Sample
Twenty-four healthcare professionals were interviewed in total via a phone call or video call. Interviews ranged in length from 38 to 55 min. Table 1 summarises the demographic characteristics of the HCP sample.
Three main themes were identified from the data: (1) lack of awareness and understanding of perinatal mental illness and service structure in both healthcare professionals and patients; (2) patients’ relationships with family, friends and healthcare professionals can both hinder and facilitate access to services; (3) healthcare professionals promote raising awareness, flexibility, developing shared understandings and questioning assumptions to improve the accessibility and acceptability of services. Each theme had several subthemes, as can be seen in Table 2.
Theme 1: Lack of awareness and understanding of perinatal mental illness and service structure in both healthcare professionals and patients
Cultural and spiritual attributions: “[Patients] don’t like to accept that they have depression, they don’t believe in it”
HCPs may work with patients who attribute mental illness to spiritual or religious factors. This could impact the recognition of perinatal mental illness symptoms as understood in Western medicine. This may later impact the ability of patients to engage with HCPs as symptoms may be attributed to other non-medical explanations such as spirits. This has an effect along the referral process as patients may be less likely to accept a referral to PMHS.
I’ve seen quite a lot of mums from that background that live in denial. They don’t seek help. There are certain cultural beliefs. Most mums in that position, from where they come from, and like where I come from, they don’t like to accept that they have that depression. They don’t believe in it.—HCP017 (Health Visitor)
Not knowing where to get help: “[There is] a lack of knowledge that PMHS exist in the first place”
A perinatal psychiatrist suggested there is “a lack of actual knowledge that Perinatal Mental Health Service exist in the first place” (HCP010). Other HCPs also discuss the lack of knowledge HCPs may have about the symptoms of a perinatal mental illness. These may be dismissed as baby blues or other feelings patients expect to be common and pass with time. This lack of understanding can impact the ability of patients to recognise symptoms to self-refer or seek support through their GP, who tends to be their first point of contact with healthcare services. Therefore, the lack of awareness of sources of support constitutes a barrier to accessing services for patients.
Just even knowing that the services exist, or you know, the way in which mental health is spoken about within the home, or is recognised in itself, probably places a barrier, in terms of those women accessing support, knowing when they need to access support, and knowing when things are becoming, you know, unsafe, or becoming a problem—HCP005 (Nurse)
HCPs of different professions working in and out of perinatal settings all echoed the sentiment that the lack of awareness of services’ existence acted as a barrier for many of their patients.
Remit and scope of services are unknown and misunderstood across groups: “Services could be better at explaining what is going to happen”
There is a lack of knowledge of what perinatal mental health services offer once patients are referred or are being seen by services and what continuity of care looks like. HCPs described a common misunderstanding of the focus of perinatal services. They said that many patients feared services were there to take their child away, and said many patients felt unable to disclose struggling in case it led to the child being removed. Another important factor described was patients being referred who do not know about the referral. All these factors impact the acceptance of a referral and active engagement with services. HCPs from perinatal mental health services recognise that other services and HCPs may not know about perinatal mental health services which can impact the ability for patients to receive timely support for their mental health problem. HCPs said they often were not sure who to signpost to and therefore referrals can be back and forth between professions, leaving patients without support.
I guess services could be better about explaining exactly what’s going to happen. I know … you have a visual what happens during the ward, I think it probably would be really helpful to know exactly what’s going to happen when you go and meet somebody for the first time for the initial assessment and what questions you’ll be asked. I think that might be useful.—HCP002 (Psychologist)
The lack of understanding went in both directions, with HCPs suggesting they did not know how to communicate the questions on their forms to their patients in ways that were mutually understandable. Some HCPs discussed the use of assessments and how they may not be clear or understood universally. This could be in relation to the language used to describe mental health which may not have been explained, or translated appropriately, and thus were not understood. The Western medical, highly clinical language was identified as exacerbating this lack of understanding.
