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A Sudanese Perinatal Mental Health Support Group: 24-month Evaluation Report

WA Perinatal Mental Health Unit

August 2011

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Citation The citation below should be used when referencing this work: WA Perinatal Mental Health Unit, Women and Newborn Health Service (2011). A Sudanese Perinatal Mental Health Support Group: Final Evaluation Report. Perth, WA: Department of Health. © Department of Health, State of Western Australia (2011). Copyright to this material produced by the Western Australian Department of Health belongs to the State of Western Australia, under the provisions of the Copyright Act 1968 (C’wth Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the WA Perinatal Mental Health Unit and the Department of Psychological Medicine, King Edward Memorial Hospital for Women, Western Australian Department of Health. The Department of Health is under no obligation to grant this permission. Please acknowledge the WA Department of Health when reproducing or quoting material from this source. Important Disclaimer All information and content in this Material is provided in good faith by the WA Department of Health, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents, do not accept legal liability or responsibility for the Material, or any consequences arising from its use.

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Acknowledgments

This report is the culmination of several years of effort by a diverse team of

dedicated and generous people, and their organisations. The WA Perinatal

Mental Health Unit expresses sincere thanks to all involved.

In particular, the project would not have been possible without the dedicated

efforts of the staff at Ishar, Multicultural Women’s Health Centre. We would

also like to thank the Sudanese women who had the courage to participate in

the group, the generosity to complete the interviews and questionnaires, and

then the trust to consent for this information to be used for evaluation

purposes.

For further information contact:

Dr Janette Brooks, Senior Research Psychologist

Miriam Maclean, Research Officer

WA Perinatal Mental Health Unit

15 Loretto Street, Subiaco, WA. 6008

Phone: (08) 9340 1795

Fax: (08) 9340 1782

Email: [email protected]

or [email protected]

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Contents

EXECUTIVE SUMMARY ..............................................................................1

INTRODUCTION ..........................................................................................3

BACKGROUND ..............................................................................................5 EXPECTED OUTCOMES .................................................................................6 KEY PERFORMANCE INDICATORS (KPI) ..........................................................7

EVALUATION FRAMEWORK / RESEARCH DESIGN............. ...................7

INTERVIEWS .................................................................................................8 RIGOUR .......................................................................................................8 INSTRUMENTS ............................................................................................11 PROCEDURE ..............................................................................................13 PARTICIPANTS............................................................................................14

ANALYSIS........................................... .......................................................17

EPDS DATA ..............................................................................................17 INTERVIEW DATA ........................................................................................17

RESULTS ...................................................................................................19

QUANTITATIVE RESULTS - EPDS DATA ........................................................19 QUALITATIVE RESULTS - INTERVIEW DATA ....................................................20

DISCUSSION..............................................................................................37

RECOMMENDATIONS ..............................................................................43

REFERENCES ...........................................................................................44

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Executive Summary Immigrant and refugee status has been identified as a risk factor for

mental illness during the perinatal period, with numerous factors postulated

that may predispose these women to suffer from mental health problems,

including social isolation, separation from family, financial difficulties,

experiences of discrimination, and a lack of familiarity with health care

practices in the host country. For women migrating from Sudan to Australia,

exposure to violence or trauma in Sudan, prior to migration, may also

increase risk of mental health problems during the perinatal period.

Acknowledging these issues, the WA Perinatal Mental Health Unit

(WAPMHU) and State Perinatal Mental Health Reference Group (SPMHRG)

endorsed the provision of funding to establish and trial a support group for

Sudanese women in the perinatal period based on a psycho-educational

group format. In May 2008 a Service Agreement was made between the

Women and Newborn Health Service, Department of Health and Ishar

Multicultural Women’s Health Centre Inc. to carry out this project. This

report presents the evaluation framework and results of the 2 years of data

collection and analyses conducted under the auspices of that framework by

Ishar and WAPMHU.

Evaluation is based on a pre and post-group design using both

quantitative and qualitative data collection methods. Five groups were

conducted during the evaluation period. Both qualitative and quantitative

data were collected from the first two groups. Twenty-six Sudanese mothers

completed pre-group assessments, including an interview, a demographic

questionnaire and an Edinburgh Postnatal Depression Scale (EPDS).

Seventeen of these women completed post-group assessments and were

thus included in data analyses. To reduce the burden of data collection, only

the EPDS data was collected from participants in subsequent groups (i.e.

three of the five groups run during the evaluation period). Pre and post-

intervention EPDS data was collected from a further 30 women in the final

three groups, resulting in a total of 47 participants.

Quantitative data collected via the EPDS was used to assess

changes in depressive symptomatology over the course of the 8-week

group term. Interview transcripts were thematically content analysed in nine

sections - corresponding to the questions posed during the interviews.

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Eligibility for participation in the perinatal mental health support group

was based upon Sudanese ethnicity and motherhood status, irrespective of

the presence or absence of depressive symptomatology. In light of this,

the level of depressive symptomatology found pre and post-group in this

sample of Sudanese mothers is concerning. Eighty-nine percent of the

Sudanese women participating in the support group (42 out of 47) scored

above cut-off (≥10) on the EPDS pre-group, suggesting that the prevalence

of perinatal depression may be significantly higher in this population of

childbearing women than general community samples. The percentage of

women scoring above the cut-off decreased to 43% post-group (20 out of

47). Although still higher than the general community, the reduction in

depression risk as indicated by the EPDS was both statistically and clinically

significant.

Overall, the evaluation results indicate that the key performance

indicators were met. Local Sudanese women are attending the support

groups, and showing a number of positive outcomes. In addition to the large

decrease in depressive symptomatology, the participants’ awareness of

perinatal mental health issues improved post-group and the importance of

accessing services if/when needed was apparent. There was an increase in

level of perceived psychosocial support by the participants, with support

networks expanding from family and friends to incorporate health

professionals and community services. Moreover, the participants indicated

that they would be more comfortable asking for help from a range of health

professionals post-group. Based on the results of this evaluation, continued

funding of the service has been recommended.

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Introduction

The perinatal period1 is associated with major biological, psychological

and social changes for women. Subsequently, it comes as no surprise that

mood disorders (which include depression and bipolar disorder) have been

found to peak in onset during the childbearing years (Australian Bureau of

Statistics, 2008) and there is now increasing evidence that anxiety may be

just as prevalent (Austin, 2004).

Postnatal depression (PND) or anxiety affects approximately 10% of

women during pregnancy and approximately 15% of women during the year

after birth (beyondblue, 2011). Research has linked depression during

pregnancy and postpartum to chronic depression, marital difficulties and

behavioural and cognitive delays in children (Pope, Watts, Evans,

McDonald, & Henderson, 2000), yet despite the prevalence and

consequences, many women living in Australia still remain unidentified and

untreated.

Women from culturally and linguistically diverse (CALD) backgrounds

(i.e. non-English speaking background and born overseas or with at least

one parent born overseas) make up 12% of the Australian female

population, and Australia’s shifting immigration policies are leading to

greater inflows of women (Gwatirisa, 2009). The acculturation or

resettlement experiences of refugee women are often compounded by

harsh pre-migration experiences that can make the transition difficult

(Gwatirisa, 2009). A meta-analysis combining the results from 67,294

participants in 56 published studies found poorer mental health outcomes

among refugees than non-refugees (Porter & Haslam, 2005). Very high

rates of mental distress and mental health disorders have been observed

among refugees who have experienced war/conflict (Roberts, Damundu,

Lomoro, & Sondorp, 2009).

The civil conflict in Sudan, between the Government of Sudan in the

north and rebels in southern Sudan, lasted over 20 years. The signing of the

Comprehensive Peace Agreement in January 2005 marked a tenuous end

to 21 years of conflict. During the conflict approximately 1.9 million people

were killed by violence, disease and starvation, up to 4 million people were

1 For the purposes of this project the perinatal period is defined as pregnancy to three years following birth.

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forcibly displaced from their homes (as internally displaced persons), and

there were up to 1 million refugees living in countries throughout the world,

including Australia (Roberts, et al., 2009). There have been escalations of

conflict in recent years (Refugees International, 2010; Tempany, 2009), and

in July 2011, South Sudan declared its independence and became a

sovereign state (Australian Broadcasting Company, 2011).

