Abstract of thesis entitled. "Evidence-based antepartum psychoeducational interventions for preventing. postpartum depression among primiparous women

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1 Abstract of thesis entitled "Evidence-based antepartum psychoeducational interventions for preventing postpartum depression among primiparous women Submitted by LEE Ka-yee for the degree of Master of Nursing at The University of Hong Kong in Aug 2015 Background: Postpartum Depression (PPD) is a worldwide public health problem which significantly affecting the quality of life and social functioning of the mother, the intimate partner relationships and their offspring's life-long development as a whole. In Hong Kong, there are 13.5 % Chinese women suffering from PPD in the first three months after delivery (Lee, Yip, Chiu, Leung & Chung, 2001). In this translational nursing research, an evidence-based guideline is developed for primary prevention of PPD for pregnant women attending MCHCs

2 Purpose: This study aims at identifying the best evidence of antepartum psychoeducation to formulate an evidence-based practice (EBP) guideline which can be implemented in MCHCs as a routine primary intervention of antenatal mental health care service. The goal is to reduce the risk of postnatal women to evolve from PPD. Method: Literature review was performed by searching in four database: PubMed, PsycINFO, CINAHL Plus (EBSCOhost) and Cochrane Library. A systematic review was done on group psychoeducation program targeted at pregnant women which deserved implementation in primary health-care setting in Hong Kong. Quality appraisal of the studies were assessed with the checklists of critical appraisal of Scottish Intercollegiate Guidelines Network (SIGN). Results: Six articles were selected of which five studies were RCT and one study was pretest-posttest, control group quasi-experimental design. By discussion on the transferability, feasibility and cost/benefit ratio, the innovation is considered as clinically applicable with ample implementation potential. The EBP guideline was refined and communication plan, pilot test and evaluation plan were drawn to ensure smooth implementation of the proposed EBP into current health care practice.

3 Conclusion: The evidence-based antepartum psychoeducational interventions for preventing PPD is potentially fit for implementation in MCHCs in Hong Kong. This dissertation contribute an evidence-based protocol to health care professionals for further betterment of health care services.

4 Evidence-based antepartum psychoeducational interventions for preventing postpartum depression among primiparous women by LEE Ka-yee BNurs. (C.U.H.K.); RN A thesis submitted in partial fulfillment of the requirements for the Degree of Master of Nursing at The University of Hong Kong Aug 2015

5 Declaration I declare that this dissertation represents my own work, except where due acknowledgement is made, and that is has not been previously included in a thesis dissertation or report submitted to this University or to any other institution for a degree, diploma or other qualifications. Signed... LEE Ka-yee i

6 Acknowledgements I would like to express my deepest gratitude to my supervisor, Dr. William Li, for his brilliant guidance and courteous support to my dissertation. His benevolence of guiding students and his superb advice are highly appreciated. Also, I want to express my gratitude to all teaching staff of the Master of Nursing Program. Their expert knowledge enriched my horizon of nursing profession over an extensive understanding of health aspect. I want to further express my gratitude to my classmates, we support with each other and work happily in these two years. Also, I want to thanks to my past and existing colleague, for their gentleness and assistance towards my work and study. Last but not least, I would like to express my warmest thanks to my family and my husband, Ziv, who always stands beside me and be patient with me. Without his support, I cannot get through the hardship over the past two years. The accomplishment of this dissertation is creditable to his selfless dedication all along. ii

7 Table of Contents Declaration...i Acknowledgements...ii Table of Contents...iii Abbreviations and symbols...iv Lists of Appendices...v Chapter 1 Introduction 1.1 Background Significance Significant to patients Significant to healthcare professionals Affirming the Need Local Setting Current Practice Description of Clinical Issue Potential Innovation Objective and Research Question... 7 Chapter 2 Critical Appraisal 2.1 Search and Appraisal Strategies Identification of Studies Data Extraction Appraisal Strategies iii

8 2.2 Results Date of Search Table of Evidence Study Characteristics Methodology Issue Summary and Synthesis Chapter 3 Implementation Potential 3.1 Transferability Target Setting Target Population Philosophy of Care Capacity of Beneficence Timeframe of Implementation and Evaluation Feasibility Freedom of Termination Interference of Current Operation Staff Training Equipment and Facilities Consensus Among Staff Organization Climate External Support or Resources Potential of Clinical Evaluation Cost/Benefit Ratio of the Innovation Innovation Risk Potential Benefits iii

9 3.3.3 Costs for the Innovation Costs of Not Implementing the Innovation Cost/benefit Ratio Chapter 4 Implementation plan 4.1 Communication Plan Potential Stakeholders Concerns from Stakeholders Communication Process Sustain and Guide the Change Pilot Testing Chapter 5 Evaluation Plan 5.1 Identification of Outcomes Patient Outcomes Healthcare Provider Outcomes System Outcomes Time for Taking Measurements Nature of Clients Determining the Number of Clients Data Analysis Basics for an Effective Change of Practice Chapter 6 Conclusion Appendices 45 References. 94 iii

