INTRODUCTION AND BACKGROUND

Depression is a significant contributor to the global burden of disease in terms of its prevalence, suffering, dysfunction, morbidity and economic burden. The burden of depression is increased over decades, in 1990 depression ranked as the fourth leading cause of disease burden worldwide after lower respiratory infections, diarrheal diseases, and conditions arising during the perinatal period. In the year 2000 depressive disorders were the third leading cause of disease behind lower respiratory infections and diarrheal disease. Depressive disorders now rank second in terms of global disability burden, according to the 2010 Global burden of Disease report.¹ In 2012, depression is estimated to affect 350 million people in all communities at all age groups across the world. It also reported that, if current trends for demographic and epidemiological transition continue, by the year 2020 depression would be the foremost cause of disability – adjusted life years (DALYs), secondary to ischemic heart disease.²

Though depression is the primary cause of disability for both genders, the burden is 50% higher for females than males. In fact, depression is the leading cause of disease burden for women in both high- income and low- and middle-income countries. The report on Global burden of Disease estimates the point prevalence of unipolar depressive episodes to be 1.9% for men and 3.2% for women, and the one-year prevalence has been estimated to be 5.8% for men and 9.5% for women.² In women’s life time the risk is particularly high around child birth period, especially the postnatal period is well established as an increased time of risk for the development of serious mood disorders. Depression after child birth is known as postpartum depression.

Postpartum depression is a mood disorder characterized by a prolonged period of emotional disturbance, occurring at a time of major life change and increased responsibilities in the care of a newborn that begins after childbirth and usually lasts beyond six weeks.⁷¹ By definition postpartum depression is a non psychotic depressive episode of mild to moderate severity, beginning in or extending into the first postnatal year. Beck described it as a thief that steals motherhood.⁴

Studies reported that the global prevalence of postpartum depression is from 5% to 25%.⁵Halbreich and Karkun, reviewed 143 studies to identify the prevalence of postpartum depression around worldwide. The results found that there is a wide range of reported prevalence of postpartum depression ranging from 0% to 60%. The authors concluded that the widely cited mean prevalence of postpartum depression 10% to 15% is not representative of the actual global prevalence and magnitude of the problem, due to wide range of reports.⁷²

Bener et al reported that among Arab women prevalence of postpartum depression was 18.6%, compared to the prevalence of anxiety 13.1% and stress 8.7%.⁷³ A study by Matthey et al also showed similar psychological morbidity among postpartum mothers, with 17% of prevalence for postpartum depression and 13% for anxiety.⁷⁴ In the same range, a population – based survey of Australian women reported that the prevalence rate 17.4% for postpartum depression and 12.7% for anxiety.⁷⁵

Hegde et al, found that in India the prevalence of depression was 11.3% in the immediate postpartum week, 15.8% at six weeks and 15.5% at fourteen weeks after delivery.⁶ Patel reported that prevalence of post-partum depression was  23% among Goa women in India.⁷ Nimisha et al found that, 12.5 % of Gujarati women affected with postpartum depression .⁸ Chandran M, reported the incidence of postpartum depression was 11%  among women from rural area of Tamil Nadu, India.⁹  These results consistently suggest that more than 10% of mothers suffer from depression, in the postpartum period.

Commonly identified predictors of maternal common mental disorders in South Asia include low socio-economic status, lack of social support, adverse life events, disappointment with the sex of the baby and a bad relationship with a mother-in-law or partner.⁹A cross-sectional community-based study identified  that high maternal age, low asset ownership, health problems in the ante partum, delivery or postpartum periods, caesarean section, an unwanted pregnancy for the mother, small perceived infant size and a stillbirth or neonatal death are the predictors of maternal psychological distress in a rural, largely tribal community sample in eastern India.¹² Another qualitative study in the community from rural south India shows that the following factors were associated with postpartum depression: age less than 20 or over 30 years, schooling less than five years, thoughts of aborting current pregnancy, unhappy marriage, physical abuse during current pregnancy and after childbirth, husband’s use of alcohol, girl child delivered in the absence of living boys and a preference for a boy, low birth weight and a family history of depression.¹³

A study of mothers in Goa shows that economic deprivation, poor marital relationship, the gender of infant as important risk factors for occurrence of postpartum depression.⁷ Nimisha,  identified that the gender of the child especially birth of girl when boy desired was the significant factor for PPD. Other factors include, multi gravida, women having past history of miscarriage, women feeling tense during pregnancy, women who could not share a confidence with partner and absence of someone other than mother and partner in whom the woman could confide were found to be the strongest predictors for developing postpartum depression among Guajarati women.⁸

In a cohort study from rural area of Tamil Nadu found that, Low income, birth of a daughter when a son was desired, relationship difficulties with mother in law and parents, adverse life events during pregnancy and lack of physical help were risk factors for the onset of post partum depression.⁹According to Sichel and Driscoll’s ‘EARTHQUAKE MODEL’, these risk factors can repeatedly weaken a mother’s fault line placing her in a dangerous position for an emotional earthquake, such as post partum depression.¹⁴

There is now considerable evidence to show that postpartum depression has a substantial impact on the mother and her partner, ¹⁵ the family, ¹⁶mother baby interactions, ¹⁷ and the longer term emotional and cognitive development of the baby, ¹⁸ especially when depression occurs in the first year of life.¹⁹ Though clinically and cost effective treatments are available, ^{20, 21} less than half of cases of postpartum  depression are detected in routine clinical practice.^{21, 22} Considering not only the high prevalence, and also the consequences of postpartum depression make it important public health issue need to be identified and treat as early as possible. So many studies addressed that postpartum depression screening is feasible in the outpatient setting and can improve the rates of detection and treatment.^{76, 77}In a recent Md current- India survey, 70% of doctors delivering 5 are more babies a week did not always screen for postpartum depression.