The most commonly researched mental health disorders in refugee

and conflict affected populations appear to be post-traumatic stress disorder

(PTSD) and depression (de Jong, Komproe, & Van Ommeren, 2003; de

Jong et al., 2001). Although mental health research with Sudanese

populations is scarce, PTSD rates of 46% have been recorded amongst

Sudanese refugees living in Uganda during the conflict (Karunakara et al.,

2004). In post-war Southern Sudan 36.2% prevalence rates of PTSD and

49.9% prevalence rates of depression have been reported (Roberts, et al.,

2009). A recent review of research on the mental health of Sudanese

refugees found evidence of high rates of PTSD and depression, as well as

concerns about current stressors such as family problems (Tempany, 2009).

Immigrant and refugee status has been identified as a risk factor for

depression during pregnancy and in the postpartum period (Dankner,

Goldberg, Fisch, & Crum, 2000; Glasser et al., 1998; Onozawa, Kumar,

Adams, Dore, & Glover, 2003; R. Small, Lumley, & Yelland, 2003; Goyal,

Murphy, & Cohen, 2006; Rubertsson, Wickberg, Gustavsson, & Radestad,

2005; Zelkowitz et al., 2008). Numerous factors have been postulated that

may predispose immigrant and refugee women to suffer from mental health

problems, including social isolation, separation from family, financial

difficulties, experiences of discrimination, and a lack of familiarity with health

care practices in the host country (Mulvihill, Mailloux, & Atkin, 2001).

For women migrating from Sudan to Australia, exposure to violence

or trauma in Sudan, prior to migration, may also increase the risk of mental

health problems during the perinatal period. Results of recent research

conducted in post-war Sudan reported that 44% of female respondents had

witnessed the murder of family or friends, 48% had directly experienced a

combat situation, 22% had been forcefully separated from family and

friends, 15% beaten or tortured, 10% imprisoned, and 8% raped (Roberts,

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et al., 2009). The same study found a PTSD rate of 42.5% and a depression

rate of 58.7% amongst female respondents (Roberts, et al., 2009)

So, although research into the perinatal mental health status of

Sudanese women is unavailable at this time, statistics such as these,

together with the extensive knowledge regarding the risks of psychological

distress during the perinatal period for the general population, leave no

question that Sudanese women can be regarded as a high-risk population in

need of culturally appropriate support during the transition to Australia and

motherhood.

Background In 2004, a state-wide mapping of perinatal mental health services

was conducted and consultations with a range of community health workers

undertaken. The resulting report (State Perinatal Mental Health Reference

Group, 2005) highlighted significant gaps in health professionals’ cultural

awareness when addressing the perinatal mental health needs of women

from culturally and linguistically diverse (CALD) backgrounds. Adding to the

difficulties was a lack of culturally or linguistically appropriate perinatal

mental health resources.

Subsequent to this report, a series of focus groups were conducted

with women from Iraq, Sudan and Ethiopia, with the objective of gathering

information on their experiences and thus mental health requirements

during the perinatal period. The selection of these three CALD communities

was based on a number of factors, including population size, percentage of

child-bearing women, family size, and levels of education and literacy.

The results of the focus groups, as well as a literature review, are

presented in “Social and emotional experience of the perinatal period for

women from three culturally and linguistically diverse (CALD) communities”

(State Perinatal Mental Health Reference Group, 2008). Recommendations

from this report highlighted the importance of linking together pregnant

women and new mothers within the community. It was proposed that ethnic-

specific cultural liaison workers could co-ordinate self-help or support

groups from within the community. It was envisaged that these groups could

be used as forums for women to share their experiences and develop

culturally appropriate coping strategies.

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On the basis of these results, the State Perinatal Mental Health

Reference Group (SPMHRG) endorsed the provision of funding to establish

and trial a support group for Sudanese women in the perinatal period based

on a psycho-educational group format. In May 2008 a Service Agreement

was made between the Women and Newborn Health Service (WNHS),

Department of Health and Ishar Multicultural Women’s Health Centre Inc.

to carry out this project.

Over the 2 year evaluation period, five groups were conducted. Each

group met for two hours a week over eight weeks. The program was

designed to incorporate informational/educational sessions, discussion of

personal issues and time for networking/socialising. The

informational/educational sessions included topics such as healthy lifestyle

and parenting skills, dealing with government and non government services,

and self responsibility.

An interim evaluation report presented the results from the first 12

months of data collection, with the evaluation framework and results from

the first group. The present report builds upon the 12-month evaluation to

include results from all five groups conducted during the 24-month

evaluation period.

Expected Outcomes It was hoped that as a result of attending the support group,

Sudanese women living in the Perth metropolitan area would become more

comfortable engaging with community and mental health services.

Subsequently, the level of psychosocial support perceived by Sudanese

women was expected to increase. A raised awareness of perinatal mental

health issues within the Perth Sudanese community and increased perinatal

specific knowledge by local service providers were also objectives of the

project. These outcomes were expected to assist in facilitating early

identification and intervention for women at high psychological risk,

potentially leading to an increase in engagement with mental health and

community services.

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Key Performance Indicators (KPI) 1. Participation in support groups by local Sudanese women (i.e.

interest and attendance)

2. Increase in level of perceived psychosocial support by Sudanese

women in the local area

3. Decrease in depressive symptomatology, as assessed by the

Edinburgh Postnatal Depression Scale

4. Increased perinatal specific knowledge by participants and local

service providers

5. Increase in reported levels of ‘comfort’ during engagement with

obstetric services during pregnancy by local Sudanese women


community services during pregnancy and postpartum by local

Sudanese women


mental health services in pregnancy and postpartum by local

Sudanese women

8. Increased capacity within local communities for bicultural community

worker to facilitate support groups (independent of original facilitator).

Evaluation Framework / Research Design

The evaluation was based on a pre and post-group design using both

quantitative and qualitative data collection methods. Awareness of cultural

sensitivity and literacy issues led to greater emphasis placed upon collection

of qualitative data in the initial stages of the evaluation. For the first two

groups, demographics, background information and interview data were

collected from participants along with EPDS scores. Analysis of the data

from Group 1 suggested that the EPDS was effectively detecting changes

within the target population. Therefore, to reduce the burden associated with

data collection, only the EPDS scores were collected for Groups 3, 4 and 5.

The results for all five groups are included in this report.

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Interviews Specifically designed semi-structured interviews were employed to

collect the qualitative data for this evaluation. The research interview is one

form of a conversational approach to qualitative analysis (Kvale, 1996). The

interview allows the researcher to gather vast amounts of data and to use

that data to understand the experiences of the participants and the meaning

they make of their experiences. Interviewing provides a powerful and

flexible way to gain insight into people’s experiences and allows

unanticipated responses to be expressed and analysed. An exploratory

semi-structured interview technique was employed, providing a framework

within which respondents could express their own personal perspectives.

The interview questions served as a checklist to ensure all pertinent issues

were raised but allowed for unexpected lines of enquiry to emerge.

Rigour Five main, somewhat overlapping issues have been addressed in the

design, implementation and analysis of the present study to obtain the

highest quality conclusions: (1) Objectivity/Confirmability, (2)

Reliability/Transferability, (3) Internal Validity/Credibility, (4) External

Validity/Credibility, and (5) Utilisation/Application.

Objectivity/Confirmability.

The question of whether conclusions depend on the subjects and

conditions of the enquiry rather than on the inquirer (Guba & Lincoln, 1989)

is sometimes labelled as ‘external reliability’ with emphasis on the

replicability of the study by others (Le-Compte & Goetz, 1982). Objectivity or

confirmability of the current findings was strengthened by numerous

strategies, including: methods and procedures were described in detail and

presented explicitly, the actual sequence of data collection and analyses

that lead to the conclusions can be followed, conclusions were explicitly

linked with exhibits of condensed/displayed data, and study data has been

retained and is available for re-analysis by others (Miles & Huberman,

1994).

Reflexivity was used to identify areas of potential bias. “The ability to

put aside personal feelings and preconceptions is more a function of how

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reflexive one is than how objective one is because it is not possible to set

aside things about which they are not aware” (Ahern, 1999).