10 Abbreviations and Symbols Abbreviations N.S. AN PN PPD PND APD EPDS BDI-II SCID SCID- I/P PHQ LQ CES-D RCT MCHC FHS HA Non-significant Antenatal Postnatal Postpartum depression Postnatal depression Antepartum depression Edinburgh Postnatal Depression Scale Beck Depression Inventory Structured Clinical Interview SCID-TR Axis I Disorders Patient Health Questionnaire Leverton Questionnaire Centre for Epidemiologic Studies- Depression Scale Randomized controlled trial Maternal and Child Health Centre Family Health Service Hospital Authority Symbols (I) (C) Intervention group Control group iv

11 List of Appendices Appendix A Table of evidence 45 Appendix B Summary of table of evidence Appendix C Methodology Checklist: Randomized Controlled Trials 55 Appendix D Quality assessment checklist 57 Appendix E Summary of quality assessment checklist 63 Appendix F SIGN grading system 64 Appendix G Search history 66 Appendix H Yearly statistics in 2013 from the Department of Health 67 Appendix I Approving letter 69 Appendix J Timeframe 70 Appendix K Evidence-based antpartum psychoeducation program guideline Appendix L Content of 'Happy mothering' antepartum psychoeducation program Appendix M PND Management services costs in Appendix N Estimation of capacity of innovation to be implemented in MCHCs. 83 Appendix O Estimated set-up cost of the innovation. 84 Appendix P Estimated staff-hour and cost for core team of the innovation. 86 Appendix Q Cost-benefit ratio of the innovation. 87 Appendix R Communication plan.. 88 Appendix S Pilot test of antepartum psychoeducation 'Happy mothering' evaluation form.. 89 Appendix T Edinburgh Postnatal Depression Scale (EPDS) Questionnaire (Modified from screening form of MCHCs) Appendix U Staff survey on antepartum psychoeducational interventions for preventing postpartum depression among primiparous women v

12 Running head: EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS CHAPTER 1 INTRODUCTION 1.1 Background Postpartum depression (PPD) or Postnatal Depression (PND) is a major unipolar depressive disorder which happens within four to six weeks after giving birth and lasting for at least two consecutive weeks (American Psychiatric Association, 2000). According to the World Health Organization, major depression, including postpartum depression, will be the second highest worldwide cause of death and disability by 2020 (Leung, Lee, Chiang, Lam, Yung & Wong, 2013). In a meta- analysis of 28 studies across diverse countries and cultures with different ethnicities including Caucasian, Hispanic, Chinese and Japanese, it is found that 19.2% of women were affected by postnatal depression (Gavin, Gaynes, Lohu, Melrzer- Brody, Gartlehner & Swinson, 2005). Among Asian countries, % of women were affected by PND including Hong Kong. This study also showed that 13.5 % of Hong Kong Chinese women were reported to suffer from postpartum depression in the first three months after delivery (Lee, Yip, Chiu, Leung & Chung, 2001). Another prospective study of diagnostic interview among Hong Kong Chinese women has identified about 6% of postpartum women suffer from major depression, 5% with minor depression during first postnatal month and 19.8% at the sixth postnatal week based on the Edinburgh Postnatal Depression Scale (EPDS) scores of 13 or above (Leung, Martinson & Arthur, 2005). 1

13 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS PPD does not only affect mothers' well- being, it also causes disruptive effect of poor partner relationships as it is associated with feelings of despair and hopelessness together with co- morbid anxiety frequently (Milgrom et al., 2010). It is linked with elevated rates of depression in their partners as well (Matthey, Kavanagh, Howie, Barnett & Charles, 2002). Furthermore, maternal depression is associated with poor quality parenting behavior which ultimately affect mental health outcomes in the offspring. Undesirable offspring mental outcomes are more prominent when there is prolonged maternal depression. Negative infant behavioral or temperamental features can be persisted into toddlerhood and the pre- adolescent years. The adverse consequences do not only exert immediate impact on birth outcomes, but also long- term effects on the health of mothers, infants and the family as a whole (Liou et al., 2013; Ngai & Chan, 2010). As PPD is such a costly public health problem that cannot be ignored, health care professionals should pay more attentions to the psychological needs of the pregnant women and provide sufficient information and education about their mental well- being. More primary preventive measures should be adopted earlier to alleviate the seriousness of distress for women during pregnancy (Liou et al., 2013). 1.2 Significance Significant to patients There is growing evidence proving that PPD is significantly affecting the quality of life and social functioning of the mother and the mother- child relationship, as well as the child s 2

14 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS cognitive, behavioral and emotional development (Leung et al., 2013; Siu, Leung, Ip, Hung & Hara, 2012; Milgrom, Schembri, Ericksen, Ross & Gemmill, 2010; Liou, Wang & Cheng, 2013). Such high prevalence mental health problems follow that with plenty of undesirable outcomes to mothers and the new-born child well worth a routine primary preventive intervention to reduce the chance of subsequent development of PPD for women in Hong Kong. However, current program for antenatal (AN) women may not adequately prepare mothers to transit into parenthood. Women may receive lots of opinion from their social circumstances which is hard for them to differentiate whether the information is evidence- based (Rowe & Fisher, 2010). So it is crucial to provide adequate health services to address their worries or problems during their pregnant period. Moreover, it is more feasible to implement the interventions before child birth as mother will become busy and not able to show up to get the intervention Significant to Healthcare Professionals From a public health perspective, the establishment of group antenatal psychoeducation as universal preventive strategies can mildly modify risk factors in a larger populations, which is much beneficial to treat individuals who are symptomatic (Rowe & Fisher, 2010). Compared with other psychological interventions, psychoeducation is less intensive with lower financial demand as an initial intervention. It can be exercised extensively as a general primary intervention in different health care settings. As psychoeducation is simple which is 3

