FONG KAM MUI - School of Nursing Kam Mui.pdf · FONG KAM MUI For the Degree of Master of Nursing At the University of Hong Kong In July 2015 Postnatal depression (PND) is the most

Abstract of the thesis entitled

An evidence-based guideline of peer support intervention

in minimizing postnatal depressive symptoms in postnatal women

Submitted by

FONG KAM MUI

For the Degree of Master of Nursing

At the University of Hong Kong

In July 2015

Postnatal depression (PND) is the most common and complicated mental illness

that affects approximately 15% of postnatal women around the world. Many of the

studies documented the detrimental effects of PND, not only on the physical and

psychological aspects of the postnatal women, but also had active and prolonged

negatives effects on their children, family and society.

Although many of the researches were conducted regarding the treatments of

PND, reviews suggested that prevention was much more important than treatment. In

previous literatures, preventive interventions were focused on professional

psychological counseling and cognitive behavioral therapies. Recent researches

documented that psychosocial peer support interventions also significantly reduced

the risk of developing PND in postnatal women.

In this translational research, the current available evidences on the effect of peer

support intervention in minimizing postnatal depressive symptoms in postnatal

women are evaluated. Seven related literatures were retrieved from three electronic

bibliographical databases. Critical appraisals were done to assess the validity and

quality of the selected evidences. Then the implementation potential of the proposed

intervention was assessed by the transferability of the findings, the feasibility of the

implementation and the cost/benefit ratio. A clinical guideline was then developed

based on the evidences from the high standard of literatures identified, followed by

the proposals of the plan of implementation and the conduction of a pilot study plan in

one local MCHC. Finally, a detailed evaluation plan was discussed in this paper.

In conclusion, by evaluating the available evidences regarding the

implementation of new peer support intervention on postnatal women in MCHCs, it is

believed that the postnatal depressive symptoms of the postnatal women will be

minimized and postnatal women will be benefited from the intervention.

An evidence-based guideline of peer support intervention

in minimizing postnatal depressive symptoms in postnatal women

By

FONG KAM MUI

BNurs (Hon) (HKU), RN (HK)

A thesis submitted in partial fulfillment of the requirement

for the Degree of Master of Nursing

at the University of Hong Kong

July 2015

i

Declaration

I declare that this dissertation represents my own work, except where due

acknowledgement is made, and that it 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:

FONG KAM MUI

ii

Acknowledgement

I would like to express my sincere gratitude to my dissertation supervisor Ms.

Veronica S. F. Lam, for her patient guidance, insightful comments and suggestions,

and expert advice in my dissertation throughout the past two years in my master study.

Without her expert recommendations and supports, I could not be able to finish my

work. Her kindness and patience are surely appreciated. It was my pleasure to be her

student in my master study in the University of Hong Kong.

I would also like to extend my deep gratitude to my Senior Nursing Officer, Ms.

Sally Wan, and Nursing Officers, Ms. Lee Kit Lai and Ms. Cheung Wai Yee, and my

colleages for their unfailing support throughout my two-year master study.

Lastly, warmest thanks to my husband, Mr. Paul Ip, and my mother, Ms. Lo Fung

Chun, for their ongoing love, support, understanding and encouragement in either my

homework or my household matters.

This dissertation definitely would not have been accomplished without the

above-mentioned people’s dedication and contribution.

iii

Table of contents

Page

Declaration …………………………...………………………………………… i

Acknowledgement …………………………………………………………….. ii

Table of contents ……………………………………………………………… iii

List of Abbreviations ………………………………………………………… vi

List of Appendices …………………………………………………………… vii

Chapter 1: Introduction Page

Background ………………………………………………………………….. 1

Prevalence of postnatal depression

Impacts of postnatal depression problem

Affirming the needs …………………………………………………………. 4

Postnatal mental support and services in own setting

Gap in current postnatal mood services

Significance of the peer support intervention ……………………………… 7

Limited peer support service in own setting

Dissertation objectives ……………………………………………………... 8

Research question …………………………………………………………… 8

PICO components …………………………………………………………… 9

Chapter 2: Critical Appraisal

Search strategies ……………………………………………………………. 10

Search date

Inclusion and exclusion criteria

Search results ……………………………………………………………….. 12

Data analysis: table of evidences

Quality assessment …………………………………………………………. 13

Appraising Tool: Scottish Intercollegiate Guidelines Network (SIGN)

Summary of quality assessment of studies

Summary of Results …………………………………………………………. 17

Publication year

Country of study

Sample size

Characteristics of the patient

Peer support intervention

Intensity of intervention

iv

Table of contents (continued)

Page

Peer training

Time for evaluation

Intervention effects

Data synthesis for the new innovation ………………....………………….... 25

Target participants


Assessment tool

Evaluation time

Chapter 3: The implementation potential

Transferability of findings …………………………….…………………… 31

Target setting

Target population

Similarity of target setting and target population

Philosophy of care

Patients to be benefited

Implementation plan and evaluation time

Feasibility …………………………………………………………………… 37

Freedom in carrying out the innovation

Organization atmosphere and administrative support

Interference with staff workload

Consensus among the staff

Cost-benefit ratio …………………………………………………………… 40

Potential risks

Potential benefits

Material and non-material costs

Chapter 4: Evidence-based practice (EBP) guideline

Title ……………………………………………………………………….. 44

Purpose of the guideline …………………………………………………… 44

Target group …………………………………………………………….. 44

Recommendations ………………………………………………………... 45

v

Table of contents (continued)

Page

Chapter 5: Implementation Plan

Identification of stakeholders ……………………………………………... 51

Communication plan with potential users ………………………………… 52

Preparatory phase

Implementation phase

Pilot test

Evaluation phase

Chapter 6: Evaluation Plan

Identification of outcome measures ………………………………………. 60

Patients’ outcomes

Healthcare providers’ outcomes

Time and frequency of measurements …………………………………… 62

Nature and Number of clients involved …………………………………… 63

Nature of clients

Number of clients involved

Data analysis ………………………………………………………………... 64

Criteria for effectiveness …………………………………………………… 65

Chapter 7: Conclusion …………………………………………………….. 67

Appendices …………………………………………………………………. 68

References …………………………………………………………………. 113

vi

List of Abbreviations

BDI Beck Depression Inventory

CCDS Comprehensive Child Development Scheme

CES-DS Center for Epidemiological Studies - Depression Scale

EBP Evidence Based Practice

EPDS Edinburg Postnatal Depression Scale

FHS Family Health Service

DH Department of Health

GHQ General Health Questionnaire

IFSC Intergraded Family Service Center

IPV Intimate Partner Violence

MCHC Maternal and Child Health Center

MO Medical Officer

MOSAIC MOther’S Advocates In the Community

NO Nursing Officer

PND PostNatal Depression

PNO Principal Nursing Officer

RCT Randomized Controlled Trial

SIGN Scottish Intercollegiate Guidelines Network

SNO Senior Nursing Officer

SOPC Specialty Out-Patient Clinic

SPSS Statistical Package for Social Science

WHO World Health Organization

vii

List of Appendices

Page

Appendix A Postnatal depression Report of Department of Health, 2013 68

Appendix B Table and Prisma flow diagram for Search Strategies and Results 71

Appendix C Evidence table for relevant studies 73

Appendix D Quality Assessment of selected studies 80

Appendix E Estimated Schedule and Gantt chart for the plan of preparation,

implementation and evaluation of the EBP guideline

102

Appendix F Estimated cost for the proposed program 104

Appendix G Level of Evidence and Grades of Recommendations (SIGN, 2012) 105

Appendix H EBP Protocol: Program flow chart 106

Appendix I Intervention Progress Sheet for nurses to monitor progress of

telephone contacts by peer supporters to postnatal mothers

107

Appendix J Consent form for participants and peer supporters 108

Appendix K Content of the Half-Day Training Workshop for peer supporters 109

Appendix L Surveys for staff 110

Appendix M Survey for participants 111

Appendix N Survey for peer supporters 112

1

Chapter 1: Introduction

Background

Postnatal Depression (PND) is a major depressive disorder which depressive

symptoms appear at the first 4-6 weeks after a woman’s delivery (American

Psychiatric Association, 2013). PND affects postnatal women’s physical and

psychological health (Sadat et al., 2014; Zhang & Jin, 2014), and also brings

detrimental influences to their children and family (Civic & Holt, 2000; Lee et al.,

2004; Patel, DeSouza, & Rodrigues, 2003; Rahman, Iqbal, Bunn, Lovel, & Harrington,

2004). Nowadays, postnatal depression has evoked as the most common and

complicated mental health illness among women at postpartum period.

Prevalence of Postnatal depression

PND has emerged as a globally concerned major public maternal mental health

issue (UNFPA, 2013; WHO, 2008). Its prevalence ranged from 4.5% to 28% in

numerous epidemiological population-based international studies, depending on

different socioeconomic states and cultures (Gavin et al., 2005; Leahy-Warren,

McCarthy, & Corcoran, 2011; Leung et al., 2011; Mallikarjun & Oyebode, 2005;

Lumley, Austin, & Mitchell, 2004; Mao, Li, Chiu, Chan, & Chen, 2012; Mao, Zhu, &

Su, 2011; Patel et al., 2012). In meta-analysis and systematic reviews, PND occurred

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in an average of 13% of postpartum women by 3 months after delivery in

resource-rich countries, and with an even higher prevalence in resource-poor

countries (Fisher et al., 2012; Gavin et al., 2005; Grigoriadis et al., 2013; Leung &

Kaplan, 2009; Thombs et al., 2014).

In Hong Kong, postnatal depression prevalence ranges from 6.2% to 19.8% in

different epidemiological studies conducted in different years (Chen et al., 2013;

Leung et al., 2011; Leung, Martinson & Arthur, 2005; Mao et al., 2011). According to

the latest statistical data provided by the Family Health Service (FHS) of the

Department of Health (DH), 14.6% of postnatal mothers were identified with

suspected PND in 32 Maternal and Child Health Centers (MCHCs) in Hong Kong in

2013 (Appendix A).

Impacts of postnatal depression problem

The birth of a child is a time of joy for the mother and the family, however, the

occurrence of postnatal depression in postnatal mother brings detrimental effect to her

own physical and mental health (Rahman et al., 2013). Woman suffers from PND is

characterized with symptoms of persistent low mood, tearfulness, fatigue, anxiety,

affected sleep, decreasing appetite, feeling hopeless and guilty, and excessive anxiety

towards their baby (WHO, 2003). Among them, 5-14% of PND women have suicidal

3

ideation and behavior, making suicide be the most leading cause of death among

postpartum depressed women (Lindahl, Pearson, & Colpe, 2005). Nevertheless,

growing evidences have shown that PND reduces mother’s childcare ability and limits

her capacity to engage in positive parenting and child interactions (O'Hara & McCabe,

2013). Hence, the developments of their children are affected. A meta-analysis,

reviewing 193 studies, reported that children of PND women demonstrated higher

levels of misbehaviors and general psychiatric illnesses (Goodman et al., 2011) and

such effects could last for 11 years (Pawlby, Sharp, Hay, & O'Keane, 2008).

Maternal PND also increased the risk of paternal PND as shown by literatures

(Paulson & Bazemore, 2010; Gawlik et al., 2014; Goodman, 2004; Kerstis, Engstrom,

Edlund, & Aarts, 2013; Ramchandani et al., 2011). Potential negative outcomes such

as poor marital relationship and ineffective co-parenting may result (Hickey et al.,

2005; Lee, Taylor, & Bellamy, 2012; Milgrom, Schembri, Ericksen, Ross, & Gemmill,

2011). Therefore, marital relationship and family harmony may be destroyed.

Regarding the detrimental impacts of PND problem, postnatal depression has

also evoked as a global public health problem (Almond, 2009; Dennis & Dowswell,

2013). In the United States, the total health care services expenditures used on

depressed women were significantly higher than non-depressed women (US $1046.3

vs $365.2) (Dagher et al., 2012). Such an increase in health costs would bring

4

financial burden to the future health care system and has posed a major public health

burden in terms of lost productivity (Dagher, McGovern, Dowd, & Gjerdingen, 2012;

Dukhovny et al., 2013). Therefore, according to WHO (2008), maternal mental health

has been set as a fundamental in achieving the Millennium Developmental Goals in

the future (Glavin & Leahy-Warren, 2013) to promote the mental health of postnatal

women.

Affirming the needs

To tackle the problems of PND, routine screening for PND has started in Hong

Kong since 1998 to identify the postnatal women at risk (Lee et al., 1998). Monitoring

of women with PND has been implemented since 2005 in Family Health Service

(FHS) in MCHCs to reduce its severity and impact in future (Department of Health,

2014).

Postnatal mental support and services in own setting

In Hong Kong, family health service is provided by 32 MCHCs of Department of

Health (DH). A community-based Comprehensive Child Development Service

(CCDS) cooperated with the Hospital Authority has been implemented in five pilot

MCHCs since 2005 for early identification of mothers with postnatal depression

5

(PND) to closely monitor their maternal psychological well-being and future child

development (Department of Health, 2014). Since 2012, CCDS program has been

implemented in all 32 MCHCs.

In these MCHCs, all postnatal women are routinely screened for PND at 6 weeks

to 3 months of post-delivery using the Edinburgh Postnatal Depression Scale (EPDS)

questionnaire. If the score of EPDS is >9, a systemic mood assessment about mood

status and the presenting symptoms of PND of the woman will be carried out by

trained nurses. Women with significant depressive symptoms or self harm/baby harm

thoughts/acts will be referred to on-site psychiatric nurse’s assessment and counseling.

Other specialists e.g. pediatrician and social support services referrals will be made

when necessary.

According to the statistical data provided by FHS of DH (Appendix A), 14.6%

(n=6,734) of suspected PND mothers were identified in all MCHCs in 2013 either by

EPDS or clinical interview, in which 78.9% (n=5,311) were recommended to have

their mood to be continued monitoring by nurses during their subsequent MCHC visit

under the CCDS program. At the same time, 38.3% (n=2,579) of these suspected PND

mothers were referred to community social services for social worker counseling and

supports, such as Integrated Family Service Centers (IFSCs) (Appendix A).

6

Gap in current postnatal mood services

MCHC is a great platform for mothers to seek professional and social support.

Last year, 54,656 infants were registered in all MCHCs and 38,113 mothers

completed the PND screening with EPDS in MCHCs (Appendix A). At the moment,

this service targets women with high EPDS scores (EPDS >13) and women with

significant depressive mood symptoms or harmful thoughts. These women will be

referred to doctors or psychiatric nurses for mood counseling or to psychiatric

outpatient clinics in regional hospitals.

However, women with EPDS scores >9, and those with high EPDS scores

(EPDS >13) but with stable mood after the above said professional assessments, will

only have their mood to be monitored and reassessed during their next subsequent

visits in MCHCs. No active nursing intervention services in minimizing their negative

moods will be provided in the setting between their subsequent visits. In conclusion,

although the current CCDS program can identify suspected PND women earlier and

refer them to respective services promptly, no intervention is provided by nurses in

helping these suspected PND women in minimizing their depressive moods at the

moment.