Reliability/Transferability.

Reliability or transferability, that is, stability of observations over time

and across researchers and methods was sought through the development

of clear key performance indicators (KPIs) and congruence between these

KPIs and the evaluation design.

The researcher’s role within the research context was explicitly

described, and a ‘meaningful parallelism’ was sought across data sources

by maintaining parameters with respect to participants, contexts and times

(Miles & Huberman, 1994). That is, for each of the groups, one researcher

conducted all pre and post interviews in the participant’s homes and this

same researcher was responsible for transcribing all interviews, and then a

different researcher was allocated to the collation and analysis of the data.

Internal validity/Credibility.

Unlike the classic, measurement-oriented view which differentiates

face, content, convergent, discriminant, and predictive validity,

for the purposes of the current study a more qualitative approach was taken,

thus the inclusion of the term ‘credibility’. Maxwell (1992) distinguishes

among the types of understanding that may emerge from a qualitative study:

descriptive (what happened in specific situations); interpretive (what it

meant to the people involved); theoretical (concepts, and their relationships,

used to explain actions and meanings); and evaluative (judgments of the

worth or value of actions and meanings). Warner (as cited by Miles &

Huberman, 1994) also refers to ‘natural’ validity – the idea that the events

and settings studied are not modified by the researcher’s presence and

behaviours.

Unfortunately there are often issues in gathering data from non-

English speaking participants in Australia. For example, the use of

interpreters is sometimes necessary, however within a small community the

interpreter may be known to participants which can raise concerns about

privacy and confidentiality. However having an unfamiliar interviewer can

also result in a lack of openness as they may not have had the opportunity

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to develop the required level of trust from the participants (Tempany, 2009).

To this end, interviews were conducted by a person from the service who

was familiar to the participant in the participant’s home. Although this can

also raise issues such as the potential to provide more positive comments

about the service, on balance a familiar and trusted interviewer was deemed

preferable. The inclusion of more ‘objective’ measures in the form of the

EPDS scores provides a complementary form of evaluation against which to

consider the qualitative responses.

Triangulation of data sources (i.e., Edinburgh Postnatal Depression

Scale, interviews and research literature) were used in an effort to produce

converging conclusions and give support for adequate validity/credibility

within the present study.

External Validity/Credibility.

Maxwell (1992) speaks of ‘theoretical’ validity, the presence of a

more abstract explanation of described actions and interpreted meanings.

Maxwell suggests that generalisability requires connections to be made,

either to unstudied parts of the original case or to other cases. Although

such an explanation could be considered as ‘internal’ validity, it gains added

power if connected to theoretical networks beyond the immediate study.

With this in mind the present evaluation employed ‘multiple case sampling’

(Miles & Huberman, 1994), that is, 17 Sudanese mothers living in the Perth

metropolitan area and attending the perinatal support group were

interviewed prior to group commencement and again at the end of the

group. A literature review was then used to ‘connect’ the conclusions to

existing theory. The characteristics of the current sample of mothers are

described in enough detail to permit adequate comparisons with future

samples and the boundaries and limitations of this sample are also

discussed.

Utilisation/Application.

‘Pragmatic validity’ (Kvale, 1996) is an essential addition to more

traditional views of ‘goodness’. In addition to informing future funding

decisions, the present study ultimately aimed to provide useful information

to people working with and providing support and information to Sudanese

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mothers living in Australia. Whether those people were health professionals,

policy makers or volunteer mothers working within organisations concerned

with providing services to CALD mothers was unimportant. What was

important was the identification of positive strategies, techniques and

information that could be passed on to expectant or new mothers to ease

their transition and enhance their parenting experience.

Instruments The evaluation instruments included the Edinburgh Postnatal

Depression Scale (EPDS; (Cox, Holden, & Sagovsky, 1987), an interview

schedule and a demographic questionnaire.

Interview schedule

A semi-structured interview schedule was developed by the

WAPMHU Project Officer, in consultation with the WAPMHU Senior

Research Psychologist, to guide the face-to-face interviews with

participants. Questions included in the interview schedule were guided by

the KPIs, that is, questions were included to elicit discussion of perinatal

mental health issues, ascertain current levels of support and assess comfort

levels whilst engaging with available services. The establishment of rapport,

cultural sensitivity and flexibility were considered in the design of the

schedule.

The following nine questions were included in the interview schedule

and prompts were suggested for use as required to elicit elaboration and/or

clarification:

1. How do you feel about the amount of support you have at the

moment? Do you have enough support from your family, friends,

community, community services?

2. Do you think a woman’s emotional health is important when she

becomes a mother? Why?

3. Can you think of any emotional problems a mother might experience

while she is pregnant or after she’s given birth? Have you heard of

mothers who have depression? Anxiety?

4. For a woman who may be pregnant, or has a baby, what kinds of

things do you think are helpful to ensure good emotional health?

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When you feel like you’re not coping / sad what kinds of things do

you do or could you do to make yourself feel better?

5. What kinds of services have you visited during your pregnancy or

since you’ve had the baby? Where do you go if you need help with

your health or your baby’s health?

6. How comfortable do you feel using/going/visiting these services?

7. Where would you go to get help if you felt like you’re not coping?

8. (Group 1 Only) How would you feel about asking for this kind of help?

(Group 2 Only) Would you ask for help from family, friends, your

community, child health nurse or doctor or counsellor? And would

you feel comfortable to ask for help?

9. How comfortable would you feel about using a counselling service?

Demographic Questionnaire

The demographic questionnaire was purpose designed for this

evaluation to gather information on basic demographic variables. It was a

structured questionnaire containing 10 questions to be completed by the

interviewer at the time of interviewing the participant. These questions

provided information on the participant’s age, parity, number of children,

woman’s country of origin, whether the children were born in Australia,

marital status, primary spoken language, other language/s, EPDS version

used, and whether the EPDS and interview were completed with the

assistance of an interpreter. There were also spaces provided to record the

total EPDS score before the group began and at the end of the 8-week

term. For Group 2, a slightly shortened version was used, excluding

information on assisted completion of the questionnaire, country of origin

and referral source. Recording of marital status was also altered.

Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden &

Sagovsky, 1987)

The EPDS was used to measure depressive symptomatology. This

10-item screening questionnaire takes about 5 minutes to complete and

pertains to the women’s feelings during the past 7 days. The items refer to

depressed mood, anhedonia, guilt, anxiety, and thoughts of self harm.

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The EPDS has been widely used in cross-cultural work to measure

depressive symptoms during the perinatal period and appears to be a

reliable measure for both immigrant and non-immigrant respondents

(Rhonda Small, Lumley, Yelland, & Brown, 2007). The EPDS has been

translated into many languages and validated in many countries, including

Africa.

In the present study, an EPDS score of 10 or more was considered

‘high risk’ or indicative of depressive symptomatology, as recommended for

use when screening migrant women during the antenatal and postnatal

period in Western Australia (Department of Health - Government of Western

Australia, 2006).

Procedure Eligibility for participation in the perinatal mental health support group

was based upon Sudanese ethnicity and motherhood status, irrespective of

the presence or absence of depressive symptomatology. As such, group

participants varied in terms of current mental health status/psychosocial

well-being, as well as age, education, whether English was spoken,

occupation, marital status, and parity.

Once informed consent was obtained from group participants

(i.e., to use de-identified data for evaluation purposes), the Project

Coordinator, employed by Ishar, administered an EPDS. For Groups 1 and

2 the Project Coordinator also completed the demographic questionnaire

and conducted a semi-structured interview with each participant prior to

commencement of the group.

Interviews and questionnaire completion took place in the women’s

homes. After introductions and cultural formalities the interviews took place

in an area in the home where the women felt comfortable (e.g., bedroom,

kitchen or lounge room). The reason for the interviews was explained to the

women and a written program outline was given to them. It was made clear

to the women that the information was confidential and would not be

identifiable when analysed and reported.

