therapy. Step 4 includes referral for specialty care in more complex and serious cases. Patient follow-up is essential for at least 6 to 9 months. Providers should be educated regarding the high prevalence of symptoms of PPD in this population, and that simply providing the woman with a prescription for medication may not be an acceptable solution. Women should be provided with information on available community resources, and appropriate referrals made. Suggested management of PPD has strong clinical implications that can make a di¡erence in vulnerable women experiencing perinatal mood disorders.

Acknowledgments Funded by AWHONN 2010 Research Grant, Sigma Theta Tau International Iota Chapter Research Grant, and Brigham Young University O⁄ce of Research and Creative Works Research Grant.

REFERENCES Beck, C. T., & Gable, R. K. (2003). Postpartum Depression Screening Scale. Nursing Research, 52(5), 296-306. doi:10.1097/00006199200309000-00004. Beck, C. T., & Gable, R. K. (2005). Screening performance of the Postpartum Depression Screening Scale^Spanish Version. Journal of

Transcultural

Nursing,

16(4),

331-338.

doi:10.1177/

1043659605278940. Bernstein, R., & Edwards, T. (2008). An older and more diverse nation by midcentury. Washington, DC: U.S. Census Bureau. Boyd, R. C., & Worley, H. (2007). Utility of the postpartum depression screening scale among low-income ethnic minority women. In A. I. Rosen¢eld (Ed.), New research on postpartum depression (pp. 151-166). New York, NY: Nova Science. Brandon, A. R., Shivakumar, G., Lee, S. C., Inrig, S. J., & Sadler, J. Z. (2009). Ethical issues in perinatal mental health research. Current Opinions Psychiatry, 22, 601-606. doi:10.1097/YCO.Ob013e3283318e6f. Brod, M., Tesler, L. E., & Christensen, T. L. (2009). Qualitative research and content validity: Developing best practices based on science and experience. Quality of Life Research, 18, 1263-1278. doi:1007/ s11136-009-9540-9.

If the screen is positive, diagnosis should be con¢rmed by a Diagnostic and Statistical Manual of


Callister, L. C., Beckstrand, R., & Corbett, C. (2010). Postpartum depression in culturally diverse women: Pesado Corazon (a heavy heart).

447

RESEARCH


MCN: The American Journal of Maternal Child Nursing, 35(5), 254261. doi:1097/NMC.Ob013e3181e597bf.

strength factors, resources, and risks in relation to depressive

Campbell-Grossman, C., Hudson, D. B., Keating-Le£er, R., Yank, J. R., &

symptoms among childbearing women of Mexican descent.

Obafunwa, T. (2009). Community leaders’ perceptions of

Health Care for Women International, 25, 88-106. doi:10.1080/

Hispanic, single, low-income mothers’ needs, concerns, social

07399330490253265.

support, and interactions with health care services. Issues

Hinds, P. S., Gattuso, J. S., Barnwell, E., Cofer, M., Kellum, L. K., Mattox, S., &

in Comprehensive Pediatric Nursing, 32, 31-46. doi:10.1080/

Sanders, C. (2003). Translating psychosocial research ¢ndings into

01460860802610194. Carlson, N. S., & Lowe, N. K. (2006). Centering pregnancy: A new approach to prenatal care. MCN: The American Journal of Maternal Child Nursing, 31(14), 218-223. Chaudron, L. H., Kitzman, H. J., Peifer, K. L., Morrow, S., Perez, L. M., & Newman, M. C. (2005). Prevalence of maternal depressive symptoms in low-income Hispanic women. Journal of Clinical Psychiatry, 66(4), 418-423. doi:10.4088/JCP.v66n0402. D’Angelo, E. J., Llerena-Quinn, R., Shapiro, R., Colon, F., Rodriguez, P., Gallagher, K., & Beardslee, W. R. (2009). Adaptation of the preventive

practice guidelines. Journal of Nursing Administration, 33(7/8), 397-403. doi:10.1097/00005110-20030700-0009. Huang, Z. J., Wong, F. Y., Ronzio, C. R., & Yu, S. (2007). Depressive symptomatology and mental health help-seeking patterns of US and foreign born mothers. Maternal Child Health Journal, 11, 257-267. doi:10.1007/s10995-006-0168-x. Institute of Medicine. (2010). Future directions for the national healthcare quality and disparities report. Retrieved from http://www.iom.edu/ Reports/2010/Fture-Directions-for-the-National-Healthcare-Qual ity-and-Disparities-Reports.aspx

intervention program for depression for use with predominantly

Julliard, K., Vivar, J., Delgado, C., Cruz, E., Kabak, J., & Sabers, H. (2008).

low-income Latino families. Family Process, 48(2), 269-291.