Therefore, there is a gap in providing nursing intervention to this group of PND

patients at risk. It is proposed that the practice of potential nursing intervention be

7

introduced in minimizing the depressive symptoms and improving the mental health

of PND women on the platform of MCHCs.

Significance of the peer support intervention

Given the high prevalence of PND, its tremendous negative effects on the

suffering women, the likelihood of its long term impacts on growth and development

of children and its increasing health care costs to global economic burden, it is worth

to give prompt recognition to the matter. Early prevention and treatments should be

provided at an early stage in order to reduce severity and impact of PND in future.

Limited peer support service in own setting

Peer-based health intervention has been implemented to promote health for more

than forty years (Simoni, Franks, Lehavot, & Yard, 2011) and is commonly used to

improve health of different health outcomes with significant effects, e.g. breastfeeding

(Kaunonen, Hannula, & Tarkka, 2012), smoking cessation (Campbell et al., 2008),

diabetes management (Chan et al., 2014), and depression (DeAndrea & Anthony,

2013) etc.

Since impaired psychosocial functioning is one of the major risk factors leading

to PND (Dennis, 2014), many research findings has consistently highlighted the

8

importance of implementing psychosocial support to PND women (Chen, Kuo, Chou,

& Chen, 2007; Dennis, 2014). The effect of social support has also been found in

Chinese populations, in which women are reported to have fewer depressive

symptoms if being provided with better social supports by family, friends or

community (Lau & Wong, 2008; Zhang & Jin, 2014).

As a result, a new innovation – peer support intervention, which may bring forth

additional benefits (minimizing postnatal depressive symptoms and strengthening

suspected PND mothers’ social support network) is another potential intervention to

be carried out in the MCHC setting to minimize the depressive symptoms in

suspected PND women.

Dissertation objectives

1. To conduct a comprehensive literature search on effectiveness of peer support

intervention in minimizing depressive symptoms in postnatal mothers

2. To critically appraise, summarize and synthesize the relevant research papers

3. To develop an EBP guideline of using peer support intervention in minimizing

postnatal depression symptoms in postnatal women in MCHCs

4. To develop implementation and evaluation plans for a pilot test in a MCHC

Research Question

9

Is peer support intervention effective in minimizing postnatal depressive

symptoms in postnatal women?

PICO Components

Population: Postnatal women

Intervention: Peer support intervention

Comparison: Routine postnatal care service

Outcome: Postnatal depressive symptoms

10

Chapter 2: Critical Appraisal

To review the effectiveness of peer support intervention in minimizing

depressive symptoms in postnatal women, a systemic search and quality assessment

of relevant literatures is performed for the development of an evidence-based peer

support intervention guideline.

Search strategies

A comprehensive literature search was performed in three relevant electronic

databases: PubMed, PsycINFO, and CINAHL Plus.

During the searching process, date of publication was restricted from 1st January

1999 to present, and language was limited to English. Although studies that were done

over 10 years ago (before the year of 2004) were considered too old, not many studies

could be found within the past 10 years. Therefore, to have more relevant studies to

refer to, studies that were done 15 years ago (from January 1999) were included.

Two sets of key search terms were used. The first set was ‘peer support’, ‘social

support’, ‘mentor support’, ‘support group’. The second set was ‘postnatal depression’,

‘postpartum depression’, and ‘perinatal depression’. Complementary search was then

performed with different combination of the key terms of these two sets of keywords.

Potential relevant studies were selected and filtered by limiting to clinical trials,

11

matching titles, abstracts, fulfilling inclusion and exclusion criteria, then full texts

were reviewed. After identification of relevant literatures, manual search was

performed by reviewing the reference lists of selected studies to include extra relevant

studies. The search process and results are described in a search table and a Prisma

flow diagram in Appendix B.

Search date

The latest electronic search was done on 17th

August, 2014.

Inclusion and exclusion criteria

Inclusion criteria

Randomized Controlled Trials (RCTs) / clinical trials

Primary studies on investigating the effects of peer support intervention on

postnatal women

Primary studies that measure maternal depressive symptoms as the outcomes

Primary studies published between 1st January 1999 till 17

th August 2014

Exclusion criteria

Studies that support interventions are provided by health professionals

The target group postnatal women with currently diagnosed psychiatric diseases

12

Studies that the outcome measures are focused on infant and child

Studies that the publication languages are not English

Search Results

After performing electronic search with different combination of key search

terms, 1,934 studies in PubMed, 1,398 studies in PsycINFO and 333 studies in

CINAHL Plus were identified. When limited to clinical trials, 285 studies in PubMed,

57 studies in PsycINFO and 14 studies in CINAHL Plus were identified. With

reference to the inclusion and exclusion criteria and by manual screening of the titles,

abstracts and full texts, finally a total of 9 relevant studies are yielded, all written in

English, in which 7 studies from PubMed, 1 study from PsycINFO and 1 study from

CINAHL Plus were selected. Among the 9 studies yielded, 2 were excluded because

of duplication. Manual searching was then performed by screening the reference lists

of the 7 included studies, but no other relevant literature was yielded in the process.

As a result, 7 relevant eligible studies were included finally for review and

synthesis. All the 7 studies were randomized controlled trials (Chen, Tseng, Chou, &

Wang, 2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen, McGovern, Pratt,

Johnson, & Crow, 2013; Letourneau et al., 2011; Taft et al., 2011; Wiggins et al.,

2005). Details of the systemic search are shown in the search table and the Prisma

13

flow diagram in Appendix B.

Data analysis: table of evidences

The seven studies were reviewed and analyzed. In order to allow systemic and

organized comparison and analysis of the findings, relevant data from the studies was

extracted and represented in a table of evidence. Citation of the study, study type,

characteristics of the patients, intervention(s), comparison, outcome measure(s) and

results were extracted. Evidence level of study was graded in accordance with the

seven-level hierarchies of evidence invented by Melnyk and Fineout-Overholt (2011).

A detail of evidence table for each study is shown in Appendix C.

Quality Assessment

Appraising Tool: Scottish Intercollegiate Guidelines Network (SIGN)

Randomized Controlled Trials (RCTs) Checklist for quality assessment,

developed by the Scottish Intercollegiate Guidelines Network (SIGN) (2008), was

used in appraising the selected literatures. The SIGN checklist provides medical and

nursing health professionals a systemic appraising process of individual literature, in

order to establish an evidence-based practice guideline to improve healthcare quality.

The appraisal criteria are: appropriateness and correct focus of research questions,

14

method of randomization, concealment allocation, blinding, similarity between

intervention and control group, difference in treatment under investigation, validity

and reliability of outcome measurements, dropout rate, intention-to-treat, and

comparable result from different sites.

Ratings for each criterion are responded as ‘well covered’, ‘adequately

addressed’, ‘poorly addressed’, ‘not addressed’, ‘not reported’ and ‘not applicable’.

Based on the SIGN grading system (SIGN, 2008), the level of evidence is graded

“1++”, “1+” and “1-” depending on the fulfillment of criteria. Details of individual

quality assessments of the seven studies using SIGN RCTs checklists are shown in

Appendix D.

Summary of Quality Assessment of studies

All the selected studies addressed an appropriate and clearly focused research

question in relation to the study interest.

Among all seven studies, two studies were cluster RCT. Although all the seven

studies described themselves as RCTs, only four of them clearly described the

methods of randomization in assignment of subjects to treatment groups, e.g.

randomly generated numbers (Dennis, 2003); web-based randomization service

(Dennis et al., 2009); computer generated software program (Wiggins et al., 2005)

15

and random number tables (Gjerdingen et al., 2013). Three studies mentioned and

used concealment methods by using opaque and sealed envelopes (Dennis, 2003;

Letourneau et al., 2011; Taft et al., 2011), while the remaining four studies did not

mention the concealment method (Chen et al., 2000; Dennis et al., 2009; Gjerdingen

et al., 2013; Wiggins et al., 2005).

Blinding is difficult to be carried out in this research design because the

provision of peer support intervention involves manipulation of intervention together

with participants, peers and health care professionals. As a result, none of the studies

was kept triple or double blinded. A single blinding of research assistants or data

entry staff was applied in three studies (Dennis, 2003; Dennis et al., 2009; Wiggins et

al., 2005); two studies did not mention blinding (Chen et al., 2000; Letourneau et al.,

2011) and the remaining two studies were not blinded (Gjerdingen et al., 2013; Taft et

al., 2011).

In five of the studies, the treatment and control groups were similar at the start of

the trial with the only difference between groups being the treatment under

investigation (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009; Letourneau et al.,

2011; Wiggins et al., 2005). Baseline demographic and mental health characteristics

differences were found in the studies of Gjerdingen et al. (2013) and Taft et al. (2011),

in which the intervention groups displayed a higher percentage of mothers with a

16

history of PND in the past. Therefore, potential bias was presented.

All the seven studies used standard, valid and reliable assessment tools to

measure the outcomes. Five studies used Edinburg Postnatal Depression Scale (EPDS)

(Dennis, 2003; Dennis et al., 2009; Letourneau et al., 2011; Taft et al., 2011; Wiggins

et al., 2005), one study used Beck Depression Inventory (BDI) (Chen et al., 2000) and

one study used Center for Epidemiological Studies-Depression Scales (CES-D score)

(Gjerdingen et al., 2013).

Dropout rate ranged from 0% to 23.6% within the studies. Five studies had

maintained the dropout rate below 15% (Chen et al., 2000; Dennis, 2003; Dennis et al.,

2009; Gjerdingen et al., 2013; Letourneau et al., 2011). The dropout rate of the studies

by Wiggins et al. (2005) and Taft et al. (2011) were 20% and 23.6% respectively. It

might be caused by long intervention and long follow up that lasted 12 and 18 months

in Taft et al. (2011) and Wiggins et al. (2005)’s studies respectively. An intention to

treat analysis was used in all seven studies. Two studies were carried out multisite, but

results were not represented separately for comparison in all sites (Dennis et al., 2009;

Taft et al., 2011).

As a conclusion, all study results were applicable to target group identified by

the research question. Two studies were graded “1++” (Dennis, 2003; Dennis et al.,

2009) while the other five studies were graded “1+” (Chen et al., 2000; Gjerdingen et

17

al., 2013; Letourneau et al., 2011; Taft et al., 2011; Wiggins et al., 2005).

Summary of Results

Publication year

Bibliographic citations of the seven studies are cited from 2000 to 2013.

Country of study

Three studies were conducted in Canada (Dennis, 2003; Dennis et al., 2009;

Letourneau et al., 2011); one in the United States of America (Gjerdingen et al., 2013);

one in Australia (Taft et al., 2011); one in the United Kingdom (Wiggins et al., 2005)

and one in Taiwan China (Chen et al., 2000).

Sample size

Sample sizes ranged from 39 (Gjerdingen et al., 2013) to 731 (Wiggins et al.,

2005).

Characteristics of the patient

Postnatal women who delivered a live and healthy baby were recruited in all

studies. All studies recruited postnatal women who were at or above 16 years old and

18

were with a mean age of around 30 years old. A majority of the studies started their

recruitment of participants less than 2 months postpartum. E.g. within 24 hours

(Gjerdingen et al. 2013); 2 weeks (Dennis et al., 2009); 3 weeks (Chen et al., 2000); 8

weeks (Dennis et al., 2009) and 2 months (Wiggins et al., 2005). Over 75% of

mothers were married in five studies (Dennis, 2003; Dennis et al., 2009; Gjerdingen et

al., 2013; Letourneau et al., 2011; Wiggins et al., 2005), over 25% of mothers were

single mothers in one study (Taft et al., 2011), while one study did not measure

marital status of mothers in demographic characteristic (Chen et al., 2000).

For the pre-assessment recruitment screening and post-intervention assessment

comparison, five studies used EPDS (Dennis, 2003; Dennis et al., 2009; Letourneau et

al., 2011; Taft et al., 2011; Wiggins et al., 2005) as the single or one of the assessment

tools; one study used Beck Depression Inventory (BDI) (Chen et al., 2000) and one

study used CES-D depression score (Gjerdingen et al., 2013). The cut-off score were

set at EPDS >9 (Dennis, 2003; Dennis et al., 2009), EPDS >12 (Letourneau et al.,

2011) and BDI ≧9 (Chen et al., 2000) respectively during the pre-assessment

recruitment screening, while the cut-off score in other studies was not mentioned.

The age of the infants of the postnatal mothers ranged between 0 to 5 years old.

Such a large range in infant age was recorded because some mothers had more than

one child (Dennis, 2003; Gjerdingen et al., 2013; Letourneau et al., 2011; Taft et al.,

19

2011). Five studies recruited mothers with infants aged ≦6 months (Chen et al.,

2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013; Wiggins et al., 2005)

and over 50% of them were primiparous in a great majority of the studies (Dennis et

al., 2009; Letourneau et al., 2011; Chen et al., 2000; Gjerdingen et al., 2013; Wiggins

et al., 2005).


All the support interventions in the treatment group were provided by peers:

laypeople or non-professionals (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009;

Gjerdingen et al., 2013; Letourneau et al., 2011; Taft e al., 2011; Wiggins et al., 2005).

These supporters or mentors were recruited in the communities through referral from

health professionals in three studies (Chen et al., 2000; Gjerdingen et al., 2013; Taft et

al., 2011); newspaper advertising, and distribution of flyers or by word-of-mouth in

two studies (Dennis, 2003; Dennis et al., 2009); while the method of recruitment was

not mentioned in the remaining two studies (Letourneau et al., 2011; Wiggins et al.,

2005). The peer supporters recruited in four studies were clearly described as

volunteered mothers who had history of PND and had recovered from PND (Dennis,

2003; Dennis et al., 2009; Gjerdingen et al., 2013; Letourneau et al., 2011) while the

nature and characteristics of peer supporters were not described in two studies (Taft et

20

al., 2011; Wiggins et al., 2005).

The way to carry out support intervention varied in the seven studies but the

main strategy was by telephone support provided by peer supporters. Three studies

used solely telephone support (Dennis, 2003; Dennis et al., 2009; Gjerdingen et al.,

2013), two studies used a combination of telephone support with or without home

visiting as decided by the volunteer peer supporter (Letourneau et al., 2011; Wiggins

et al., 2005), one study used group discussion (Chen et al., 2000) and one study used

home visiting or direct meeting with participants in homes or other places (Taft et al.,

2011).

Intensity of intervention

The duration in providing peer support intervention ranged from 1 month (Chen

et al., 2000) to 18 months (Wiggins et al., 2005) and the total time spent on each PND

women ranged from 63.6 minutes (Gjerdingen et al., 2013) to 185.76 minutes (Dennis,

2003) of contacts.

The mean numbers of phone contacts launched were 5.4 (mean 34.4 minutes),

8.8 (mean 14.1 minutes) and 5.6 sessions (11.4 minutes) on each participated mother

in the studies by Dennis (2003), Dennis et al. (2009) and Gjerdingen et al. (2013)

respectively. In the study by Letourneau et al. (2011), each participant received an

21

average of 9 contacts (each lasted more than 20 minutes) of phone calls or visits; and

in the study by Wiggins et al. (2005), a total of 1.5 hours of telephone support or

home visiting were spent on each participant. No specific time spent nor average

number of contacts was reported in Taft et al. (2011)’s study. Instead, it was stated

that 58% of participant received weekly meeting with their peer supporters. In the

study by Chen et al. (2000), 4 weekly sessions (1.5-2 hours) of group discussion was

carried out with 5-6 mothers in a group.