15 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS appropriate to be implemented among non-psychiatric conditions, health care providers are not required to receive prolonged and extensive training before they are qualified to deliver the intervention (Colom, 2011). Also, the intervention do not involve complex collaborative work of multidisciplinary professional. So it is relatively simple and flexible to be implemented in the existing health care system. 1.3 Affirming the Need Local Setting In Hong Kong, the Comprehensive Child Development Service (CCDS) has been launched in 2005 (Gender Mainstreaming, 2013) and was operated collaboratively with the Hospital Authority (HA) and Maternal and Child Health Centre (MCHC) to provide services to child and families with indications. For example, at risk pregnant women and mothers with history of PPD were two large group of people with indication to be recruited into CCDS Current Practice Different MCHCs within their network will have their own logistic about the AN check-up services. For example, in Hong Kong East cluster, new cases of pregnant women will first be registered in the hospital for routine check-up until second trimester. Cases will continue follow up in the MCHC until term pregnant. Regardless of the deviation of practice between different clusters, high risk group of pregnant women including teenage pregnancy, drug abuser, history of psychiatric illness and mood problem cases once being identified, they 4

16 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS will be recruited in CCDS for appropriate intensive service referral such as follow up with clinical psychologist or medical social worker for either supportive, monitoring or treatment purpose according to their needs (Siu, Chow, Kwok, Koo & Poon, 2010) Description of Clinical Issue With the aim at early identification and prompt interventions to prevent PPD, high- risk groups are recruited into CCDS during the AN period. However, present AN health care system in MCHCs seemed overlooking the less risky group as the check- up service is limited to physical check-up only. Women's mental health was never a focus until the suspicious cases were screened out in postnatal six weeks. According to the yearly statistics in 2013 from the Department of Health, there were 6734 cases with suspected postnatal depression (PND), which consisted of 14.6% of total cases in current routine PND screening with EPDS and clinical interview coverage. Permission letter of data retrieval from the Department of Health is included in appendix I. The alarming result revealed that those pregnant women who are not being identified in AN period also consist of hidden factors which are the predictor of risk of PPD. Risk factors are multidimensional and complex with the context of socioeconomic factors such as low income, young age, marital status, low educational level and housing problem (Milgrom et al., 2010; Lau & Wong, 2007); psychosocial factors such as stress level and social support (Ngai & Chan, 2010); obstetric factors such as unwanted pregnancy, previous perinatal loss 5

17 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS (Lau & Wong, 2007) and mother s self- esteem (Matthey et al., 2002; Lee, Lam, Lay, Chong, Chui& Fong, 2007); biological and hereditary factors such as history of personal or family psychiatric problems (Lau & Wong, 2007); interpersonal relationship problem such as marital conflicts (Lau & Wong, 2007) and dissatisfied relationship with mother-in-law, the culturally- specific phenomenon among Chinese women (Siu et al., 2012; Lau & Wong, 2007). Those risks factors become psychological distress experienced by pregnant women and presented in form of maternal stress, depressive symptoms and anxiety (Lee et al., 2007; Lau, Wong & Chan, 2010). Studies showed that pregnancy involves substantial physiological, psychological and interpersonal changes and their emotion can be ranged from happiness and joy to a considerable burden because of physical strain and psychosocial disorders (Sieber, Germann, Barbir & Ehlert, 2006). Even a physically and psychologically healthy pregnant women will encounter natural progress of emotional changes Potential Innovation MCHCs are the major primary healthcare services delivery channel in the community. It is a golden period to provide primary and early interventions for perinatal women as they have frequent contact with this health services. With the goal of transferring knowledge and acquiring skills individually or in groups for preventive measures in primary health care units such as MCHCs (Van Daele, Hermans, Van Audenhove & Van den Bergh, 2011), psychoeducation was a training which empowered patients with the aim of promoting 6

18 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS awareness and proactivity so that they could cope and live with a chronic condition and changed behaviors and attitudes in response to the condition (Colom, 2011). No conclusive evidence was available to point out that one approach was superior to the other (Gao, et al., 2010). Study of Elliott et al. (1988) suggested that commencing of psychoeducation during pregnancy and continuing until six months postpartum was effective to reduce the prevalence of PPD in first time mother Objective and Research Question Research Objectives: 1. To determine the effect of group antenatal psychoeducational intervention in reducing risk of developing postpartum depression in primiparous women. 2. To develop an evidence-based guideline to establish a routine primary intervention of antenatal mental health care service in Hong Kong MCHCs. Research Questions: Does an evidence-based group antenatal psychoeducational intervention more effective in preventing postpartum depression in primiparious women than standard childbirth education and routine antenatal care? 7

