Racial Cultural Perceptions of Nurses Associated With Screening for Postpartum Depression - Dissertation Example

?Racial Cultural perceptions of Registered Nurses associated with screening for PPD Postpartum Depression or PPD, as it is commonly referred to as, is a commonly encountered psychiatric ailment inflicting women after they have given birth to a child. The exact definition of postpartum depression is oft debated and several different criteria for defining this disorder have been proposed. According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV), PPD is defined as a major depressive illness having its onset upto four weeks after delivery (Bashiri & Spielvogel, 1999). However, other definitions include an onset period lasting upto 6 months to one year postpartum (Zubaran, Schumacher, Roxo, & Foresti, 2010). PPD belongs to a spectrum of psychiatric disorders experienced by women which ranges in severity from maternal blues, which is short-lived lasing from a few hours to a few days, to postpartum psychosis, which is the most severe disorder belonging to this group (Halbreich & Karkun, 2006). The prevalence of postpartum depression varies amongst different socioeconomic, racial, cultural and age groups and can range from 10%-15% in the general population (Driscoll, 2006), to as high as 37% amongst women belonging to lower socioeconomic strata (Segre, O'Hara, Arndt, & Beck, 2010) and 48%, in the adolescent age group (Driscoll, 2006). PPD is thought to occur from interplay between a variety of different factors which can be broadly categorized into three main categories, viz. Biological/Physiological factors, Psychological factors and Social/Cultural factors (Nahas & Amasheh, 1999; Callister, Beckstrand, & Corbet, 2010). Cultural and social factors have been found to play an important role in the etiology of PPD. This has several implications in the screening, diagnosis and treatment of PPD. Since nurses play a pivotal role in screening and diagnosis of postpartum psychiatric disorders, they should be aware of the role of culture in the causation and screening of PPD and should provide ‘Transcultural Care’ as proposed by Leininger (Leininger, 1998). This paper discusses the several cultural factors involved in the causation of PPD, the role of nurses in providing screening and treatment services for women regarding PPD during the postpartum period and the racial cultural perceptions of Registered Nurses regarding the screening for PPD. Etiology of PPD As discussed above, the etiology of PPD is multifactorial. It was previously postulated that PPD was exclusively biological in nature, caused by the drop in the levels of different hormones such as estrogen and progesterone in the body of the mother occurring after the delivery of the baby (Driscoll, 2006). Other biologic/physiological factors implicated in the etiology of PPD include genetic predisposition and physiological disturbances occurring as a result of sleep deprivation, amongst others. However, it has been now elucidated that PPD results from interplay between biologic and environmental factors, including and not limited to, social and cultural factors. Some of cultural factors which have been found to contribute towards the causation of PPD include a history of pre-existing depression in the mother, lack of social support, belonging to a low socioeconomic status, untoward or difficult pregnancy, history of stresses occurring during the postpartum period such as those associated with child care or an infant born with health issues, difficult family relationships, maternal age at the time of delivery and the gender of the newborn, since sons are more desirable than daughters in certain cultures and the birth of a daughter is associated with significant psychological distress (Driscoll, 2006; Goldbort, 2006). As depicted above, cultural influences contribute significantly in the causation of PPD. Thus, any strategies which are aimed at either screening, diagnosing and treating PPD should be tailored in a culturally appropriate manner. The role of Registered Nurses in the management of PPD Nurses play a significant role in the management of PPD, in that they are involved in both screening the women for PPD and also in its treatment, including the provision of counseling services and appropriate referral services when required. Over the decades, several screening tools have been developed for the recognition and early diagnosis of this disorder so that prompt treatment can be initiated accordingly. Amongst these, some of the commonly used screening modalities include the Edinburgh Postnatal Depression Scale (EPDS), Postpartum Depression Screening Scale (PDSS), Beck Depression Inventory (BDI-II) (Zubaran, Schumacher, Roxo, & Foresti, 2010). The most commonly used screening modality is the