I feel like the outcome measures are really clinical. So they have quite complex words for it. Some people don’t even understand, I know when I’ve done outcome measures and people always ask, what does this mean? Or I don’t know the answer of this? And sometimes it’s just you can’t really put zero on there because it effects the scores. So you’re thinking as a professional yourself, oh God what box do I tick for them.—HCP006 (Nursery Nurse)
Theme 2: Patients’ relationships with family, friends and healthcare professionals can both hinder and facilitate access to services
Personal support networks are pivotal: friends and family can help and prevent people from accessing help
Family and friends can be important facilitators or barriers to patients accepting and accessing services. They are important facilitators as they can support HCPs to monitor the patient to pick up signs of deterioration and to support patients to engage with mental health services.
When she [the patient] experiences deterioration in her mental state, dad is the one that will, we can rely on, that we can contact and say, dad, we’re really worried about our patient, your daughter, can you help us?—HCP009 (Social Worker)
On the other hand, family and friends could be gatekeepers to patients initiating contact with services. There may be a fear of their community knowing about their mental health problem and a fear of what their wider family will think about their mental health problem. Family members may minimise or not discuss mental health problems which feed into stigma and therefore are a barrier for patients to engage in services.
Family can prevent people from accessing help. I think that is something that’s come up in sessions, an idea that it’s helpful to keep things within family and that you sort things out within your family and that’s it.—HCP002 (Psychologist)
…two out of the eight ladies that I spoke to had difficulties in accessing mental health, purely because their family didn’t agree with them accessing any mental health services. It’s OK if it was pregnancy, it was OK if it was medical, but mental health wise, they were kind of being discouraged away from doing that.—HCP008 (Midwife)
This led many HCPs to meet in ways that made it seem like the assessment was not about mental health. This helped patients feel safe and less anxious about having meetings. HCPs would send appointments without mental health written on the letter. It would be seen as an appointment with a midwife rather than an appointment with a mental health midwife.
I’ve had ladies on my caseloads who are Asian, not even from the Pakistani background, from like the Bengali background and I’ve been told to pretend to be a friend rather than a professional.—HCP006 (Nursery Nurse)
So we’re very careful, we don’t actually put that it’s a mental health appointment on the letters that get sent out.—HCP008 (Midwife)
Interpreters have power to affect the patient-healthcare professional dynamic: “You do explain the confidentiality grounds but even still, it feels like an invasion”
Several HCPs discussed different elements of communication when working with patients from Black and South Asian backgrounds who do not speak English as their first language. Language interpreters were seen as essential to facilitate discussion between clinicians and these patients. There are downfalls with both the use of an external, or a family member interpreter. An appropriate interpreter knowing the correct language and dialect was not always available. When an interpreter was available, there was a slight fear from HCPs of misinterpretation of the information shared. Furthermore, an external interpreter brings an additional person into the room which may impact patients’ ability to speak freely about their experiences and thoughts.
If somebody’s gone through something really, really traumatic it’s … the dynamics change when you’ve got an interpreter there. So really, how suitable is it to have an interpreter interpreting such potentially hugely traumatic events in that person’s life to someone? So you’ve got to think about their wellbeing [and] confidentiality.—HCP005 (Nurse)
HCPs thought language interpreters were useful to increase access to appointments. Some HCPs preferred to have an interpreter in the room rather than online or over the phone as they felt it made it more manageable as a HCP to contain.
Just using interpreters generally makes it harder, I think, to properly connect with women especially since Covid and doing things either online or over the phone.—HCP018 (Social Worker)
It’s certainly easier especially when people are very unwell to have the interpreter physically there—HCP010 (Psychiatrist)
Furthermore, HCPs mentioned concerns patients may have around confidentiality. This was for both external interpreters and family members. In relation to external interpreters, there was a fear that the interpreter would know the patient or someone in the community and information would be shared, breaking confidentiality agreements. One HCP discussed a case of this happening with a patient they worked with and the impact this had on engagement.