Peer Training

In the studies conducted by Dennis (2003) and Dennis et al. (2009), peers or

mentors took a four-hour training session about the skills in providing telephone

supports and making hospital referrals. A 121-page training manual was given to the

peer supporters. In Letourneau et al. (2011)’s study, peer volunteers received an

eight-hour training about the skills in providing informational and counseling supports,

and practical maternal-infant interaction supports to mothers. In Taft et al. (2011)’s

study, peer supporters were trained with skills in knowledge not only related to

depression, but also Intimate Partner Violence (IPV), parenting, and self-care supports.

They were recruited under the program - Mother’s AdvocateS in the Community

(MOSAIC). Peer supporters in Taft et al. (2011)’s study were provided a five-day

22

training program and an online training manual. In addition, regular sharing sessions

at 1, 4, 8 and 12 month were carried out for peer supporters for inter-peer supports

and experience sharing. In Gjerdingen et al. (2013)’s study, peer telephone supporters

received a half-day training session on PND diagnosis and treatment, suicidal ideation

and techniques for supporting PND women. Periodical meetings were also organized

for supporters to share their experiences. In the study of Wiggins et al. (2005), peer

training was not mentioned.

Time for evaluation

Post-intervention assessments were done after the intervention period in all seven

studies. Three studies measured their intervention effects twice during the

intervention period (Dennis, 2003; Dennis et al., 2009; Wiggins et al., 2005). In the

study of Dennis (2003) and Dennis et al. (2009), EPDS scores were measured in the

middle (4 weeks and 12 weeks of the intervention period) of the study period and at

the end (8 weeks and 24 weeks of the intervention period) of the study period

respectively. In the study of Wiggins et al. (2005), intervention effect was measured at

12 months and 18 months of the intervention period. For the remaining four studies,

post-intervention measurements were taken after the intervention period according to

their length of study: at 4 weeks (Chen et al., 2000); at 12 weeks (Letourneau et al.,

23

2011); at 6 months (Gjerdingen et al., 2013) and at 12 months (Taft et al., 2011).

Intervention Effects

Statistical significance (p<0.05) results were recorded in four studies (Chen et al.,

2000; Dennis, 2003; Dennis et al., 2009; Letourneau et al., 2011) and clinical

significance results were obtained in the remaining three studies (Gjerdingen et al.,

2013; Taft et al., 2011; Wiggins et al., 2005).

In a pilot study conducted by Dennis (2003), lower mean EPDS scores were

obtained from the intervention group at both 4 weeks (p=0.008) and 8 weeks (p=0.006)

of intervention periods. Also, significantly (p=0.008) fewer percentage of mothers

were reported with EPDS score >9 (Intervention group: 35% to Control group: 76.2%)

after 8 weeks of intervention provided.

Another multisite study conducted by Dennis et al. (2009), significant difference

(p=0.02) in EPDS score between intervention and control group after 12 weeks of

intervention period was reported. In the study by Letourneau et al. (2011), EPDS

score significantly decreased by 6.4 in intervention group (p=0.04). In Chen et al.

(2000)’s study, BDI scores of PND women significant reduced by 6.41 after the

one-month intervention period (p<0.01).

24

In Taft et al. (2011)’ study, as the drop-out rate recorded was the highest (23.6%)

among the studies, the insufficient number of participants recruited and included in

the final analysis led to a statistically non-significant result (p=0.09) in the reduction

of EPDS score in the intervention arm. The reason for the high drop-out rate might be

due to long intervention period that lasted 12 months. However, the study did record a

reduction of 6.1 marks in the EPDS score in the intervention group (clinically

significant). Considered its clinical effect, the intervention was still regarded useful.

Instead of using the mean reduction in EPDS score on participants, percentage of

participants scoring EPDS ≧12 and the risk ratio (RR) of developing depression in

postnatal women were used for interpreting the effect of support intervention in the

study by Wiggins et al. (2005). 28% and 30% of participants were recorded EPDS ≧

12, and the RRs of depression were 0.86 and 0.93 in the support group and control

group respectively. A smaller reduction in percentage of participants with EPDS ≧12

in the intervention group recorded might be due to the fact that the uptake of

intervention support was low (only 35 participants out of 184 received supports

offered). As the study was carried out with an intention to treat basis, the result of

the intervention group was significantly diluted. However, the methodology used in

Wiggins et al. (2005)’s study was well designed, and it showed the feasibility in

25

recruiting voluntary peer supporters. Therefore, its results were still considered valid

and useful.

Lastly, in Gjerdingen et al. (2013)’s study, although statistically non-significant

result (p=0.397) was obtained in the reduction of CES-D score in the interventions

groups, the decrease in CES-D score was greater in the intervention group (reduction

of 14.5 marks) when compared to the control group (reduction of 10.1 marks). Such

result obtained was explained and confounded by small sample size (n=39) and the

presence of allocation bias of subjects to treatment groups (larger percentage of

depression history in intervention group).

As a conclusion, all the results of the seven identified studies were effective in

minimizing postnatal depressive symptoms in postnatal women.

Data synthesis for the new innovation

Integrating the collected data and results of the seven selected studies, peer

support intervention is considered feasible to be carried out on PND mothers and is

effective in minimizing postnatal depressive symptoms in PND women.

The recommendation of the new innovation to be carried out in a local setting in

MCHC in Hong Kong is shown below.

26

Target participants

1. Characteristics of mothers

Since a majority of the studies recruited participants is ≧18 years old (Chen et al.,

2000; Dennis, 2003; Dennis et al., 2009; Letourneau et al., 2011; Wiggins et al.,

2005), it is suggested to recruit postnatal mothers who are greater than 18 years

old. Moreover, as all infants in the seven studies were born live and healthily

(Chen et al., 2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013;

Letourneau et al., 2011; Taft et al., 2011; Wiggins et al., 2005); therefore, only

mothers who gave birth to an healthy infant are included. Lastly, based on the

recruitment time of the majority of the studies started at less than three-month

postpartum (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen et al.,

2013; Wiggins et al., 2005), mothers who delivered babies within three months are

therefore recruited.

2. EPDS score

A majority of studies used EPDS in the pre- and post- assessment screening and

evaluation (Dennis, 2003; Dennis et al., 2009; Letourneau et al., 2011; Taft et al.,

2011; Wiggins et al., 2005) and three of them set the cut-off score for inclusion as

9 marks. As a result, it is recommended mothers whose EPDS scores >9 should be

invited.

27

3. Exclusion criteria

Based on the exclusion criteria that set in recruitment of participants in a majority

of the studies (Dennis, 2003; Dennis et al., 2009; Letourneau et al., 2011; Taft et al.,

2011), women who have history of or currently diagnosed with major psychiatric

or mental disorders (e.g. schizophrenia, major bipolar disorder, psychosis, chronic

depression) and are currently taking antidepressants or antipsychotic medications;

and women who have history of receiving psychotherapy in the past 1 year are

excluded.


Since all the seven studies had either a statistically significant (Chen et al., 2000;

Dennis, 2003; Dennis et al., 2009; Letourneau et al., 2011) or clinically significant

effect (Gjerdingen et al., 2013; Taft et al., 2011; Wiggins et al., 2005) of the peer

support intervention, it implies that such intervention is workable, feasible and

effective in minimizing postnatal depressive symptoms in postnatal women. Since the

supporters who provided the peer support intervention in most of the studies were

trained (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013;

Letourneau et al., 2011; Taft et al., 2011), therefore, it is considered training is

essential before the provision of the intervention.

28

Based on the contents and schedule of peer supporter training in a majority of the

studies (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013;

Letourneau et al., 2011; Taft et al., 2009), the length of training should last at least 4

hours (Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013; Letourneau et al.,

2011) and the training contents should include information about PND, skills in

providing informational, instrumental, counseling and parenting supports. The

supports to be provided should encompass emotional supports, instrumental

assistances, informational supports and any support that are considered useful to help

participants to cope with their problems.

Moreover, peer supporters from three studies, with statistically significant results,

were those who had history of PND and had recovered from PND (Dennis, 2003;

Dennis et al., 2009; Letourneau et al., 2011), and therefore, they are preferred.

A majority of the studies used telephone contacts to provide peer support (Dennis,

2003; Dennis et al., 2009; Gjerdingen et al., 2013; Letourneau et al., 2011; Wiggins et

al., 2005). As a result, using telephone is preferred in carrying out the peer support

intervention. Since the duration of peer support intervention lasted less than 6 months

in most of the studies (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009;

Gjerdingen et al., 2013; Letourneau et al., 2011), and long intervention period longer

than 12 months might record high dropout and minimize the effectiveness of the

29

intervention in the remaining two studies (Taft et al., 2011; Wiggins et al., 2005).

Therefore, it implies that a six-month intervention period is suitable and effective in

achieving positive results.

Regarding the length of each phone conversation provided by peer supporters to

mothers, an average of 6 contacts of each lasted at least 15 minutes were recordered in

most the studies (Dennis, 2003; Dennis et al., 2009; Letourneau et al.,

2011;Gjerdingen et al., 2013). It is suggested that the peer supporters should provide a

minimum of 6 telephone supports of each lasts more than 15 minutes to the

participants.

Assessment tool

Based on the results of the studies, a majority used EPDS as the assessment tool

in measuring the effectiveness of intervention (Dennis, 2003; Dennis et al., 2009;

Letourneau et al., 2011; Taft et al., 2011; Wiggins et al., 2005). Therefore, EPDS is

considered a valid tool in assessing the intervention effect. In addition, the Chinese

version of EPDS was validated by Lee and his team in 1998 and have been used in

MCHCs to screen suspected PND women during their routine visits at 2-3 months of

post delivery since 1998 (Lee et al., 1998). In conclusion, it is workable to use the

30

10-item Chinese EPDS questionnaire as it is a validated assessment tool in measuring

the effect of the peer support intervention.

Evaluation time

As suggested by a majority of the studies (Chen et al., 2000; Dennis, 2003;

Dennis et al., 2009; Gjerdingen et al., 2013; Wiggins et al., 2005), pre-assessment for

mothers at baseline depressive levels should be carried out at the time when they are

recruited, that is smaller than three-month postpartum. Post-assessment should be

done immediately after the intervention period for six months as suggested by most of

the studies (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen et al.,

2013; Letourneau et al., 2011).

31

Chapter 3: The implementation potential

In the previous chapter, evidences from the seven reviewed studies concluded

that peer support intervention was effective in minimizing postnatal depression

symptoms in postnatal women. Therefore, it is worthwhile to translate the current

evidences into real practice and to apply it in the local setting in Hong Kong.

In this chapter, the implementation potential of this peer support intervention was

assessed by the transferability of findings, feasibility of the implementation and the

cost/benefit ratio of the intervention.

Transferability of findings

Target setting

The target setting is one of the 32 MCHCs under DH in Hong Kong. In the target

MCHC, child health and postnatal services are provided to newborn infants and

postnatal mothers accordingly as soon as they are discharged from their delivery

hospital. Routine maternal mood assessment, either by clinical interview or EPDS,

will be done at the first registration and at two-month postnatal period while the baby

will be reviewed respectively.

Target population

32

The target population is postnatal women who have registered in the targeted

MCHC and are identified as suspected PND sufferers after the EPDS screening.

Currently, postnatal woman who completes the EPDS questionnaires and with EPDS

scores >9 or is presented with any self-harm or baby-harm thoughts, will undergo a

systemic mood assessment done by trained nurses. Those with significant depressive

mood problems or psychotic symptoms or with thoughts of harmful behaviors will be

referred to doctors or psychiatric nurse for further assessments. On the other hand,

those postnatal women with EPDS >9 but with stable mood will have their mental

state reviewed again at their next MCHC visit accordingly during their babies’ next

vaccination schedule. And these group of postnatal women with EPDS score >9 and

with stable moods will be our target participants. Mothers who are under 18 years old,

have history of or currently diagnosed with major psychiatric or mental disorder, and

have history of receiving psychotherapy in the past 1 year will be excluded as

suggested by the reviewed studies (Dennis, 2003; Dennis et al., 2009; Letourneau et

al., 2011; Taft et al., 2011).

Similarity of target setting and target population

In all the seven reviewed studies, the recruitment and peer support intervention

were being carried out in a place or clinic which provided services both to infants and

33

mothers (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013;

Letourneau et al., 2011;Taft et al., 2011; Wiggins et al., 2005). This is very similar to

our target MCHC which also provides both services to infants and postnatal women.

In addition, the schedule of mood assessment of postnatal mothers in our target

MCHC (at first registration and at 2-3 months after delivery) is also similar with that

from the majority of the reviewed studies (Chen et al., 2000; Dennis, 2003; Dennis et

al., 2009; Gjerdingen et al., 2013; Wiggins et al., 2005). Therefore, it is considered the

target MCHC is a suitable setting for the innovation to fit in.

A vast majority of postnatal mothers that have registered in the target MCHC are

aged between 18-40 years old, which is very similar to those participants recruited in

the reviewed studies, which the mean age range was between 20-35 years (Chen et al.,

2000; Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013; Letourneau et al.,

2011; Taft et al., 2011; Wiggins et al., 2005). Many of the registered postnatal mothers

in the target MCHC have given birth to healthy babies without major complications

within 3 months of post delivery. It is also similar to the patient characteristics

recorded in the reviewed studies (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009;

Gjerdingen et al., 2013; Letourneau et al., 2011; Taft et al., 2011; Wiggins et al.,

2005).

34

Chinese is the main ethnicity in the target population, which is apparently

different from most of the reviewed studies, in which the target participants were

Australian, Canadian and American (Dennis, 2003; Dennis et al., 2009; Gjerdingen et

al., 2013; Letourneau et al., 2011;Taft et al., 2011; Wiggins et al., 2005). Yet, Chen et

al. (2000) demonstrated the innovation was also effective in Chinese populations.

Despite the difference in ethnicity of the target participants, similar PND prevalence

rates are recorded in both Chinese and Westerners. Therefore, the target population is

still considered transferable from the reviewed studies.

Philosophy of care

The core mission of the FHS of DH is to promote a holistic (physical,

psychological, cognitive, social) health and well-being of children and women

through developing evidence-based programs and strategies to empower people the

knowledge and ability to improve health in the community (Family Health Service,

2014). The proposed innovation is an evidence-based intervention that helps to

promote the psychological and social health of postnatal mothers by minimizing their

PND symptoms during the postnatal period by peer supporters in the community,

which comprehensively achieved the mission and value of our target setting in DH.

