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1. 1
2012: A newborn baby girl was
thrown from apartment

2. 2
2012: Young mother beating her 10-
month old helpless baby

3. 3
2014: Mother of 9 month old baby
dead of committing suicide

4. 4

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POSTNATAL DEPRESSION (PND):
AN UNDERSTANDING FROM MALAYSIAN
PERSPECTIVES
 Siti Roshaidai Binti Mohd Arifin
 Supervisors: Prof. Helen Cheyne & Prof. Margaret Maxwell
 NMAHP Research Unit, School of Nursing, Midwifery and Health, University of
Stirling

6. OUTLINES
INTRODUCTION
LITERATURE REVIEW
PROBLEM STATEMENT
RESEARCH OBJECTIVES &
RESEARCH QUESTIONS
METHODOLOGY & METHODS
ETHICAL CONSIDERATIONS
PLAN FOR ANALYSIS
CONCLUSION
6

7. INTRODUCTION
Improvement in maternal health as
one of the 8 Millennium Development
Goals.
(United Nations Development
Programme, 2014)
PND often remains underdiagnosed
and undertreated in clinical practice.
(WHO, 2008)
Wide variation in reported rates of
PND within and across countries and
cultures.
(Halbreich and Karkun, 2006)
7

8. Systematic review of prevalence of PND
Continents Prevalence of PND
USA (Lobato, et al. 2011; Dennis,
Heaman and Vigod, 2012)
8.0-37.5%
Africa (Agoub, Moussaoui and Battas
2005; Kakyo et al., 2012)
5.6-43.0%
Australia (Brooks et a.l, 2009; Austin
et al., 2010)
6.0-32.8%
European (Grote et al. , 2010;
Meltzer-Brody et al. , 2013)
4.0-40.4%
Asia (Ekuklu, 2004; Ho-Yen et al.
2006)
4.9-40.4%
 The prevalence of PND ranged from 4.9% to 40.4% with Nepal and
Turkey/Netherlands recording the lowest and highest rates of PND,
respectively (Ekuklu 2004; Ho-Yen et al, 2006; Meltzer-Brody et al, 2013)
8

9. Prevalence of PND in Malaysia
Years Cultural Setting Prevalence of PND (%)
Kit et al., 1997 Malay, Indian,
Chinese
3.9
Wan Mohd Rushidi et al., 2002 Malay 9.8
Wan Mohd Rushidi et al., 2003 Malay 14.1
Azidah et al., 2006 98% Malay 20.7
Wan Mohd Rushdi et al., 2006 Malay 16.38
Kadir et al., 2009 Not mentioned 27.3
Zainal et al., 2012 Malay, Indian,
Chinese
6.8
9

10. 10
 Women in different cultures and countries
interpreted PND in their own ways.
 Cultural practices and beliefs would
somehow protect women from PND in some
cultures but could also associate with PND in
another community.
 The experience of PND is not fully shared
experience.
(Rahman, 2007; Edwards and Timmons, 2005;
Oates et al, 2004; Rodrigues et al, 2003).
 No published study on women’s experience
of PND in Malaysia.
Qualitative Synthesis of women’s experience of
PND

11. 11
 The women not only require validation of their feelings but also should be
offered a wide range of treatment options not fully dependent on the
medical model (Bilszta et al, 2012; Rush, 2012).
 Need for culturally appropriate intervention
 The professionals care towards women with PND was limited by
 the use of different language
 different cultural background
 inadequate assessment tool
 a lack of knowledge on PND
 less experience in dealing directly with depressed women
(Teng, Blackmore and Stewart, 2007; Oliveira Santos Junior et al,
2012)
 In Malaysia, more than 50% of nurse-midwives confused PND with
postnatal 'blues' (Keng, 2005)
Healthcare Professionals perceptions’ of PND

12. PROBLEM STATEMENT
12
A significant health
problem
Wide variation in
prevalence
Need for culturally
appropriate
intervention
Quantitative
descriptions
Cultural
understandings and
sensitivity is crucial
BUT underdiagnosed
and undertreated
BUT unclear
explanations
BUT based on the
Western culture
NOT nature experiences
of PND
BUT lack of cross
cultural study
(Chien et al, 2006; Rahman, 2007; Niemi et al, 2010; Davy 2013; Mamisachviliet

13. RESEARCH AIMS & RESEARCH QUESTIONS
13
Research Aims Research Questions
1. Understand the
experience of women
with PND in Malaysia
• What are the experiences of
PND among Malaysian
women?
2. Explore women’s
perceptions of the
causes of PND in
Malaysia.
• Do women’s causal
explanations of PND differ
across different cultural
backgrounds within Malaysia?
If so, how does it differ?

14. RESEARCH AIMS & RESEARCH QUESTIONS
14
Research Aims Research Questions
3. Explore the knowledge
and perception of
Malaysian health care
professionals on PND
and its helpful strategies.
• What are the knowledge and perceptions
of health care professionals about PND
in Malaysia?
• How women suffered with PND were
supported in the healthcare systems?
• What are resources available in the
Malaysian healthcare systems for women
suffering from PND?
4. To explore potential
interventions for women
with PND in Malaysia.
• Postnatal Women: What are the
Malaysian women’s perceptions towards
the roles of healthcare professionals in
managing PND?
• HCPs: What are the experiences of care
and helpful strategies for Malaysian
women with PND?