Key components of postpartum depression screening includes, which screening test or instrument to use, when to screen, who should screen and how to use the results of the screening test. Edinburgh postnatal Depression Scale (EPDS) is a validated instrument for screening of postpartum depression. EPDS is a short screening tool, easy to complete, free to providers, has been used in multiple ethnic and socioeconomic groups and settings and is available in multiple languages. Tamil version of Edinburgh postpartum depression scale available with a sentivity of 94.1% and a  specificity of 90.2% .EPDS increased the rate of diagnosis of postpartum depression  from 3.7% before screening to 10.7% post screening, with 19.8% of women having an abnormal screening test.

The Postpartum depression screening may be administered at any stage after birth. Very high scores within the first week may indicate severe “baby blues” and in this, in turn, may signal that postnatal depression likely to eventuate. Routine administration at 6-8 week, with repetition between 3-6 months is recommended, however, screening through to 12 months is beneficial. The minimum time period which the EPDS should be re administered    is after two weeks of initial assessment. The provider and the nature of his/her relationship with the mother may affect the willingness of the women to admit the symptoms of depression. Postpartum screening tool can be administered by any health professional who understands its use.

Several treatments options are available for postpartum depression, including antidepressants, psychotherapy and counselling. Many mothers with postpartum depression are hesitant to take antidepressants due to concerns about infant exposure to medication through breast milk or concerns about potential side effects⁴⁸, and therefore often prefer psychological treatments.⁴⁹ A Cochrane meta-analysis of ten randomized controlled trials of psychosocial and psychological treatments for postpartum depression concluded that both psychosocial and psychological interventions are effective in decreasing depression and are viable treatment options for postpartum depression.⁵⁰

A qualitative systematic review was done by Dennis CL, Chung-Lee L, to identify postpartum depression help-seeking barriers and maternal treatment preferences. A common help-seeking barrier was women’s inability to disclose their feelings, which was often reinforced by family members and health professionals’ reluctance to respond to the mothers’ emotional and practical needs. The lack of knowledge about postpartum depression or the acceptance of myths was a significant help-seeking barrier and rendered mothers unable to recognize the symptoms of depression. Women preferred to have "talking therapies" with someone who was nonjudgmental rather than receive pharmacological interventions.²⁴

Previous research on depression in primary care practices has identified 3 general types of barriers to effective depression diagnosis and treatment: patient-centered, physician-centered, and systems barriers.⁵²  Patient-centered variables include cost and lack of insurance coverage,time constraints,^53,57 social stigma,^53,55 non adherence to depression treatment, lack of follow-through with mental health referrals, and lack of access to care for various reasons.⁵⁵ Physician centered variables include lack of time,^56,55 managed care policies, competing demands,⁵⁴ insufficient training/knowledge, insurance or payment problems, and fear of legal repercussions. Systems based variables also play a role and include infrequent follow-up visits for mothers, lack of objective, proactive monitoring of recovery, and separation of primary care and mental health services.⁵⁴ In addition, mothers of infants may experience barriers that are unique to the postpartum or early child-rearing period, such as need for childcare during mental health visits, ⁵⁷ concern about medication effects on nursing infants,⁵⁸ and fear of judgment and referral to child protection.⁵⁹

Despite these numerous barriers, the opportunities afforded by postpartum depression screening and treatment are potentially vast and include not only improving the signs and symptoms of postpartum depression, but also enhancing the new mother’s ability to parent, and her ability to continue to actively participate in a marriage or relationship. Recognizing and treating postpartum depression provides opportunities to decrease divorce rates, improve rates of normal child development and lower suicide and infanticide rates.^60-65

NEED FOR THE STUDY

Postpartum depression is a hidden but important public health problem, depression during postpartum period compromises a woman’s parenting ability this, in turn, is associated with delays in cognitive, social and emotional development of exposed children.

Given the potentially serious consequences of postpartum depression, it is unfortunate that the rates of diagnosis and treatment of this serious problem are low^38-40 primarily because of lack of recognition.  According to WHO depression can be reliably diagnosed and treated in primary care. Studies that have addressed postpartum depression screening demonstrate that screening is feasible in the outpatient setting and can improve the rates of detection and treatment.⁴²

Vaishnavi et al studied on inequity in provision of maternal health care services in Tamil Nadu and Kerala, by using the National sample survey organization database on morbidity and health care (2004). The results found that, In Tamil Nadu public sector  antenatal care utilization was 68 percent in rural regions and 53 percent in urban regions, few (5%,n=35,489) and urban(1%; n=5937) women did not seek antenatal care . Regarding patterns of utilization of Institutional delivery, Urban Tamil Nadu had 97 percent institutional delivery, while in rural regions institutional delivery was 88 percent. In rural Tamil Nadu home deliveries were about 12 percent, of which 85 percent was concentrated among lower three quintiles. Patterns of utilization in postnatal care reveals that, public health system was the major provider of postnatal care in rural Tamil Nadu(54%), While 40% of postnatal care was provided by public providers in urban regions, about 22 percent(n=587834) rural women and 26 percent(n=301596) urban women did not seek postnatal care, of which more than 77 per cent belonged to lower quintiles. Authors concluded that in Tamil Nadu, improvement in all the three maternal health care services particularly in rural region is required.

Though most of the women receives postnatal care, in routine postnatal care were importance given to general examination of the mother and baby were mental health of the mother were largely neglected. Many literatures found that, postpartum mood disorders can be reliably diagnosed by community health workers.