35

Patients to be benefited

In 2013, a total of 6,734 suspected PND women were identified in all MCHCs in

Hong Kong, in which 5,311 (78.9%) mothers with EPDS >9 were given brief

follow-up of mood status by nurses in the next MCHC visit (Department of Health,

2013). In the target MCHC, 3,362 mothers have completed PND screening, either by

EPDS or clinical interview in 2013, in which 550 (16.4%) were identified as mothers

at risk with suspected PND (Department of Health, 2013). From the statistic report of

the target MCHC in 2013, 437 mothers (about 36 mothers being identified in each

month) with EPDS >9 were identified as clinically mood stable after assessments

done by nurses (Department of Health, 2013). Their mood condition would be

reassessed again by brief follow-up during their next MCHC visit. According to

literatures, the PND prevalence rate was estimated to increase in the future. Therefore,

it is estimated that more than 400 suspected PND mothers will be benefited from our

target setting annually when the innovation is put into real implementation. When it is

applied in all MCHCs, it is estimated that more than 5,000 suspected PND postnatal

mothers in Hong Kong will be benefited in the future every year.

Implementation plan and evaluation time

36

The implementation period of the whole program will take about 31 months and

will be divided into 3 phases: preparatory phase, implementation phase and evaluation

phase.

It starts with preparatory phase which takes about 2 months. Proposal and budget

plan will be sent to the Director of Health of the FHS at the monthly meeting for

approval. An organizing committee will be formed, and briefing and training of clinic

staff will be carried out accordingly.

Then implementation phase will start with a pilot study and will take about 9

months. Recruitment of suspected PND participants and volunteered peer supporters

will be carried out, peer supporters will be trained and allocation of recruited

participants and peer supporters will be done by nurses accordingly in the first month.

Once the peer supporters are being informed of their corresponding participants, the

support intervention, mainly conducted by phone, will be carried out for 6 months.

Evaluation of the pilot test will be carried out immediately after the pilot test.

Participants’ depression levels and perception of the innovation program from

participants, peer supporters and staff will be evaluated by distribution of satisfaction

surveys.

After the pilot test, a full-scale of the program will start and will take another 18

months. Recruitment and training will be continuously carried out from the 12th

37

month to the 23rd

month, while peer support intervention will be provided to

participants by peer supporters through phone intervention from the 13th

month to the

29th

month accordingly.

Lastly, the evaluation of the whole implementation program will be carried out

from the 19th

to the 31st month, which the whole period takes 13 months.

Post-intervention EPDS questionnaires and surveys will be distributed to participants,

peer supporters and staff.

An estimated schedule for the preparation, implementation and evaluation plan

of the pilot test and full-scale program is shown in a Gantt chart in Appendix E.

Feasibility

The feasibility of carrying out the innovation is assessed by freedom in carrying

out the innovation, organization atmosphere, administrative support, interference with

staff workload, consensus among staff and evaluation tools.

Freedom in carrying out the innovation

As mentioned before, promoting holistic health to women, including postnatal

mothers, through providing evidence-based program is the major mission of the FHS

of DH. Clinical meetings are carried out regularly at least once a month in the target

38

MCHC to discuss the most up-to-date nursing and medical practices. In the past 2

years, experiences in applying new evidence-based practice have been also taken

place, for example, the practice of skin-to-skin care has been introduced to improve

breastfeeding outcomes. It is shown that, with enough evidences supported, nursing or

medical staff have the freedom to propose, to modify current practices and to carry

out any updated guidelines which benefits patients.

Moreover, Director of Health, Principal Nursing Officer and Senior Nursing

Officers in the service are supportive to new evidence-based practices which can

benefit clients and they also give autonomy to nurses in the target MCHC to

implement, as well as to determinate a new intervention if any new and updated

evidence-based practices were published in the journals. As a result, it is estimated

that the implementation of the proposed program will be feasible in the target MCHC.

Organization atmosphere and administrative supports

The organization atmosphere also supports evidence-based practices in the

department. A majority of the currently available nursing protocols and practices are

evidence-based. Doctors and nursing staffs are always given opportunity to propose

and discuss the most up-to-date practices in clinical meetings. Since the proposed

program of peer support intervention is an evidence-based strategy that has been

39

supported by qualified studies in effectively minimizing postnatal depression

symptoms in postnatal women, it is no doubt that the higher administration and

management level, as well as the front line staffs, will positively support the proposed

program.

Interference with staff workload

At the moment, all nurses in the target MCHC are trained in assessing and

managing postnatal depression women. Therefore, it is estimated that the proposed

program will not put much burden to nurses’ daily workload as all nurses have

experience in handling and managing suspected PND mothers. Moreover, as the chief

manipulators of the proposed innovation are peer supporters recruited in the

community, nurses only carry out the role of monitoring and supporting, which do not

disturb their routine practices much. Therefore, nurses are positive about accepting the

new program.

However, extra time may be needed during nurse interview for recruiting

suitable participants and peer supporters in the community and in getting consents

from participants and peer supporters. Also, extra workload may be added to the

designated nurses in running the program, for example, in pairing up supporters and

participants.

40

Consensus among the Staff

Whenever a new innovation is to be proposed and implemented, there must be

somebody that has diverse opinions and viewpoints towards the change. Therefore, to

get consensus among all staff is important. Before the launch of the program, an

enquiry period that will last for one month will be given to staff to give comments and

to suggest modifications about the innovation. The proposal will also be distributed to

staff to read and familiarize with during the period. The organizing committee will be

responsible for collecting the comments and suggestions and will explain the details

and benefits of the program to postnatal mothers in the clinic. Moreover, a pilot test

will be worked out in order to test the feasibility of the program.

Cost-benefit ratio of the innovation

In order to assess the worthiness of the program, the cost and benefit of the

whole program will be assessed.

Potential risks

The current practice of handling PND is focused on the group of mothers whose

EDPS score >13 and with significant depressive mood symptoms, they will be

41

referred to doctors or psychiatric nurses assessment for further managing their mood.

However, there is no active intervention currently available for the group of mothers

whose EDPS score >9 and with comparatively stable moods after nurses’ assessments.

In addition, this group of postnatal mothers may develop PND if they are not being

supported and not given prompt intervention in minimizing their depressive

symptoms. Therefore, if the proposed peer support intervention is not implemented,

the psychological, mental and social health of this group of high-risk mothers may

deteriorate due to the lack of social supports and peer counseling.

Potential benefits

As mentioned in the previous chapter, peer support intervention is effective in

minimizing postnatal depression symptoms in postnatal women (Chen et al., 2000;

Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013; Letourneau et al.,

2011;Taft et al., 2011; Wiggins et al., 2005). Their EPDS scores significantly

decreased after receiving the intervention (Dennis, 2003; Dennis et al., 2009;

Letourneau et al., 2011). Therefore, high-risk postnatal women in developing PND

(EPDS scores >9) will be benenfited if the intervention is put into real practices. At

the same time, the psychological well-being and social networking of these suspected

42

PND postnatal women will be improved and broadened respectively under this

program.

Material and non-material cost

The cost of setting up and maintaining the intervention program is categorized

into material and non-material cost.

In the pilot test, it is estimated that 36 suspected PND mothers, 18 peer

supporters and around 22 nurses in the target MCHC will be involved. As for the full

scale of the program, it is estimated that around 460 participants and 230 peer

supporters will be involved. The required materials and calculation for the costs are

shown below.

Materials needed are: (a) a function room equipped with computer and overhead

projector: for providing staff briefing and a half-day training workshop for the

recruited peer supporters; (b) four EBP protocols: for nurses to read and take as

reference during the pilot test; (c) 18 ten-page training booklets with contents

regarding the provision of peer supporting intervention: to be distributed to each peer

supporters during the half-day training workshop; (d) 76 one-page questionnaires: for

collecting comments and feedbacks from peer supporters, participants and staff.

43

Material cost is the money spent on facilities and equipments needed,

photocopying the guidelines, booklets and questionnaires, while the non-material cost

is the labor cost. As the function room, overhead projector and computer are already

available in the target MCHC, the money is mainly spent on photocopying. It is

estimated that $54.4 will be spent on photocopying the protocols, booklets and

questionnaires (unit price for 1 page: $0.2).

The non-material cost is manpower cost. In the target MCHC, there are 22

registered nurses. Each nurse will be provided with a one-hour briefing on the

proposed program during the preparation stage, in which, the cost is $3,984. At the

same time, two identical four-hour peer supporter training workshops (each with

about 10 peer supporters) will be organized by two nurses on two separate dates (one

nurse is responsible for one workshop) to ensure all peer supporters are trained before

they provide support intervention, in which, the training costs $1,416. It is estimated

that $5,310 is needed as the manpower cost.

The details of the estimated expenditure in running the pilot program (both

material and non-material costs) are shown in Appendix F. It is estimated that a total

of $5,364.4 is required for the pilot test and a total of $17,590 to run the proposed

full-scale program.

44

Chapter 4: Evidence-based practice (EBP) guideline

After assessing the implementation potential, it is considered the proposed

intervention is transferable, feasible and beneficial when being applied in local setting.

In this chapter, a clear and user-friendly EBP guideline will be developed to guide the

use of this proposed intervention.

Title

Evidence-based practice guideline of peer support intervention in minimizing

depressive symptoms of postnatal women in MCHCs.

Purpose of the guideline

To guide MCHC nurses in providing and monitoring peer support intervention

based on the best available evidences;

To standardize the information on training peer supporters to provide peer

supports;

To guide peer supporters in delivering peer support intervention to postnatal

women

Target group

45

Postnatal women who are (a) with EPDS scores >9 after mood assessment and

professional judgment of nurses; (b) within 3 months of post delivery; and (c) aged

≧18. Exclusion criteria: women who (a) have history of or are currently diagnosed

with major psychiatric or mental disorders; (b) are taking antidepressants or

antipsychotic medications; or (c) have history of receiving psychotherapy in the past 1

year.

Recommendations

The grades of recommendations and levels of evidence are assessed by the

application of the Scottish Intercollegiate Guidelines Network (2012). The criteria of

recommendations are attached in Appendix H.

Recommendation 1 – Characteristics of participants

1.1 Participants being recruited should age at least 18 years.

(Grade of recommendation: A)

Evidences:

The participants recruited are at least 18 years old in a majority of the studies

and peer support intervention has shown to be effective in minimizing

postnatal depressive symptoms in these subjects (Chen et al., 2000; Dennis,

2003; Dennis et al., 2009; Letourneau et al., 2011; Wiggins et al., 2005).

46

1.2 Participants should have delivery within 3 months.


Evidences:

Mothers who delivered healthy live babies within three months after delivery

are recruited in a majority of the studies (Chen et al., 2000; Dennis, 2003;

Dennis et al., 2009; Gjerdingen et al., 2013; Wiggins et al., 2005).

Most women develop PND in the first 12 weeks after delivery (Dennis, 2003;

Dennis et al., 2009).

1.3 Participants should have no previous and current psychiatric medical history.


Evidences:

Women who have history of or currently diagnosed with major psychiatric or

mental disorders and are taking antidepressants or antipsychotic medications

are excluded in most studies (Dennis, 2003; Dennis et al., 2009; Letourneau

et al., 2011; Taft et al., 2011).

Recommendation 2 – Pre-assessment screening

2.1 Pre-assessment screening should be done with EPDS assessment tool.


47

Evidences:

Most of the studies had pre-assessment screening before 3 months of

post-delivery: 2-3 days (Chen et al., 2000); 8 weeks (Denns 2003); 2 weeks

(Dennis et al., 2009); 2 months (Wiggins et al., 2005); 24 hours (Gjerdingen

et al., 2013).

EPDS is a well-established depression scale and is the most frequently used

instrument in assessing PND symptoms (Letourneau et al., 2011).

2.2 Participants should have EPDS score >9 and stable mood after professional

judgment by nurses.


Evidences:

Five studies used EPDS cut off score >9 in pre-assessment screening (Dennis,

2003; Dennis et al., 2009; Letourneau et al., 2011; Taft et al., 2011; Wiggins

et al., 2005).

Recommendation 3 – Assignment of peer supporters to participants

3. Assignment of peer supporters to participants should base on geographic

residency and availability.


Evidences:

48

Dennis (2003), Dennis et al. (2009) and Letourneau et al. (2011) matched the

peer supporters or volunteers to the recruited postnatal mothers according to

their region of resident and time of availability.

Recommendation 4 – Advice and monitor the peer supporters

4.1 The peer supporters should contact the participants by phone once a month.


Evidences:

Telephone supports provide more privacy and flexibility, but less

stigmatization than clinical visits (Letourneau et al., 2011).

Using telephone in providing various kinds of supports, for example

emotional, informational supports, counseling and referral, was used in most

of the studies (Dennis, 2003; Dennis et al., 2009; Gjerdingen et al., 2013;

Letourneau et al., 2011; Wiggins et al., 2005).

Phone contacts were launched by peer supporters at almost once a month in

most of the studies (Dennis, 2003; Dennis et al., 2009; Gjerdingen et al.,

2013; Letourneau et al., 2011).

4.2 The length of telephone conversation should last more than 15 minutes.


49

Evidences:

Challenges were reported by peer supporters in establishing rapport with

some mothers over the phone if conversation time was limited (Gjerdingen et

al., 2013).

The average length of each phone conversation launched by peer supporters

was longer than 15 minutes in studies with significant results (Dennis, 2003;

Dennis et al., 2009; Letourneau et al., 2011).

4.3 The duration of the phone intervention should last for six months.


Evidences:

Significant intervention effect was seen in studies with intervention period

less than six months (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009;

Letourneau et al., 2011).

Recommendation 5 - Post-assessment screening

5. Post-assessment should be done using EPDS assessment tool after the

intervention.


Evidences:

50

Post-intervention assessments were being done after the intervention in all

studies (Chen et al., 2000; Dennis, 2003; Dennis et al., 2009; Letourneau et

al., 2011; Gjerdingen et al., 2013).

51

Chapter 5: Implementation Plan

After developing the evidence-based practice guideline for minimizing postnatal

depressive symptoms in suspected PND women, the next crucial step is to build up a

systemic communication plan before the real implementation in the selected local

setting taken place. In this chapter, the plan of communication process with potential

stakeholders and the conduction of a pilot study test will be discussed.

Identification of stakeholders

Establishing an effective communication with the stakeholders can build up a

cooperative relationship and gain their support throughout the whole implementation

of a new innovation (Ingersoll, 2005). Therefore, the first step is to identify all the

stakeholders, who are important persons to decide if an innovation can be successfully

carried out (Melnyk & Fineout-Overholt, 2011), then to develop a communication

plan with all of them. Three levels of stakeholders are involved: administrative and

management level, clinical level and client level.

Administrative and management level includes Director of Health, Principal

Nursing Officer (PNO) and Senior Nursing Officers (SNOs) in the FHS under DH.

They are in the administrative hierarchy who are responsible for making adoption of

proposals and implementing decisions, as well as allocating resources and manpower.

52

SNOs in the service also function as a bridge for communication and liaison with

higher level of administrators. Hence, approval should be obtained from this level.

The clinical level includes all staff working in the clinic. Frontline staff involves

of the Medical Officers (MOs), Nursing Officers (NOs) and Registered Nurses (RNs).

Nursing Officers (NOs) are important personnel to approve and to lead the whole

team in the implementation of the proposed program in the clinic. Hence, an effective

communication and detailed explanation of the guideline with RNs can necessarily

facilitate and sustain the program. Although MOs are not actually involved in carrying

out the program, their understanding and support is essential in monitoring and

sustaining the process.