What Latina patients don’t tell their doctors: A qualitative study.

doi:10:1111/j.1545-5300.2009.01281x.

Annals of Family Medicine, 6(6), 543-549. doi:10.1370/afm.912.

Dennis, C. L. (2010). Postpartum depression peer support: Maternal per-

Lagana, K. (2003). Come bien, camina y no se preocupeçEat right, walk,

ceptions from a randomized controlled trial. International Journal

and do not worry: Selective biculturalism during pregnancy in a

of Nursing Studies, 47, 560-568. doi:10.1016/j.ijnurstu.2009.10.015.

Mexican American community. Journal of Transcultural Nursing,

Dennis, C. L., & Chung-Lee, L. (2006). Postpartum depression help-seek-

14(2),117-124. doi:10.1177/1043659602250629.

ing barriers and maternal treatment preferences: A qualitative

Lancaster, C. A., Gold, K. J., Flynn, H. A., Yoo, H., Marcus, S. M., & Davis, M.

systematic review. Birth, 33(4), 323-331. doi:10.1111/j.1523-536X.

M. (2010). Risk factors for depressive symptoms during pregnancy:

2006.00130.x.

A systematic review. American Journal of Obstetrics and Gynecol-

Diaz, M. A., Le, H. N., Cooper, B. A., & Munoz, R. F. (2007). Interpersonal

ogy, 202(1), 5-14. doi:10.1016/j.ajog.2009.09.007.

factors and perinatal depressive symptomatology in a low-income

Lara, M. A., Le, H. N., Letechipia, G., & Hochuhausen, L. (2008). Prenatal

Latina sample. Cultural Diversity and Ethnic Minority Psychology,

depression in Latinas in the United States and Mexico. Maternal

13(4), 328-336. doi:10.1037/1099-9809.13.4.328.

Health Journal, 13(4), 567-576. doi:10.1007/s10995-008-03079-4.

Edberg, M., Cleary, S., & Vyas, A. (2010). A trajectory model for under-

Lara-Cinisomo, S., Gri⁄n, B. A., & Daugherty, L. (2009). Disparities in

standing and assessing health disparities in immigrant/refugee

detection and treatment history among mothers with major

communities. Journal of Immigrant and Minority Health doi:

depression in Los Angeles. Women’s Health Issues, 19, 232-242.

10.1007/s10903-010-9337-5.

doi:10.106/j.whi.2009.03.007.

Edge, D., & Mackian, S. C. (2010). Ethnicity and mental health encounters

Lassetter, J., & Callister, L. C. (2009). The impact of migration on the health

in primary care: Help-seeking and help-giving for perinatal de-

of voluntary migrants in Western societies: A review of the literature.

pression among Black Caribbean women in the UK. Ethnicity and

Journal of Transcultural Nursing, 20(1), 93-104. doi:10.1177/

Health, 13,1-19. doi:10.1080/0557850903418836.

1043659608325841.

Fitelson, E., Kim, S., Baker, A. S., & Leight, R. (2011). Treatment of PPD: Clin-

Le, H. N., Lara, M. A., & Perry, D. F. (2008). Recruiting Latino women in the

ical, psychological, and pharmacological options. International

U.S. and women in Mexico in postpartum depression prevention

Journal of Women’s Health, 3, 1-14. doi:10.2147/ijwh.S6983.

research. Archives of Women’s Mental Health, 11(2), 159-169.

Gjerdingen, D., Katon, W., & Rich, K. E. (2008). Stepped care treatment of

doi:10.1007/s00737-008-0009-6.

postpartum depression: A primary care-based management

Le, H. N., Munoz, R. F., Soto, J. A., Delucchi, K. L., & Ippen, C. G. (2004).

model. Women’s Health Issues, 18(1), 44-52. doi:10.1016/j.whi.2007.

Identifying risk for onset of major depressive episodes in low-

09.001.

income Latinas during pregnancy and postpartum. Hispanic

Glavin, K., Smith, L., Sorum, R., & Ellefsen, B. (2010). Supportive counseling by public health nurses for women with postpartum depression. Journal of Advanced Nursing, 66(6), 1317-1327. doi:10. 1111/j.1365-2648.2010.05263.x. Goodman, J. H. (2009). Women’s attitudes, preferences, and perceived barriers to treatment for Hispanic depression. Birth, 36(1), 60-69. doi:10.1111/j.1523-536X.2008.00296.x.