Segre LS et al assessed nurses’ views of a nursing model in which nurses’ screen and also treat new mothers who exhibit symptoms of depression. Results found that, the majority of nurses “strongly agreed” or “agreed” with the statement “having nurses screen for depression using a brief screening tool is a good idea”. Most (67.1%) chose the Ob-Gyn Clinic as the appropriate site for such screening.⁴⁵  A descriptive qualitative study explores the use of a procedure for postpartum depression screening by public health nurses in a Norwegian municipality, and is based on in-depth interviews. The 11 nurses regarded the screening procedure as valuable and felt that the training they had received in its use made them more confident about supporting parents by discussing mental health problems. They found the Edinburgh Postnatal Depression Scale easy to score and easy for the mothers to complete, and they identified PPD more frequently than before.⁴⁶Women also had favourable views of being screened by nurses for depression. According to the study conducted by Segre, the majority (95.4%) indicated a willingness to complete a depression screening tool given by a nurse. When asked to indicate appropriate settings for a screening program (respondents could choose more than one), the most frequently chosen settings were the home, the Family Practice clinic (51.9 %,), and the Ob-Gyn clinic.⁴⁷

In the study on Nurses views on offer both Screening and Counselling for postpartum depression, the vast majority of nurses (93.7%) “Agreed” or “strongly agreed” with the statement “nurse-delivered counselling with mildly depressed women is a good idea.” Almost one-half of the nurses already regularly provided some form of counselling and approximately three quarters were willing to participate in a counselling skills training program. Respondents were evenly divided regarding whether nurse-delivered counselling should be taught to all nurses working with pregnant and postpartum women or whether it should be a specialty area for those nurses who would provide treatment. Less than 1.0% indicated that nurse-delivered counselling should not be implemented. The most frequently chosen setting for a nurse-delivered counselling program was home visits followed by the Ob-Gyn Clinic, the Family Practice Clinic, and the Paediatric Clinic . The extent to which the nurses in this sample already provided counselling differed significantly according to employment setting, with three distinct groups emerging: 1) administrators rated themselves as “never” providing counselling; 2) nurses in clinics frequented by postpartum women rated themselves as “occasionally” providing counselling, and 3) psychiatric nurses rated themselves as “usually” providing counselling.⁴⁵

Women also reported positive views of being counselled for depression by a nurse: most felt “depression counselling by a nurse is better than not receiving any treatment.” Fewer than one in five considered depression counselling by nurses to be risky. Only eight out of 132 indicated they would not be willing to see a nurse for treatment. In fact, most of the mother “strongly agreed” or “agreed” with the item, “I would be more likely to obtain help from a nurse than another type of mental health professional.” When asked from which type of professional they would prefer to obtain mental health care, this sample of low-income women most frequently chose nurses followed by social workers ,and then obstetricians or other physicians . When asked to indicate appropriate settings for a nurse delivered counselling program (respondents could choose more than one) these women most frequently chose the home, followed by the Family Practice clinic, the Ob-Gyn clinic, and the Paediatric clinic.⁴⁷

Appleby et al recommended that training health visitors in psycho social therapies leads to improved counselling skills and corresponding changes in management of postpartum depression, without increasing the costs of health visitor practice.  Authors also suggested that nurses in perinatal settings should screen their patients for depression, both as a part of a woman’s care and during paediatric care for their children. Implementation of a nurse-delivered perinatal screening will require educational programs for staff as well as the establishment of a screening protocol and referral sources. Screening and referral often highlight the lack of treatment resources and/or reluctance on the part of women to see a mental health professional.⁵¹ Glavin K et al examined the effect of supportive counselling by public health nurses on postpartum depression. Results found that Supportive counselling based on a non-directive counselling method provided by public health nurses is an effective treatment method for postpartum depression.⁶⁷

Morrell C et al did a clustered randomised trial to assess the effectiveness of training health visitors on screening and deliver psychologically informed interventions for postnatal depression. Health visitors are randomly divided in to one of three groups, first group trained to deliver cognitive behavioural approaches for postpartum depression, another group for person centred approach and control group health visitors delivered routine care and the outcomes are assessed with Edinburgh Postnatal Depression Scale. Results found that health visitor training reduced the proportion of women who were still at risk after 6 months compared with usual care 33.9% with training 45.6% with usual care; this effect remained for 1 year. Within the training group, there was no significant difference in the proportion of women remaining at risk between the cognitive behavioural approach and person centred approach. Economic analyses found that the training was highly likely to be cost effective compared with the control.⁶⁶

Literature shows, well documented prevalence and consequences of postpartum depression if left unidentified and untreated. In primary care psychological interventions are as clinically effective in the management of depression as routine care from a village health nurse. In spite of this evidences, researcher identified there is a gap in the identification and management of postpartum depression in the primary care setup especially in India. Hence, the researcher planned to develop and nursing protocol for village health nurses on postpartum depression management.

STATEMENT OF THE PROBLEM

A STUDY TO DEVELOP NURSING PROTOCOL ON MANAGEMENT OF  POSTPARTUM DEPRESSION  FOR VILLAGE HEALTH NURSES AND EVALUATE ITS EFFECTIVENESS AMONG MOTHERS WITH POSTPARTUM DEPRESSION  IN COIMBATORE DISTRICT, TAMILNADU.

RESEARCH QUESTIONS

1.      Does the nursing protocol useful for village health nurses in acquiring adequate knowledge and competency in screening and managing postpartum depression?

2.      Does the training of village health workers in using of nursing protocol result in improvement of knowledge and competency of village health nurses on screening and management of postpartum depression?

3.      Does nursing protocol on management of postpartum depression will be effective in decreasing the level of depression among mothers with postpartum depression?

4.      Were the mothers with postpartum depression satisfied with the care given by village health nurses?

OBJECTIVES

·         To develop a nursing protocol on management of postpartum depression for village health nurses.

·         To develop and conduct a training programme on screening and management of postpartum depression for village health nurses.

·         To evaluate the knowledge and competency  of village health nurses in screening and management of postpartum depression before and after the training programme in the experimental group and control group

·         To determine the relationship between knowledge and competency of village health nurses after the training programme on screening and management of postpartum depression.

·         To determine the association between knowledge, competency of village health nurses with selected demographic variables.

·          To evaluate the level of depression among postpartum mothers before and after implementation of nursing protocol on management of postpartum depression by village health nurses in experimental group.