The person that was interpreting for her then shared information. She had worked out who the woman was, … then started sharing information about her with the Gujrati community in [CITY NAME]. So then that completely lost her faith then in ever using interpreting services again. Then we had to try and get by without one. , Using interpreters can cause a lot of challenges—HCP018 (Social Worker)
HCPs discussed their preference to not to use a family member as an interpreter, as information may not be shared appropriately and issues around confidentiality may arise as patients may not feel comfortable to disclose thoughts and feelings in front of family members, especially about those family members.
… I remember a few times with this one patient and her auntie was the interpreter so she would always be allocated to her. But her auntie wouldn’t really say to her team that I know this lady. (…) The patient would say, I don’t want the interpreter for today and it [was] too short of a notice to book another one. So then we have to rebook the appointment again and it’s just a nightmare. So I feel like the interpreting service is really bad.—HCP006 (Nursery Nurse)
Peer support workers are trusted by communities: “They are a bridge to bringing people in”
Peer support workers help bring patients who are in distress into services. They may come from third-sector organisations and act as a bridge into perinatal mental health services and can also support patients in third-sector organisations if they do not meet the threshold for NHS specialist perinatal mental health services. Peer support workers can also be a bridge as an interpreter (i.e. bilingual support workers exist in some services) but with an additional layer as they are someone from a similar ethnic background who has gone through a similar mental health experience and which can away the need for an external or family interpreter. Consideration does need to be given to the wellbeing of the peer support workers as they are in a potentially vulnerable position when talking to their own communities about their own experiences.
In addition, patients themselves can help to develop services using their experiences by working with staff. HCPs suggest it is important to listen to patients’ stories firsthand to improve and develop services, and their involvement can make generic training more effective.
Having peer support workers is a recovery-based initiative and it is fantastic because it really does bring hope to people.—HCP001 (Nurse)
… trying to involve the peer support workers really at every stage to ensure, try and ensure engagement, make the woman feel relaxed. …. This is our everyday bread and butter work but it’s not for other people. So I think we, kind of, need to, to, sort of, acknowledge that with, with people and, and put measures in place to put them at ease.—HCP009 (Social Worker)
Theme 3: Healthcare professionals promote raising awareness, flexibility, developing shared understandings and questioning assumptions to improve the accessibility and acceptability of services
Work towards shared meanings between HCPs and patients: “There’s a different type of understanding of mental health and what mental health means to some cultural groups”
There needs to be a shared meaning and understanding between HCPs and the patients they work with in relation to their mental health, culture and ethnicity. HCPs suggest there is not “a one size fits all” approach and warned against generalising or assuming anything about any individual patient because of their culture or ethnicity. HCPs recognise that women need to be considered on an individual and holistic basis. HCPs also felt it was important that assumptions were not made about women’s childrearing practices, or how they would see the role of being a mother. This should all be considered on an individual basis and differences between western and non-western models should be respected. HCPs reflected on their own experiences and said they were careful not to impose their own cultural standards on their patients. HCPs are also reflective about their own background and experiences and the impact this can have on the dynamic with their patients.
There’s obviously a lot of heterogeneity between the different, you know cultures, we can’t quite you know, we can’t really lump it altogether but there is also a lot of common themes.—HCP007 (Psychiatrist)
HCPs emphasised how patients might find it difficult to express their feelings in the language that HCPs are used to. They emphasised how important it is to meet a patient where they are, to reflect their language back to them and to work towards a shared understanding without making assumptions that patients understand their terms for mental distress, or that they are understanding their patients’ use of language to describe distress.
