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  • Service Managers | MATRIx

    Service Manager Organisational aspects Characteristics of services across care pathway Characteristics of assessment Characteristics of treatment Back to Conceptual Framework

  • Deciding to Seek Help | MATRIx

    INDIVIDUAL Deciding to seek help There are two steps to women deciding to seek help. These are recognising that something is wrong and having the knowledge and understanding to know where to go to seek help.​ Supported to recognise something was wrong. Not knowing what services are available. ​ Supported to recognise something was wrong When women are supported to recognise something was wrong, this acts as a facilitator to women perinatal mental health care. ​ ​ "That’s when I thought, you know: “Something is really wrong here, I need to go to the doctors if I’m thinking about killing myself.”​" ​ Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ Key literature: ​ Button S, et al. 2017 Not knowing what services are available Women not knowing what services are available and where to go to seek help may be a barrier to perinatal mental health care. ​ ". . .you don’t know where to go, what to do, who to trust…". ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ ​Key literature: ​ Megnin-Viggars O, et al. 2015 Recommendations We recommend the development of information aimed at increasing awareness of perinatal mental health illness such as (1) infographics/leaflets disseminated through maternity services, primary care, third sector organisations (e.g. NCT), and antenatal classes (2) short animations & videos disseminated via social media on:​ Symptoms of different perinatal mental illnesses​. The best way to cope with symptoms and when to seek help​. ​ We recommend this information is developed by individual trusts, or third-party organisations (e.g., the NCT) in collaboration with the NIHR Applied Research Collaboration (ARC) Perinatal Mental Health Themes, The Perinatal Mental Health Network Scotland, the National Managed Clinical Network, and the Royal Colleges. We have provided some guidance for women navigating an imperfect system here. Back to Individual

  • Culture | MATRIx

    SOCIETY Culture Culture is a complex factor that refers to a “group’s thoughts, experiences, and patterns of behaviour and its concepts, values and assumptions about life that guide behaviour” 1. Culture varies both across countries and within countries, as it can be affected by factors such as race, religion, gender etc.​ Culture different to Western view. Culturally sensitive care​. Culture different to Western view Cultural belief systems that differ to the Western view of mental illness are a barrier to perinatal mental health care. "Because depression, like if you see the symptoms of depression, it’s a mental illness. The minute you say mental illness in my country, you are crazy​."​ ​ Evidence level: ​ High ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Schmied V, et al. 2017 Culturally sensitive care​ Mental illnesses are not spread evenly around the world. Culture influences what we see as a mental illness. For example, ​ Amok – mostly experienced by Indonesian men after a social insult, characterised by brooding and then rage.​ Zar – Experienced by those living in the Middle East. Is related to spirit possession, characterised by laughing, crying, shouting and singing. ​ Post-traumatic stress disorder – a western mental illness occurring after a trauma. Characterised by flashbacks to the event, and avoidance of things that remind people of the event. ​ ​ Culturally sensitive care can be defined as “the ability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic, or cultural heritage” 2. It is care that offers services in a manner that is relevant to patients’ needs and expectations​ 3. Recommendations Provide culturally sensitive care​. ​ Collaborate with organisations such as The Motherhood Group to ensure cultural appropriateness.​ ​ Co-design care with a diverse range of people to ensure appropriateness and sensitivity. Back to Society