19 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS CHAPTER 2 CRITICAL APPRAISAL 2.1 Search and Appraisal Strategies Identification of Studies To evaluate empirical evidence for translation of evidence-based practice to address current clinical issue, a systematic review was conducted focusing on group antenatal psychoeducational intervention which were potentially feasible to be implemented in primary health-care setting in Hong Kong. Six studies were included. Details concerning patient characteristics, intervention content, number of sessions, control group for comparison, follow-up interval, outcome measures and effect size were analyzed and compared. Methodology was reviewed for quality assessment of different studies. Literature review was done by searching in four database: PubMed, PsycINFO, CINAHL Plus (EBSCO host) and Cochrane Library. Search terms were divided into three categories: target group, intervention, outcome. The word 'or' was used for extensive searching between keywords with similar meaning within each category as different articles may use different wordings. 'And' was used to link up three categories to narrow down the literature search suitable for the selected topic. First group of keywords to identify the target group were 'pregnant women', 'primi*', 'pregnancy' and 'childbearing women'. Second group of keywords to identified the 8

20 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS intervention were 'group therapy', 'psychoeducation', 'prevent*' and 'ante* intervention'. Third group of keywords to identify the outcome measure were 'postpartum depression' and 'postnatal depression'. Initially, the search strategies generated a total of 1441 results. To select recent studies, searching was limited to 1 January 2004 until the search date for four databases and yielded 1147 results. Searching was restricted to RCT, which yielded 225 results. After screening of title and abstract, by consideration of the inclusion and exclusion criteria as stated below, 40 studies were located. 5 studies were determined as suitable for systematic review. Manual screening of reference list of the identified articles was done and one study of pretest-posttest, control group quasi-experimental design was identified. Search summary was attached in Appendix G. Inclusion criteria: (1) Primary source of studies (2) Pregnant women with routine check up in their designated institution (3) Antenatal psychoeducation for prevention of postpartum depression (4) Preventive education strategies in group format. Exclusion criteria: (1) Meta-analyses or reviews (2) Studies specified to very high risk pregnant women 9

21 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS (3) Substance abused pregnant women (4) Studies which included women who were diagnosed of postpartum depression and on treatment (5) Antenatal preventive strategies aimed as prevention of antepartum depression Data Extraction There were six studies being identified in databases. Data were extracted and categorized into several columns in a table of evidence, which were attached in Appendix A. Component of the table was modified according to the completed checklist of Scottish Intercollegiate Guidelines Network (2014b) Appraisal Strategies Quality appraisal of the studies were assessed with the checklists of critical appraisal of Scottish Intercollegiate Guidelines Network (SIGN) (2014a) attached in Appendix C. As five studies were RCT and one study was pretest-posttest, control group quasi-experimental design, methodology checklist of randomized controlled trials was used for all six studies (Appendix D). The checklist content covered two parts: internal validity and overall assessment of the study. For internal validity, questions concerning whether there was a clearly focused question, the issue of randomization, concealment, blinding, a similar baseline data between groups, a standard and reliable measurement tool, an acceptable attrition rate, application of intention to treat analysis and a comparable results from multiple 10

22 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS site of measurement were mentioned. For the study with quasi-experimental design, items concerning randomization, concealment and blinding were omitted (SIGN, 2014d). The criterion to address the question were Yes, No, Can t say and Does not apply. Based on the criterion, six studies would be determined as 1++, 1+, 1-2++, 2+ or 2- according to the level of evidence of SIGN grading system (2014c) in Appendix F. A summary of SIGN assessment checklist of six studies was attached in Appendix E. 2.2 Results Date of Search The electronic searching of PubMed, PsycINFO, CINAHL Plus (EBSCOhost) was performed on 2 March 2014 and that of Cochrane Library was done on 10 March Table of Evidence Content of studies were presented with table of evidence including the study type, number of subject to be recruited, patient characteristics, descriptions of intervention group, descriptions of comparison group, length of follow-up, outcome measures and effect size. To facilitate the ease of comparison between different studies, Appendix B was attached for reference Study Characteristics Six studies were selected, in which five were RCT (Gao, Chan, Li, Chen & Hao, 2010; Lara, Navarro, & Navarrete, 2009; Leung & Lam, 2012; Mao, Li, Chiu, Chan &Chen, 2012; 11

23 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS Kozinszky et al., 2012) and one was pretest-posttest, control group quasi-experimental study (Ngai, Chan & Ip, 2009). Two studies were conducted in China (Gao et al., 2010; Mao et al., 2012), two studies in Hong Kong (Leung et al., 2012; Ngai et al., 2009), one study in Mexico (Lara et al., 2009) and one study in South-east Hungary (Kozinszky et al., 2012) Methodology Issue All six studies had stated the focused question clearly. They were all investigation of the effectiveness of antenatal group training program containing educational and psychological component in the prevention of PPD. For the five RCT articles, randomization method were clearly addressed. Studies of Kozinszky et al. (2012), Mao et al. (2012) and Leung et al. (2012) randomized subjects by using computer software and that of Leung et al. (2012) was permuted block randomization in subsets of 4 without stratification. Lara et al. (2009) was also blocked randomization which were sequentially opened whenever a group started. Gao et al. (2010) performed randomization by table of random numbers. Four out of five RCT studies did not address the concealment method. Only Leung et al. (2012) stated that serially numbered opaque sealed envelopes were used and the random sequences of intervention and control group were put. For the blinding design of treatment allocation, it was difficult to blind participants as intervention were educationally based. 12