·         To determine the level of satisfaction of the postpartum mothers regarding screening and management of postpartum depression by village health nurses using nursing protocol.

·          To determine the utility of nursing protocol on management of postpartum depression among village health nurses.

RESEARCH HYPOTHESES

H₁:  The mean post test knowledge score on nursing protocol in 7^th, 15^th and 30^th day will be significantly higher than the mean pre test knowledge score on nursing protocol of village health nurses in experimental group as measured by structured knowledge questionnaire at 0.05 level of significance.

H_2:  The mean post test knowledge score of nursing protocol on day 7^th, 15^th and 30^th of village health nurses in experimental group will be significantly higher than the mean post test knowledge score of control group as measured by structured knowledge questionnaire at 0.05 level of significance.

H₃: The mean post test competency score related to nursing protocol on 7^th, 15^th and 30^th day will be significantly higher than the mean pre test competency score of village health nurses in the experimental group as measured by counselling competencies scale at 0.05 level of significance.

H₄:  The mean post test competency score of nursing protocol on day 7^th,15^th and 30^th  of village health nurses in experimental group will be significantly higher than the mean post test competency score of control group as measured by counselling competencies scale at 0.05 level of significance.

H₅: There will be significant relationship between the knowledge and competency level on nursing protocol of the village health nurses in the experimental group after the training programme at 0.05 level of significance.

H₆: There will be a significant association between the knowledge, competency on nursing protocol of the village health nurses in the experimental group with selected variables at 0.05 level of significance.

H₇: The mean post test EPDS score  on 8^th,12^th and 24^th week  will be significantly lower than the mean pre test EPDS of mothers with postpartum depression in experimental group as measured with EPDS at 0.05 level of significance.

H₈: The mean post test EPDS score on 8^th, 12th and 24^th week will be significantly lower than the mean post test EPDS score of control group as measured by EPDS at 0.05 level of significance.

OPERATIONAL DEFINITIONS

Nursing protocol on management of postpartum depression:

It includes specific guidelines for village health nurses regarding screening and management of postpartum depression. It includes the following aspects:

Part I: Includes definition, risk factors, clinical manifestations and complications of postpartum depression.

Part II: Screening of postpartum depression, application of EPDS its scoring and interpretation.

Part III: Steps of Listening visits

Part IV: Referring the mother to specialist consultation.

Village health nurse: Refers to Auxiliary Nurse Midwives/MPHW who is working at sub centre level of Coimbatore district.

Postpartum depression: Non psychotic depressive episode with onset of 4 weeks after childbirth, which will be assessed with EPDS score of > 8 on EPDS, indicates probable risk of developing postpartum depression.

Postpartum mother: Refers to a mother who are in the period of 4 weeks to 6 months of postpartum period, above 18 years of age, not an anaemic and without suicidal ideas.

Training programme: It refers to a programme which aims at training of village health nurses on screening and management of postpartum depression.

The training programme includes,

·         Postpartum depression screening workshop, which includes,

§  Definition of postpartum depression

§  Prevalence and risk factors

§  Clinical manifestations

§  Negative effects of postpartum depression.

§  Screening methods

§  EPDS – application and scoring

·         Listening visits workshop

§  Description of listening visit

§  Teaches the component of listening visit

·         Introducing listening visits to the mothers

·         Active reflective listening

·          Collaborative problem solving

Through lectures, exercises and video-demonstrations.

·         Knowledge:

It refers to the ability of the village health nurses to respond to the questions regarding screening and management of postpartum depression as evident from knowledge score as measured by structured knowledge questionnaire.

·         Competency: 

Refers to the ability of the village health nurses to perform non-directive counselling in the form of listening visit as evident from competency score measured by counselling competencies scale.

CONCEPTUAL FRAMEWORK

Context, Input, Process, and Product Evaluation Model (CIPP)

The CIPP model of evaluation was developed by Daniel Stufflebeam and colleagues in the 1960s. The CIPP model represents a holistic approach to conducting evaluations of education, health and other public programs. The acronym CIPP represents the four main components of this type of evaluation: context, input, process and product. According to Stufflebeam, the objective of context evaluation is to assess the overall environmental readiness of the project, examine whether existing goals and priorities are attuned to needs, and assess whether pro­posed objectives are sufficiently responsive to assessed needs. The purpose of an input evaluation is to help prescribe a program by which to make needed changes. During input evaluation, experts, evaluators, and stakeholders identify or create potentially relevant approaches. Then they assess the potential approaches and help formulate a responsive plan. Process evaluation affords opportuni­ties to assess periodically the extent to which the project is being carried out appropriately and effectively. Product evaluation identi­fies and assesses project outcomes, both intended and unintended.⁶⁸

Specifically, CIPP evaluation model as a comprehensive framework to guide the planning, implementation, and assessment of service-learning programs this can help to identify service providers’ learning needs and the community’s needs. The input evaluation component can then help prescribe a responsive project that can best address the identified needs. Next, the process evaluation component monitors the project process and potential procedural barriers, and identifies needs for project adjustments. Finally, the product evaluation component measures, interprets, and judges project outcomes and interprets their merit, worth, sig­nificance, and probity.⁶

RESEARCH METHODOLOGY

APPROACH         

 For the present study the researcher plans to adopt quantitative approach to achieve the objectives of the study.

DESIGN 

The researcher plans to adopt true experimental pre test-post test with control group design to fulfil the objectives of the study. 

The study will be conducted in two phases

Phase I : Development of Nursing protocol and training of Village Health Nurses in  implementation of  nursing protocol

Phase II: Implementation of Nursing protocol on management of postpartum depression by Village health nurses and evaluating its effectiveness in terms of reduction in level of depression among mothers with postpartum depression.

PHASE- I      (TRAINING OF VILLAGE HEALTH NURSES)

R_E - Randomly selected Experimental group of VHNs

R_C - Randomly selected Control group of VHNs

OK₁ – Assessment on Knowledge of VHNs before administration of Training programme.

