Postnatal Depression Screening Among Nurses Research Paper

Given the potential impact of early detection on long-term outcomes, it is crucial to encourage nurses to engage in the initial screening process even if they lack confidence or are pressed for time. The use of brief tools such as PHQ-2 or the Whooley Questions as the first stage of screening can streamline the process and make it more manageable within the constraints of routine clinical practice. If a positive response was obtained during the initial screening, nurses referred the patient to a medical officer or another mental health professional for further evaluation using the EPDS. This referral system ensures that PND cases are identified and addressed early, while alleviating the burden on nurses by allowing them to focus on their primary responsibilities.

The EPDS is widely regarded as the gold standard for PND screening because it focuses on postpartum-specific symptoms, ease of administration, and strong psychometric properties. In Malaysia, the EPDS has been validated with a Malay-language version, demonstrating a sensitivity of 0.727 and a specificity of 0.92 at a cut-off score of 12, further supporting its use in the local context. The National Institute for Health and Care Excellence (NICE) guidelines recommend using the Whooley Questions at a woman’s first contact with primary care or during her booking visit and the early postnatal period. If a woman responds positively to either of the Whooley Questions, or if there is clinical concern, the EPDS or PHQ-9 is advised, or the woman may be referred to a general practitioner (GP) or mental health professional based on the severity of her symptoms.

This two-stage screening approach is particularly appropriate in Malaysia. This method allows for the initial identification of potential PND cases through brief screening tools, which can be conducted by nurses even in busy clinical settings. Following this, medical officers or mental health professionals can conduct more comprehensive assessments using EPDS. By adopting this approach, healthcare facilities can enhance the detection and treatment of PND, ultimately improving the mental health outcomes in postpartum women.

In conclusion, the adoption of a two-stage screening process for PND, involving brief tools such as PHQ-2 or the Whooley Questions followed by the EPDS, provides an effective and time-efficient strategy for early detection. It allows nurses to confidently engage in the screening process, knowing that they can refer cases for further evaluation, if necessary. This system not only optimises the identification and management of PND but also addresses the help-seeking barriers that contribute to its underdiagnosis. By integrating this approach into routine postnatal care, healthcare providers can ensure that women receive timely support and treatment, ultimately benefiting both mothers and their children’s overall health and well-being.

2.3 Barriers to Effective Screening

The challenges faced while conducting PND screening include limited assessment skills among practitioners, limited time spent with patients, and cultural misconceptions about the disorder. Such barriers may contribute to the delayed diagnosis and treatment of PND, which is detrimental to the lives of both the mother and the newborn. A study conducted in Canada examined these barriers in detail [20]. The authors pointed out that there are currently no defined guidelines for screening for PND and that the training of healthcare personnel is insufficient, as it leads to lower screening rates for PND. The authors also noted that with no adequate equipment and knowledge, new mother clients may easily slip through the cracks and not receive healthcare providers’ attention for a possible PND diagnosis. The other hitches that were equally hindered were time. In numerous practices, healthcare practitioners are usually pressed for time, which means that the evaluation of a patient’s mental health may be cursory, or that PND screening may not be performed at all. Survey conducted by Rashaan et al. [21] involving 391 primary care providers in the United States found that most providers had little time from the many tasks that a practice presented to engage in thorough PND screening [21]. This problem is worse in busy clinical facilities, where clients’ health and general well-being are mostly related to their physical ailments.

Existing stigma is one of the most significant challenges affecting not only patients, but also healthcare workers. Notably, in many cultures, major signs of mental illness, including PND, are considered taboo. This discrimination causes the mother to conceal her symptoms, thereby preventing her from seeking medical assistance. A cross-sectional survey conducted by Abdollahi et al. [22] on mothers in Singapore revealed that cultural taboos were a major factor preventing them from speaking about their symptoms to their doctors, resulting in the underreporting and under treatment of this condition.

Furthermore, the training of healthcare providers and cultural considerations had a significant impact on the success of PND screening. In their study, Ahad et al. [23], the success of PND screening programs is influenced by healthcare workers’ attitudes towards mental health and cultural competency. Well-trained and culturally aware healthcare professionals are more likely to use efficient screening procedures and offer pertinent referrals and assistance. The significance of removing obstacles in PND screening is demonstrated by these results. PND screening programs may be more successful by implementing tactics including providing healthcare professionals with thorough training, scheduling sufficient time for mental health examinations, and encouraging cultural sensitivity. By removing these obstacles, PND may be more accurately diagnosed and treated, thus benefiting the health of both the mothers and their babies.