24 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS Participants easily noticed that which group they are designated to. Study of Leung et al. (2012) stated that it was impossible to blind patients, but an independent researcher for collection of baseline data and follow-up measures was blinded. Gao et al. (2010) performed single blinding as data collection and data analysis was conducted by a research assistant who was blinded to the study. Mao et al. (2012) stated that researcher was blinded to the subject who proceed to Structured Clinical Interview, but did not mention whether researchers were blinded to group allocation. Kozinszky et al. (2012) achieved double blinding by stating that participants know that they were allocated to two groups but unaware of the difference and interventionist in control group were blinded. Outcome data collection by assessors were blinded to group allocation. Only the study of Lara et al. (2009) did not address blinding issue. To ensure the baseline measures of the control and intervention group were comparable, all six studies applied statistical analysis to both groups to detect any significant differences between two groups such as Chi-square analysis and independent t-tests in the studies of Gao et al. (2010), Mao et al. (2012), Lara et al. (2009) and Ngai et al. (2009); Chisquare test in the study of Kozinszky et al. (2011); 2-tailed t tests for continuous data and Chi-square test and 2-tailed Fisher exact tests for categorical data in the study of Leung et al. (2012). Significant variables were computed as covariates to control pretreatment differences. All six studies did not offer additional treatment other than the interventions to be 13

25 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS investigated. Several measurement tools were used in different studies for outcome measures including EPDS, PHQ, LQ, BDI-II, SCID and SCID-I/P. EPDS was a 10-item instrument and was validated on pregnant women and postnatal women to assess the presence of depressive symptoms (Cox, Holden & Sagovsky, 1987). The Chinese version was validated by Guo et al. (1993) and Lee et al. (1998). PHQ was a 9-item depression module with Chinese version with satisfactory validity and reliability (Yeung et al., 2008). LQ was a 24-item questionnaire for the detection of PPD with sensitivity of 88% and a specificity of 94.4% (Csatordai et al., 2009). BDI-II was a 21- item self- report instrument that was validated by Gaynes et al. (2005). Both SCID and SCID-I/P were mood disorder module based on the Diagnostic and Statistical Manual of Manual Disorders (DSM-IV) and Diagnostic and Statistical Manual of Manual Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria, which was a golden standard to define clinical depression among postnatal women across countries and cultures (Gorman et al., 2004). Attrition rate ranged from 2.4% to 63.9%. Four studies got a drop-out rate within 10% (Gao et al., 2010; Leung et al., 2012; Mao et al., 2012; Kozinszky et al., 2012) and two studies got over 20% of drop-out rate (Lara et al., 2009; Ngai et al., 2009). All studies applied intention to treat for data analysis. 14

26 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS For the overall assessment of studies, four studies were ranked as acceptable (Gao et al., 2010; Mao et al., 2012; Lara et al., 2009; Ngai et al., 2009) and two studies was ranked as high quality (Kozinszky et al., 2012; Leung et al., 2012).The result of all studies were considered of directly related to its study intervention, which is compatible with other health care system in general. After the quality assessment of all six studies, they were assigned with a scoring according to the SIGN grading system (2014c) which represented their level of evidence. Study of Gao et al. (2010), Lara et al. (2009), Mao et al. (2012) and Ngai et al. (2009) got a score of '1+' and that of Leung et al. (2012) and Kozinszky et al. (2012) got the score of '1++'.' 2.3 Summary and Synthesis Number of subject. Sample size ranged from 156 to Three studies recruited between 150 and 200 subjects (Leung et al., 2012; Gao et al., 2010; Ngai et al., 2009). Two studies recruited between 200 and 400 subjects (Mao et al., 2012; Lara et al., 2009). Only one study recruited more than 1000 subjects in 62 antenatal centers (Kozinszky et al., 2012). Patient characteristics. All studies showed the mean age and gestational age of pregnant women. Mean age was between to 31.3 while gestational age covered across all three trimester from 12 week to 35 week antenatal. Five studies addressed the portion of primipara in which three studies with 100% primiparous women (Gao et al., 2010; Mao et al., 2012; Ngai et al., 2009). Five studies set the exclusion criteria of women with past psychiatric 15

27 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS history (Leung et al., 2012; Gao et al., 2010; Mao et al., 2012; Kozinszky et al., 2012; Ngai et al., 2009), while only one study recruited subject at risk of depression by using the screening tool of CES-D of 16 or with history of depression (Lara et al., 2009). Three studies provided information about the sociodemographic characteristics. One with majority of middle class women (Gao et al., 2010); one with low income women (Lara et al., 2009); one with 2/3 participants of more than 12 years education (Mao et al., 2012). Intervention. All six studies delivered group psychoeducation to the experimental group. The contents are surrounding stress management, conflict settling, effective communication, support resources identification and infant caring, with variations of content focus subjected to different studies. One study provided one extra phone follow up during PN period within 2 weeks (Gao et al., 2010). One study added with one individual counseling session besides group session (Mao et al., 2012). The number of group session was 2-8 with duration of 1-3 hours for each lesson for all six studies. Father was involved in two studies (Mao et al., 2012; Kozinszky et al., 2012). Psychoeducation programme were based on the concept of IPT (Gao et al, 2010; Leung et al, 2012), CBT (Mao et al., 2012), both component of IPT and CBT (Kozinszky et al., 2012), learned resourcefulness (Ngai et al., 2009) or content containing educational and psychological component (Lara et al., 2009). Four studies designed the intervention with cultural issue, so the intervention is culturally sensitive to its research site (Gao et al., 2010; Lara et al, 2009; Leung et al., 2012; Mao et al., 2012). Half of 16