Depending on the woman’s level of English and feelings of

competence either she would be asked the interview questions in English or

through an interpreter. Probes and prompts were used when required to

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assist the women in understanding the questions, especially because of the

language barrier. The questions were asked and their answers written as

closely as possible to verbatim by the interviewer at the time of interview in

the woman’s home. The answers were interpreted back into English if

required by the interpreter present at the interview. Each interview took

between 60 and 120 minutes to complete.

The typing of the handwritten answers to the interview questions was

done by the Project Coordinator, who had also conducted the interviews.

This de-identified pre-group data was then submitted to the WAPMHU

Research Officer in hard copy and electronic format.

Post-group evaluation data, was collected and submitted via the

same process and using the same questionnaires, at the completion of the

8-week support group term by the Project Coordinator. The WAPMHU

Research Officer was responsible for collating and analysing pre and post-

group data and preparing this evaluation report in consultation with the

Project Coordinator.

Appropriate ethical clearance, and registration, for this Quality

Improvement activity was obtained from the King Edward Memorial Hospital

for Women Ethics Committee.

Participants Participants were females born in Sudan and now living in the Perth

metropolitan area, who had been referred to Ishar, were pregnant or had

given birth in the last 36 months, and were subsequently attending a

perinatal mental health support group being run by Ishar. Developed as a

‘universal’ service, that is, by recognising that all women born in Sudan and

currently in the perinatal period could potentially benefit from the support

group (Williams & Berry, 1991), mothers who scored above or below the

recommended cut-off on the EPDS (i.e., ≥10; Department of Health, 2006)

were eligible for group attendance and were thus included in this evaluation

sample.

The demographics of Group 1 participants are shown in Table 1.

Although 14 women in total were interviewed and completed questionnaires

pre-group, 10 women attended for the entire 8-week term and were thus

interviewed again post-group and included in the pre-group / post-group

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analysis. Mothers’ ages ranged from 17 to 31, with a mean age of 22. Three

of the women were primiparous and six of the women had an infant less

than 1 month of age at the commencement of the group. Six of the women

attending the group were unmarried.

The demographics of Group 2 participants are shown in Table 2.

Pre-group questionnaires and interviews were completed by 11 women,

with post-group data collected from 7 women. On average, participants in

Group 2 were older than those in Group 1. Mothers’ ages ranged from 17 to

34 with a mean age of 26. They were also more likely to be married.

The evaluation did not attempt to gather information about the

participants’ prior circumstances, such as exposure to violence or trauma

that may have been experienced in Sudan. However, a number of the

participants faced difficulties during the time the groups were run. These

included deaths in the family, serious health concerns for themselves or

family members, caring for a child or relative with disabilities, crowded

accommodation with relatives, isolation and language barriers, and family

conflict or violence. Such circumstances could make it more difficult for the

effects of the support group to reach statistical significance, as a stressful

life event occurring partway through the eight weeks could significantly

reduce well-being. However, difficult circumstances are part of the everyday

reality for many of these families and serve to highlight the need for support

groups.

Table 1 Profile of Participants in Group One

Age Parity Infants age (months)

Marital status

17 Primiparous 1 Traditional marriage

17 Multiparous 2 Unmarried

18 Primiparous 1 Unmarried

20 Primiparous 0.5 Traditional marriage

20 Primiparous 0.5 Unmarried


23 Primiparous 0.5 Unmarried


27 Multiparous (4+) 3 Married


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Table 2 Profile of Participants in Group Two

Demographic data and drop-out rates were not collected for Groups

3-5. The total number of participants who completed post-group EPDS

questionnaires in each of these groups was 10, 11 and 9, respectively.

Several participants attended more than one group, and additional data was

collected in these instances. However, in order to maintain consistency in

the analysis, where data has been identified as being from a second or

subsequent group, it was not included in the main analysis. Pre and post-

group EPDS scores were collected from 47 participants in total.

Attrition of participants

In Group 1, a total of four women who were interviewed pre-group did

not complete the 8-week term and did not complete post-group interviews.

One of these women decided not to attend the group prior to session one,

whilst the remaining three women had attended a number of sessions but

had then ceased attending prior to end of term. Reasons for non-attendance

were not sought from two of these three group members. Due to unfortunate

personal circumstances, the third mother was unable to complete the group

(despite regular attendance for most of the term), and it was deemed

inappropriate for her to be interviewed post-group.

Of the five women from Group 2 that did not complete post-group

interviews and questionnaires, two had not commenced the program, while

three had only attended a few sessions. As they had not completed the

program they were not asked to provide post-group data. Attrition data was

not collected for subsequent groups.

Age Parity Infants age (months)

Marital status 2

17 Primiparous 0 Defacto

20 Primiparous 1 Married

24 Multiparous 0.5 Married





17

Analysis

EPDS Data The EPDS (Cox, Holden & Sagovsky, 1987) was used to assess

depressive symptomatology among the mothers that participated in the

group. Data from 47 participants was available for the analysis. Data was

coded and entered into PASW version 18.0 (formerly known as SPSS) for

data analyses. Frequency distributions, graphs and descriptive statistics

were generated for initial data exploration. A score of 10 or higher was used

as the cut-off score to indicate the presence of depressive symptoms in this

population of migrant women, as recommended by the Department of

Health, Government of Western Australia (2006).

Interview Data Thematic content analysis of the qualitative interview data involved

three phases: coding, pattern coding, and reporting of findings and

interpretations.

Coding

The initial coding phase involved the development of a question-

ordered matrix using Microsoft Excel for the participants’ responses to each

of the interview questions. Each transcript was divided into nine sections,

according to the participants’ responses to the nine interview questions.

The sections were then read and speech units of varying lengths, typically 7

to 10 words, were coded and transferred into the matrix.

Pattern Coding

Pattern coding is a method for grouping initial codes into a smaller

number of themes, sets or constructs (Miles and Huberman, 1994).

To facilitate pattern coding and enhance transparency of the process, a new

matrix was constructed for each of the interview questions: 1) current

support, 2) importance of emotional health, 3) knowledge of depression and

anxiety, 4) helpful ideas, 5) service usage, 6) service comfort, 7) future

service seeking, 8) comfort asking for help, and 9) mental health service

comfort. Coded text was transferred from the question ordered matrix to the

18

corresponding new matrix and then searched for key words/phrases, which

were entered into two separate columns – one for pre-group and one for

post-group responses.

The number of times each of the key words/phrases was repeated

across cases/participants was then counted and entered into the matrix,

maintaining separate columns for pre and post-group data. This process

was repeated within each of the 9 matrices, identifying the most common

responses to each of the focus group questions.

With the repetition of key words/phrases across cases clearly

displayed within each matrix, the most ‘dominant’ or ‘prevalent’ patterns

could be identified – and analysis of pre-group and post-group themes was

facilitated. Colour coding was then applied to identify similarities and

differences between key words/phrases and as a result themes emerged.

Appropriate precautions were undertaken in the development and revision

of themes (i.e., ensuring all themes were distinct from each other in

meaningful ways and keeping them as semantically close to the terms they

represent) as recommended by Miles and Huberman (1994).

The use of matrices facilitates transparency of the research

methodology – from initial coded data to themes, strengthening objectivity or

confirmability of the current findings (Miles & Huberman, 1994). The

participants own words were used within matrices and refinement (i.e.,

development of themes) was made explicit, leaving a clear ‘audit trail’ so

that ‘lower levels’ of analysis could be referred to easily.

19

Results The results of the analysis are presented in two sections: quantitative

and qualitative. The quantitative section contains results from participants in

all five groups, while the qualitative section provides additional rich

information from the interviews conducted with Groups 1 and 2. The

qualitative section is divided into nine sections, corresponding to the

questions posed during the interviews. Each of these qualitative sections

begins with a diagrammatic presentation of themes generated from the

responses to that question and the text that epitomised these themes (in

italics) is then discussed.

Quantitative Results - EPDS Data On average, participants attending the Sudanese Perinatal Mental

Health Support Groups during the 24-month evaluation period reported a

significant reduction in depressive symptomatology from admission (M

=13.81, SE = 0.52) to discharge (M = 9.17, SE = 0.52, t(46) = 8.10, p <

0.001, r = 0.77)3. Importantly, this reduction moved the average EPDS score

from over 13 which was above the recommended cut-off of ≥10 indicating

the likelihood of depression was considered high at admission, to below 10,

indicating the likelihood of depression was reduced.

