Most participants were female (66.7%) and single (57.6%). Two-thirds of them were at most 30 years old, their age ranging from 22 to 54 years. See Table 1.
Table 1. Characteristics of participants in the study
Characteristics of participants
|
N (percent)
|
Gender
|
|
Female
|
22 (66.7)
|
Male
|
11 (33.3)
|
Age (years)
|
|
≤30
|
20 (60.6)
|
31-40
|
8 (24.2)
|
>40
|
5 (15.2)
|
Mean (SD) = 32.2 (7.60), Range = 22-54
|
|
Marital status
|
|
Single
|
19 (57.6)
|
Married
|
13 (39.4)
|
Widowed
|
1 (3.0)
|
Training experience in mental health field
|
|
No
|
30 (90.9)
|
Yes
|
3 (9.1)
|
Working duration in a PCC
|
|
1-5 years
|
15 (45.4)
|
6-10 years
|
12 (36.4)
|
>10 years
|
6 (18.2)
|
Mean (SD) = 7.1 (5.31), Range = 1-26
|
|
Size of current PCC
|
|
Small
|
4 (12.1)
|
Medium
|
22 (66.7)
|
Large
|
7 (21.2)
|
Note: PCC=Primary care centre; SD=Standard Deviation
Quantitative results
The knowledge scores of perinatal depressive symptom identification and management increased significantly from 8.94 at T1 (before lectures the day of theory) to 9.45 at T2 (after lectures the day of theory), and remained the same from T2 to T3 (after four weeks of field practice) (p for trend=0.031). The attitude scores toward identification and management of perinatal depressive symptoms improved significantly from 28.94 at T1 to 29.88 at T2, and from T2 to 30.42 at T3 (p for trend=0.004). Self-efficacy scores for perinatal depressive symptom identification and management were unchanged from 26.79 at T1 to 26.33 T2, and showed improvement from T2 to 28.73 at T3 (p=0.043 for trend). See Table 2.
Table 2. The differences of scores of knowledge of, attitude towards and self-efficacy for perinatal depressive symptom prevention between times
Items
|
Mean ± SD
|
Changed T1 to T2
|
|
Changed T2 to T3
|
|
|
T1
|
T2
|
T3
|
p for trend†
|
mean (95%CI)
|
p-value
|
mean (95%CI)
|
p-value
|
Knowledge
|
8.94 ± 0.75
|
9.45 ± 0.75
|
9.42 ± 1.12
|
.031*
|
0.52 (0.22, 0.81)
|
.001*
|
0.03 (-0.41, 0.35)
|
.872
|
Attitude
|
28.94 ± 3.17
|
29.88 ± 4.21
|
30.42 ± 2.54
|
.004*
|
0.94 (0.09-1.78)
|
.031*
|
1.52 (0.39-2.64)
|
0.010*
|
Self-efficacy
|
26.79 ± 3.87
|
26.33 ± 4.12
|
28.73 ± 2.95
|
.043*
|
-0.45 (-1.45, 0.55)
|
.363
|
2.39 (1.23, 3.56)
|
<.001*
|
Note: SD, Standard Deviation; T1, before lectures in the theoretical day; T2, after lectures in the theoretical day; T3, before the FGDs conducted; CI, confidence interval; †, obtained by Chi-square trend analysis
* statistically significant at 0.05 level
Qualitative results
Four categories related to PHPs having participated in the KAS-program emerged: increased understanding and knowledge, being aware and having a positive attitude, having confidence and ability to work, and need of regular training and feedback.
Increased understanding and knowledge
All FGD participants described that after the KAS-program they had increased their understanding of perinatal depressive symptoms among women. Most participants without previous knowledge of perinatal depression indicated that after participating in the theoretical and practical parts of KAS-program they had gained knowledge. Also, a few participants with mental health education indicated increased knowledge. The participants mentioned that the program was valuable because it made them pay more attention to the mental health of women during pregnancy and after childbirth. It was important to identify pregnant women for antenatal depressive symptoms and manage postpartum depressive symptoms by giving them help and support. The participants described that pregnant women coming to ANC clinics used to have a pink book of mother-and-child health called “Samud Anamai Manda”, and they received a mental health screening called 2Q with only two questions at their first ANC visit. Usually, no mental health problem or depression was found among pregnant women by use of 2Q. If a mental health problem of a pregnant woman was found, she was referred to hospital. The participants also found that compared with 2Q, the screening tool from the KAS-program was very useful for evaluation of depressive symptoms of pregnant and postpartum women.
After participating in this program, I have increased my knowledge of mental health during pregnancy and after childbirth. … I did not have this knowledge before. I can use it in my work. (FGD1)
I know more about screening of perinatal depressive symptoms, particularly in pregnant women. Before my work was about screening for depression among teenagers, from 15 years, without focus on pregnant women. I think I have got a new method that is helpful for screening work after the program. (FGD2)
The program is good for us (PHPs). We have increased our understanding of mental health among women. I have received a manual for prevention of perinatal depressive symptoms to use. I know that women can have depressive symptoms from pregnancy to one year after childbirth. (FGD4)
Being aware and having a positive attitude
All participants described that after the KAS-program they had increased their awareness and changed their attitude towards perinatal depression. They mentioned that they had a more positive attitude than before to work with this problem. They described that when pregnant women come to ANC clinics they focused on the women’s physical health and carried out pregnancy examinations. Therefore, they could not see if pregnant women had depressive symptoms. When their attitude had been changed they considered working with the women’s mental health by talking, listening and giving advice.
After the program, I have opened my mind to have a new perspective on women’s depressive symptoms during pregnancy and after delivery. I have a positive attitude to work that supports the women. (FGD1)
I think we realize this problem (perinatal depressive symptoms) after the program. Before, I believed that the symptom could disappear by itself after delivery. As PHPs we should consider and detect this problem and promote mental health. (FGD2)
Having confidence and ability to work
All participants indicated that they had more self-confidence after participating in the KAS-program. They believed that they could work with identifying depressive symptoms by using the manual they had received from the program. They mentioned that their work was disease prevention. Therefore, they should cooperate with nurses/midwifes at PCCs and in this way work with perinatal depression as a team and close to people in their community, particularly women during pregnancy and after childbirth. They described that according to the Ministry of Public Health in Thailand, the important work of primary care should be “located close to where people live” (Klaibarn, Klaijai). Therefore, they worked together with nurses/midwives at PCCs to approach women closely concerning mental health promotion in their community.
Our work is prevention of diseases in the community. We know everybody and they trust us. When we visit villages in the community, we could screen depressive symptoms among pregnant women to prevent these symptoms after delivery. (FGD1)
I have more confidence after participating in the program. I believe that I could work with prevention of perinatal depressive symptoms. I will work together with nurses/midwifes to screen women during pregnancy and after delivery. (FGD3)
Need of regular training and feedback
In the KAS-program, the participants received knowledge for identification and management of perinatal depressive symptoms based on theory and also on practice through screening and its evaluation. They mentioned that it had been very useful to receive coaching during the fieldwork of their practice. However, they would have appreciated getting more such coaching, discussion and feedback. Regular training for identification and management of perinatal depressive symptoms should be provided to PHPs to update their knowledge and increase their self-confidence. The participants also mentioned that nurses/midwives should participate in this training program.
I think it will help us if we would have more time for coaching while we practice screening in the fieldwork. (FGD2)
I think we are aware of perinatal depressive symptoms and have more knowledge than before but I think PHPs and nurses/midwives still need regular training in this area so that we can work with women’s mental health promotion. (FGD4)