EPDS which has been shown to be ahighly sensitive and specific tool for the screening of PPD and has been translated into 11 languages to facilitate its use amongst women belonging to diverse cultural backgrounds (Driscoll, 2006; Callister, Beckstrand, & Corbet, 2010). Screening for PPD can be carried out by nurses in a wide variety of settings including home visits by nurses and during well-child visits in pediatric clinics since women belonging to certain cultures might not return at 6 weeks postpartum for a follow-up visit with their obstetrician. Moreover, other novel innovative strategies for screening include screening over the telephone or via internet based questionnaires, but the effectiveness of such strategies is yet to be proven (Callister, Beckstrand, & Corbet, 2010). In the UK, nurses provide home visits to women who have recently delivered a child as a part of universal child health surveillance during which they not only screen women for PPD, but also provide counseling sessions to women who are identified as being depressed. These counseling sessions, termed as "Listening Visits," are one hour sessions during which nurses offer active listening services and offer solutions to the women (Segre, O'Hara, Arndt, & Beck, 2010). Such an intervention has been found to be effective in improving the surveillance system for PPD and for the management of mild to moderate PPD in a home based setting and it has been proposed that such a system is implemented in other cultures too. Thus, it is evident from the above discussion that nurses are keyplayers in both the screening and treatment of women suffering from PPD. In order to facilitate the provision of these services, nurses need to be culturally sensitive and should approach each woman keeping in mind her cultural, racial and ethnic background and offer culturally appropriate solutions accordingly. A Transcultural approach to PPD Postpartum depression has been defined as a “culture-bound syndrome” (Zubaran, Schumacher, Roxo, & Foresti, 2010) and thus its management, including both diagnosis and treatment requires a transcultural approach. While studying cultural factors in the etiology of PPD, two different cultural divisions have been identified, viz. Technocentric and Ethnokinship cultures (Callister, Beckstrand, & Corbet, 2010). In Technocentric cultures, the main focus of care provided to women during the postpartum period is on ‘the technological monitoring of new mothers and their infants’ (Callister, Beckstrand, & Corbet, 2010) while Ethnokinship cultures are based mainly on family social support systems as options available for the care of mothers. Therefore, the problems encountered by women belonging to these two groups are distinct from each other. While women from Technocentric cultures experience problems such as role conflict, fatigue, and a diminished sense of self-worth, women from Ethnokinship cultures experience difficulties in coping up with different rituals and customs associated with child birth such as those related to social seclusion, hygiene, familial conflicts and child care (Callister, Beckstrand, & Corbet, 2010). It is important for the nurses to be aware of all these cultural differences in order to accurately identify and address the depressive symptoms being encountered by women being screened. Leininger’s theory of Transcultural Care Leininger proposed a holistic model for the care of patients belonging to culturally diverse backgrounds. According to Leininger, every individual’s expectations and experiences with care are related to his or her own cultural background. Thus, while dealing with individuals from culturally diverse backgrounds, interventions should be individualized and tailored in a culture appropriate manner (Leininger, 1995). In regard with PPD, nurses need to understand the different experiences, rituals and expectations associated with childbirth amongst women belonging to diverse cultural background. They should then use this knowledge to design culture-appropriate interventions accordingly. For example, the nurses should communicate with the women on a regular basis, provide them with opportunities to express their concerns, encourage women to share their experiences regarding childbirth with them and then offer culturally appropriate solutions (Driscoll, 2006). It has also been proposed that the encounter between the nurse and the woman should preferably happen in the absence of other family members as women might be uncomfortable in expressing their feelings and concerns in the presence of their family (Bashiri & Spielvogel, 1999). Similarly, the use of screening tools in the women’s native language, if available, is recommended. In addition, some studies have also advocated the use of simple, open ended questions such as “Are you sad and