15. 15
PHILOSOPHICAL FRAMEWORK
Positivism
Social
constructivis
m
Critical
Realism
(Pilgrim & Bentall, 1999)

16. STUDY DESIGN AND STUDY SETTING
16
Study
design
Exploratory qualitative design
Study
setting
Five Maternal and Child Health Clinics (MCH)
under Health Department of Federal Territory
Kuala Lumpur Malaysia.
Female Psychiatric Ward, Hospital Kuala Lumpur

17. 17
Populatio
n
Postnatal women with different cultural backgrounds including
Malay, Chinese and Indian women who attend for postnatal or
child health care at MCH Clinics in Kuala Lumpur and
Putrajaya, and their healthcare professionals.
Sample 30 women with PND:
• Comprised of Malay, Chinese and Indian who attend for
postnatal care or child health at MCH Clinics in Kuala
Lumpur.
15-20 Healthcare Professionals:
• Comprised of nurse manager, head nurses, nurse-midwives,
public nurses and medical doctors who involve with
postnatal care in the selected clinics.
SAMPLING STRATEGY

18. RECRUITMENT OF POSTNATAL WOMEN
Approach the
potential participant
during postnatal /
child health visit
Screening stage:
PHQ-2 ≥ 3
and/or
Self identified
and/or
Being referred by HCP
Provide an
invitation letter
and a Patient’s
Information
Sheet
Contact the
potential participant
through phone after
at least 24 hours-
for interview
session
Interview
stage:
Home/private
room in the clinic
Post-interview
stage: EPDS
NOTES: Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionairre-2
(PHQ-2)

19. RECRUITMENT OF POSTNATAL WOMEN
19
Sampling • Purposive sample: to ensure diversity in cultural beliefs
and practices.
Inclusion
criteria
• Age 18-45 years.
• No more than 1 year postnatal at the time they enter the
study.
• Had been staying in Malaysia after the last childbirth and
until the time of the interview.
• PHQ-2 ≥ 3 and/or self identified and/or being referred by
HCP
• Malaysian by nationality.
• Sufficiently fluent in English or Malay Language to
participate in the interview.
Exclusion
criteria
• Not fluent in English or Malay Language
• Severely depressed to the extent that participation in the
interview might worsened their condition.
• Non-Malaysian by nationality.

20. RECRUITMENT OF HEALTHCARE
PROFESSIONALS
Identify potential
participant through
organization chart
and clinic manager
Approach potential
participant by
invitation letter
Explain about the
research aims and
process- provide
Participant’s
Information Sheet
Contact the
potential
participant through
phone/ approach
face to face in the
clinic after at least
24 hours
Arrange for
interview session
and seek for
inform consent
prior to interview
session

21. RECRUITMENT OF HEALTHCARE
PROFESSIONALS
21
Inclusion
criteria
• Caring for postnatal women
• Work for not less 6 months in the MCH clinic.
Exclusion
criteria
• Work in MCH clinic for less than 6 months.

22. RESEARCH INSTRUMENT FOR DATA
COLLECTION
 Screening Tools
 Patient Health Questionairre-2 (PHQ-2)
 Face to face Semi-structured interview
 Interview guide:
 Two different set:
Women with experience of PND
Healthcare professionals
 Post interview stage
 Edinburgh Postnatal Depression Scale (EPDS)
22

23. PLAN FOR ANALYSIS
23
Data
collection
and data
analysis will
be
conducted
concurrently
Nvivo
Thematic
analysis
Conducte
d by only
one
researche
r
All themes
will be
cross-
checked by
two PhD
supervisors

24. Informed
consent
Anonymity
and
Confidentialit
y
Data
Protection
Cultural and
Linguistic
Barriers
Ethical
Approval
Process
Potential
Distress
Researcher
Skills
Resources
ETHICAL CONSIDERATIONS
24

25. Ethical Approval Process
25
Upon the approval the researcher has visited the clinics on an agreed date
and time.
An application letter has been sent to the respective Director, Health
Department of Federal Territory Kuala Lumpur and the Clinic Managers in
the respective clinics.
Malaysian government: online registration with the Malaysian National
Medical Research Register (NMRR) – to get approval from The Malaysian
National Institute of Health Research (NIHR) and Malaysian Research
Ethics Committee (MREC).
University’s Ethical approval: School Research Ethics Committee (SREC)

26. CONTRIBUTION OF THE STUDY
26
Academic
contribution ⃰ Add on the theoretical understandings of
PND in relation to cultural differences.
⃰ Encourage further high quality research
to provide effective, relevant and
culturally sensitive intervention for PND.
Clinical
contribution ⃰ The findings of this study will be the
foundation of developing preventative
intervention for PND in Malaysia.

27. GANTT CHART
27
Year First Year: 2013/ 2014 Second Year: 2014/2015 Third Year: 2015/2016
Months Sep-
Dec
Jan-
Mac
Apr-
Jun
Jul-
Aug
Sep-
Dec
Jan-
Mac
Apr-
Jun
Jul-
Aug
Sep-
Dec
Jan-
Mac
Apr-
Jun
Jul-
Aug
Tasks
Initial thesis planning with supervisors
×
Refinement of topic with aims and
methodology
×
Submission of proposal draft to supervisors
×
Refinement of proposal for 10th month panel
review
×
Submission for10th month panel review
×
Presentation for 10th month panel review
×
Submission of study protocol to
University Ethics committee
×
Submission of study proposal to Malaysian
ethics committee (NIHR and MREC)
×
Data collection
×
Data analysis
×
Writing final report
Submission of final report

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35. 35