  • Demographic and Mental Health Factors | MATRIx

    INDIVIDUAL Demographic and Mental Health Factors Certain demographic and mental health factors may impact perinatal mental health care. Ethnicity. Previous experiences of mental health services. Age. Symptoms of mental illness​. Previous diagnoses​. Ethnicity A woman’s ethnicity may influence whether she decides to consult and whether she is able to access care. There is some evidence that suggests white women are more likely than Black, Asian and Minority ethnic women to seek help and be offered perinatal mental health care​. ​ "Asian and Black women were less likely to be offered treatment than White women and health care providers were perceived to discriminate against the women on account of their ethnicity". ​ Evidence level: ​ Low ​ ​Parts of the care pathway affected: Decision to consult, Access to treatment​. ​ Key literature: ​ Watson H, et al. 2019 Age Being older may be a facilitator to perinatal mental health care. More research is needed.​ “…older women sought treatment more often, due to maturity and a greater awareness about how to find care”​. ​ ​Evidence level: Very low​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ ​​Key literature: ​ Hansotte E, et al. 2017 Previous experiences of mental health services Previous positive experiences of mental health services can be a facilitator, whereas previous negative experiences can be a barrier​. ​ "That is probably why a lot of black women don’t bother going to the system . . . the majority have had nightmares. So you’re thinking, “What’s the point in going back?”​​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Access to treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Watson H, et al. 2019 Symptoms of mental illness​ Current symptoms of mental illness may act as a barrier to perinatal mental health care. ​ "When I was experiencing mental health issues, it was harder for me to get out, sort of on a schedule and be punctual."​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Sorsa MA, et al. 2021 Previous diagnoses​ Having a previous diagnosis of a mental health difficulty may be a facilitator to perinatal mental health care. ​ "Furthermore, having a history of depression or anxiety and/or treatment for it was found to be associated with service use for PPD…​[postpartum depression]". ​ ​Evidence level: Very low​​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Bina R. 2020 Recommendations We recommend the government and policy makers provide adequate funding for all mental health services, to ensure employment of the optimal number of staff to meet individual’s needs.​ ​ We recommend high quality training to be provided to all health professionals who come into contact with people who are experiencing mental health difficulties, to ensure a high level of care is provided to all. ​ Back to Individual

  • Shared Decision Making | MATRIx

    INTERPERSONAL Shared decision making Shared decision making between healthcare professionals and women.​ Shared decision making. Resources. Shared decision making Shared decision making between women and health professionals may be a facilitator to perinatal mental health care. "Women with postpartum psychosis discussed the need for greater consultation and negotiation in antipsychotic prescription…​ … it would have been good I think to have been listened to about the side effects…It’s just they’re managing your risk.., maybe that’s what they’ve got to do clinically, but I wanted a bit more of a human face of it really."​ ​ Evidence level: ​Low ​ ​Parts of the care pathway affected: Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Megnin-Viggars O, et al. 2015 Resources NHS England provides guidance on shared decision making.​ Recommendations We recommend health professionals participate in continuing professional development activities related to perinatal mental health including participating in high quality training. ​ To ensure there are opportunities for health professionals and women to form trusting relationships, we recommend continuity of carer across the care pathway​. Back to Interpersonal

  • Social and Family Life | MATRIx

    INDIVIDUAL Social and Family Life​ A woman’s social and family life can impact help seeking, access to care, and delivery and implementation of care. ​ Social isolation​ Family and friends​ Additional personal difficulties​ Social isolation​ Social isolation can act as a barrier to perinatal mental health care, whereas social support can be a facilitator​​. ​ "Those without social relationships felt an additional burden when dealing with PPD​​ [postpartum depression]" ​ Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to consult, Women’s experience of treatment​. ​ Key literature: ​ Hansotte E, et al. 2017 Family and friends​ Supportive family and friends can be a facilitator to perinatal mental health care, whereas having little support from family and friends is a barrier​. ​ "It was sort of my partner saying to me: “Right, if you don’t go, I’m basically making nyou an appointment … You can’t just keep feeling like this".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Access to treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Button S, et al. 2017 Additional personal difficulties​ Personal difficulties outside of perinatal mental illness such as unemployment can act as barriers to perinatal mental health care​. ​ "I have this one client. . .(who) has so many issues going on, abusive relationship which she got out of and then custody battle with the children that are going to be a year in June and she is also pregnant. . .She had so much going on that she rejected the (mental health) referral​​". ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to disclose, Access to treatment​. ​ ​Key literature: ​ Boyd RC, et al. 2011 Recommendations Social isolation can be a barrier to care for some women. We therefore recommend service managers considering offering peer support to women where appropriate. Not being financially stable, and other personal difficulties can be a barrier to care. We therefore recommend the government provide a fair welfare and economic system that ensures that no one is living in poverty or in financial hardship. Back to Individual