28 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS the studies involved trained nurse as interventionist (Gao et al., 2010; Leung et al., 2012; Ngai et al., 2009). Two studies involved Obstetrican and Psychiatrics (Maoet al., 2012; Kozinszky et al., 2012) and one study did not specify the post of trained professionals (Lara et al., 2009). Comparison. Two studies provided placebo intervention for the control group (Mao et al., 2012; Kozinszky et al., 2012). For the other four studies, participants in intervention group also received usual care as that of control group provided by their institutions (Gao et al., 2010; Lara et al., 2009; Leung et al., 2012; Ngai et al., 2009). Follow up. Follow up interval of 6 studies had similar pattern. Variation of measurement interval between studies could be summarized as four points: before intervention, immediately after intervention, 6-8 weeks PN, 4-6 months PN. Both studies from Lara et al. (2009) and Ngai et al. (2009) had long term follow-up at 4-6 months and 6 months PN respectively, while the other four studies measured the outcome in short term up to 6 weeks (Gao et al., 2010; Mao et al., 2012) and 6-8 weeks PN (Leung et al., 2012; Kozinszky et al., 2012). Studies of Leung et al. (2012), Mao et al. (2012) and Ngai et al. (2009) had immediate measurement after intervention while the other did not. Outcome measures and effect size. Depressive symptoms were presented in terms of within group or between group differences. EPDS was the most common tool among all studies in which half of them had applied it as pre and post measurement of depressive 17

29 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS symptoms of the intervention (Gao et al., 2010; Leung et al., 2012; Ngai et al., 2009). For Gao et al. (2010), within intervention group mean change of score decreased from 8.15 to 6.59 and that of control group increased from 7.93 to 8.87; between group, there was significant difference of mean score (t= -3.76, p= 0.000) as well as mean change of score (t= , p= 0.000). For Leung et al. (2012), data was analyzed separately in form of two groups of participants who scored EPDS 12 and >12 in pre- test. It showed that mean change of EPDS within and between groups for that of EPDS 12 was insignificant. For participants of EPDS>12, significant mean decrease of 2.36 EPDS score (p= 0.025) within intervention group at the end of intervention and mean decrease of 4.79 at 6-8 weeks PN (p<0.001) when comparing with baseline, but insignificant between group mean score difference. For Ngai et al. (2009), there was continuous decrease of mean score over times in long term significantly within intervention group from 7.2 to 2.8 at 6 months PN (F(1, 180)= 6.58, p= 0.01). For the other three studies, some tools were applied as measuring depressive symptoms and diagnostic tools to make diagnose of postnatal depression. For Lara et al. (2009), there were significantly fewer depression cases in intervention group at 6 weeks and 4-6 months PN, while there was non-significant between group mean changes of depressive symptom by using BDI-II. For Mao et al. (2012), by using PHQ, mean score of intervention group and control group were 5.45 and 7.23 respectively at 6 weeks PN and the mean change of score between group is significant (t=3.34, p<0.01). Both Mao et al. (2012) and Kozinszky et al. 18

30 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS (2012) showed significantly fewer people being diagnosed as PPD at 6 weeks and 6-8 weeks PN. For Mao et al. (2012), subject with PPD were 2.7% in intervention group and 9.3% in control group (x 2 = 4.35, p<0.05). For Kozinszky et al. (2012), the result were 12.7% and 17.5% respectively (x 2, p<0.01; OR: 0.68). To summarize, six studies delivered the intervention in group format based on different theoretical framework with similar component. Psychoeducation interventions with educational purpose by information giving and psychological purpose by reducing risk of developing depressive symptoms in form of role playing, experiencing sharing, brain storming and skills learning are shown. For the studies of Gao et al. (2010) and Leung et al. (2012), interventions are based on IPT which covered the content of development of skills and strategies for relationship and conflict management for better communication, clarification of misconception in role expectation, identification of problems and develop problem-solving skills and alternative strategies. Although they had the same approach and used same measurement tool for depressive symptoms, the study of Gao et al. (2010) yielded a more effective EPDS change of score at 6 week PN. It may be due to the boostering effect of the telephone follow-up at PN within 2 weeks in additional to the group session, which could explore new concern after child birth and reinforce learned skills. Thus the intervention effect could be sustained. Lara et al. (2009) got the highest attrition rate of 63.9%. Although double amount of subjects were recruited in the intervention group to compensate attrition, 19