OC₁- Assessment on Competency of VHNs on non directive counselling before administration of Training programme.

X- Administration on training programme for VHNs on screening and management of postpartum depression

OK₂- Assessment on Knowledge of VHNs on 7^th day of after administration of Training programme.

OC₂- Assessment on Competency of VHNs on 7^th day of after administration of Training programme.

OK₃- Assessment on Knowledge of VHNs on 15th day of after administration of Training programme.

OC₃- Assessment on Competency of VHNs on 15^th day of after administration of Training programme.

OK₄- Assessment on Knowledge of VHNs on 30^th day of after administration of Training programme.

OC₄- Assessment on Competency of VHNs on 30^th day of after administration of Training programme.

PHASE- II (EVALUATION OF EFFECTIVENESS OF NURSING PROTOCOL OF MANAGEMENT OF POSTPARTUM DEPRESSION)

R_E – Randomly selected experimental group of mothers with postpartum depression

R_C – Randomly selected control group of mothers with postpartum depression

OD₁- Assessment on level of depression with EPDS before administration of listening visits.

OD₂- Assessment on level of depression with EPDS at the end of 8^th week after administration of listening visits.

OD₃- Assessment on level of depression with EPDS at the end of 12^th week after administration of listening visits.

OD₄- Assessment on level of depression with EPDS at the end of 24^th week after administration of listening visits.

VARIABLES IN THE STUDY

PHASE I:

·         Independent variable:  Training programme on screening and management of PPD

·         Dependent  variable: Knowledge and competency of VHNs

 PHASE II:

·         Independent variable:  Nursing protocol on management of Postpartum depression

·         Dependent variable:  Level of depression among mothers with postpartum depression.

SETTING OF STUDY

This proposed research will be conducted in Coimbatore district. In Coimbatore primary health care was delivered through primary health centres and sub centres. There will be one village health nurse for each sub centre which covers 8,000 to 20,000 populations. Coimbatore district includes 328 sub centres. The eligibility of setting was determined based on availability of village health nurses in sub centre, 67 sub centres were excluded because of non availability of village health nurse. Remaining of 251 sub centres was included as setting in the study.

POPULATION

PHASE I: All the VHN’s who are working at the sub centre level in Coimbatore district

PHASE II: All  Mothers with postpartum depression who are attending sub center

SAMPLING

PHASE I:  Multi stage random sampling

Initial stage blocks in Coimbatore district will be randomly selected

PHC’s will be randomly selected from each block

Sub centres under each PHC will be further selected through randomization

The sub centres will be randomly allocated to experimental and control group

The VHN’s belong to the experimental sub centres will be the experimental group and who belongs to control group sub centres will be the control group.

PHSAE II: Simple random sampling by using lottery method.

Mothers with postpartum depression belongs to selected sub centre population will be randomly selected by using simple random sampling.

Sample size:

PHASE I:    60 Village health nurses

Experimental group – 30, Control group – 30

PHASE II:  120   mothers with postpartum depression

Experimental group – 60, Control group - 60

CRITERIA FOR SELECTION OF SAMPLES

Inclusion criteria:-

-          Mother with EPDS score of > 8 without suicidal ideation.

-          Mother who delivered within 4 weeks to 6 months of the period of data collection.

-          Aged 18 years are more.

Exclusion criteria:-

-          Pregnant at baseline.

-          With pervious history of psychosis.

-          Mothers who are taking anti psychotic medication.

-          Mothers who are anaemic having haemoglobin less than 8 gm/ dl.

TOOLS & TECHNIQUES

PHASE I:

PHASE II

DESCRIPTION OF THE TOOL

STRUCTURED KNOWLEDGE QUESTIONNAIRE

The structured knowledge questionnaire comprises of two sections

 Section A: comprises of information pertaining to the VHN’s background characteristics

Section B: comprises of items pertaining to knowledge covering the following areas:

Ø  Definition of postpartum depression

Ø  Risk factors for postpartum depression

Ø  Clinical manifestations

Ø  Screening of postpartum depression

Ø   Management of postpartum depression

COUNSELLING COMPETENCIES SCALE

The Counselling Competencies Scale (CCS) includes three parts,

Ø  Primary counselling skills

Ø  Professional dispositions

Ø  Primary professional behaviours

Jacqueline et al examined the psychometric properties of the Counselling Competencies Scale. The results found that interrater reliability for the CCS score was .570, and criterion- related validity was .407. Thus, the results provided support for using the CCS to assess the counselling professional competencies.

SUICIDE BEHAVIOUR QUESTIONNAIRE – REVISED         

The Suicide Behaviors Questionnaire- Revised ( SBQ- R) has 4 items,

·         Item 1 taps into lifetime suicide ideation and /or suicide attempt

·         Item 2 assesses  the frequency of suicidal ideation over the past twelve months

·         Item 3 assesses the threat of suicide attempt

·         Item 4 evaluates self reported likelihood of suicidal behaviour in the future.

This scale is available with sensitivity of 93% and specificity of 95%.

WHO HAEMOGLOBIN COLOUR SCALE

WHO haemoglobin colour scale is a scale which indicates haemoglobin level by dropping of blood on a test strip provided with six colours to find the closest match. The six shades of red reflect haemoglobin levels at 4, 6, 8, 10, 12, and 14 g/dl. The haemoglobin level will indicate whether the patient is anaemic and the severity of anaemia

EDINBURGH POSTNATAL DEPRESSION SCALE

EPDS is a self report scale includes, 10 – item instrument to assess the depressive symptoms in postpartum period. Tamil version of EPDS available with sensitivity 86% and   specificity of 78%.

INTERVENTION

PHASE I:

Training programme on screening and management of postpartum depression among VHNs.

PHASE II:

            Implementation of nursing protocol on management of postpartum depression by VHN for mothers with postpartum depression.