The client level includes postnatal women (with EPDS scores >9 and mood

stable after professional judgments by nurses) and volunteered peer supporters.

Postnatal women with EPDS scores >9 with stable moods after nurse’s professional

judgment are the recipients, while volunteered peer supporters are responsible for

delivering phone counseling and supports to postnatal women.

Communication plan with potential users

A systemic communication plan facilitates better collaboration between

proposers and stakeholders to execute and implement a new program smoother and

53

easier. To make the communication effective, the whole communication process is

divided into three phases: preparatory, implementation and evaluation phases.

Preparatory phase (2 months)

The aim of the preparatory phase is to obtain the approval from higher

administrative, to develop a working committee, to explain and collect concerns and

feedbacks of staffs about the new peer support intervention.

In this phase, the proposal and budget plan will be sent to higher administrative

hierarchy for adoption and approval in one of the monthly departmental meetings

which is held by Director of Health, PNO, SNOs and regional NO and MO in-charges.

They are welcomed to give feedbacks and comments about the details of the program,

therefore, one can understand more about the interests of these senior administrators.

At the same time, an organizing committee comprises clinic NO in-charge, one

NO and two RNs will be formed to organize the planning and evaluation of the

process. Clinic NO in-charge takes the role of a leader in promoting the new program

and helps in liaison and communication with higher administrative and management

level. NO acts as a supervisor and a director in execution of the program, while the

two RNs take the role of instructor and trainer in providing training to other nurses

and peer supporters.

54

Once the proposal and budget are approved from administrators, the proposal

and guideline will be presented with PowerPoint presentation in one of the monthly

clinic staff meetings. The organizing committee will seek support from nursing staffs

by presenting the needs and significance of the current PND problem and the gap in

providing nursing intervention in minimizing PND symptoms among women at risk

in the current setting. Then the proposed program flow chart (Appendix H), budget

plan will be explained and benefits of the new program will be emphasized to further

convince all staffs. An enquiry period lasts for one month, which allows nurses

enough time to express concerns and comments on the proposed program. Refinement

of the proposed program may be required after addressing all concerns and

suggestions raised by staffs. It is estimated to take two months for this phase.

Implementation Phase (27 months)

In this phase, an implementation of a pilot study plan will be carried out in one

of the local MCHCs to assess the program logistics, participants, peer supporters and

nurses’ acceptances and satisfactions about the proposed guideline, and to monitor

patients’ and healthcare providers’ outcomes. After that, a full-scale implementation

will be carried out.

55

Pilot Testing (9 months)

A pilot test allows feasibility checking of the guideline, feedback collection and

identification of unanticipated barriers before the full-scale implementation of a new

innovation (Melnyk & Fineout-Overholt, 2011). It provides opportunities to refine

and finalize the EBP guideline before the real implementation and future

dissemination of the proposed guideline in other clinical units. Details of the pilot test

are discussed below.

Pilot Study Plan

Aim: to test the feasibility, evaluation, refinements and finalization of the new

proposed peer support intervention.

Objectives: ． to review program logistics

． to evaluate staff acceptability, satisfaction and workload

． to evaluate postnatal women’s acceptability & satisfaction

． to evaluate peer supporters compliance, acceptability & satisfaction

． to fix potential pitfalls

Participants:

The target participants in the pilot test will be postnatal women who are (i) with

EPDS scores >9 with mood stable after professional judgments by nurses; (ii) within

3 months of post delivery; and (iii) aged ≧18. They should not have history of or are

currently diagnosed with major psychiatric or mental disorders, not taking

56

antidepressants or antipsychotic medications, or have history of receiving

psychotherapy in the past year.

Procedure:

The pilot test will be carried out in three stages: recruitment and training (1

month), and implementation of the peer support intervention (6 months), and

evaluation (2 months).

In the recruitment and training stage, all nurses will help to recruit participants

and peer supporters. Posters will be posted in the target MCHC in recruiting potential

peer supporters. Women who fulfill the recruitment criteria will have mood

assessment done for eligibility screening by nurses based on their professional

judgments. High-risk suspected PND women (e.g. with significant mood and mental

disturbances or harm thoughts) will be referred to specialists or doctors for immediate

treatments. Eligible women (EPDS >9 and mood stable after professional judgment

by nurses) will be given consent forms to enroll into the program (Appendix J). At the

same time, recruitment of peer supporters will be done by putting up posters in the

clinic and by nurses. According to statistical data from the target MCHC, there were

550 postnatal mothers recorded with EPDS >9 last year, approximately with about 45

suspected PND mothers identified in each month. With about 80% of agreement in

57

participation into the pilot study, it is expected to recruit 36 postnatal women and 18

peer supporters within the period.

Two identical four-hour training workshops will be organized for peer supporters

by two nurses to ensure all peer supporters will be trained before they provide

supports. Detailed training content for the peer supporters is illustrated in Appendix K.

It is estimated to take 1 month for the whole recruitment and training process.

After the recruitment, the 6-month implementation phase will start immediately.

The organizing committee will allocate the recruited 36 participants to the 18 peer

supporters (classified as one group, for nurses to monitor the progress) according to

their basic socio-demographics and geographic residency, in which, two participants

will be allocated to one peer supporter. Hence, there will be 18 pairs in one group and

their condition will be monitored by nurses at 1 week, 3 months and 6 months after

the start of the program using the intervention progress sheet (Appendix I). Nurses

will phone the peer supporters and will record their availability of contact of the

allocated postnatal woman, the number of contacts being made during the period and

the details of supporting services being given. Lastly, nurses will check with peer

supporters if any problems are encountered so that they can offer help if necessary.

Details of the intervention progress sheet are shown in Appendix I.

58

Evaluation of the pilot study will start immediately after the 6-month

intervention and will last 2 months. Women’s depression levels and perceptions of the

program will be evaluated by distributing EPDS questionnaires and satisfaction

surveys. At the same time, surveys will also be distributed to peer supporters and

nursing staff to evaluate their acceptability and satisfaction about the program. A

focus group meeting will be organized by the organizing committee to further discuss

and collect feedback from the nurses in the target setting. Data and comments will be

analyzed by the organizing committee for further refinement of the final guideline to

prepare for full-implementation in future.

Formats of the surveys for participants, peer supporters and staff are shown in

Appendix L, M and N.

Full-scale program implementation (18 months)

After the implementation of the pilot test, a full-scale program of peer support

intervention will start and last for 18 months. Recruitment and training will be

continuously carried out from the 12th

month to the 23rd

month, while the peer support

intervention will be provided to participants by peer supporters through phone

intervention from the 13th

month to the 29th

month accordingly.

Evaluation phase (13 months)

59

Lastly, evaluation of the whole implementation program will be carried out from

the 19th

to the 31st month, which the whole period takes 13 months. Post-intervention

EPDS questionnaires and surveys will be distributed to participants, peer supporters

and staff respectively after the intervention period.

An estimated schedule for the preparation, implementation and evaluation plan

of the pilot test and the full-scale program is shown in a Gantt chart in Appendix E.

60

Chapter 6: Evaluation Plan

Evaluation is the final part of a program to determine if the objectives are

achieved. Information in the evaluation is also crucial in refining and finalizing the

EBP guideline. In the evaluation plan, the identification of outcome measures, time

and frequency of measurements, nature and numbers of clients involved, and method

of data analysis will be discussed.

Identification of outcome measures

In this EBP guideline of minimizing postnatal depressive symptoms in postnatal

women at risk by peer supporters, patients’ outcomes and health care providers’

outcomes are measured.

Patients’ outcomes

Primary outcomes

As mentioned earlier in the chapter of affirming the need of the intervention,

there is a time lag in providing nursing intervention to minimize postnatal depressive

symptoms in suspected PND women in the local setting. The proposed program fills

this gap by providing peer support intervention for suspected PND women to manage

their depressive moods. Therefore, the primary outcome of this program is to prevent

61

and decrease the chance of deterioration of their mood by minimizing the postnatal

depressive symptoms in postnatal women using EPDS assessment tool.

EPDS is a 10-question self-rating scale in measuring the level of depression of

perinatal women by calculating the total score of the 10 items (Cox, Holden, &

Sagovsky, 1987). The Chinese version of EPDS has been validated by Lee & his team

since 1998 and has been used in all MCHCs to screen suspected PND women during

their routine visits at 2-3 months of post delivery since 1998 (Lee et al., 1998).

Secondary outcomes

The secondary patients’ outcome is to evaluate the satisfaction and acceptance

of peer support intervention in target women and peer supporters. Satisfaction survey

with a report scale between 1 (totally disagree) to 5 (totally agree) will be distributed

after the completion of the program. The questionnaire can be returned either by mail

or in person. In the questionnaire, an open-ended question is set and it helps to gather

any comments and suggestions for the program. Sample of surveys are illustrated in

Appendix M and N.

Health care providers’ outcomes

In addition to patient outcomes, healthcare providers’ outcomes are also

62

important for the successfulness of the program implementation. To evaluate nurses’

perception of the innovation, questions are asked towards acceptability, satisfaction

and competence of the healthcare providers in carrying out the intervention. A report

scale between 1 (totally disagree) to 5 (totally agree) will be used to measure the

results. An open-ended question is included in the questionnaire for nurses to

comment on the program. Moreover, a focus group meeting will be held after the

program by the organizing committee. All nurses are welcomed to provide any

feedback and suggestions regarding the whole process of the implementation in the

meeting. Sample of the questionnaire is shown in Appendix L.

Time and frequency of measurements

The full-scale implementation of the guideline takes 31 months. For eligible

postnatal women, pre- and post-EPDS questionnaires will be distributed at 2-3 months

post delivery and after the 6-month intervention period respectively. In addition,

satisfaction survey will be distributed and collected from participants and peer

supporters at the end of the program. During the 6-month intervention period, nurses

are required to monitor the progress of the intervention by phone contacting the peer

supporters regularly at 1st week, 3

rd month and 6

th month after the intervention starts.

An Intervention Progress Sheet (Appendix I) will help the nurses in monitoring the

63

progress of support provided by peer supporters to participants. Finally, satisfaction

survey will be distributed and focus group meetings will be held by the organizing

committee for the nurses after the program.

Nature and Number of Clients Involved

Nature of Clients

The clients to be involved in the evaluation plan are the target population. They

are postnatal women who are (a) with EPDS scores >9 and mood stable after

professional judgment by nurses; (b) within 3 months of post delivery; and (c) aged

≧18. Women who (i) have history of or are currently diagnosed with major

psychiatric or mental disorders; (ii) are taking antidepressants or antipsychotic

medications; or (iii) have history of receiving psychotherapy in the past one year are

excluded.

Number of Clients Involved

The sample size will be calculated by the online sample size calculator by Lenth

(2011) using one sample t-test. Since the EPDS scores measured are from the same

postnatal women and their corresponding mean pre- and post-intervention EPDS

scores are compared, one sample t-test is used.

64

Based on the literature, an effect size of 0.4 is taken from Dennis (2003)’s study,

as the study design most resembles the proposed program and it has the highest level

of evidence. Therefore, by taking significance level of 0.05 and a power of 80%, a

minimal sample size of 397 is needed. Since the dropout rate reported in the literature

ranged from 0% to 23.8% (the longer the intervention period, the higher the reported

rate), the highest rate recorded in the literature with an intervention period less than 6

months is chosen. That is, a dropout rate of 14.8% from Letourneau et al. (2011)’s

study is taken for calculation. As a result, a total sample of 460 women is required.

Data Analysis

The collected data, including the socio-demographic data of the participants and

peer supporters, the pre- and post-intervention EPDS scores and the satisfaction level

of participants, peer supporters and nurses will be entered into Statistical Package for

Social Science (SPSS) version 21 and analyzed statistically. Chi-square test will be

used in analyzing the socio-demographic data collected which includes age of

participants and their infants, geographic residency, education level, occupation,

status of marriage, household income, delivery type and breastfeeding status, while

one sample t-test will be used in measuring the mean score of EPDS rated by

participated postnatal women pre- and post-intervention. Satisfaction level of the

65

participants, peer supporters and staff will also be analyzed by calculating the

percentage of satisfaction of each item in the questionnaire. Qualitative data reported

by nurses in the focus group meeting will be analyzed with identification of categories,

key themes and patterns.

Criteria for Effectiveness

The guideline is considered effective when the depressive symptoms of

postnatal women are minimized by recording a lower EPDS score after six months of

peer support intervention. A reduction of 3 marks in EPDS score in Dennis (2003) is

taken into consideration to evaluate the effectiveness of the program since the study

has the highest level of evidence. Therefore, by using a mean reduction of 3 marks in

EPDS score, the program will be considered effective in minimizing depressive

symptoms in suspected PND women if the post-intervention EPDS score is reduced

by 3 marks or more.

On evaluating the satisfaction level of participants, peer supporters and nurses, a

10-item satisfaction survey using the five-point Likert-type scale is designed for

grading respondents’ satisfaction level. The program is considered effective if the total

score from the survey is being graded over 70% or an individual item in the survey

being graded equals to or greater than 4 marks.

66

Regarding the focus group meeting conducted by the organizing committee with

the nurses, the program is considered effective if positive comments were received

regarding the program implementation.

67

Chapter 7: Conclusion

Postnatal depression affects postnatal women’s physical and psychological

well-beings, and brings detrimental effects to their children and their family. In view

of the high and increasing prevalence of postnatal depression (PND) in Hong Kong, a

new approach should be taken to prevention the disease.

As many of the researchers have consistently concluded the importance of

psychosocial variables in managing and preventing PND, the seven selected studies

provided evidences for the provision of a new psychosocial intervention: peer support

intervention, which is feasible, possible and worthy to be carried out in MCHCs to

postnatal women in minimizing their PND symptoms.

The evidence-based guidelines for nurses and peer supporters are developed

respectively in this proposal and its transferability, feasibility, the cost of the

implementation, a detailed communication plan, pilot study plan and evaluation plan

were reviewed and examined to ensure its smooth application to the real setting. It is

believed that more PND women at risk can be benefited from the program by

minimizing their postnatal depressive symptoms.