depressed?” and “Have you had a loss of pleasurable activities?” as an initial screen for PPD, as the use of such questions helps the women in opening up and sharing their experiences and concerns, some of which might not be covered by the screening tool being used (Goldbort, 2006). Similarly, while screening for PPD, nurses should keep several different cultural perspectives in view including cultural traditions and practices associated with birth and the conceptualization of different symptoms such as pain, etc since women may not recognize their symptoms as being related to PPD (Callister, Beckstrand, & Corbet, 2010). Thus, nurses need to be aware of culturally different expression of symptoms of PPD amongst different racial, ethnic and socioeconomic groups. For example, cultural studies have revealed that women belonging to Asian populations tend to display depressive symptoms in the form of somatic symptoms, such as headache, fatigue, etc while those belonging Western populations display more affective symptoms such as anxiety, irritability, etc (Halbreich & Karkun, 2006). Directions for future research Till date, most of the research focused on cultural aspects of PPD has centered on identifying the role of culture in the etiology and causation of PPD and there is a paucity of studies which have examined different culture appropriate solutions which can be provided by health care professionals to women suffering from PPD. Some implications for future research in this arena include development of culture sensitive assessment and screening tools in different languages (Zubaran, Schumacher, Roxo, & Foresti, 2010; Bashiri & Spielvogel, 1999); effective culture congruent interventions for the treatment of PPD (Callister, Beckstrand, & Corbet, 2010); developing methodologies to correctly identify the diverse symptomatologies and manifestations of PPD in women belonging to culturally diverse backgrounds(Callister, Beckstrand, & Corbet, 2010); and identifying the most appropriate setting for the interaction between health care professionals and women during which they can be screened for PPD, such as home health visits by nurses (Segre, O'Hara, Arndt, & Beck, 2010), amongst others. Conclusion Thus, in conclusion, postpartum depression is a disorder which affects women belonging to culturally diverse backgrounds. Social and cultural factors play an important role in the etiology of postpartum depression and should also be taken in to consideration while providing management strategies and interventions to women who are suffering from this disorder. Since nurses play an important role in the diagnosis and management of PPD, they should be aware of all these cultural factors and should provide culture appropriate solutions for women based on Leininger’s theory of transcultural care. Bibliography Bashiri, N., & Spielvogel, A. M. (1999). Postpartum Depression: A cross cultural perspective. Primary Care Update Obs/Gyne , 82–87. Beck, C. T. (2002). Postpartum Depression: A Metasynthesis. Qualitative Health Research , 453-472. Callister, L. C., Beckstrand, R. L., & Corbet, C. (2010). Postpartum Depression and Culture: Pesado Corazon. Mother and Child Care Nursing , 254-261. Driscoll, J. W. (2006). Postpartum Depression: How Nurses Can Identify and Care for Women Grappling With This Disorder. AWHONN Lifelines , 400-409. Glavin, K., Ellefsen, B., & Erdal, B. (2010). Norwegian Public Health Nurses' Experience Using a Screening Protocol for Postpartum Depression. Public Health Nursing , 255-262. Goldbort, J. (2006). Transcultural Analysis of Postpartum Depression. The American Journal of Maternal/Child Nursing , 121-126. Halbreich, U., & Karkun, S. (2006). Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. Journal of Affective Disorders , 97-111. Kendall-Tackett, K. A. (2005). Depression in new mothers: Causes, consequences, and treatment alternatives. New York: Haworth Maltreatment and Trauma Press. Leininger, M. M., (1995). Transcultural nursing: Concepts, theories, research, and practice. (2nd ed.). New York: McGraw-Hill. Leininger, M. M., (1998). Leininger’s Theory of Nursing: Cultural care diversity and universality. Nursing Science Quarterly, 1,152-160 Nahas, V., & Amasheh, N. (1999). Culture Care Meanings and Experiences of PostpartumDepression Among Jordanian Australian Women:A Transcultural Study. Journal of Transcultural Nursing , 37-45. Segre, L. S., O'Hara, M. W., Arndt, S., & Beck, C. T. (2010). Nursing Care for Postpartum Depression, Part 1: Do Nurses Think They Should Offer Both Screening and Counseling? The American Journal of Maternal/Child Nursing , 220-225. Zubaran, C., Schumacher, M., Roxo, M. R., & Foresti, K. (2010). Screening tools for postpartum depression: validity and cultural dimensions. African Journa of Psychiatry , 357-365. Read More