ETHICAL CONSIDERATIONS AND CLEARANCE

-          The ethical approval will be obtained from the institutional ethical committee.

-          The formal administrative permission will be obtained from District directorate Health, Coimbatore.

-          Informed consent will be    taken from the VHN’s willing to participate in the study

-          Written consent will be obtained from the mothers before proceeding.

-          Anonymity and confidentiality of the data will be maintained.

PLAN FOR PILOT STUDY

-          The pilot study will be conducted in the Thudiyalur block which includes 10 sub centres to find out the feasibility of the tool and the study.

-          Pilot study will be conducted on 10 VHNs in Phase I ( 5 in experimental group and 5 in control group)

-          In Phase II 20 mothers with postpartum depression will be selected.( 10 for experimental group and 10 for control group)

PROCEDURE OF DATA COLLECTION

·         Formal administrative permission will be obtained from the medical officer of the concerned PHC under which the sub centre falls.

·         The VHNs will be informed about the training programme during the monthly review meeting at the PHC by the medical officer and the investigator.

·         The sample will be selected as per the sampling process for the experimental and control group.

DURING PHASE I OF THE STUDY:

·         On day one : Assessment on  knowledge and  competency of the VHN’s will  be done using structured knowledge questionnaire followed by the counselling competencies scale will be carried out in experimental and control group.(Pre test)   

·         On the same day :  Intervention ( Training programme on screening and management of postpartum depression ) will be administered to experimental group whereas no treatment will be given to the control group ( treatment)

·         On day 7^th 15^th and 30^th day: Assessment of the  knowledge and competency of the VHN’s will be done when they are called for the follow up meeting during which the structured knowledge questionnaire  and counselling competency scale will be administered for  experimental and control group  to evaluate the effectiveness of the training programme ( post test).

              DURING PHASE II OF THE STUDY:

·         Formal administrative permission will be obtained from the medical officer of the concerned PHC under which the sub centre falls.

·         The subjects ( mother with postpartum depression) will be selected as per the sampling process for the experimental and control group

·         The subjects will be informed about the research and informed consent will be taken.

·         On day one:  Assessment on  level of depression among mothers with postpartum depression will be done by using EPDS in experimental and control group ( Pre test)

·         Day one to eight weeks (Weekly once / one hour):  Experimental group mothers will be receives listening visits by VHNs based on nursing protocol on management of postpartum depression whereby control group receives routine care by VHNs.(Treatment)

·         End of 8^th, 12^th and 24^th week:  Assessment on the level of depression among mothers with postpartum depression will be assessed for both experimental and control group to evaluate the effectiveness of the nursing protocol on management on postpartum depression implemented by VHNs. ( post test)

·         The satisfaction of the mothers with regard to the care provided to them by VHNs will be assessed at end of 24^th week.

·         The utilization of the nursing protocol will be assessed among VHNs at the end of 24^th week

PLAN FOR DATA ANALYSIS & STATISTICAL APPLICATION

·         The data will be analysed using descriptive and inferential statistics (Phase I &Phase II)

·         Frequency and percentage will be used to describe the sample characterises

·         Mean, median, standard deviation will be calculated

·         “t” test will be done to determine the difference between per test and post test mean in experimental and control group

·         Co efficient of correlation between pre test and post test knowledge and competency score mean will be calculated for experimental group.

·         Chi square test will be done to determine the association of knowledge and competency of VHNs with selected variables.

CONCLUSION                                                                                       

Postpartum depression is a disorder of major public health importance, in terms of its prevalence and consequences. In spite of well documented risk factors and health consequences it often remains undetected and untreated. There are numerous barriers for identification and management of postpartum depression includes social stigma, non availability of services, and lack of recognition from health care team, concern about medication effects and fear of being diagnosed with mental disorder. Regardless of these barriers, the opportunities for early identification and management of postpartum depression are vast, including screening and care by primary health care workers and following proper referral system. Hence the researcher plan to develop and evaluate the effectiveness of nursing protocol on postpartum depression management for the use of village health nurses to screen and manage postpartum depression and follow appropriate referral system.

ACTION PLAN

REFERENCES

1.      Lopez AD,Mathers CD, Ezzati M, JamisonDT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet [internet]. 2006 [cited 2013 May 4]; 367(9524):1747-57.Available from:

              http://www.ncbi.nlm.nih.gov/pubmed/16731270

2.      Marina Marcus, M. Taghi Yasamy, Mark van Ommeren, and Dan Chisholm, Shekhar Saxena. Depression A Global Public Health Concern [internet].2012 [ updated 2013 Jan 10 cited 2013 June 3].Available from

http://www.who.int/mental_health/management/depression/who_paper_depression_wfmh_2012.pdf

3.       Sadock JB, Sadock VA  Ruiz P, editors. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry [9th etd].  Wolter kluwer:Lippincott Williams & Wilkins;2009.

4.      Beck CT. Postpartum depression: It isn’t just the blues. Am J Nurs 2006; 106: 40-50.

5.      Paulson, James F. Focusing on depression in expectant and new fathers: prenatal and postpartum depression not limited to mothers. Psychiatry Times.2010; 27 (2). http://www.psychiatrictimes.com/depression/content/article/10168/1519072.

6.      Hegde S, Latha KS, Bhat SM , Sharma PSVN, Kamath A, et al. Postpartum Depression: Prevalence and Associated Factors among Women in India. J Womens Health. 2012 ; Issues Care 1:1. doi:10.4172/2325-9795.1000101.

7.      Patel V, DeSouza N, Rodrigues M. Postnatal depression and infant growth and development in low income countries: A cohort study from Goa, India. Arch dis child. 2003; 88: 34-7.

8.      Nimisha DD, Ritambhara MY, Jaishree G. Study of prevalence and risk factorsPostpartum depression. National Journal of Medical Research. 2012; 2 (2), ISSN: 2249 4995 Essen: 2277 8810.