68

Appendix A: Postnatal depression Report of Department of Health, 2013

69

Appendix A (continued):

Postnatal depression Report of Department of Health, 2013

RPT001A – Workload statistics on Child Health Service

Total no. (New registration, aged <1yr incl. local and non-local born): 54,656

RPT305 – Identification and management of mothers with postnatal depression

EPDS coverage n %

No. of mothers completing EPDS forms 38,113 -

Total score ≦9 and Q10 score = 0 32,632 85.6

Total score ≧10 or Q10 score > 0 5,481 14.4

EPDS coverage - 91.6

Suspected PND identified 6,734 14.6

By EPDS 5,335 79.2

By clinical interview 1,399 20.8

With psychosocial risk categories 1,171 17.4

Recommended HA service(s) n %

HA service indicated 4,479 66.5

Psychiatric nurse in MCHC 4,192 62.3

Psychiatric doctor in MCHC 4 0.1

HA psychiatric department 19 0.3

A & E 42 0.6

Community Paediatrician 406 6

Receiving appropriate services 166 2.5

Recommended MCHC service n %

Brief FU for progress 5,311 78.9

Phone FU session 1,126 16.7

MO assessment/counseling 1,113 16.5

Social Service needs n %

Social service indicated 2,579 38.3

Referral to IFSC 2,097 81.3

Client is receiving appropriate services 434 16.8

70

Appendix A (continued):

Postnatal depression Report of Department of Health, 2013

Identification and management of mothers with postnatal depression

in target MCHC in 2013

EPDS coverage n %

No. of mothers completing EPDS forms 2,249 -

Total score ≦9 and Q10 score = 0 1,792 79.7

Total score ≧10 or Q10 score > 0 457 20.3

No. of mothers assessed by clinical interview 1,113 -

EPDS coverage - 88.9

Suspected PND identified 550 16.4

By EPDS 443 80.5

By clinical interview 107 19.5

With psychosocial risk categories 126 22.9

Recommended HA service(s) n %

HA service indicated 355 64.5

Psychiatric nurse in MCHC 323 58.7

Psychiatric doctor in MCHC 0 0

HA psychiatric department 0 0

A & E 0 0

Community Paediatrician 34 6.2

Receiving appropriate services 21 3.8

Recommended MCHC service n %

Brief FU for progress 437 79.5

Phone FU session 87 15.8

MO assessment/counseling 62 11.3

Social Service needs n %

Social service indicated 210 38.2

Referral to IFSC 151

Client is receiving appropriate services 53 16.8

71

Appendix B: Table of Search Strategies and Results

Date: 17th

August, 2014

An evidence-based guideline of peer support intervention in minimizing postnatal

depressive symptoms in postnatal women

Search terms PubMed PsycINFO CINAHL

Plus

S1 Peer support 21,479 287,835 1,850

S2 Social support 248,387 151,931 14,670

S3 Mentor support 3,244 2,222 101

S4 Support group 989,921 135,027 3,888

S5 S1 or S2 or S3 or S4 1,190,081 343,077 19,436

S6 Postnatal depression 6,735 3,399 1,778

S7 Postpartum depression 5,142 4,430 3,675

S8 Perinatal depression 1,534 1,413 293

S9 S6 or S7 or S8 7,457 6,399 4,290

S10 S5 and S9 1,934 1,398 333

Limits to clinical trials 285 57 14

Limited to relevant titles & abstracts 50 5 10

Limited to inclusion & exclusion

criteria 7 1 1

Searched by references of selected

articles 0 0 0

Included articles 7 1 1

Total no. of articles included: 7

72

Appendix B (continued): PRISMA Flow Diagram of literatures searching

Studies identified through electronic database searching

(n = 2,665)

Scre

enin

g In

clu

ded

El

igib

ility

Id

enti

fica

tio

n

Studies after limited to clinical trials

(n = 356)

Studies screened

(n = 65)

Studies excluded

(Not fulfilling inclusion and

exclusion criteria)

(n = 56 )

Full text articles included

(n = 9)

Studies included in final appraisal

(n = 7)

Studies identified in

PubMed

(n = 1,934)


PsycINFO

(n = 1,398)


CINAHL Plus

(n = 333)

Studies excluded

(Irrelevant titles and abstracts)

(n = 291)

Studies excluded

(Duplicated copies)

(n = 2)

No extra studies yielded after

searching references

(n = 2)

73

Appendix C: Evidence table for relevant studies

Dennis C. L. (2003). The effect of peer support on postpartum depression: a pilot randomized controlled trial. Can J Psychiatry, 48:115-124.

Citations Study type

Patient

Characteristics Intervention(s) Comparison

Outcome measure(s)

Results

(p-value)

Dennis

(2003)

Pilot RCT

(n=42)

Level of

evidence:

(1++)

New, married,

English speaking

mothers who

gave singleton

birth ≧37 weeks

gestation;

living in Canada;

Age: ≧18 y.o.

(>73% 25-34 y.o.);

Between 8 & 12

weeks postnatal;

With EPDS >9.

Exclusion: Taking

antidepressants; Hx

of psychotherapy in

past 1 yr and Hx of

choronic depression,

psychiatric disorder

or postpartum

psychosis.

Recruitment started

at 8 weeks

postpartum.

Standard community

postpartum service and

telephone support provided

by a peer volunteer

supporter (mothers who

experienced and recovered

from PPD).

19 peer supporters were

recruited and completed a

4-hour training about

telephone support and

referral skills with a

118-page handbook.

Intervention by phone

contacts were initiated

within 48 hours after

pairing up.

Intervention lasted for 2

months.

Mean duration of

contacts: 5.4 sessions x 34.4

minutes = 185.76 minutes

(n=20)

Standard

community

postpartum

service

(n=22)

[1] Depressive

symptomatology:

EPDS 4 and 8 weeks

after intervention

[2] Maternal Self Esteem:

SES

[3] Child-Care Stress:

CCSC

[4] Maternal loneliness: LS

[5] Maternal perceptions of

peer support: PSEI

[6] Peer-volunteer

perceptions of peer

support: PVEQ

[7] Peer-Volunteer

Activities: Activity Log

[1]

After 4 weeks:

Mean EPDS score:

I: 8.5

C: 12.1

(p=0.008)

After 8 weeks:

similar gp diff.

(p=0.006)

After 8 weeks:

% of mothers with

EPDS >9:

I: 35%

C: 76.2%

(p=0.008)

74

Appendix C (continued): Evidence table for relevant studies

Dennis, C. L., Hodnett, E., Kenton, L., Weston, J., Zupancic, J., Stewart, D. E., & Kiss, A. (2009). Effect of peer support on prevention of

postnatal depression among high risk women: multisite randomised controlled trial. BMJ, 338, a3064.


Patient

Characteristics

Intervention(s) Comparison Outcome measure(s)

(Tool)

Results

(p-value)

Dennis et

al., (2009)

Multisite

RCT

(n=701)

Level of

evidence:

(1++)

New English

speaking mothers:

gave a live birth

baby and

discharged home

with baby;

lives in Canada

≦2 weeks

postpartum;

Age: ≧18 y.o.

(78% 20-34 y.o.);

>92% married;

EPDS score >9

(baseline EPDS:

I:12.5 & C:12.6).

Exclusion: taking

antidepressants or

antipsychotic drugs.

Recruitment started

within 24-48 hours

postpartum.

Standard postpartum

care and telephone support

provided by a peer

volunteer.

204 supporters were

training 4 hours with skills

in providing effective

telephone based support and

making hospital referrals

with a 121 page training

manual given.

Telephone supports

were initiated within 72

hours after peer allocation.

Intervention lasted for

24 weeks.

A minimum of 4

contacts should be taken by

each peer volunteer.

Mean duration of

contacts: 8.8 sessions x

14.1minutes = 124.08

minutes

(n=349)

Standard

postpartum

care

(n=352)

[1] Postnatal depression

After 12 & 24 weeks:

EPDS score;

[2] Anxiety: State-trait

anxiety inventory;

[3] Loneliness: UCLA

loneliness scale;

[4] Use of health service:

[1] EPDS score

after 12 weeks:

I: 7.93

C: 8.89

(p=0.02)

EPDS score after

24 weeks:

I: 7.00

C: 7.61

(p=0.10)

75


Letourneau, N., Stewart, M., Dennis, C. L., Hegadoren, K., Duffett-Leger, L., & Watson, B. (2011). Effect of home-based peer support on

maternal-infant interactions among women with postpartum depression: a randomized, controlled trial. Int J Ment Health Nurs, 20(5), 345-357.


Patient

Characteristics


(Tool)

Results

(p-value) Letourneau et al.,

(2011)

RCT

(n=60)

Level of

evidence:

(1+)

English speaking

mothers who

gave a singleton

healthy birth;

Age: 17-39 y.o.

(87.9% 21-35 y.o.);

Infant’s age≦9m

(mean 5.58m &

4.8m in I&C);

EPDS score >12

(baseline EPDS:

I:18.2 & C:16.1);

Antidepressants or

antipsychotics use:

( I:54.6% &

C:75.8%);

Peer support and

maternal-infant interaction

intervention by home visits

and telephone contacts.

Peer volunteers were

mothers who recovered from

postnatal depression and

taken an 8-hour training to

provide informational,

emotional, affirmational and

practical supports.

Regular follow-up

debriefings were carried out.

Intervention lasted for12

weeks.

Average duration of

contacts: 9 visits and/or

phone calls with each ≧20

minutes = 180 minutes

(n=27)

12 weeks

standard

postpartum

care (waiting

period) and 2

weeks of peer

support after

the await

period.

(n=33)

[1] Mother-infant

interactions: Nursing

Child Assessment

Satellite training;

[2] Postpartum depressive

symptomatology: EPDS;

[3] Cognitive development:

Baley MDI;

[4] Maternal reports of

social-emotional

development: ICQ;

[5] Perception of social

support: SPS;

[6] Maternal saliva cortisol

levels;

[7] Intervention dose and

contents: activity logs;

[2] EPDS score:

I: -6.4

C: -7.42

(p=0.04)

76


Taft, A. J., Small, R., Hegarty, K. L., Watson, L. F., Gold, L., & Lumley, J. A. (2011). Mothers' AdvocateS In the Community (MOSAIC) --

non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care. BMC

Public Health, 11, 178.


Patient

Characteristics


(Tool)

Results

(p-value)

Taft et al.,

(2011)

Cluster

RCT

(n=174)

Level of

evidence:

(1+)

English speaking,

disclosed IPV or

psychosocially

distressed women:

Aged >= 16 y.o.

(mean: ~32 y.o.);

Pregnant or had

child(ren) <5 y.o.;

Depression status:

(EPDS score≧13:

I:70% & C:58%);

Exclusion: serious

mental illness and

level of English

inadequate for

informed consent.

MOSAIC’s mentoring

provided by 32 mentors

recruited in the community.

Mentoring was provided

by weekly home visiting.

Mentors were mothers

and were trained for five

days that included

befriending, domestic

violence advocacy, working

with depression, parenting

support, safety and self care

skills.

Intervention lasted for

12 months and regular

meetings (1, 4, 8, 12m) were

provided for mentors for

further training and support.

Intensity of intervention:

58% of participants reported

weekly meetings with

mentors.

(n=113)

6 hours IPV

training for

clinician only.

(n=61)

Primary outcomes:

[1] Partner abuse: CAS

[2] Depressive symptoms:

EPDS

Secondary outcomes:

[3] Mental and physical

health well-being: SF-36;

[4] Parenting stress: PSIS

[5] Social support: MOS SF

[2] EPDS score:

I: -6.1

C: -3

(p=0.09)

77


Chen, C. H., Tseng, Y. F., Chou, F. H., & Wang, S. Y. (2000). Effects of support group intervention in postnatally distressed women. A controlled

study in Taiwan. J Psychosom Res, 49(6), 395-399.


Patient

Characteristics


(Tool)

Results

(p-value)

Chen et

al., (2000)

RCT

(n=60)

Level of

evidence:

(1+)

Postnatally

distressed mothers:

of at least junior

high school

education;

Age: ≧18 y.o.

(mean=29.1 y.o);

with live birth

infants of 6-10

weeks old;

BDI score ≧9

I:15.9 & C: 15.73;

Recruitment started

at 3 weeks

postpartum.

Postnatal supportive

group sessions


month: 4 weekly sessions of

1.5-2 hours duration each.

5-6 mothers in a group

to share their experiences.

Contents comprised of

discussion concerning

transition to motherhood,

postnatal stress management,

communication skills and life

planning.

A registered nurse

functioned as a group leader.

(n=30)

Control group

(postnatal

support group

not given)

(n=30)

[1] Depression: BDI;

[2] Stress: Perceived Stress

Scale (PSS);

[3] Availability of support:

Interpersonal Support

Evaluation List (ISEL);

[4] Self-esteem:

Coopersmith’s

Self-Esteem Inventory

(SEI).

[1] BDI score:

I: -6.41

C: -0.92

(p<0.01)

78


Wiggins, M., Oakley, A., Roberts, I., Turner, H., Rajan, L., Austerberry, H., Mujica, R., Mugford, M., & Barker, M. (2005). Postnatal support for

mothers living in disadvantaged inner city areas: a randomised controlled trial. J Epidemiol Community Health, 59(4), 288-295.


Patient

Characteristics


(Tool)

Results

(Confidence

Interval: CI)

Wiggins et

al., (2005)

RCT

(n=731)

Level of

evidence:

(1+)

Postnatal mothers

who:

Lived in deprived

enumeration

districts of UK;

Mean age:~29 y.o.;

Lives with a

healthy baby of a

mean age of 9 wks;

Mean EPDS score

at 8 weeks

postpartum: ~8.8;

~50% had two

infants;

Recruitment started

at 8 weeks

postpartum.

1. Support Health Visitor

(SHV):

monthly supportive home

visits by a health visitor;

(n=183)

2. Community Group

Support (CGS):

support from community

groups (CGS) providing drop

in sessions, home visiting

and/or telephone support

which participants took the

initiative to contact peers

(women recruited from the

community).

(n=184)

Interventions lasted for

18 months;

Average duration of

contacts: total 1.5 hours

(90minutes) per participants

Control group

(C) received

standard health

visitor service.

(n=364)

Maternal outcomes:

[1] Maternal depression:

1st FU @ 12m:

% of women with

EPDS ≧12;

Risks ratio (RR) of

PND;

2nd

FU @ 18m:

% of women with

GHQ>=12;

Risk ratio of PND;

[2] Maternal smoking;

[3] Maternal health;

[4] Social resources;

[5] Experience of

motherhood;

[6] Health service use;

Children outcomes:

[1] Child injury; [2] Child

health; [3] Infant feeding;

[4] Health service and

medication use;

[1] 1st FU @ 12m:

% of women with

EPDS≧12:

SHV: 26%

CGS: 28%;

C: 30%

RR of PND:

SHV/C: 0.86

(CI: 0.62-1.19)

CGS/C: 0.93

(CI: 0.69-1.27)

79


Gjerdingen, D. K., McGovern, P., Pratt, R., Johnson, L., & Crow, S. (2013). Postpartum doula and peer telephone support for postpartum

depression: a pilot randomized controlled trial. J Prim Care Community Health, 4(1), 36-43.


Patient

Characteristics


(Tool)

Results

(p-value)

Gjerdinge

n et al.,

(2013)

RCT

(n=39)

Level of

evidence:

(1+)

English speaking

mothers:

living in

Minneapolis/St.

Paul metropolitan

area of the US;

Age ≧16 y.o.

(mean=29.7 y.o.) ;

Infant age: 0-6

months old;

PHQ-9 score≧10;

Baseline mean

CES-D scores:

PD: 33.7

PTS: 32.5

C: 28.1;

1. 6 Postpartum doulas (PD):

Home visits

Average ~6.9 home

visits and 23.4 hours

contacts with each

assigned mothers;

Services included

education regarding infant

care and feeding, practical

and emotional support.

(n=12)

2. 6 Peer telephone

supporters (PTS):

Telephone supports on

educational, emotional

and comparison support.

Total duration of

contacts: ~5.6 calls (63.6

minutes) in telephone

conversation with each

participant.


months.