2.4  Knowledge, Confidence, and Practice Among Nurses

Nurses play a critical role in the screening and management of PND in Malaysia. Their knowledge, confidence, and practices significantly influence the effectiveness of the screening programs. Research indicates that nurses with higher levels of knowledge and confidence are more likely to conduct thorough screenings and effectively manage PND. [16, 27]

2.5 Theoretical Framework

This study was grounded in the Health Belief Model, which posits that individuals are more likely to engage in health-promoting behaviours if they perceive a threat to their health, believe in the benefits of acting, and feel confident about their ability to successfully perform an action [24].  This model helped explain how nurses’ perceptions of PND and their confidence in screening practices could influence their screening behaviour.

CHAPTER 3: METHODOLOGY

3.1 Study Design

This study employed a cross-sectional survey design to evaluate nurses’ knowledge, confidence, and practice regarding postnatal depression (PND) screening in health clinics across Penang. This cross-sectional study design was selected because of its efficiency and effectiveness in gathering data from many participants at a single time-point.

3.2  Study Population

This study focused on registered nurses working in Maternal and Child Health (MCH) units within public health clinics across five district health offices (Pejabat Kesihatan Daerah, PKD) in Penang, namely: Seberang Perai Utara (SPU), Seberang Perai Tengah (SPT), Seberang Perai Selatan (SPS), Timur Laut (Northeast District), and Barat Daya (Southwest District). The nurses included in this study were nursing officers, sisters, public health nurses, staff nurses, and community nurses, all of whom were directly involved in providing comprehensive maternal and child healthcare services. These services include antenatal and postnatal care, safe childbirth practices, child immunization, growth monitoring, and early detection of developmental issues.

The selection of clinics was strategically focused on those within each district with the highest number of MCH nurses. This approach ensured that the study captured a representative sample of the MCH nursing workforce across Penang, reflecting diverse healthcare environments and challenges in both urban and rural settings. For example, Seberang Perai Tengah (SPT) was chosen because of its central location and high population density, particularly in busy areas, such as Bukit Mertajam. Similarly, the Timur Laut (Northeast District), which includes the metropolitan area of George Town on Penang Island, was selected for its significant number of MCH nursing staff, which is essential for managing the large patient load in this densely populated region.

The clinics representing each district were as follows: Klinik Kesihatan Butterworth in Seberang Perai Utara (SPU), Klinik Kesihatan Seberang Jaya in Seberang Perai Tengah (SPT), Klinik Kesihatan Bandar Tasik Mutiara in Seberang Perai Selatan (SPS), Klinik Kesihatan Jalan Perak in Timur Laut, and Klinik Kesihatan Bayan Lepas in Barat Daya. These clinics were chosen for their large MCH nursing teams, making them central in delivering maternal and child health services within their districts.

3.3 Sample Size Determination

The sample size for this study was determined using the Raosoft sample size calculator, a tool widely recognised for its accuracy in health research. The total population of nurses working in the MCH units at the selected clinics across Penang was 134 based on data provided by the district health offices (PKD).

Using a 95% confidence level and a 5% margin of error, the initial calculation indicated that a sample size of 100 participants would be sufficient to achieve statistically significant results. However, to account for potential non-responses, a common issue in survey-based research, the sample size was increased by 20%, resulting in a final sample of 120 nurses. This adjustment was critical in maintaining the study’s statistical power, ensuring that the results remained robust, even if some nurses chose not to participate.

The final sample of 120 nurses was proportionally distributed across the selected clinics, reflecting the number of nurses in each location. Clinics with more MCH nursing staff contributed to a higher number of participants, while those with fewer nurses contributed proportionally fewer participants. This methodological approach to sample size determination and distribution is essential for capturing a representative range of experiences and practices among MCH nurses across Penang.

3.4  Inclusion and Exclusion Criteria

3.4.1 Inclusion Criteria

• Nurses included were those who worked actively in the MCH units of the selected health clinics during the study period.
• All participants agreed to participate and provided their informed consent.

3.4.2  Exclusion Criteria

• Nurses on maternity, extended medical, or study leave during the study period.
• Operational Definitions

3.5  Study Instrument

The self-report questionnaire used in this study was adapted from Kang et al. (2019), entitled “Nurses’ Knowledge, Beliefs and Practices Regarding the Screening and Treatment of Postpartum Depression in Maternal and Child Health Clinics: A Cross-Sectional Survey,” published in the Malaysian Family Physician Journal. This open-access questionnaire was selected for its comprehensive coverage of crucial aspects related to postpartum depression (PND) among nurses.