  • Immigration Status | MATRIx

    POLICY MAKERS Immigration Status Whether women were born in the country they are currently living in and how this may impact their perinatal mental health care journey​. Not being born in the country currently living in. NHS Charging regulations​. Not being born in the country currently living in Not being born in the country women are currently living in. "…as Hispanics we do not have insurance and money is what really counts."​ ​ "Because when you’re legal you can take the child to the daycare and look for a job. . . If you don’t work, it’s like you’re dead, being alive. We want our papers so we can progress; not so we can leave or be a load to anyone, but just to work—to buy a home and give our kids a good life. . . I get depressed because I can’t live like normal people because I’m always thinking if I leave or if I stay. . . ​"​ ​ Evidence level: ​High ​ ​Parts of the care pathway affected : Decision to consult, Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Hansotte E, et al. 2017 ​Schmied V, et al. 2017 NHS Charging regulations​ Despite the NHS being free for UK residents, there are NHS charging regulations in place for those who are not residents of the United Kingdom. ​ NHS charging regulations have a large negative impact on pregnant and postnatal women, in terms of their mental health - increasing stress and anxiety, their vulnerability to domestic violence and maternal deaths that may have been prevented through access to antenatal care. ​ Furthermore, Public Health England has identified NHS charging for maternity care as one of the key issues that exacerbates poorer health outcomes for women and babies of colour.​ Recommendations We recommend support for refugee or immigrant women to be able to access care without being penalised (e.g., through deportation, through charging systems).​ ​ We recommend the suspension of NHS charging regulations until a full independent review of their impact on individual and public health, simplification of charging criteria and exemptions and safeguards to protect vulnerable patients and ensure they are not denied the care they are entitled to, is carried out​. This recommendation is in line with: (a) a joint statement set out by the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of Obstetricians and Gynaecologists and the Faculty of Public Health in 2018, calling for a suspension of NHS Charging; (b) a statement from the Academy of Medical Royal Colleges in 2019 released a statement calling for the suspension of the NHS charging regulations until a full independent review on individual and public health is carried out; (c) a statement from the Royal College of Paediatrics and Child Health calling for an end to NHS charging due to its adverse effects on child health and wider public health; (d) a report from Maternity Action calling for the immediate suspension of charging for NHS maternity care given the deterrent effect on women’s access to maternity care. ​ Back to Policy Makers

  • Stigma | MATRIx

    SOCIETY Stigma​ Negative attitudes or discrimination against someone based on a distinguishing characteristic such as a mental illness, health condition, or disability. 1 ​ Barrier to perinatal mental health care. Stigma reduction​. Barrier to perinatal mental health care Stigma is a barrier to perinatal mental health care. "Oh well, I think there’s plenty, I mean I think there’s a huge stigma about feeling depressed particularly postnatal depression​."​ ​ Evidence level: ​ High ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Shakespeare J, et al. 2003 Stigma reduction​ Research suggests public mental health campaigns can increase knowledge about mental illness and improve attitudes about people with mental illness. 2 ​ A UK based example was Time to Change: Video Recommendation NHS Mental Health Campaign focused on raising awareness of perinatal mental illness and reducing stigma for perinatal mental illness. Back to Society

  • Funding | MATRIx

    COMMISSIONERS Funding This refers to how services are paid for. A lack of funding. Funding complexities. A lack of funding A lack of funding or complexities in accessing funding can be a barrier​ to care. "We are unable to serve every woman in need of ongoing care. We are therefore working on additional funds, both internally and externally, to secure long-term physical and behavioural health care for our patients.​"​ ​ Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Doering JJ, et al. 2017 Funding complexities The government’s spending plans can be changed within the financial year. This can make it hard for services to plan their spending at the beginning of the year. See How Funding Flows by The King’s Fund for more information. Recommendations A clear and easy to access funding structure for commissioners and service managers​. ​ Continued policy support from NHS England, and the NHS related to perinatal mental health care, such as the publication of the Five Year Forward View and Long Term Plan for NHS England, and Delivering Effective Services report for NHS Scotland.​ ​ We recommend the provision of a comprehensively researched and adequate budget provided to the Department of Health and Social Care, Health and Social Care Directorates so all healthcare needs for that financial year can be met. Where possible, a reduction of in-year funding changes is needed to allow for more thorough and comprehensive service planning. Back to Commissioners