(n=13)

Control group

(C)

(n=14)

[1] General health

[2] Mental & physical

health: Center for

Epidemiological

Studies-Depression

Scale: CES-D score;

[3] Social support

[2] CES-D score @

6 months:

PD: 16.9 (-16.3)

PTS: 17.8 (-14.5)

C: 17.9 (-10.1)

(p=0.397)

80

Appendix D: Quality Assessment of selected studies.

S I G N

Methodology Checklist 2: Controlled Trials

Dennis C. L. (2003). The effect of peer support on postpartum depression: a pilot randomized

controlled trial. Can J Psychiatry, 48:115-124.

Guideline topic:

An evidence-based guideline of peer support intervention in

minimizing postnatal depressive symptoms in postnatal

women

Key Question No: Reviewer:

Section 1: Internal validity

In a well conducted RCT study… Does this study do it?

1.1 The study addresses an appropriate and clearly focused question. Yes

1.2 The assignment of subjects to treatment groups is randomised. Yes Randomization was

achieved by using

consecutively

numbered, sealed,

opaque envelopes

containing randomly

generated numbers.

1.3 An adequate concealment method is used. Yes

1.4 Subjects and investigators are kept ‘blind’ about treatment

allocation.1

Yes Only research

assistants are blinded

to the group

allocation. Trial

participants and peer

supporters cannot be

blinded.

81

1.5 The treatment and control groups are similar at the start of the trial. Yes No significant

differences in age,

education, income,

and EPDS score were

found. There were no

statistically

significant differences

between the 2 groups.

1.6 The only difference between groups is the treatment under

investigation.

Yes

1.7 All relevant outcomes are measured in a standard, valid and reliable

way.

Yes

1.8 What percentage of the individuals or clusters recruited into each

treatment arm of the study dropped out before the study was

completed?

No drop out in the

experimental group. Only 1

mother (out of 22) dropped out

in the control group who did

not complete the 8-week

assessment.

1/42 = 2.38%

1.9 All the subjects are analysed in the groups to which they were

randomly allocated (often referred to as intention to treat analysis).

Yes Discontinuation of the

intervention did not

entail the participant’s

exclusion from the

study, and an

intention to treat

approach was used to

analyze these data.

1.10 Where the study is carried out at more than one site, results are

comparable for all sites.

Does not apply

Section 2: OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimise bias?

Code as follows:

High quality (++)

2.2 Taking into account clinical considerations, your

evaluation of the methodology used, and the

statistical power of the study, are you certain that

the overall effect is due to the study

intervention?

In this pilot randomized controlled trial, the

methodology used and the statistical power

presented are of good quality in evaluating the

effect of telephone peer support

(mother-to-mother) on depressive

symptomatology among mothers identified as

82

high-risk of postpartum depression (PPD). The

overall effect is due to the study intervention.

2.3 Are the results of this study directly applicable

to the patient group targeted by this guideline?

Yes

2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study,

and the extent to which it answers your question and mention any areas of uncertainty raised above.

Author’s conclusion: This pilot RCT effectively evaluated the effect of peer support telephone

intervention in decreasing the risk of PPD among high risk mothers.

Own comments: Recruitment of participants and volunteered peer supporters are well described.

Training contents of the peer supporters are also well illustrated. In reporting the intervention results,

only percentage of mothers who had EPDS scores >9 and >12 are presented instead of the actual

scores. Through p-values are stated, the actual effect of how much the intervention in decreasing the

EPDS score were not reported in the paper. Another limitation is the small sample size which

comprised of total 42 participants.

83

S I G N


Dennis, C. L., Hodnett, E., Kenton, L., Weston, J., Zupancic, J., Stewart, D. E., & Kiss, A. (2009).

Effect of peer support on prevention of postnatal depression among high risk women: multisite

randomised controlled trial. BMJ, 338, a3064.

Guideline topic:



women.





1.2 The assignment of subjects to treatment groups is randomised.

Yes Randomization was

centrally controlled with

a web based

randomization service

www.randomize.com.

1.3 An adequate concealment method is used.

Can’t say Concealment

method was not

mentioned.

84

1.4 Subjects and investigators are kept ‘blind’ about treatment allocation. Yes Single blind (assessors

blinded). The research

nurses were blinded to

the group allocation and

were responsible to

assess trial outcomes.

Trial participants and

peer supporters could

not be blinded to group

allocation, health

professionals and

service providers of

standard community

postpartum care were

not informed of any

mother’s participation

in the trial or group

allocation. .

1.5 The treatment and control groups are similar at the start of the trial. Yes There were no clinically

important differences

between the two groups.

The mean scores of

EPDS were similar in

the 2 groups.

1.6 The only difference between groups is the treatment under investigation. Yes

1.7 All relevant outcomes are measured in a standard, valid and reliable way. Yes


treatment arm of the study dropped out before the study was completed?

At 12 weeks postpartum,

87.4% participants completed

the FU telephone interview,

decreasingly slightly to 85.6%

participants at 24 weeks.

Dropout rate was 12.6% and

14.4% at 12 & 24 weeks FU

respectively.

1.9 All the subjects are analysed in the groups to which they were randomly

allocated (often referred to as intention to treat analysis).

Yes Data were analyzed

with SAS version 9.1

and an intention to treat

approach.

85



No Results were not

presented separately

from the7 large health

regions in Canada.

SECTION 2: OVERALL ASSESSMENT OF THE STUDY


Code as follows:

High quality (++)



statistical power of the study, are you certain that the

overall effect is due to the study intervention?

Taking into account the clinical methodology used and

statistical power of the study, the overall effect is due

to the study intervention of peer telephone support

intervention.

2.3 Are the results of this study directly applicable to the

patient group targeted by this guideline?

Yes

2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the

extent to which it answers your question and mention any areas of uncertainty raised above.

Author’s conclusion: Telephone based peer support might be effective in preventing PPD among high risk

postpartum mothers immediately after delivery. It is feasible to recruit lay people who have experienced a

similar health problem or stressor (e.g. PND) and they can have a positive effect on potential sufferers’

psychological wellbeing. Women in the study were satisfied and receptive in receiving telephone support and

such experience.

Own comments: In this study, the methodology used was RCT; statistical power was >80%; a significant

reduction of PPD risk (women received peer support through telephone were at 1/2 of the risk in developing

PPD at 12 weeks postpartum); lost to follow-up was <15% and >80% of participants were satisfied with the

intervention. The overall effect of the study was successful. Telephone based peer support could help to

prevent postnatal depression in mothers who have recently given birth.

The only limitation of the study was that the clinical diagnostic data for PND might be questionable because

the study only identified 7% of high risk PPD mothers in which the prevalence was lower than the current PND

prevalence of ~13% in recent meta-analysis. This was possibly due to the fact that data collection process was

carried out by generalized nurses who may be undertrained. In future, structured clinical interview could be

administered face-to-face by a mental health specialist as suggested by the author.

86

S I G N


Letourneau, N., Stewart, M., Dennis, C. L., Hegadoren, K., Duffett-Leger, L., & Watson, B. (2011).

Effect of home-based peer support on maternal-infant interactions among women with postpartum

depression: a randomized, controlled trial. Int J Ment Health Nurs, 20(5), 345-357.

Guideline topic:



women





1.2 The assignment of subjects to treatment groups is randomised. Can’t say Participants were

randomized using

opaque, sealed

envelopes with

group

assignment.

1.3 An adequate concealment method is used. Yes Participants were

randomized using

opaque, sealed

envelopes with group

assignment.

1.4 Subjects and investigators are kept ‘blind’ about treatment allocation. Can’t say Blinding was not

mentioned.

87

1.5 The treatment and control groups are similar at the start of the trial. Yes No statistical

differences were

observed between the

groups on any

demographic or

descriptive variables,

except for medication

use and infant sex.

1.6 The only difference between groups is the treatment under investigation. Can’t say After the 12

weeks of await

period, the

participants

would receive 2

weeks of peer

supports.




Dropout rate was 14.8% and

15.2 % in treatment and

control group respectively.



Yes Outliners were not

removed, and covariates

were not included in the

final analysis.



Does not apply



Code as follows:

Acceptable (+)





After taking into account clinical considerations, it is

not certain that the overall effect of the study is due to

the intervention.



Part of the results (e.g. intervention effect in

minimizing postnatal depression level) was applicable

to the targeted patient group.

88



Author’s conclusions: Though significant results were observed in the intervention group, the effect was

larger in the control group (control group had a greater reduction in the EPDS score for measures of symptoms

of postpartum depression and perceived social support.

Reasons: significant higher depressive symptoms experienced by the treatment group over the 12 weeks

intervention period might have impaired mothers’ ability to interact with their infants and participants in the

treatment group presented and persisted in having more sever depressive symptoms may have confounded the

findings. Training, follow-up and debriefing provided to peers might have been insufficient. Moreover, mothers

with PND are uncomfortable in receiving advices and would perceive it as judgment of their parenting

abilities.

Own comments: The primary outcome measure of this study is maternal-infant interactions via observational

nursing child assessment satellite training (NCAST) programme feeding and teaching scales through direct

home visits and/or telephone supports, while postpartum depressive symptomatology by EPDS is only one of

the secondary outcome measures. Therefore, supports provided by peer supporters might favors skills in

modifying feeding and parenting needs of the participants instead of providing supports on mental needs of

mothers. Also, the participants in the study were mothers having high scores (EPDS>12) and some were even

already taking depressive medications. These may confound the study outcome and the effectiveness of the

intervention.

Taking into account the significance of the study result in reducing maternal depressive symptoms, peer

telephone support with home visit intervention was effective in reducing postpartum depression symptoms in

mothers.

89

S I G N


Taft, A. J., Small, R., Hegarty, K. L., Watson, L. F., Gold, L., & Lumley, J. A. (2011). Mothers'

AdvocateS In the Community (MOSAIC) -- non-professional mentor support to reduce intimate

partner violence and depression in mothers: a cluster randomised trial in primary care. BMC Public

Health, 11, 178.

Guideline topic:



women





1.2 The assignment of subjects to treatment groups is randomised. Yes

GP practices and

MCHN teams were

randomized at separate

public meetings for the

recruitment. For GPs,

names (stratified by

practice size – one GP

or more than one GP

participating)… the

selection made by an

invited guest from

outside the project or

research team.

90

1.3 An adequate concealment method is used. Yes Randomization were

concealed in opaque

envelopes and randomly

selected by someone

outside the study.

Similarly names of the

MCHN teams were

concealed in opaque

envelopes, with teams

stratified by the number of

births in the local

government area and GPs

and MCH nurse Team

Leaders were present to

ensure the fairness of the

process and to check the

contents of the envelopes

prior to their being sealed.

1.4 Subjects and investigators are kept ‘blind’ about treatment allocation. No MOSAIC is a

pragmatic

intervention study.

Due to cluster

randomization, it was

not possible to blind

the health care

providers… research

staff were not blind to

participant status.

91

1.5 The treatment and control groups are similar at the start of the trial. No At baseline, there

were few differences

in the

socio-demographic

profiles of

participants retained

in the study.

The intervention

group displayed

higher levels of

probable depression

and parenting stress

and significantly

lower social support.

Women lost to the

study were more

likely to be more

severely abused.

1.6 The only difference between groups is the treatment under investigation. No Baseline

socio-demographic,

depression and

parenting stress level

were different.




133 (76.4%) women

completed follow-up at 12

months.

Dropout rate is 23.6%.



Yes



No This is a cluster RCT

which participating

clinicians and GPs were

stratified and

randomized at the time

of participation.


92


Code as follows:

Acceptable (+)





Taking into account clinical considerations, evaluation

of the methodology used and the statistical power of

the study, it was certain that the overall effect was due

to the study intervention.



Yes



Author’s conclusion: The evidence for effective interventions to reduce IPV and improve abused women’s

wellbeing is very limited. In this first primary care randomized trial of non-professional mentor support for

women abused by intimate partners, there was evidence of a true difference of reduced partner violence

between mentored women referred from primary care populations compared with those not mentored. There

was weak evidence for other findings suggestive of mentor benefit in reducing depression and improving

physical and mental wellbeing.

Own comments: The weak intervention effect on both to reduce intimate partner violence and depression in

mothers might be due to potential bias in participant selection without blinding of clinicians during the

recruitment process and the small sample size being recruited (smaller number of participants being recruited

than anticipated). However, the intervention of providing home visits to mothers did show a clinical significant

result, and therefore, innovation was still useful and effective.

93

S I G N


Chen, C. H., Tseng, Y. F., Chou, F. H., & Wang, S. Y. (2000). Effects of support group intervention in

postnatally distressed women. A controlled study in Taiwan. J Psychosom Res, 49(6), 395-399.

Guideline topic:



women.





1.2 The assignment of subjects to treatment groups is randomised. Can’t say Women who met

the inclusion

criteria were

randomly

assigned to either

the support or

control groups.

1.3 An adequate concealment method is used. Can’t say Concealment

method was not

mentioned

1.4 Subjects and investigators are kept ‘blind’ about treatment allocation. Can’t say

94

1.5 The treatment and control groups are similar at the start of the trial. Yes There were no

significant differences

in the demographic

characteristics of the

experimental and

control groups. The

psychosocial

parameters of these

two groups before the

group meetings were

also similar.





Although 34 of the distressed

women who were assigned to the

experimental group consented to

attend the support group sessions,

4 of them declined participation.

30 women received intervention

and all completed the study.

Drop out = 0%



Yes



Does not apply



Code as follows:

Acceptable (+)







the study, it was certain that the overall effect is due to

the study intervention.



Yes


95


Author’s conclusion: A significant decrease from the baseline in the BDI scores was found in those

subjects who attended the support meetings. There was a significant decrease in the % of women with

BDI scored greater 9 (experimental group to 33% while the control group 60%) during their follow

up at the end of the four group sessions. The results demonstrated that participation in the support

group resulted in significant psychosocial benefits for postnatally distressed women.

Own comments: Participants in this RCT were Asians while subjects in other papers were

Westerners. The different in cultures and ethnicity may have confounders in future application of

innovation. This study adds evidence that the innovation of peer support also applies in Asian

cultures.

96

S I G N


Wiggins, M., Oakley, A., Roberts, I., Turner, H., Rajan, L., Austerberry, H., Mujica, R., Mugford, M.,

& Barker, M. (2005). Postnatal support for mothers living in disadvantaged inner city areas: a

randomised controlled trial. J Epidemiol Community Health, 59(4), 288-295.

Guideline topic:



women.





1.2 The assignment of subjects to treatment groups is randomised. Yes The allocation sequence

was computer generated

(MINIM software

program). These data

were entered into the

computer program to

determine the

participant’s allocation.

1.3 An adequate concealment method is used.

Can’t say The central

administrator

then wrote to the

participant giving

allocation status.

Potential

selection bias

presented.

97

1.4 Subjects and investigators are kept ‘blind’ about treatment allocation. Yes Because of the nature of

the interventions, it was

not possible for either

the trial participants or

the researchers to be

blinded to group

allocation. Data entry

staff were blind to

allocation at the second

follow up.

