High- versus low-intensity interventions for perinatal depression delivered by non-specialist primary maternal care providers in Nigeria: cluster randomised controlled trial (the EXPONATE trial)

Background: Contextually appropriate interventions delivered by primary maternal care providers might be effective in reducing the treatment gap for perinatal depression.Aim: To compare a high intensity psychological intervention with a low intensity enhanced usual care in the treatment of perinatal depression.Methods: This cluster randomized clinical trial was conducted in Ibadan, Nigeria between June 18, 2013 and December 11, 2015. Twenty-nine maternal care clinics were randomized to either high intensity (HIT, n=15) or low intensity (LIT, n=14) treatment. Pregnant women, registering for antenatal care, assessed to have DSM-IV major depression, received either enhanced usual care delivered by providers using the WHO Mental Health Gap Action Programme – Intervention Guide (LIT arm) or 8 weekly structured problem solving prenatal sessions delivered within a stepped care model (HIT arm). Primary outcome was recovery from depression 6 months postpartum (score < 6 on the Edinburgh Postnatal Depression Scale, (EPDS). Results: There were 686 participants, 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed recovery rates of 70% in the HIT arm and 66% in the LIT arm: adjusted risk difference 4% (95%CI: -4·1%, 12·0%), adjusted odds ratio 1·12 (95%CI: 0·73, 1·72). HIT was more effective among women with higher baseline EPDS scores (adjusted interaction OR 2·29, 95%CI 1·01, 5·20).Conclusions: Except among more severely depressed perinatal women, we found no strong evidence to recommend high intensity in preference to low intensity psychological intervention in routine primary maternal care

Embodying 'health citizenship' in health knowledge to fight health inequalities

This paper wishes to contribute to the debate around citizen participation in health system decision-making that has been present internationally for the last 30 years. I argue that if we aim to change health inequalities, health professionals and planners need to understand the illness and health service experience of citizens. The concept of 'health citizenship' introduced here refers to health knowledge that integrates the lay knowledge of patients and that this integration is translated into health actions such as clinical communication and the planning of health care, programs, and policy. We illustrate our argument with the two cases: health literacy and the promotion of breastfeeding in a Canadian population living in context of poverty. This paper then concludes by addressing the leadership role, Brazilian graduate nursing schools can play in promoting 'health citizenship' and by doing so, contribute to fight health inequalities

Hyperemesis Gravidarum in the context of migration: when the absence of cultural meaning gives rise to “blaming the victim”

Abstract Background Hyperemesis gravidarum (HG) is a rare complication of pregnancy that involves persistent nausea and extreme vomiting to an intensity that differentiates HG from nausea and vomiting commonly experienced during pregnancy. Research has suggested potential biological and psychological etiological pathways for HG, but the augmented prevalence in immigrant populations, which is 4.5 times higher, remains unclear. Studies show that in order to better address the psychosocial needs of immigrant patients with HG, we must first improve our understanding of how they experience their illness. The objective of this study was to understand the meaning and experience of HG among immigrant women in Canada. Methods Our “qualitative comparative analysis design” involved a sample of 15 pregnant mothers following their hospitalization for HG, including 11 immigrant women and 4 Canadian-born women recruited for comparison purposes. We used the Edinburgh Perinatal Depression Scale to assess distress, and the McGill Illness Narrative Interview Schedule to explore how pregnant women understood and experienced their HG and the health services that they received. Results With the exception of a few women whose mothers suffered from HG, immigrant women and their loved ones did not have cultural knowledge to attribute meaning to HG symptoms. This left them vulnerable to criticism from family, as well as feelings of self-doubt, stress, and anxiety. We interpret this phenomenon as ‘victim blaming’. Immigrant women’s experience of HG was also characterised by high levels of depressive symptoms (40%) which they linked to the severity of their symptoms, high levels of stress associated with adapting to their new country, social isolation, and loss of female family members. Furthermore, in contrast to Canadian-born women, immigrant women frequently reported feeling that their symptoms were minimized by hospital emergency room medical staff, which led to delays in obtaining appropriate health care. However, once admitted to hospital, they perceived the care provided by dieticians and nurses as helpful in managing their symptoms. Conclusions Wider awareness of the impact of HG may improve the quality of family support for immigrant women. There is a need to improve the delays and appropriateness of clinical care

Help-seeking for moderate to severe perinatal depression in Nigeria: Implications for a cultural-ecosocial approach to global mental health

Perinatal depression is a major public health problem that is under-treated in low- and middle-income countries, with negative community attitudes often cited as a major barrier to help-seeking and treatment. In this paper, we investigate help-seeking for perinatal depression, some of whom may have experienced psychosis in the context of perinatal depression, and its cultural shaping in Nigeria. Our approach was informed by cultural constructivist and critical anthropological perspectives to situate perinatal depression in ecosocial context with systematic attention to the social-structural determinants. Help-seeking was controlled by caregivers, but patients and caregivers differed in their definitions of illness onset: caregivers focused on violation of norms for maternal behavior, whereas patients focused on somatic and psychological distress. Help-seeking entailed use of two different reasoning approaches. The default approach was ad-hoc and contingency-based, depending on: 1) the kinds of help immediately available and the fit with experiential knowledge; 2) the meanings of the patient's problem as negotiated in social interactions; 3) concerns about stigma that led to secrecy in seeking help; and 4) the perceived degree of immediate risk to safety. The second approach involved more explicit deliberation and took over in situations of uncertainty including: 1) worsening or unremitting illness despite treatment; 2) harm from treatment; and 3) perceived inadequacy of a treatment to bring about healing. Avoiding mental illness stigmatization was seen as dependent on limiting public awareness of the individual's affliction. The meanings of illness were locally informed and negotiated in ongoing social interactions and practices of social recognition and status negotiation that legitimated illness and influenced help-seeking. Clarifying the social context of mental health problems and identifying cultural and structural risk and protective factors can inform the design of health care systems to improve access to care and the development of culturally appropriate and effective intervention programmes