31 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS and measures such as provision of free child care service in study venue, offering of transportation allowances and phone reminder to participants for attending sessions and follow- up interviews, subject drop-out rate was still high and weakened the design. It was obviously attributed to the number of sessions of the study design. Eight sessions were too much and it was difficult for participants to finish even 4 sessions of the minimum requirement. It is more appropriate to limit the intervention session to two to four sessions as suggested in the remaining five studies with less attrition rate. To facilitate patient s attendance, intervention sessions can be arranged at the end of routine antenatal childbirth education as stated in the studies of Gao et al. (2010) and Ngai et al. (2009), which got an acceptable attrition rate of 9.8% and 33% respectively. Both studies of Lara et al. (2012) and Mao et al. (2012) found that their interventions significantly reduced the incidence of PPD, but only the study of Mao et al. (2012) showed a significant between group difference in reduction of depressive symptom. It may be due to the intervention effect of the self help book on depression for both group in the study of Lara et al. (2012). Nevertheless, it stated that the intervention had certain effect for women with high initial levels of depression and anxiety, but statistically insignificant between group. Although it is said that the introduction of cultural issue into the intervention in the studies of Gao et al. (2010), Lara et al. (2009), Leung et al.(2012) and Mao et al.(2012) limited the generalizability of results from the point of view of quality assessment, it is in fact an advantage for the setting in Hong Kong as both 20

32 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS studies of Gao et al. (2010) and Mao et al. (2012) were conducted in China and that of Leung et al. (2012) was conducted in Hong Kong. As five studies recruited subjects with the exclusion criteria of past psychiatric history (Leung et al., 2012; Gao et al., 2010; Mao et al., 2012; Kozinszky et al., 2012; Ngai et al., 2009) are of high quality with either effective change of depressive symptoms or reduction of cases of PPD, the target group fit the setting in MCHCs in Hong Kong as pregnant women whom receiving routine antenatal service were free of any psychiatric history. Moreover, group intervention is cost effective and feasible for first time mother in MCHCs. So the group antenatal psychoeducational intervention has the potential to be implemented as routine practice in Hong Kong. 21

33 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS CHAPTER 3 IMPLEMENTATION POTENTIAL In previous chapters, the needs of changing practice and significance to both patients and health care professionals have been discussed. Evidence extracted from six selected articles were performed with quality appraisal according to SIGN (2014a) (Appendix E). To bridge the gap between scientific evidence and clinical decision making, clinical applicability and flexibility were essential attributes to develop the guideline. In this chapter, implementation potential of the innovation will be analyzed from three approach: transferability, feasibility and cost/benefit ratio. 3.1 Transferability Target Setting The innovation will be implemented in 24 out of 31 MCHCs (those without AN service and located in outlying islands are excluded), which encompass different service sessions providing comprehensive health promotion and disease prevention for children and women within valid age range (Department of Health, 2006a). Since MCHCs is a government organization providing primary care service to the public, it is an appropriate platform to deliver preventive interventions whenever clients get access to it. The AN psychoeducation class in the studies can be held during service session where groups of pregnant women were gathered together in every week for routine visit. Manpower varies with different MCHCs 22

34 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS with at least one doctor and 8 to 20 nurses were on duty. To facilitate fully utilization of manpower, non-midwife nurses whom were not assigned to share midwife duty can also become interventionist after training Target Population First time pregnant women is the target population of the innovation. To facilitate the ease of arrangement of the proposed program, first-time pregnant women with gestation age of 28 week will be recruited. As MCHCs operate antenatal shared-care programme in collaboration with the Obstetric Department of the HA in Hong Kong, pregnant women with obstetric complications or psychiatric history will have AN check-up in the hospital. Only those with uneventful pregnancy can receive AN service in MCHCs until term pregnancy. The selected studies demonstrated similarities between subjects in the studies and AN clients attending MCHCs mentioned above. Subject characteristics such as normal pregnancy (Gao et al, 2010; Mao et al, 2012; Ngai et al, 2009) and exclusion criteria of past psychiatric history for selecting participants (Gao et al, 2010; Leung et al, 2012; Mao et al, 2012; Kozinszky et al, 2012; Ngai et al, 2009) fit for that of AN client in MCHCs. Also, two studies were carried in Hong Kong (Leung et al, 2012; Ngai et al, 2009) and China (Gao et al, 2010; Mao et al, 2012) respectively, which shared similar culture and traditions with the target population. For the study of Leung et al. (2012), subjects were pregnant women of MCHCs in Hong Kong, which tallied with the target populations in local setting. 23

35 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS Philosophy of Care To lead the community in promoting the health and well-being of children, women and families in Hong Kong is the vision for Family Health Service (FHS) (Department of Health, 2006b). The organization supports using evidence-based strategies to build up a continuous, quality and cost- effective service to empower the communities on health improvement. As mentioned in chapter one (background), PPD imposed negative impact on child development, mother s psychological well-being and intimate partner relationship. So the implementation of an evidence-based guideline by medical professionals for pregnant women to prevent deleterious consequences on the families goes along with their philosophy of care Capacity of Beneficence According to the yearly statistics in 2013 from the Department of Health, there were new registration cases in child health session which were indicated as first child in the family (Appendix H). As there are 70% of local pregnant women receiving antenatal and birthing care from the shared-cared program jointly operated by the Obstetric Department of the HA and the MCHCs (Family Health Service, 2013), it is estimated that around cases approaching MCHCs annually. Despite of those cases already be defined as high-risk which were followed by hospitals under the HA throughout whole pregnancy period, the potential population is already sufficiently large to be benefited from the AN psychoeducation innovation. 24