Furthermore, in considering what these results mean for the

participants, 68% of women showed an improvement of at least four points

on the EPDS, which has been recommended as a useful criteria for

determining clinically significant change using the EPDS (Matthey, 2004).

The percentage of participants scoring above the cut-off on the EPDS

reduced from 89% (42 out of 47 women) pre-group to 42% (20 out of 47

women) post-group.

As can be seen in Table 3, most of the groups began with an

average EPDS score of approximately 14, reducing to just over 9 after

3 Note: As the links between research and policy strengthen (Watson & Tully, 2008); it is important to make findings transparent with regard to the actual effect on the lives of women and their families. Subsequently, researchers have adopted a more standardised method of reporting results in which they use effect sizes (or change expressed in terms of a percent of standard deviation) instead of, or as well as, the more traditional alpha values (such as, p < 0.05). Rules of thumb used in evaluations of social service programs define effect sizes of up to 0.2 as small, 0.5 as moderate and 0.8 as large (Cohen, 1983; McCartney & Rosenthal, 2000). Effect sizes were calculated for statistically significant results, as reported above. The effect size of 0.77 for the pre-post comparison of the EPDS represents a substantive finding.

20

participating in the groups. Group 2 showed a different pattern, with a

notably lower pre-group EPDS score and a smaller improvement at post-

group.

Table 3 Mean Pre and Post-Group EPDS Scores by Group

Group 1 Group 2 Group 3 Group 4 Group 5 Combined

Pre-Group 14.3 9.7 14.9 14.4 14.6 13.8

Post-Group 10.5 7.1 9.0 9.4 9.2 9.2

Qualitative Results - Interview Data There are a number of similarities, but also differences between

Group 1 and Group 2. As noted previously, Group 2 members were typically

older, more likely to be married and started with a lower level of depression

than Group 1. The qualitative comments showed that Group 2 was more

familiar and comfortable with a range of services, and their pre-group

responses were often similar to the post-group responses of Group 1. In

addition, the prompts may have been used more routinely in Group 2, with

separate answers recorded for first and prompted responses. Consequently,

the responses from Groups 1 and 2 were analysed separately. For each

question, thematic results graphs for Group 1 are presented, followed by

discussion and comparisons with Group 2. As noted above, Group 2

showed a different profile of depression scores to the other groups.

Therefore, it seems reasonable to speculate that the Group 1 results may

be more representative of the participants in subsequent groups.

Participants’ comments are shown in italics. To maintain the privacy

of participants, they have been assigned an identifying number that is used

in this report. P1.2 indicates participant number 2 from Group 1. This

numbering system is not aligned with the demographics details in Table 1

and Table 2 due to the small number of participants.

21

Question 1: How do you feel about the amount of sup port you have at the moment?

Figure 1. Themes generated pre-group from question 1: Current support (Group 1)

Figure 2. Themes generated post-group from question 1: Current support (Group 1)

Responses about current support were similar for Group 1 and 2.

Three themes emerged in response to this first question regarding the level

of support the women believed they had before the group began:

‘Insufficient support’, ‘Adequate support’ and ‘Support from family and

friends’. It should be noted that although family support was a common

theme, in a number of cases available family members were in-laws or

extended family, and some women reported they missed family members in

Sudan. Thus, even when family members living locally or overseas are

supportive, there can still be important gaps in the support available.

Support from family and friends

Good level of support

Insufficient

support

Community services and group support

CURRENT SUPPORT

Improving

Support from family and friends Adequate

support

Insufficient

support

CURRENT SUPPORT

22

Of the pre-group themes, ‘Insufficient support’ and ‘Support from

family and friends’ remained post-group, but ‘Adequate support’ improved to

become ‘Good level of support’. For example, P1.8 pre-group said “I live

with my brother and sister in law and their children. They support

sometimes”. P1.8 post-group then said “It is good. I am getting support from

Ishar and I am getting support from Anglicare and from family and friends

and the community.” In addition to the three pre-group themes, two new

themes emerged post-group: ‘Improving’ and ‘Community and group

support’, both conveying a positive shift in support networks available to

participants. The ‘Improving’ theme was built from women talking about the

support they felt from participating in the group as well as from information

they had gained about other community supports they could utilise. For

instance P1.2 spoke about the group itself: “I am very happy about the

amount of support, for example the program that has been running here

every Friday has been very helpful for me”. P2.8 noted some improvement

in the support she received, commenting pre-group “I feel good about the

emotional support I received although sometimes it is ok or not. Social

support is ok. Practical support is very hard to come and it is too much for

me and sometimes I nearly cry. I have no relatives.” And post-group

“Emotional support is good; social support is also good. Practical support –

half-half – not much. Practical support from my husband is improved. He is

supportive now since I started the women’s group - perinatal training at

Ishar”.

There was a noticeable broadening in the sources of support

mentioned post-group, with more women mentioning receiving good support

from the community and community groups, as well as family or friends.

This is the “Community services and groups” theme.

The women in Group 2 were asked a further probing question “do

you have enough support from your family, friends, community services?”,

and were therefore more likely to mention community services pre-group.

Some indicated they received enough support from community services,

whereas others indicated they did not. In both Groups 1 and 2, the

‘Community services and groups theme’ appeared unprompted post-group.

The knowledge and empowerment gained from attending the groups

was commented on by participants from both groups. For example P1.1

23

stated: “The support was really good because we learn a lot of things about

babies and myself; and how to manage things for the family. I also learnt

what to do when my baby is sick.” An important part of the knowledge

gained was learning how to access support when it is needed. For example

P1.10 commented “I feel good at the moment, because I know where to go

and there are many people who support me on what I don’t know”. P2.5

stated “I have good support socially, emotionally, practically through the

programme provided by Ishar. It taught me how I can get support.” P2.1 felt

more able to help herself because of the support provided by Ishar: “I am

very happy with the support I get from Ishar, because I am able to help

myself now because of their support… I have never got support from

anybody like Ishar, and the friends I have from Ishar during the program”.

Interestingly, the interview transcripts indicated that more support

was needed by the women whose English was limited (i.e., the women who

had required an interpreter for the interviews). These women appeared to

be the group members who had not made such a noticeable positive shift

post-group with regard to accessing support in the community.

For example P1.3 said pre-group: “I am missing my mother a lot who

is back in Sudan. I live with my brother and my sister in law and their

children. I don’t speak English so find it very difficult. All my other family is

back in Sudan. I have no friends here.” Post-group she still spoke of feeling

lonely: “I have a bit of support at home, but I feel very alone outside the

house”. Given this woman has left her family behind in Sudan, has moved to

a country where she cannot speak the language, and has given birth to an

infant by caesarean section 6 weeks prior to beginning the group, it is not

surprising that she may be struggling emotionally or that it may take longer

than 8 weeks for positive changes to occur.

Nevertheless, for those women whose English is limited, attending

the group has given them a much-needed opportunity to connect with a

community service and other Sudanese speaking women that would not

otherwise have been available. Their willingness to make this connection

and attend the group can thus be seen as an important step in the right

direction.

24

Question 2: Do you think a woman’s emotional health is important

when she becomes a mother? Why?

Figure 3. Themes generated pre-group from question 2: Emotional health (Group 1)

Figure 4. Themes generated post-group from question 2: Emotional health (Group 1)

Within Group 1, two strong themes emerged from analyses of the

pre-group transcripts: ‘Don’t know’ and ‘Yes, for baby’. Both of these themes

indicated that the women were largely unaware of the many psychosocial

and biological changes that occur during the perinatal period and how these

changes can affect them emotionally. P1.1: “I don't really know…”

For those women who did acknowledge that emotional health is

important, the pre-group discussion was very limited, with the focus being

placed solely upon the woman’s role as the carer for the infant rather than

as an individual with her own needs for emotional health and well-being. For

example P1.8 pre-group said: “Yes, because she is a mother.” And P1.14

pre-group said: "Yes, because she has to look after her children.”

