Universal screening for postpartum depression? Inequalities and barriers among immigrant mothers

Abstract Background Postpartum depression (PPD) is a serious public health concern affecting 12% of women globally. Early detection is necessary to provide timely support. In Scandinavian countries, universal screening is recommended. However, migrant women, who are at increased risk of PPD, seem to be screened less often. Still, there is limited knowledge about 1) how acculturation relates to screening, and 2) how healthcare providers navigate PDD screening with migrant women. Aims and methods We used a mixed-methods approach to explore whether and why inequalities in PPD screening using the Edinburgh postpartum depression scale (EPDS) may exist in the context of universal PPD screening within the free home-visiting program in Denmark. Data from 77,694 infants and their mothers participating in the Danish home-visiting program (2015-2018) was used to examine the prevalence of participation in PPD screening and its association with migrant status and acculturation factors. We interviewed 16 health visitors to examine qualitatively challenges and strategies used when assessing PPD among immigrant mothers. Results Immigrant women were 80% more likely to lack screening (adj. RR 1.81-1.90). All factors indicating lower acculturation, such as shorter length of residence, older age at migration, and having studied abroad were independently associated with increased risk of lack of screening. Thematic analysis of qualitative data showed how cultural and linguistic differences and organizational constraints limit health visitors’ ability to assess immigrant women's mental health needs. Although health visitors often used EPDS as an opener to talk about mental health, they did not use it as an ‘assessment’. Conclusions This study shows inequalities in PPD screening than may result in reduced use of mental health services among immigrant women. The experiences of health visitors shed light on how to improve the identification of PPD among immigrant mothers. Key messages • Migrant women in Denmark, even those who have migrated as children, are at risk of being left out of PPD screening programs. • Limited organizational support and cultural competences makes PPD screening among immigrant women not feasible for maternal health visitors.


Background:
Family functioning can have positive and negative mental health consequences. Positive relationships can boost mental health, the opposite is true for negative relationships. 1 in 4 individuals are affected by at least one mental health condition in their life. Family-based interventions can help prevent the onset of mental health conditions and mitigate its consequences. Methods: Following databases were systematically searched: Medline; PsychInfo, Web of Sciences and Cochrane, resulting in 3719 hits. After removing 12 duplicates, 3707 studies were screened. After exclusion of irrelevant studies, 362 studies were assessed for eligibility and 40 studies were included. Inclusion criteria were original studies with !100 participants, !18 years, general population, and family members. Exposure had to be family social cohesion or conflict, or social capital. The outcome had to be a mental health condition.

Results:
Most studies (n = 37) used a cross-sectional design. 37 studies included a measure of family functioning and 3 studies used one of family structure. Most used was the Family Adaptability and Cohesion Evaluation Scale (n = 17), followed by the Family Functioning Scale (n = 5). Family relationship quality was related to depression, anxiety, and substance use. All aspects family cohesion were related to mental health outcomes. Family conflicts are associated with an increase in mental health conditions.

Conclusions:
Family cohesion shows an association with positive mental health while conflict is associated with negative mental health. This is an indication, that interventions at the family level are useful to help prevent/mitigate mental health conditions over the life course. Main message: As mental health conditions are a big public health issue affecting at least 1 in 4 individuals, family-based interventions for mental health condition prevention could not only help individuals but the whole family to strengthen and maintain positive mental health.

Background:
Postpartum depression (PPD) is a serious public health concern affecting 12% of women globally. Early detection is necessary to provide timely support. In Scandinavian countries, universal screening is recommended. However, migrant women, who are at increased risk of PPD, seem to be screened less often. Still, there is limited knowledge about 1) how acculturation relates to screening, and 2) how healthcare providers navigate PDD screening with migrant women.

Aims and methods:
We used a mixed-methods approach to explore whether and why inequalities in PPD screening using the Edinburgh postpartum depression scale (EPDS) may exist in the context of universal PPD screening within the free home-visiting program in Denmark. Data from 77,694 infants and their mothers participating in the Danish home-visiting program (2015)(2016)(2017)(2018) was used to examine the prevalence of participation in PPD screening and its association with migrant status and acculturation factors. We interviewed 16 health visitors to examine qualitatively challenges and strategies used when assessing PPD among immigrant mothers. Results: Immigrant women were 80% more likely to lack screening (adj. RR 1.81-1.90). All factors indicating lower acculturation, such as shorter length of residence, older age at migration, and having studied abroad were independently associated with increased risk of lack of screening. Thematic analysis of qualitative data showed how cultural and linguistic differences and organizational constraints limit health visitors' ability to assess immigrant women's mental health needs. Although health visitors often used EPDS as an opener to talk about mental health, they did not use it as an 'assessment'.

Conclusions:
This study shows inequalities in PPD screening than may result in reduced use of mental health services among immigrant women. The experiences of health visitors shed light on how to improve the identification of PPD among immigrant mothers. Key messages: Migrant women in Denmark, even those who have migrated as children, are at risk of being left out of PPD screening programs.
Limited organizational support and cultural competences makes PPD screening among immigrant women not feasible for maternal health visitors.

Background:
Resources are essential for mental health. In temporary stressful situations throughout life, people need to use a particular type of resources, their ''reserves'', to handle the stress. We do not know whether ''reserves'' (economic, cognitive, and relational) are more protective of mental health than ''conventional'' resources. Using a cohort of undocumented migrants experiencing a stressful transition in their life course (in the process of regularisation with local authorities), we will determine which resources, or reserves, and which types, better protect their mental health.

Methods:
A two-wave cohort study followed 362 undocumented migrants from 2017 to 2020, half of whom (48%) were involved in a regularisation process with the local authorities. Depressive symptoms were measured with the Patient Health Questionnaire, anxiety with the Generalized Anxiety Disorder. Economic reserves were measured at baseline and follow-up, cognitive and relational reserves at baseline only. Conventional economic and relational resources were assessed at both time points. The association between reserves and resources and mental health were examined using generalised estimated equations adjusted for age, sex and working hours per week, as well as the interactions between reserves/resources and regularisation status.

Results:
The indicators of economic and relational reserves were consistently and strongly associated with lower levels of anxiety and depressive symptoms. On the other hand, we found that mental health outcomes were marginally associated with conventional economic resources but independent of the relational resources indicators. We did not find strong evidence of interactions between reserves/resources and regularisation status.

Conclusions:
In a vulnerable population experiencing a stressful transition, reserves are more protective than resources. More research is needed in other vulnerable groups experiencing other stressful events.
Key messages: Undocumented migrants' economic and relational reserves protect their mental health. More research on the protective effect of reserves is needed in other vulnerable groups experiencing other stressful events.