9.      Chandran M. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India: Incidence and risk factors. The British Journal of Psychiatry [Internet]. 2002 Dec 1 [cited 2012 Jul 26];181(6):499–504. Available from: http://bjp.rcpsych.org/cgi/doi/10.1192/bjp.181.6.499

10.  Beck, Cheryl Tatano. The Lived Experience of Postpartum Depression: A Phenomenological Study. Nursing Research.1992; 41 (3).

11.  Robinson GE, Stewart DE. Postpartum disorders. In: Stotland NL, Stewart DE, editors .Psychological aspects of women’s health care, 2nd ed. Washington, DC: American Psychiatric Press,Inc;2001. p. 117-139

12.  Prost  A et al. Predictors of maternal psychological distress in rural India: A cross-sectional community-based study. J Affect Disord. 2012 May; 138(3): 277–286.doi:  10.1016/j.jad.2012.01.029

13.  Savarimuthu R.J.S, Ezhilarasu P, Charles H, Antonisamy B, Kurian S, Jacob K.S. Post-Partum Depression in the Community: a Qualitative Study From Rural South India. Int J Soc Psychiatry 2010; 56: 94-102.

14.  Sichel D, Driscoll J W. Women’s moods: What every woman must know about hormones, the brain and emotional health. Newyork: William morrow and company, inc; 1999.

15.  Boath EH, Pryce AJ, Cox JL. Postnatal depression: the impact on the family. J Reprod Infant Psychol 1998;16:199-203.

16.  Lovestone S, Kumar R. Postnatal psychiatric illness: the impact on partners.Br J Psychiatry 1993;163:210-6.

17.  Murray L, Fiori-Cowley A, Hooper R, Cooper P. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome.Child Dev 1996;67:2512-26.

18.  Murray L, Sinclair D, Cooper P, Ducournau P, Turner P, Stein A. The socioemotional development of 5-year-old children of postnatally depressed mothers. J Child Psychol Psychiatry 1999;40:1259-71.

19.  Cogill S, Caplan H, Alexandra H, Robson K, Kumar R. Impact ofmaternal postnatal depression on cognitive development of young children.BMJ1986;292:1165-7.

20.   NICE. Antenatal and postnatal mental health: clinical management and service guidance. 2007. www.nice.org.uk/CG45.

21.   Hendrick V. Treatment of postnatal depression.BMJ 2003;327:1003-4.

22.  Hearn G, Iliff A, Jones I, Kirby A, Ormiston P, Parr P, et al. Postnataldepression in the community.Br J Gen Pract1998;48:1064-6.

23.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Discriptions and Diagnostic Guidelines Geneva: World Health Organization

24.  Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth. 2006 Dec; 33(4):323-31.

25.  Robertson, E., Celasun, N., and Stewart, D.E. (2003). Risk factors for postpartum depression. In Stewart, D.E., Robertson, E., Dennis, C.-L., Grace, S.L., & Wallington, T. (2003). Postpartum depression: Literature review of risk factors and interventions.

26.  Wisner KL et al Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women With Screen-Positive Depression FindingsJAMA Psychiatry. 2013;70(5):490-498. doi:10.1001/jamapsychiatry.2013.87. http://archpsyc.jamanetwork.com/article.aspx?articleid=1666651

27.  Dabrowski R. Thousands suffer in silence from postnatal depression [Internet].2011[updated 2012 feb 10 ; cited 2013 June 6]. Available from http://www.rcm.org.uk/midwives/news/thousands-suffer-in-silence-from-postnatal-depression/

28.  Beck CT, Indman P. Themany faces of postpartumdepression. J Obstet Gynecol Neonatal Nurs 2005;34(5):569-76.

29.  Paulson JF, Bazemore SD, Prevalence HE, Fac R. CLINICIAN ’ S CORNER Prenatal and Postpartum Depression in Fathers. 2010;303(19):1961–9.

30.  Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behavior: a metaanalytic review. Clinical Psychology Review 2000;20:561–592.

31.  Ferber SG, Feldman R, Makhoul IR. The development of maternal touch across the first year of life.Early Human Development 2008;84:363–370.

32.  Fergus, EL.; Schmidth, J.; Pickens, J. Touch during mother-infant interactions: the effects of parenting stress, depression and anxiety; Poster presented at the meeting of the International Society of Infant Studies; April; Atlanta, GA. 1998.

33.  Dennis C-L, McQueen K. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics [Internet]. 2009 Apr [cited 2012 Jul 18];123(4):e736–51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19336362.

34.  Goodman SH, Rouse MH, Connell AM, Broth MR, Hall CM, Heyward D. Maternal depression and child psychopathology: a meta-analytic review. Clinical child and family psychology review [Internet]. 2011 Mar [cited 2012 Aug 30];14(1):1–27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21052833.

35.  Minkovitz CS, Strobino D, Charfstein D, Hou W, Miller T, Mistry KB, Swartz K. Maternal depressivesymptoms and children’s receipt of health care in the first 3 years of life. Pediatrics 2005; 115:306–314.

36.  Jennings KD, Ross S, Popper S, Elmore M. Thought of harming infants in depressed and non depressed mothers. Journal of Affective Disorders 1999; 54:21–28.

37.  McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. The timing of maternal depressivesymptoms and mothers’ parenting practices with young children: implications for pediatric practice. Pediatrics 2006; 118:e174–e182.

38.  Georgiopoulos AM, Bryan TL, Wollan P, Yawn BP. Routine screening for postpartum depression. J Fam Pract. 2001; 50: 117–22.

39.  Evins GG, Theofrasstous JP, Galvin SL. Postpartum depression: a comparison of screening and routine clinical evaluation. Am J Obstet Gynecol. 2000; 182: 1080–2.