… when I work with women who come from minority ethnic communities, I will have a, we will find a way of talking about similar things but in very different terms.—HCP002 (Psychologist)
Reflexive and reflective practices are needed to uncover biases: “I think people are scared to say that they have an unconscious bias”
HCPs recognised that they have pre-existing biases that can impact the care given to patients during the perinatal period. Examples are within multidisciplinary team decisions, interactions with patients and within the mental health system. Assumptions can be made by HCPs which can impact patient’s care, for example, single parenting assumptions based on a woman’s race, or not considering the contributing factors of culture towards mental health presentation. Staff said being honest about the biases with themselves was the only way to identify them and move to removing them.
So I think it would be naïve to suggest that were not, that we don’t, that some of these biases are, aren’t playing out at times, however much we try and be on top of them. And it’s not something we really talk about either—HCP001 (Nurse)
Due to stress, HCPs working in services may become less aware of their own practices and how their unconscious biases may play out—which may normally have been picked up on. Biases also exist if services are not tailored to meet the needs of patients.
I think having support as a team to work with it, I think would be very helpful, having supervision to think about our own unconscious biases.—HCP002 (Clinical Psychologist)
Having protected time and dedicated training focused on these topics was also recommended by HCPs as a way to ensure the best care was provided to all patients.
I feel like there needs to be a lot of training in our team to understand each other’s cultures and different cultures that we may not have heard of. So I feel like if we had this proper training I feel like people’s views would definitely change. So maybe getting religious leaders from different cultures to give a session to our team so we understand them further and we can ask them questions that we may not have been comfortable to ask anyone before. HCP006 (Nursery Nurse)
Services should offer choice where possible: “We’ll learn how to adapt our service for [patients’] needs.”
HCPs were highly reflective of the limitations of services in supporting the communities that they are serving and argued that the onus must be on services to adapt to be able to provide the best support possible to all patients. They were wary to not put the blame on patients for not accessing services and took responsibility for the ways services fell short. HCPs felt patients’ preferences should be considered when developing services. Some HCPs thought that patients from ethnic minority backgrounds may prefer to have a HCP from the same ethnic minority background. It is also suggested that HCPs who are from the same background may understand the patient’s culture better in relation to their mental health. Patients may also assume that the staff member will not understand and might therefore talk about their experiences or culture in a superficial way.
The experiences that patients have generally had is that they will see someone that’s not from their culture who wouldn’t understand, so that is another reason that people don’t access therapies, because they will see someone who doesn’t understand why their mother-in-law is so involved in baby’s care—HCP004 (Psychological Profession)
On the other hand, two HCPs discussed their experiences of working with patients who may prefer to work with a HCP from a different ethnic/cultural background due to the fear of being judged. HCPs describe the views of some of their patients who wanted clinicians from a different cultural background:
I want someone who’s not from my cultural background because I want them to see how terrible my situation is and I want them to support me with that whereas the person, the therapist from my cultural background will judge me just like the rest of my culture judges me.—HCP004 (Psychological Profession)
Where possible, HCPs felt patients should be provided with a choice and given support to engage family members in services. It was also suggested that training in culture and religion should be provided to staff. HCP’s are aware that trust can be increased through positive experiences, and thus gradually patients feel more comfortable sharing their experiences and beliefs.
Awareness campaigns about perinatal mental illness: “It can happen to you, it can happen to me, it can happen to anyone”
HCPs suggest that awareness should be raised about perinatal mental illness and services that exist to support these patients and their families. Suggestions given were in relation to public health campaigns on the media such as television, social media and in local communities. Some HCPs discussed their experiences of engaging with local communities such as third sector organisations or religious communities. HCPs acknowledged barriers that exist during this process, such as the dismissal of mental health problems in the local community and the resource of staff and time required to build the relationship. It was also noted by HCPs that resources should be translated into common local languages the communities speak and be accessible for patients who may not be able to read the language.
… maybe we do need more culturally sensitive information or awareness to be aimed specifically for communities. And it’s whether those communities would be accepting of a big public sort of awareness campaign, or actually it’s better aimed in more local, than national… I don’t know whether… targeting this in a more local way is more appropriate, acceptable.—HCP008 (Midwife)