1.5 The treatment and control groups are similar at the start of the trial. Yes Baseline characteristics

of participants are

similar.





At 1st FU (12 months):

Dropout rate:

SHV: 10%

CGS: 11%

Control: 10%

At 2nd

FU (18 months):

Dropout rate:

SHV: 18%

CGS: 15%

Control: 20%



Yes Analysis was carried

out on an intention to

treat basis.



Does not apply



Code as follows:

Acceptable (+)



Taking into account the clinical methodology used and

statistical power of the study, the overall effect is due

98



to the study intervention.



Yes



Author’s conclusions: Strengths of this trial included that allocation was well concealed, potential

confounders were balanced in randomization, an intention to treat analysis was carried out, and

outcome data were collected for 90% of the randomized participants.

At 12 and 18 months, there was little impact for either intervention on maternal depression (SHV:

0.86; 0.62 to1.19, CGS: 0.93; 0.69 to 1.27). Uptake of CGS intervention was low (only only 35

participants out of 184 received supports offered) due to the possibility of that such intervention was

inappropriate for mothers living in disadvantaged inner city areas who percept the service offered as

personally or culturally inappropriate or unnecessary.

Own comment: The CGS intervention mainly provides supports to mothers in different forms (e.g.

home visiting and/or telephone support) while the SHV intervention provides home supports given by

health professionals. The non-significant result might be affected due to long intervention period (18

months) and high dropout of participants. However, the intervention of Community Group Support

provided by community supporters did show an effect in reducing depression in mothers, and

therefore, it was still considered clinically significant.

99

S I G N


Gjerdingen, D. K., McGovern, P., Pratt, R., Johnson, L., & Crow, S. (2013). Postpartum doula and

peer telephone support for postpartum depression: a pilot randomized controlled trial. J Prim Care

Community Health, 4(1), 36-43.

Guideline topic:



women.





1.2 The assignment of subjects to treatment groups is randomised.

Yes Women were randomly

assigned to 3 groups.

Unblinded random

assignment was

performed by the

support coordinator,

who used random

number tables.

1.3 An adequate concealment method is used. Can’t say Concealment

method was not

mentioned.

1.4 Subjects and investigators are kept ‘blind’ about treatment allocation. No Unblinded random

assignment was

performed by the

support coordinator,

who used random

number tables.

100

1.5 The treatment and control groups are similar at the start of the trial. No Baseline demographic

and selected health

characteristics

categorized by group

assignment reveal that a

higher percentage of

women in the

postpartum doula group

had a previous history

of depression. There

were also trends for

more current depression

and a lower health state

among women in the

postpartum doula group,

and a higher level of

education among

controls.

1.6 The only difference between groups is the treatment under investigation. No Baseline demographics

and depression rates are

different.




Of the 39 enrolled mothers, 2

dropped out after the initial

survey, 1 (8.3%) from the

postpartum doula group and 1

(7.7%) from the peer telephone

support group.



Yes Results are analyzed

using intent-to-treat

analysis.



Does not apply



Code as follows:1

Acceptable (+)

101







the study, the overall effect was due to the study

intervention.



Yes



Author’s conclusion: At 6 months, the postpartum doula group had a higher proportion of women

who were currently depressed (82% vs 21% to 64%; P = .008) and currently receiving depression

treatment (100% vs 25% to 50%; P = .019); in addition, their duration of depression treatment was

longer (24 weeks vs 9-12 weeks, P = .003). There were no significant group differences in CES-D

scores, general health, or social support at 6 months. The changes in CES-D depression scores for

doula, telephone support, and control groups at 6 month follow-up are −16.3, −14.5, and −10.1

respectively. (P = .397).

It is feasible to recruit postpartum doulas, peer telephone supporters, and mothers with depressive

symptoms for a peer support intervention though recruitment efforts for this particular study required

a broad, multifaceted approach.

Own comments: Due to the differences in baseline characteristics of mothers of in the Doulas Group

who had a larger percentage of depression history, presence of allocation bias and small sample size,

a non-significant result was obtained in the study. However, when comparing the CES-D depression

scores of the 3 study groups, there was consistently a reduction in the total scores of the 3 groups,

including the peer telephone support group. Its clinical significance for peer telephone support in

reducing depression score in postnatal women was still considered effective.

102

Appendix E:

Estimated Schedule for the plan of preparation, implementation and evaluation

of the EBP guideline

Phases Details Estimated

duration

Pre

para

tory

- Proposal & budget approval

- Formation of an organizing committee

- Presentation & introduction of innovation to clinic

staff

- Feedbacks & comments collection for refinement &

finalization of the EBP guideline protocol

- Briefing and training of staffs

2 months

Imp

lem

enta

tion

Pilot test:

Recruitment and training:

- Recruitment of participants and peer supporters

- Training of peer supporters

- Allocation of peer supporters to participants

Peer support intervention:

- Peer support provision by peer supporters to

participants

- Regular monitoring of intervention progress of peer

supporters by nurses at 1 week, 3rd

month & 6th

month through phone contacts with peer supporters

Evaluation:

- Post-intervention EPDS questionnaires to participants

- Surveys to participants, peer supporters & staff

- Focus group interview to nurses

- Data input and analysis

1 months

6 months

2 months

Full scale implementation :

Recruitment and training


18 months

Evalu

ati

on

- Post-intervention EPDS questionnaires to participants

- Surveys to participants, peer supporters & staff

- Focus group interview to nurses

- Data input and analysis

13 months

103

Appendix E (continued):

Gantt chart for the plan of preparation, implementation and evaluation of the Guideline

Phase Month

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Pre

para

tory

Proposal & budget approval

Formation of an organizing committee

Feedbacks & comments collection

Briefing and training of staffs

Imp

lem

enta

tion

Pil

ot

test

Sta

ges

1st: Recruitment & training

2nd

: Peer support intervention 6 months

3rd

: Evaluation 2

months

Fu

ll s

cale

imp

lem

enta

tion

Recruitment & training of

participants and peer

supporters

12 months

Peer support intervention 17 months

Evalu

ati

on

Post EPDS questionnaires

Surveys to participants, peer supporters

& staff

Focus group interview

Data input and analysis

13 months

104

Appendix F: Estimated cost for the proposed program

Estimated expenditure for pilot test

Category Items Price

per unit Quantity

Amount

(HKD $)

Material

cost Function room

$0.2/

page

Already

available

0

Overhead projector and computer 0

4-pages EBP protocol for nurses 4 3.2

10-pages training booklet for peer

supporters 18 36

1-page evaluation questionnaire for nurses 22 4.4

1-page evaluation questionnaire for

participants 36 7.2

1-page evaluation questionnaire for peer

supporters 18 3.6

Non-

material

cost

Manpower for the one hour briefing for

nurses $177/

hour

22 3,894

Manpower for the 2 four- hours training

workshop for peer supporters 2 1,416

Total $ 5,364.4

Estimated expenditure for full scale implementation of the program

Estimated number of postnatal mothers 460

Estimated number of peer supporters 230

Category Items Price per

unit Quantity

Amount

(HKD $)

Material

cost

10-pages training booklet for peer

supporters

$0.2

/page

230 460

1-page evaluation questionnaire for

participants 460 92

1-page evaluation questionnaire for peer

supporters 230 46

Non-

material

cost

Manpower for the four-hours training

workshop for peer supporters

$177/

hour 24 16,992

Total $ 17,590

105

Appendix G: Level of Evidence and Grades of Recommendations (SIGN, 2012)

Levels of evidence

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a

very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk

of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++

High quality systematic reviews of case control or cohort or studies High

quality case control or cohort studies with a very low risk of confounding or

bias and a high probability that the relationship is causal

2+ Well-conducted case control or cohort studies with a low risk of

confounding or bias and a moderate probability that the relationship is causal

2- Case control or cohort studies with a high risk of confounding or bias and a

significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

Grades of recommendations

A

At least one meta-analysis, systematic review, or RCT rated as 1++, and

directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly

applicable to the target population, and demonstrating overall consistency of

results

B

A body of evidence including studies rated as 2++, directly applicable to the

target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C

A body of evidence including studies rated as 2+, directly applicable to the

target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

106

Appendix H: EBP Protocol: Proposed program flow chart

refuse

Rec

ruit

men

t In

terv

enti

on

E

valu

ati

on

+/

Postnatal mothers attend MCHC

EPDS ≦9 EPDS >9

Explain intervention

& get consent

Stable mood;

Inclusion &

exclusion criteria

Routine MCHC

PND service

Refer Psy. Nurse /

doctor assessment

& counselling

agree

Allocation of peer

supporters to participants

Recruitment of

peer supporters

Routine MCHC service

4-hours training

workshop

Nurses phone peer

supporters using

Intervention

Progress Sheet

Post intervention

EPDS

Satisfaction survey to participants, peer supporters & nurses

Focus group meeting to nurses

Routine mood assessment &

professional judgment by nurses

Unstable mood

+/

Peer supporters provides

monthly phone intervention

to allocated participants

107

Appendix I: Intervention Progress Sheet for nurses to monitor progress of telephone contacts by peer supporters to postnatal mothers

Pair Subject Names Intervention details

Regular phone contacts by nurses

1st FU

(1 week)

2nd

FU

(3rd

month)

3rd

FU

(6th

month) prn FU

1 Peer supporter:

______________

Contact no.:

______________

Participant:

______________

Are you able to contact the allocated participant?

How many contacts been made till the moment?

Details of supporting services being given:

Any problems encountered?

2 Peer supporter:

______________

Contact no.:

______________

Participant:

______________

Are you able to contact the allocated participant?

How many contacts been made till the moment?

Details of supporting services being given:

Any problems encountered?

108

Appendix J: Consent form for participants and peer supporters

產後情緒支援互助小組參加者/義工支援者同意書

本計劃是一個經外國研究及驗證得出的有效情緒支援治療，臨床證實能減低

產後母親所出現的情緒問題及波動。為配合來之廣泛推廣及實行，本計劃將會在

本健康院進行試驗，現誠邀閣下參加本計劃，以作資料搜集及研究。所有個人

資料及相關驗證結果只會被衛生署用作內部資料統計及研究用途。

計劃名稱：產後情緒支援互助小組

形式：由義工支援者提供電話聯絡支援

義工支援者： - 均需出席一個歷時四小時、由註冊護士主理、有關

處理產後情緒問題的培訓及取得資格

過程： - 整個過程會由註冊護士作出監督

- 有需要時會由醫生或護士作出協助及轉介

時間：為期六個月

由＿＿＿＿＿＿至＿＿＿＿＿

若閣下明白以上計劃詳情及同意參加（包括提供個人資料及完成計劃後意

見問卷調查），請於下列位置簽名作實。

_____________________ ______________________ ______________________

參加者/義工支援者簽署參加者/義工支援者姓名日期

_____________________ ______________________ ______________________

護士簽署護士姓名日期

109

Appendix K: Content of the Half-Day Training Workshop for peer supporters

Content Estimated time

1. General Postnatal Depression Information

(a) What is postnatal depression (PND)?

- Incidence, prevalence, symptoms &

presentations of PND

(b) Causes of postnatal depression

(c) Detection & treatments of postnatal depression

60 minutes

2. Introduction to peer support intervention

(d) What is a peer volunteer?

(a) Benefits of peer support

(b) Nature of supports being provided

- Emotional, informational, validation and

appraisal supports

30 minutes

3. Relationship development

(a) Skills in getting & staying connected

(b) Skills in developing a relationship with mother

30 minutes

Break 15 minutes

4. Techniques for effective telephone peer support

(a) Empathetic listening

(b) Reflective listening

(c) Normalization and reflection

(d) Using open-end questions

(e) Group practice and return demonstration

60 minutes

5. Referral to professional services

(a) Deterioration of mood status

(b) Self harm or bay harm thought or act

(c) Child abuse or family violence

(d) Possible community social services

(e) Possible mental health professional referral

30 minutes

Q & A Session 15 minutes

110

Appendix L: Survey for staff

Questionnaire for Assessing Satisfaction Level of Nursing Staff

Item Strongly

disagree ……………………………....

Strongly

agree

1. The guideline is clear to understand and easy

to follow. 1 2 3 4 5

2. The objectives of the guideline are achieved. 1 2 3 4 5

3. The training received is adequate. 1 2 3 4 5

4. The committee is supportive throughout the

program. 1 2 3 4 5

5. The workload is affordable. 1 2 3 4 5

6. The intervention progress sheet for

monitoring peer supporters is easy to use. 1 2 3 4 5

7. The program is well organized. 1 2 3 4 5

8. I am competent to implement the program. 1 2 3 4 5

9. The program is effective in minimizing

postnatal depressive symptoms in at risks

PND women.

1 2 3 4 5

10. Overall, I am satisfied with this program. 1 2 3 4 5

*Please circle the appropriate answer.

Other comments or suggestions:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

111

Appendix M: Survey for participants

Questionnaire for Assessing Satisfaction Level of Participants

母嬰健康院 – 產後情緒支援互助小組計劃參加者滿意度問卷調查

項目

關於計劃內容非常不同意 ………………………………… 非常同意

1. 計劃前護士講解清晰詳盡。 1 2 3 4 5

2. 計劃流程安排暢順明確。 1 2 3 4 5

3. 電話支援互助形式方便有效。 1 2 3 4 5

4. 計劃能幫助我處理或減輕產後情緒問題。 1 2 3 4 5

關於義工支援者非常不同意 ………………………………… 非常同意

5. 我能夠方便地聯絡到我的義工支援者。 1 2 3 4 5

6. 義工支援者能提供足夠次數的電話聯絡。 1 2 3 4 5

7. 義工支援者所提供的支援切合我的需要。 1 2 3 4 5

8. 我對我的義工支援者感到滿意。 1 2 3 4 5

整體非常不同意 ………………………………… 非常同意

9. 我對產後情緒支援互助小組計劃感到滿意。 1 2 3 4 5

10. 我會將此計劃推薦給其他產後母親。 1 2 3 4 5

*請圈上適當答案

其它意見:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

112

Appendix N: Survey for peer supporters

Questionnaire for Assessing Satisfaction Level of Participants

母嬰健康院 – 產後情緒支援互助小組計劃義工支援者滿意度問卷調查

項目

關於計劃內容非常不同意 ……………………………… 非常同意

1. 計劃前護士講解清晰詳盡。 1 2 3 4 5

2. 計劃流程安排暢順明確。 1 2 3 4 5

3. 計劃前培訓內容足夠清晰。 1 2 3 4 5

4. 計劃其間護士能提供適當支持。 1 2 3 4 5

5. 電話支援互助形式方便有效。 1 2 3 4 5

6. 計劃能處理或減輕參加者的產後情緒問題。 1 2 3 4 5

關於參加者非常不同意 ……………………………… 非常同意

7. 我能夠方便地聯絡到我的產後母親。 1 2 3 4 5

8. 我能夠提供參加者所需的支援。 1 2 3 4 5

整體非常不同意 ……………………………… 非常同意

9. 我對產後情緒支援互助小組計劃感到滿意。 1 2 3 4 5

10. 我會將此計劃推薦給其他產後母親。 1 2 3 4 5

*請圈上適當答案

其它意見:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

113

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