Yes, for self

Yes, for baby

EMOTIONAL

HEALTH

Don’t know

Yes, for baby

EMOTIONAL

HEALTH

25

Whilst the ‘Yes, for baby’ theme persisted post-group it was counter-

balanced with a new second theme: ‘Yes, for self’. The replacement of the

‘Don’t know’ theme with this new theme indicated that more of the women

were aware post-group of the importance of not only being able to care for

their child/ren but for themselves also. An example of this positive shift pre

to post-group can be seen in the responses of participant P1.2, who pre-

group was not able to answer this question and then post-group answered:

“Yes, because when you become a mother you have a lot of responsibility

such as taking care of yourself and your baby.”

Pre-group, the participants in Group 2 were already aware of the

importance of good emotional health for mothers and children. For example

P2.4 answered ”Yes. It is important, because a woman’s emotional health

helps her to be a good mother and take care of herself and her baby. The

woman will be happy with herself and baby”. P2.6 said “Yes, because a

woman’s emotional health is important for her own good and the good of the

child”.

Question 3: Can you think of any emotional problems a mother might

experience while she is pregnant or after she’s giv en birth? Have you

heard of mothers who have Depression? Anxiety?

Figure 5. Themes generated pre-group from question 3: Perinatal mental health knowledge (Group 1)

Don’t know

Lonely

Sad

PERINATAL

MENTAL HEALTH KNOWLEDGE

26

Figure 6. Themes generated post-group from question 3: Perinatal mental health knowledge (Group 1)

In contrast to the previous questions, completely different themes

emerged pre to post-group in the Group 1 response to this question

regarding participants’ knowledge of perinatal mental health. It should be

noted that although the question was intended to assess perinatal mental

health knowledge, it was worded in terms of emotional problems to make

the question more accessible. Pre-group themes included: ‘Don’t know’,

‘Sad’ and ‘Lonely’, indicating limited knowledge of perinatal mental health,

even when probed more specifically about depression and anxiety. For

example P1.5 pre-group answered this question with: “When you are not

with your family and they are not happy with you it makes me feel sad.”

The shift in post-group themes reflected a greater level of understanding,

with discussion of the causes of maternal mental illness and how they may

present. For example, pre-group P1.1 said: “I think a mother might be sad

and feel lonely. I don't know what depression is.”, whilst post-group this

same participant described some of the possible causes of postnatal

depression.

Although levels of understanding of this complex topic remained

basic and at times confused post-group, overall there appeared to be an

increase in awareness that women during the perinatal period may

experience various forms of mental illness. This positive change was

illustrated by participant P1.2 who pre-group did not answer this question

PERINATAL

MENTAL HEALTH KNOWLEDGE

Causes of depression and anxiety

Descriptions of mothers with

depression and anxiety

27

and post-group responded: “A mother might experience being stressed,

depressed and even be depressed when she is pregnant”.

Moreover, there appeared to be an important post-group realisation

by numerous participants that mothers could become depressed. For

instance, despite one of the participant’s brother’s apparently suffering from

depression in Sudan, P1.6 stated pre-group: “I haven’t heard about mothers

who have depression”. In contrast, P1.6 spoke at length post-group about

what she believed could be causes and symptoms of maternal depression

and anxiety.

Group 2 began with a higher level of understanding of emotional

health. They discussed a number of issues that can lead to distress, such

as sickness during pregnancy; worries during pregnancy about the baby’s

health and a safe delivery; relationship conflict or an unwanted pregnancy;

or having a baby that cries a lot, lack of help and insufficient rest. They

commented on a range of feelings that can accompany pregnancy and the

postnatal period including frustration, loneliness, sadness, anxiousness and

stress. For example, P2.1 listed a number of concerns and situations that

can impact on mothers’ emotional health: “About having a safe delivery for

both mother and the child; if parents are not happy about the pregnancy;

when the woman and the husband are having problems in the family; after

delivery – when the baby is sick and cries a lot; when you don’t have

someone to assist you; anxious to go back to school – this brings me some

emotional problems”.

In total, 4 of the 7 participants stated pre-group that they had heard of

depression and anxiety, and 2 others mentioned anxiousness or emotional

problems. As a result of this higher level of prior knowledge, there was little

change in the responses from Group 2 participants from pre-group to post-

group.

28

Question 4: For a woman who may be pregnant, or has a baby, what

kinds of things do you think are helpful to ensure good emotional

health? When you feel like you’re not coping / sad what sort of things

do you do or could you do to make yourself feel bet ter?

Figure 7. Themes generated pre-group from question 4: Helpful ideas (Group 1)

Figure 8. Themes generated post-group from question 4: Helpful ideas (Group 1)

The pre-group responses to this question, which asked for

suggestions to help a mother achieve and maintain positive emotional

health, were limited to one major theme: ‘Talking’. As beneficial as talking

can be, this result did indicate a very limited awareness of the variety of

support services, medical and non-medical treatments, and self-help

strategies available to help women during this challenging time of their lives.

The variety and depth of responses increased post-group, the

outcome of which was four themes: ‘Talk – to family and friends’, ‘Talk – to

Importance of support

Talk – to health professionals

HELPFUL IDEAS

Physical health care

Talk – to friends

(or family)

HELPFUL IDEAS

Talk

29

health professionals’, ‘Importance of support’, and ‘Physical health care’.

The increase in awareness of options was illustrated well by participant P1.6

who only spoke of the bible pre-group, but post-group said: “She should go

to a Counsellor or a friend of hers to counsel her or she could go out for a

walk or watch TV or read the bible...She can see community nurses or her

doctor.”

Although talking still featured heavily post-group, the introduction of

health professionals as an alternative person to talk to indicated that the

participants were now aware of this option and its benefits. For example,

although pre-group P1.8 spoke of visiting friends or speaking to her mother,

post-group she also spoke of accessing community supports: “The things

that are important are getting support from different people. When I feel I am

not coping I will communicate with Ishar or the Child Health Nurse”.

Group 2 participants tended to have a range of helpful ideas at pre-

group including talking, exercise, eating well, getting enough sleep and

thinking positively. Several mentioned talking to professionals. Similar to the

previous question, there was relatively little change in Group 2 responses

before and after attending the group.

Question 5: What kinds of services have you visited during your

pregnancy or since you’ve had the baby? Where do yo u go if you need

help with your health or your baby’s health?

Figure 9. Themes generated pre-group from question 5: Service usage (Group 1)

Doctor/GP

Child Health

Nurse

Ishar Midwife

SERVICE USAGE

Hospital –

OPH/KEMH

30

Figure 10. Themes generated post-group from question 5: Service usage (Group 1)

For both Group 1 and Group 2 the major services accessed by

participants did not change significantly from pre to post-group. For Group

1, Princess Margaret Hospital (PMH) was added post-group to the obstetric

hospitals, King Edward Memorial Hospital and Osborne Park Hospital. The

only other minor change in Group 1 was that reference to Ishar expanded

from the midwife pre-group to the service as a whole post-group. Group 2

had a small increase in the number of participants that mentioned Ishar and

child health nurses at post-group.

Doctor/GP

Child Health

Nurse

Ishar

SERVICE USAGE

Hospital –

OPH/KEMH/PMH

31

Question 6: How comfortable do you feel using/going /visiting these

services? (those visited in question 5).

Figure 11. Themes generated pre-group from question 6: Service comfort (Group 1)

Figure 12. Themes generated post-group from question 6: Service comfort (Group 1)

Similar to the findings of the previous question, no significant

changes were noted pre to post-group in regard to comfort levels whilst

accessing services. However, as the majority of participants stated that they

were already comfortable utilising these services pre-group, there was not

much room for improvement. Subsequently, the only shift observed was the

addition of “Very” in front of “Comfortable”, that is, from stating that they

were “Comfortable” pre-group to “Very comfortable” post-group. Many of the

Group 2 participants indicated pre-group they were very comfortable with

accessing services.

Very comfortable

Good

SERVICE

COMFORT

Comfortable

Good

SERVICE

COMFORT

32

Question 7: Where would you go to get help if you f elt like you’re not

coping?