Journal of Behavioral Sciences, 26(4), 463-482. doi:10.1177/ 0739986304269165. Leis, J. A., Mendelson,T., Darius,T. S., & Perry, D. F. (2009). A systematic review of home-based interventions to prevent and treat postpartum depression. Archives of Women’s Mental Health, 12(1), 3-13. doi: 10.1007/s00737-008-0039-0. Loureiro, M. I., Goes, A. R., Paim da Camara, G., Goncalves-Pereira, M., Maia, T., &

Hazard, C. J., Callister, L. C., Birkhead, A., & Nichols, L. (2009). Hispanic

Saboga-Nunes, L. (2009). Priorities for mental health promotion dur-

labor friends initiative: Supporting vulnerable women. MCN: The

ing pregnancy and infancy in primary health care. Global Health

American Journal of Maternal Child Nursing, 34(2), 115-121. doi:10. 1097/01.NMC.0000347306.15950.ae. Heilemann, M. S. V., Co¡ey-Love, M., & Frutos, L. (2004). Perceived rea-

Promotion, 16(1), 29-38. doi:10.1177/1757975908100748. Lucero, N., Beckstrand, Callister, L. C., & Sanchez-Birkhead, A. (in press). Prevalence of postpartum depression in Hispanic immigrant

sons for depression among low income women of Mexican

women. Journal of the American Academy of Nurse Practitioners.

descent. Archives of Psychiatric Nursing, 18(5), 185-192. doi:10.

Mann, J. R., Mannan, J., Quinones, L. A., Palmers, A. A., & Torres, M. (2010).

1016/j.apni.2004.07.006.

448

Heilemann, M. S. V., Frutos, L., Lee, K. A., & Kury, F. S. (2004). Protective

Religion, spirituality, social support, and perceived stress in preg-

Heilemann, M. S. V., & Copeland, D. (2005). Sources of emotional help

nant and postpartum Hispanic women. Journal of Obstetric,

sought by low Income women of Mexican descent. Issues in Men-

Gynecologic, & Neonatal Nursing, 39, 645-657. doi:10.1111/j.

tal Health Nursing, 26, 185-204. doi:10.1080/01612840590901653.

1552-6909.2010.01188.x.

JOGNN, 40, 440-449; 2011. DOI: 10.1111/j.1552-6909.2011.01254.x


RESEARCH


Marshall, C., & Rossman, G. B. (2006). Designing qualitative research. Thousand Oaks, CA: Sage. Martinez, I. L., & Carter-Pokras, O. (2006). Assessing health concerns and

Sandelowski, M.

(2004). Using qualitative research. Qualitative

Health Research, 14(10), 1366-1386. doi:10.1177/10497323042 69672.

barriers in a heterogeneous Latino community. Journal of Health

Segre, L. S., O’Hara, M. W., Arndt, S., & Beck, C. T. (2010a). Nursing care for

Care for the Poor and Underserved, 17, 899-909. doi:10.1353/hpu.

postpartum depression part 1: Do nurses think they should o¡er

2006.0129.

both screening and counseling? MCN: The American Journal

Massey, Z., Rising, S. S., & Ickovics, J. (2006). CenteringPregnancy prenatal care: Promoting relationship centered care. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 286-294. doi: 10.1111/j.1552-6909.2006.00040.x.

of Maternal/Child Nursing, 35(4), 220-225. doi:10.1097/NMC. Ob013e3181dd9d81. Segre, L. S., O’Hara, M. W., Arndt, S., & Beck, C. T. (2010b). Screening and counseling for postpartum depression by nurses: The

McGarry, J., Kim, H., Sheng, X., Egger, M., & Baksh, L. (2009). Postpartum

women’s views. MCN: The American Journal of Maternal/

depression and help-seeking behavior. Journal of Midwifery and

Child Nursing, 35(5), 280-285. doi:10.1097/NMC.0b013e3181e

Women’s Health, 54(1), 50-56. doi:1016/j.jmwh.2008.07.003.

62679.