  • Health Professional's Knowledge | MATRIx

    HEALTH PROFESSIONALS Health professionals' knowledge​ Health professionals' knowledge about perinatal mental health symptoms and referral pathways can influence implementation and delivery of care, as well as whether women disclose their symptoms and access care. ​ Knowledge about perinatal mental illness​. Confidence of health professionals ​. Knowledge about referral pathways ​. Knowledge about perinatal mental illness​ Health professionals having good knowledge about perinatal mental health symptoms can be a facilitator to care, whereas a lack of knowledge can be a barrier. "’Oh I was seeing so and so but when they found out I was pregnant they discontinued my medication.’” That…happens frequently. Very frequently…their provider won’t [prescribe] because of their pregnancy."​ ​ Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Contact with health professionals, Assessment, Access to treatment​. ​ Key literature: ​ Byatt N, et al. 2013 Confidence of health professionals ​ Related to knowledge, a health professional with high levels of confidence in addressing perinatal mental health can be a facilitator. Low confidence can be a barrier.​ ​ "Look, I feel insecure at the moment, as I have not yet had the chance to try [this therapy with a client], and I have to practice…​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Assessment, Referral, Provision of optimal treatment​. ​ ​Key literature: ​ Bina R, et al. 2018 Knowledge about referral pathways ​ Health professionals having good knowledge about services and referral pathways can be a facilitator to care, but lack of knowledge can be a barrier​​. ​ "The health professionals interviewed in both Trusts were not always aware of the services available in other areas of the health service and recommended the provision and circulation of named links to support more joined up working​​". ​ ​Evidence level: High ​ ​Parts of the care pathway affected: Assessment, Referral, Access to treatment​. ​ ​Key literature: ​ Rowan C, et al. 2010 Recommendations We recommend health professionals participate in continuing professional development activities related to perinatal mental health including participating in high quality training [LINK TO TRAINING RECOMMENDATION]​. ​ Service managers and policy makers could consider health professionals receiving accreditation for participating in training. Back to Health Professionals

  • Appropriate and Timely Services | MATRIx

    COMMISSIONERS Appropriate and timely services There needs to be an adequate amount of services that women can be referred on to. These services need to meet women’s needs and be offered in a timely manner. A lack of appropriate and timely services. Guidance for providing services. A lack of appropriate and timely services A lack of appropriate and timely services is a barrier​ to care​. ​ "I could see that [the EPDS score] was high and you make your referrals, and it was months out before she could go . . . she had to almost take her life to get seen right away. And that’s terrible that it has to come to that. I think that’s the biggest struggle.​"​ ​ Evidence level: ​High ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Doering JJ, et al. 2017 Guidance for providing services According to Moreton et al. 2021 to provide services that meet the needs of the population, commissioners must:​ Have a good knowledge of population and the healthcare need in question. Therefore, training on perinatal mental health should be mandatory for at least one commissioner in each Primary Care Network, Integrated Care System or Health Board (see recommended training [add link])​ Engage with people with lived experience - services should be co-produced with those who have lived experience Have access to high quality evidence e.g. the development of perinatal mental health information guide : ​ Symptoms of PNMI​ Impact on women and their families​ Barriers to women getting care they need and how to overcome these​ Effective care and treatment​ Examples of good practice​ Recommendations Provision of adequate financial resources to ensure service managers can: ​ Recruit a multi-disciplinary team with enough staff to meet service users’ needs​. Provide high-quality, time protected staff training to all staff​. Provide continuity of carer​. Provide resources that break down language barriers such as translators or Language Line​. Provide an adequate number of appropriate services that women can be referred to in a timely manner​. Provide individualised, woman-centred care. Back to Commissioners

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