40.  Hearn G, Iliff A, Jones I, et al. Postnatal depression in the community.Br J Gen Pract. 1998; 48: 1064–66.

41.  Dubey C, Gupta N, Bhasin S, Muthal RA, Arora R. Prevalence and associated risk factors for postpartum depression in women attending a tertiary hospital, Delhi, India. Int J Soc Psychiatry. 2012 Nov; 58(6):577-80. doi: 10.1177/0020764011415210. Epub 2011 Aug 5. Available at: http://isp.sagepub.com/content/58/6/577.long

42.  Chaudron LH, Szilagyi PG, Kitzman HJ, Wadkins HIM, Conwell Y. Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics. 2004; 113:551–8.

43.  Evins GG, Theofrasstous JP, Galvin SL. Postpartum depression: a comparison of screening and routine clinical evaluation. Am J Obstet Gynecol. 2000;182: 1080–2.

44.  Benjamin D, Chandramohan A, Ik A, Prasad J, Ks J. Validation of the Tamil version of Edinburgh post-partum depression scale. The journal of Obstetrics and Gynecology of India. 2005;55(3):241–3.

45.  Segre LS, O’Hara MW, Arndt S, Beck CT. Nursing care for postpartum depression, part 1: do nurses think they should offer both screening and counselling. MCN Am J Matern Child Nurs. 2010 Jul-Aug;35(4):220-5.

46.  Glavin K, Ellefsen B, Erdal B. Norwegian public health nurses’ experience using a screening protocol for postpartum depression. Public Health Nurs. 2010 May-Jun;27(3):255-62.

47.  Segre LS, O’Hara MW, Arndt S, Beck CT. Screening and Counseling for Postpartum Depression by Nurses: The Women’s Views. MCN Am J Matern Child Nurs. 2010 ; 35(5): 280–285.

48.  Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: A qualitative systemic review. Birth. 2006;33:323–331.

49.  Buist A, Bilszta J, Barnett Milgrom J, Ericksen J, Condon J, et al. Recognition and management of perinatal depression in general practice. Aust Fam Physician. 2005;34:787–790.

50.   Dennis CL, Hodnett ED. Psychosocial and psychological interventions for treating postpartum depression. Cochrane Database of Systematic Reviews 2007, Issue 4. Art No.: CD006116. DOI: 10.1002/14651858. CD006116pub2.

51.  Appleby L, Hirst E, Marshall S, Keeling F, Brind J, Butterworth T, et al. The treatment of postnatal depression by health visitors : impact of brief training on skills and clinical practice. 2003;77:261–6.

52.  Nutting PA, Rost K, Dickinson M, et al. Barriers to initiating depression treatment in primary care practice. J Gen Intern Med. 2002; 17: 103–11.

53.  Scholle SH, Haskett RF, Janusa BH, Pincus HA, Kupfer DJ. Addressing depression in obstetrics/gynecology practice. Gen Hosp Psychiatry.2003; 25: 83–90.

54.  Katon WJ, Ludman EJ. Improving services for women with depression in primary care settings. Psychol Women Quarterly. 2003; 27: 114–20.

55.  Williams JW, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ. Primary care physicians’ approach to depressive disorders. Arch Fam Med. 1999; 8:58–67.

56.  LaRocco-Cockburn A, Melville J, Bell M, Katon W. Depression screening attitudes and practices among obstetrician-gynecologists. Obstet Gynecol. 2003; 101: 892–8.

57.   Ugarriza DN. Group therapy and its barriers for women suffering from postpartum depression. Arch Psychiatr. Nurs. 2004; 18: 39–48

58.  Gjerdingen D. The effectiveness of various postpartum depression treatments and the impact of antidepressant drugs on nursing infants. J Am Board Fam Pract. 2003; 16: 372–82

59.   Heneghan AM, Mercer MB, Deleone NL. Will mothers discuss parenting stress and depressive symptoms with their child’s pediatrician?Pediatrics. 2004; 113: 460–7. 

60.  Field T. Maternal depression effects on infants and early interventions.PrevMed.1998;27:200-3. 

61.  Murray L, Sinclair D, Cooper P, et al. The socioemotional development of 5-year-old children of postnatally depressed mothers. J Child Psychiatry.1999; 40: 1259–71.

62.  Zelkowitz P, Milet TH. Screening for post-partum depression in a community sample. Can J Psychiatry. 1995; 40: 80–6.

63.  Wang SY, Chen CH, Chin CC, Lee SL. Impact of postpartum depression on the mother-infant couple. Birth. 2005; 32: 39–44. 

64.  Ramsay M, Gisel EG, McCusker J, Bellavance F, Platt R. Infant sucking ability, non-organic failure to thrive, maternal characteristics, and feeding practices: a prospective cohort study. Dev Med Child Neurol.2002; 44: 405–14. 

65.  Hay DF, Pawlby S, Sharp D, et al. Intellectual problems shown by 11-year-old children whose mothers had postnatal depression. J Child Psychiatry.2001; 42: 871–89.

66.  Morrell C, Warner R, Slade P, et al. Psychological interventions for postnatal depression: cluster randomised trial and economic evaluation. The PoNDER trial. Health Technol Assess 2009; 13:1–176.

67.  Glavin K, Smith L, Sorum R, Ellefsen B. Supportive counselling by public health nurses for women with postpartum depression. Journal of Advanced Nursing. 2010; 66(6), 1317-1327.

68.  Stufflebeam DL. The CIPP model for evaluation. In D. L. Stufflebeam & T. Kellaghan (Eds.), The international handbook of educational evalua­tion (Chapter 2). Boston, MA: Kluwer Academic Publishers.2003.

69.  Zhang G, Zeller N, Griffith R, Metcalf D, Williams J, Shea C, Misulis K. Using the Context, Input, Process, and Product Evaluation Model (CIPP) as a Comprehensive Framework to Guide the Planning, Implementation, and Assessment of Service-learning Programs. Journal of Higher Education Outreach and Engagement.2011; 15 (4), 57.