The adapted questionnaire, already provided in Bahasa Melayu, included multiple-choice and Likert scale questions. It is organized into sections that capture various dimensions of the topic: demographic information, knowledge of postpartum depression, confidence in screening and managing PND, current practices, and future training needs. The original questionnaire underwent face and content validations to ensure its relevance and accuracy. Permission to adapt and use the questionnaire for this study was granted by the author, who confirmed that the tool was suitably adapted to the research context.

This validated and authorised questionnaire offers a structured and reliable means of collecting data on MCH nurses’ knowledge, confidence, and practice regarding PND screening. This finding supports the objective of this study to assess and enhance PND care within the region.

3.6 Data Collection Procedure

3.6.1 Recruitment Procedure

Purposive sampling was employed to select 121 from the Maternal and Child Health (MCH) units of selected health clinics across Penang. This method was chosen to ensure a representative sample from each health district office by prioritizing the clinics with the highest number of MCH nurses. This approach aims to capture a broad spectrum of experiences and practices, providing a comprehensive overview of postnatal depression (PND) screening practices throughout the state.

The recruitment process involved the research team conducting on-site visits to each selected clinic on Fridays, chosen because of the lower patient load, which facilitated effective recruitment and minimised disruptions to clinical operations. During these visits, the research team provided detailed information on the study including its objectives, methodologies, and potential risks and benefits. Nurses who expressed interest were given the opportunity to ask questions and seek clarification.

Informed consent was obtained from the nurses during the visits. The participants were given ample time to review the consent form, ask questions, and sign it if they agreed to participate. This process ensured voluntary participation in the study.

To facilitate participation, the research team distributed hard copy versions of the questionnaire, which were completed onsite. To ensure genuine responses, nurses were instructed not to refer to any material or online information while completing the questionnaire. They were also reminded not to discuss the questionnaire with their colleagues to maintain the integrity of their individual responses. Using purposive sampling and distributing hard-copy questionnaires, this study effectively gathered data from a diverse and representative sample of MCH nurses, addressing practical constraints while enhancing the validity and generalisability of the findings regarding PND screening practices in Penang.

3.6.2 Questionnaire Administration

The questionnaire was self-administered by nurses during scheduled clinic visits. The researchers provided a thorough explanation of the goals of the study and the importance of each nurse’s participation in ensuring comprehension and accurate responses.

To create a focused environment, the surveys were distributed in a controlled setting on Fridays, when the patient load was typically lower. Each nurse received clear instructions on how to complete the questionnaire, provided both orally and in written form, to accommodate different learning styles and reinforce key concepts. Nurses were allocated 15–20 minutes to read the questionnaire, address any questions, and complete it. They were instructed not to refer to external materials or discuss the questionnaire with colleagues to maintain the authenticity of their responses. This approach was designed to ensure accurate and thoughtful participation

3.7 Data Handling and Privacy

The responses were anonymised and stored securely to maintain confidentiality. Data were entered into a secure database accessible only to the research team for analysis.

3.8  Statistical Analysis Plan

3.8.1 Objective Analysis

Descriptive statistics, including means, standard deviations, frequencies, and percentages, summarised the demographic data of the participants and their responses to the questionnaire items on knowledge, confidence, and practice regarding PND screening.

3.8.2 Confidence and Practices Analysis

Confidence levels were analysed using descriptive statistics, and practice patterns were assessed using frequency analysis. Inferential statistics such as correlation analysis and multiple regression were used to explore the relationships between knowledge, confidence, and screening practices.

3.8.3 Group Comparisons

T-tests or analysis of variance (ANOVA) was used to compare the mean knowledge and confidence scores across different demographic groups, while chi-square tests were used to examine the association between categorical variables.

3.9 Ethics of Study

This study was conducted in compliance with the ethical principles outlined in the Malaysian Good Clinical Practice (GCP) guidelines. Informed consent was obtained from all participants, and confidentiality was maintained throughout the study.

3.10  Risk and Benefit Assessment

The study posed minimal risks to participants, mainly involving the completion of a questionnaire. However, the potential emotional discomfort related to discussing PND was mitigated by ensuring voluntary participation and confidentiality. These benefits include contributing to the understanding of PND screening practices and potentially improving maternal mental healthcare.