Figure 13. Themes generated pre-group from question 7: Future service seeking (Group 1)

Figure 14. Themes generated post-group from question 7: Future service seeking (Group 1)

The responses from Group 1 and Group 2 differed markedly for this

question. Among Group 1 participants, pre-group responses to this question

indicated that help would only be sought from ‘Family’ or ‘Friends’ or the

‘Midwife at Ishar’, whom had referred many of the participants to the group.

In contrast, post-group themes indicated that participants would also now

consult their ‘Doctor’ (i.e., GP), ‘Child Health Nurse’ or a ‘Counselor/Social

Worker’. The expansion in awareness of possible sources of support/help

and apparent willingness to access such services if the need arose can be

seen as one of numerous positive outcomes of the group.

Informal – friends, community

Ishar

Child Health

Nurse

FUTURE SERVICE SEEKING

Counselor/ Social Worker

Doctor

Friends

Ishar midwife

Family


33

This small but positive shift is demonstrated by participant P1.3 who

pre-group responded: “I don’t have anywhere to go. I don’t know anyone

from my community. I only have my brother and sister-in-law here who don’t

speak English.” and then post-group responded: “I found out through the

program that I could ask for help from Ishar.”

Themes from Group 2 are presented below. Whereas Group 1

focussed on informal social supports, such as family or friends, Group 2

responses all related to formal support systems such as health

professionals and community services. Most participants (six of the seven)

mentioned a GP or Doctor at pre-group. Hospitals (N=4), Child Health

Nurses (N=3) and Ishar (N=2) were also mentioned by participants pre-

group. Although the majority of Group 2 participants did not increase the list

of services they would access between pre and post-group, P2.10

commented pre-group “I would not go anywhere for help, I would try to work

it out myself”, and post-group answered “I will call or go to Ishar;

Counselling services; GP; Community Child Health Nurse”. This is a positive

change as it is important for women to recognise that help is available and

that it is acceptable to seek help if they are not coping.

Figure 15. Themes generated pre-group from question 7: Future service seeking (Group 2).

Child Health Nurse

Hospital Doctor/GP


Ishar

34

Figure 16. Themes generated post-group from question 7: Future service seeking (Group 2)

Question 8: How would you feel about asking for hel p?

Figure 17. Themes generated pre-group from question 8: Comfort asking for help (Group 1)

Figure 18. Themes generated post-group from question 8: Comfort asking for help (Group 1)

Child Health Nurse

Hospital Doctor/GP


Ishar

Comfortable

COMFORT

ASKING FOR HELP

Specific Health

Professionals

Comfortable

Uncomfortable

COMFORT

ASKING FOR HELP

35

When questioned how they would feel about asking for help before the

group began, the majority of participants in both groups stated that they

would be ‘Comfortable’. Nevertheless, there were also pre-group responses

indicating a level of discomfort with the prospect of asking for help from

people they did not know. For example, participant P1.13 said “I wouldn’t

feel comfortable asking someone for help if I didn’t know them”.

However, the ‘Uncomfortable’ theme did not emerge post-group,

indicating a positive shift for those women who had expressed discomfort

pre-group. For example, post-group participant P1.13 said that she would

now feel comfortable asking for help: “I would feel comfortable”.

The new theme ‘Specific Health Professionals’ that emerged post-

group for Group 1 was due to many of the participants mentioning the health

professionals that they would go to for help (which they had not done pre-

group). The professionals included their GP, Child Health Nurse, Ishar and

a Counsellor. Compared to Group 1, Group 2 participants were more likely

to mention specific health professionals they would feel comfortable to ask

for help at pre-group.

Question 9: How comfortable would you feel about us ing a counselling

service?

Figure 19. Themes generated pre-group from question 9: Mental health service comfort (Group 1)

Comfortable

Unknown

Uncomfortable

MH SERVICE

COMFORT

36

Figure 20. Themes generated post-group from question 9: Mental health service comfort (Group 1)

Among Group 1 participants, there was a noticeable positive change

in responses to this question from pre to post-group, with the pre-group

themes ‘Uncomfortable’ and ‘Unknown’ not present post-group, and the new

theme ‘Benefits’ emerging post-group. Prior to participating in the group, all

Group 2 participants knew what a counselling service was and most felt

comfortable or very comfortable using one.

The observed increased level of comfort when presented with the

idea of accessing mental health services was illustrated well by participant

P1.1 who said pre-group: “I don’t think I would feel comfortable because I

don’t know what they do.” The response of participant P1.1 post-group

included possible benefits of going to a mental health service “It is ok to use

counselling services because they help you when you feel sad. They will

talk with you what to do for yourself.” A similar improvement in comfort with

accessing counselling services was expressed by one of the participants in

Group 2. Pre-group, P2.10 answered “Not comfortable”, however at post-

group she responded “Yes I feel good to talk problem with someone; and

then I don’t feel stress about it any longer”.

Very comfortable

MH SERVICE

COMFORT

Benefits

37

Discussion The concept of acculturation is widely used in research with migrant

groups, and refers to the changes that an individual undergoes when they

come into contact with another culture, such as when migrating to a new

country. This acculturation entails numerous psychological changes,

including adjustments in behaviour, values, attitudes and identity (Williams

& Berry, 1991). Despite earlier views to the contrary, acculturation does not

inevitably lead to psychological distress, with the level of distress dependent

upon numerous factors. One of the most influential of these factors is the

presence of social and cultural groups that may provide support for the

person entering into the experience of acculturation (i.e., a protective

cacoon). With a lack of social support also identified in ‘mainstream’

research as an important risk factor for postnatal depression (Dennis, 2004;

Pope, et al., 2000; Robertson, Grace, Wallington, & Stewart, 2004) this

perinatal mental health support group, facilitated by Ishar and funded by

WAPMHU, was intended to provide such a ‘cacoon’ for Sudanese mothers

living in the Perth metropolitan area.

Research suggests that migrants tend to fare better emotionally

when they adopt an ‘integrative’ approach to acculturation, which involves

maintaining valued aspects of one’s own culture and heritage while also

connecting with and selectively adopting aspects of the new culture (Berry,

2005). In assessing participants’ knowledge related to perinatal mental

health, and providing education and information through the support groups,

it is important to be mindful that ‘knowledge’ and understandings of health

are never culture-free. The view of perinatal mental health and help-

seeking promoted through this program were based on the scientific

research literature, and typically ‘Western’ views of health. However, the

aim has been to create a positive and culturally appropriate forum for

sharing information, through the involvement of bi-cultural project members

and placement of the service within Ishar (a multicultural women’s health

service) as well as the use of a community and strengths-building approach.

It was hoped that the information provided would support Sudanese women

to understand and access local services. The interview data suggests the

program was effective and a positive experience for participants.

38

Despite immigrant status being identified as a risk factor for

depression during the perinatal period (Dankner, et al., 2000; Glasser, et al.,

1998; Onozawa, et al., 2003; Rubertsson, et al., 2005; R. Small, et al.,

2003) (Goyal, et al., 2006), there is limited research available on specific

risk factors for immigrant women. From the research available the risk

factors for postpartum depression appear to include: a lack of social

support, stressful life events, physical health problems, and an inability to

speak the language of the host country (Small, et al., 2003;(Parvin, Jones, &

Hull, 2004). For example, a Quebec study that used language spoken at

home as an index of acculturation, found that women who spoke neither of

the ‘native’ languages (i.e., English or French) at home were at twice the

risk for postnatal depression compared with those women who did (P.

Zelkowitz & Milet, 1995). Such research findings are noteworthy given that

only one of the 14 women initially participating in the first support group

nominated English as their primary (i.e., spoken at home) language, and 6

women required an interpreter during the evaluation assessments (this

information was not recorded for the subsequent groups). Moreover, it was

the women without fluent English speaking skills who did not appear to

make a noticeable improvement with regard to accessing support services

in the community.

Under the Government Settlement Program, any newly arrived

immigrant in Australia may be eligible for a range of settlement services,

such as assistance in accessing medical services (Gwatirisi, 2009). Despite

this, immigrants and refugees continue to face challenges, such as health

providers and other service providers’ inadequate understanding of their

needs and challenges. This is particularly the case when it comes to mental

health service provision, with high costs, misunderstanding, stigma and

shame in addition to the cultural and language differences. An extensive

body of literature can be found on the barriers to mental health care

utilisation amongst refugees and immigrants (Wong et al., 2006).