36 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS Timeframe of Implementation and Evaluation The set-up of psychoeducation program will be divided into 5 parts: preparation of the program, pilot test, program evaluation, staff training and full implementation. CCDS subject nurse (nurse in-charge of all issues of CCDS in their clinic) in pilot centre will become trainee and implement the program in pilot phase. Then nurses in different centres will receive training in phases to become AN psychoeducation programme provider. The 10-item EPDS will be used before, immediately after interventions and PN 6-8 weeks with reference to the follow-up interval in six studies (Appendix B) to assess the presence of depressive symptoms. Evaluation will be performed in parallel with implementation of pilot study. The whole process will last for 1.5 year until the innovation is fully implemented (Appendix J). 3.2 Feasibility Freedom of Termination There will be a core team called 'PND prevention team' working for the proposed innovation. Team members are composed of 1 nursing officer, 4 registered nurses, 1 medical officer and 1 clinical psychologist under FHS, in which the latter two provide support and advice to the program (Appendix P). Nursing officer is program coordinator and 4 registered nurses are district coordinator of the program. The team will hold meeting as scheduled to review the progress of innovation development and evaluate its effectiveness to clients. Nurses in the 'PND prevention team' is free to propose termination of the innovation. 25

37 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS Interference of Current Operation Current AN session in MCHCs including individual interview with midwife or doctor, abdominal palpation and other routine physical check-up. When the AN psychoeducation class is incorporated into MCHCs, one nurse will be assigned to hold the group simultaneously at but independent of AN services. As there are two AN sessions every week in most of the MCHCs, it is estimated that current service has enough capacity to integrate the innovation program into routine practice (Appendix N). Also, as all registered nurse beside mid-wife are qualified of being interventionist after training, there is high flexibility to allocate nurses to take up the role of holding the program. Worries about shortage of midwife in MCHCs is excluded from this aspect as non-midwife nurses can also share the work of the psychoeducation program. Nevertheless, nursing officers have to arrange an extra timeslot for nurses to work on the telephone follow-up Staff Training At present, there are numerous training courses to equip nurses under FHS with new skills to meet with various scope of service in MCHCs e.g. breastfeeding training course, which composed of 5-day comprehensive training to train up breastfeeding coaches. With reference to the practice of training regime of FHS, the MCHCs have its mechanism to release manpower to attend training by times. Registered nurses will be nominated to attend the 2-day training sessions during office hour. They will be award of the certificate 26

38 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS 'Antepartum psychoeducation provider' after training. Clinical psychologist from the 'PND prevention team' will be the trainer. To achieve the target of fully implementation after 1.5 year, one to two staff will be released from each center every month for training so that there will be at least four to eight nurses qualified to carry out the innovation in each centre. This strategy of scheduling staff away by roaster from clinic causes less interference of current staff functioning and clinic s operation. More training courses will be provided to train up nurses to become program provider depending on the program response Equipment and Facilities To deliver the group intervention, a common room is required to settle the clients, which is already available in all MCHCs as they are designed as primary setting with the purpose of holding health talk. Equipment such as computers, projector and material for role play e.g. baby doll are also available in MCHCs. Manual for program provider and participants are needed to be prepared as teaching aids. The curriculum and the design of manual content will be discussed among core members. All printing procedure including formatting, design and editing will be dedicated to the printing company and monitored by nurses core members Consensus Among Staff Medical professionals derived extra workload from PND cases in terms of counseling time, follow-up, case management complexity and administrative expenses. The statistics of 27

39 EVIDENCE-BASED ANTEPARTUM PSYCHOEDUCATIONAL INTERVENTIONS 2013 concerning Identification and management of mothers with post-natal depression (Appendix H) stated that 7562 cases required to receive recommended MCHC services under CCDS. According to the internal CCDS guideline of FHS, nurses have to formulate a management plan corresponding to clients' indication in subsequence visits. By clinical experience, every 'nurse follow-up session' for suspected PND case consumes about 15 minutes, which is equivalent to the average time to interview a case in child health session. To acknowledge the chain reaction of PND-generated workload in clinical practice and the foreseeable benefit brought by a preventive AN psychoeducation intervention, a communication plan is needed to gain consensus among staff (Appendix R) Organization Climate To meet with the changing health needs of the community, FHS has integrated various program into its service. The 'Positive Parenting Programme' (Triple-P) created by a group of clinical psychologists at the University of Queensland in Australia was first adopted in Hong Kong MCHCs in (Department of Health, 2006c). All nurses from MCHC were entitled as 'Accredited provider of level 3 & 4 Triple P' after the 5-day training. The program is still running at present. The success of this program demonstrates the organization's degree of support to evidence-based innovation in primary health care. So the implementation of evidence-based AN psychoeducation which strives for improvement in women and child health goes along with the organization climate. 28

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