Morrell, C. J., Slade, P., Warner, R., Paley, G., Dixon, S., Walters, S. J.,

Shedlin, M. G., Decena, C. U., Mangadu,T., & Martinez, A. (2009). Research

& Nicholl, J. (2009). Clinical e¡ectiveness of health visitor

participant recruitment in Hispanic communities: Lessons learned.

training in psychologically informed approaches for depression in

Journal of Immigrant and Minority Health, doi:10.1007/s10903-

postnatal women. British Medical Journal, 338, doi:10.1136/bmj. a3045.

009-9291-1. Sheng, X., Le, H. N., & Perry, D. (2010). Perceived satisfaction with

Morrow, M., Smith, J. E., Lai,Y., & Jaswal, S. (2008). Shifting landscapes: Immi-

social support and depressive symptoms in perinatal Latinas.

grant women and postpartum depression. Health Care for Women

Journal of Transcultural Nursing, 21(1), 35-44. doi:10.1177/

International, 29(6), 593-617. doi:10.1080/07399330802089156.

1043659609348619.

Munoz, R. F., Le, H. N., Ippen, C. G., Diaz, M. A., Urizar, G. G., Soto, J.,

Shobe, M. A., Co¡man, M. J., & Dmochowski, J. (2009). Achieving the

. . . Lieberman, A. F. (2007). Prevention of postpartum depression

American dream: Facilitators and barriers to health and mental

in low-income women: Development of the Mamas y Bebes/

health for Latino immigrants. Journal of Evidence-Based Social

Mothers and Babies Course. Cognitive and Behavioral Practice, 14(1), 70-83. doi:10.1016/j.cbpra.2006.04.021. Nadeem, E., Lange, J. M., Edge, D., Fongwa, M., Belin, T., & Miranda, J. (2007). Does stigma keep poor young immigrant and US-born Black and Latina women from seeking mental health care. Psychiatric Services, 58(12),1547-1554. doi:10.1089/jwh.2008.0898. Pew Hispanic Center. (2010). Statistical portrait of Hispanics in the United States, 2008. Washington, DC: Author. Retrieved from http:/pewhis panic.org/factsheets/factsheet.php?FactsheetID=35. Pierce, P. F., & Hicks, F. D. (2001). Patient decision-making behavior. Nursing Research, 50(5), 267-274. doi:10.1097.00006199-20010900000003. Pincay, I. E. M., & Guarnaccia, P. J. (2007). ‘‘It’s like going through an earthquake’’: Anthropological perspectives on depression among Latino immigrants. Journal of Immigrant and Minority Health, 9, 17-28. Reuland, D. S., Cherrington, A., Watkins, G. S., Bradford, D. W., Blanco, R. A.,

Work, 6, 92-110. Sullivan, M. M., & Rehm, R. (2005). Mental health of undocumented Mexican immigrants: A review of the literature. Advances in Nursing Science, 28(3), 240-251. Tobin, G. A., & Begley, C. M. (2004). Methodological rigor within a qualitative framework. Journal of Advanced Nursing, 40(4), 388-396. doi:10.111/j.1365-2648.2004.03207x. Transforming Maternity Care Symposium Steering Committee. (2010). Blueprint for action: Steps toward a high-quality, high-value maternity care system. Women’s Health Issues, 20, S18-S49. doi:10.106/j. whi.2009.11.007. Transforming Maternity Care Vision Team. (2010). 2020 vision for a highquality, high-value maternity care system. Women’s Health Issues, 20, S7-S17. doi:10.1016/j.whi.2009.11.006. United States Census Bureau. (2007). Hispanic population of the United States. Retrieved from http://www.census.gov/population/www/ socdemo/hispanic.html

& Gaynes, B. N. (2009). Diagnostic accuracy of Spanish language

Utah Department of Health Center for Multicultural Health. (2010). Health

depression-screening instruments. Annals of Family Medicine, 7,

status of race and ethnicity 2010. Retrieved from http://www.

455-462. doi:10.1370/afm.981.

health.utah.gov/cmh/data/healthstatus.pdf

Roman, L. A., Gardiner, J. C., Lindsay, J. K., Moore, J. S., Luo, Z., Baer, L. J.,

Wasserman, M., Bender, D., & Lee, S. Y. D. (2007). Use of preventive mater-

& Paneth, N. (2009). Alleviating perinatal depressive symptoms

nal and child health services by Latina women. Medical Care

and stress: A nurse-community health worker randomized trial.

Research and Review, 64(1), 4-45. doi:10.1177/1077558706296238.

Archives of Women’s Mental Health, 12(6), 379-391. doi:10.1007/ s00737-009-0083-4.


449