Acknowledging all these issues (e.g., immigrant status as a risk

factor for depression, importance of social support to acculturation and

mental well-being, barriers to accessing mental health services), qualitative

techniques were applied to gather information on Sudanese mothers’

knowledge of perinatal mental health issues, the amount of support

39

Sudanese mothers believe is available for them in the Perth metropolitan

area, and their experiences whilst accessing services.

All Sudanese women living in the Perth metropolitan area who were

pregnant or had given birth in the last 3 years were eligible to participate in

the support group, being facilitated by Ishar and funded by the WAPMHU.

Twenty-six women completed full pre-group assessments, including an

interview, a demographic questionnaire and an EPDS. Seventeen of these

women completed post-group assessments and were thus included in

qualitative data analyses. Interview transcripts were thematically content-

analysed in nine sections - corresponding to the questions posed during the

interviews.

The expansion of support networks from informal sources, such as

family and friends, to health professionals, was a theme repeated during

interviews. Women participating in the group appeared to not only increase

their knowledge regarding alternative sources of support, but also became

more comfortable with the idea of accessing such supports if/when needed.

Women’s responses also indicated that their knowledge of perinatal mental

health issues had increased, that is, that mothers can become depressed or

anxious and what may cause these feelings. Moreover, women’s responses

post-group indicated that they knew talking to others and accessing support

was an important step to feeling better. Women also appeared to have an

increased awareness that emotional health is important for the sake of the

mother as well as the child.

The changes in knowledge and attitudes were particularly apparent in

Group 1 compared to Group 2, indicating that the greatest improvements

occurred where levels of knowledge and comfort with service provision were

lower to begin with. However, the support and information was also well-

received in Group 2, with some increases in knowledge, and a greater

sense of being able to help themselves using the knowledge and social

networks gained through the service.

As stated previously, eligibility for participation in the perinatal mental

health support group was based upon Sudanese ethnicity and motherhood

status, irrespective of the presence or absence of depressive

symptomatology. In light of this, the level of depressive symptomatology

40

found pre and post-group in this sample of Sudanese mothers is

concerning.

Quantitative data collected via the EPDS was used to assess

changes in depressive symptomatology over the course of the 8-week

group term. The majority of the participants had a score indicating an

elevated risk of depression: 42 of the 47 Sudanese women (89%) that

completed the support group and assessments scored above cut-off (≥10)

on the EPDS pre-group. Including the EPDS scores of women who only

completed the pre-group questionnaires, 88% of the Sudanese women had

EPDS scores above the cut-off. Compared to a prevalence rate of 13%

established via a meta-analysis of 59 studies with nearly 13,000 participants

(O'Hara & Swain, 1996), these results suggest that the prevalence of

perinatal depression may be significantly higher in this population of

childbearing women. Although prevalence estimates have varied from 3% to

30%, depending on the period of time under consideration (i.e., symptoms

in the past week or past year), the length of postnatal follow-up

assessments, and the type of measurement being utilised (Pope, et al.,

2000) the difference with this childbearing population is still significant.

If this finding is then compared to prevalence rates obtained via

research with immigrant populations, the difference is still present, although

not quite as large. It appears that the majority of perinatal mental health

research conducted with immigrant populations has been Canadian. For

example, in a community sample of pregnant immigrant women in Canada,

42% indicated high risk of depression on the EPDS (Zelkowitz, Schinazi,

Katofsky, Saucier, & Valenzuela, 2004). Furthermore, women who had lived

in Canada for less than 5 years were found to be at greatest risk. In another

large sample (N = 1250) of pregnant Canadian women assessed for

depressive symptomatolgy using the EPDS, 15% of the immigrant women

in the sample scored in the high risk range compared to 7% of women

born in Canada (Sword, Watt, & Krueger, 2006).

Postpartum research on the mental health of immigrant women is just

as scarce as that available during pregnancy, with Canada once again

being the site of the majority of study. Nevertheless, as found with

depression during pregnancy, women born outside of Canada or having

41

lived in Canada for less than 5 years have been found to be at greatest risk

of postnatal depression (Dennis & Ross, 2006).

A longitudinal study in Canada (Zelkowitz, et al., 2008) investigated

stability and change in postnatal depression in 106 childbearing immigrant

women. They reported that 37.7% of these immigrant women scored in the

high risk category of the EPDS at 2 months postpartum. Based on a

comparison to the prevalence rate of 3.4% found in a sample of over 1500

postpartum women from the same catchment area, the authors concluded

that their results “provide further evidence that immigrant women are at risk

for postpartum depression” (Zelkowitz, et al., 2008, p. 8).

The current findings (i.e., 88% scoring ≥10 on the EPDS) add support

to the Canadian research, and indicate that Sudanese immigrant women

giving birth in Australia may be at high risk of depression. Given the

traumatic and complex case histories of the women participating in this

support group, these results are not completely unexpected.

Although only one psychological study has been conducted in post-

war Southern Sudan to date (Roberts, et al., 2009), its results put the

current findings into context. The objective of this collaborative study

conducted by researchers from the Department of Public Health and Policy,

London, and the Ministry of Health, Southern Sudan, was to measure PTSD

and depression in the town of Juba, Southern Sudan and to investigate the

association of demographic, displacement, and past and recent trauma

exposure variables on PTSD and depression (Roberts, et al., 2009).

The results showed a strong association of gender on mental distress, with

women more than twice as likely as men to exhibit symptoms of PTSD

(odds ratio 2.01) and depression (odds ratio 2.37). The PTSD rates were

42.5% and the depression rates were 58.7% amongst women (Roberts, et

al., 2009).

With 92.4% of respondents experiencing one or more of the 16

trauma events covered in the Harvard Trauma Questionnaire used in the

study, and trauma being closely associated with psychological distress, it is

not surprising that prevalence of these disorders in post-war Sudan is so

high. Women and refugees were found to be two of four subgroups who

were significantly more likely to have experienced eight or more traumatic

events. For instance, 63% of women respondents had ever lacked food or

42

water, 48% had been seriously ill without access to medical care, 44% had

witnessed the murder of family or friends, 48% had directly experienced a

combat situation, 22% had been forcefully separated from family and

friends, 15% beaten or tortured, 10% imprisoned, and 8% raped.

Given the severity of these traumas, it was noteworthy that being

forcefully separated from family was one of three trauma events with

significant associations with PTSD and depression. For the women

participating in this perinatal mental health support group, who had recently

given birth and are now raising their children in a foreign land, away from

family, the impact of this separation on their mental health was tangible, with

many participants speaking of missing family and feeling lonely.

Acknowledging that there are no quick fixes that will address the level

of trauma and complex life histories that these women present with, the

current evaluation results do indicate that the key performance indicators for

this project are being met. Local Sudanese women are attending the

support groups and there was an increase in level of perceived

psychosocial support by the participants, with support networks expanding

from family and friends to incorporate health professional and community

services. The participants’ awareness of perinatal mental health issues had

improved post-group and the importance of accessing services if/when

needed for the sake of themselves and their children was apparent.

Moreover, the participants indicated that they would be more comfortable

asking for help from a range of health professionals post-group.

There was a statistically significant decrease in average depressive

symptomatology scores from pre to post-group. In addition, the percentage

of participants scoring above the cut-off on the EPDS reduced from 89%

pre-group to 42% post-group. This is a very positive change, particularly

given the complex case histories of the participants and relatively short

provision of service (one 8-week term). With continued group attendance

and the associated improvements in mental health knowledge and

awareness of support services available it is hoped that further

improvements would be made by women.

43

Recommendations The number of women reporting depressive symptomatology in the

evaluation sample was higher than both the general population and that

reported in the literature for immigrant mothers, and confirms the need for

perinatal mental health strategies for Sudanese mothers in WA.

The evaluation results indicate that there has been a significant and

meaningful change for participants. The social support, information and

exposure to community services afforded by this group appear to have had

a positive effect and can be built upon for future and extended benefits.

Depressive symptomatology decreased significantly from pre to post-group.

Based on the results of this evaluation, continued funding of the service has

been recommended.

44

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