CHAPTER 4:

RESULTs

4.1 Demographic Distribution of Respondents

A total of 121 respondents participated in the study, with their demographic distribution detailed in Table 4.1. The respondents, in this study were selected from five different clinics and the largest number of 26.5% came from Klinik Kesihatan Bayan Lepas while the smallest number of 16.5% came from Seberang Jaya Clinic. Age distribution among the respondents was categorized into four age groups which are 18-29, 30-39, 40-49, and 50-59 years respectively. The most populous age  group was 40-49 years, comprising 49.6% (n = 60) of the respondents, followed by the 30-39 age group with 43.8% (n = 53). The young ones and the older persons within the ages of 18-29 and 50-59 made up only with 1.7% (n = 2) and 5.0% (n = 6) of respondents, respectively.

In ethnic grouping, the Malays formed the bulk of the population accounting for 88.4%, followed by Indians at 10.7%, and only one of them was Bumiputera Sabah which only accounted for 0.8%. The religious distribution of the respondents was mostly Muslim (89.3%), with smaller representations of Hindus (9.1%) and Christians (1.7%).

Most respondents were married (91.7%), while smaller percentages were single (4.1%), widowed (2.5%), or divorced (1.7%). Concerning the number of children the greatest number of respondents reported having two children 28.1% followed by those with three children 22.3%, and the remaining few respondents with no child, one child or more than three children.

Regarding the professional practice, the roles embraced were mainly community nurses (38.8%), registered nurses (25.6%) and the staff nurses at (19.8%). A significant portion of respondents had between 6 to 10 years of experience working in a Maternal and Child Health (MCH) unit (34.7%), while a smaller number had extensive experience of 26 years or more (5.0%).

In terms of education most of the respondents had either a diploma in nursing (33.1%) or a certificate in nursing (33.9%). The understanding of postpartum depression by the respondents was very high with (97.5%) of them having been educated on postpartum depression, while (96.7%) of respondents had no family history of postpartum depression and (96.7%) of respondents had no experience of the condition at all.

Table 4.1 Demographic Distribution

4.2 Score of Knowledge

The data collected from the questionnaire provided valuable insights into the knowledge levels and misconceptions of the respondents regarding postpartum depression. A significant majority (74.4%) correctly understood that postpartum depression could occur at any time during the first year after delivery. However, 83.5% mistakenly believed that postpartum depression only affects females, indicating a gap in awareness regarding the impact of the condition in males. Approximately 85.1% of respondents correctly acknowledged that it affects 10-20% of mothers, but a small percentage (3.3%) incorrectly disagreed. Additionally, 70.2% correctly understood that depression in postpartum blues could last more than two weeks after delivery, although 24.8% did not believe this, and 5.0% were uncertain. Most respondents (79.3%) correctly identified that postpartum depression most commonly occurs during the first to third month after delivery, while 11.6% disagree and 9.1% are unsure.

Half of the respondents (50.4%) identified primigravida, methyldopa, family history of psychiatric illness, and history of postpartum depression in previous pregnancies as risk factors for postpartum depression. However, their responses varied as they were the most identified risk factors and indicated good knowledge.

Awareness of symptoms associated with postpartum depression was high, with 45.5% of respondents correctly identifying all six symptoms, which are difficulty sleeping, self-blaming when things go wrong, weight loss, suicidal thoughts, tiredness or lack of energy, and anxiety or unwarranted worry. However, other respondents identified fewer symptoms, reflecting partial knowledge. The second largest response of 44.6% respondent identified five specific symptoms of postpartum depression: difficulty sleeping, self-blaming when things went wrong, suicidal thoughts, tiredness or lack of energy, and anxiety or worry for no apparent reason. Of the respondents, 96.7% correctly recognised postpartum depression as a prominent contributing factor to infanticide, whereas 3.4% had a different opinion. Furthermore, a significant majority (90.1%) of participants expressed the belief that mothers with postpartum depression may fail to ensure that their babies receive the necessary follow-up vaccines, whereas a minority (9.9%) disagreed.

Most respondents (90.9%) recognised that postpartum depression (PPD) had an impact on the physical and mental development of a child, while only 9.1% did not. Moreover, a significant majority (95.0%) of the participants demonstrated awareness that untreated postpartum depression has the potential to endure for a period beyond one year, while 5.0% expressed disagreement. However, this investigation revealed several misunderstandings: Significantly, 44.6% of participants held the mistaken belief that all mothers experiencing postpartum depression required antidepressant medication, 43.8% rightly disagreed, and 11.6% were uncertain. In addition, 47.9% of the participants had an incorrect belief that antidepressants were not recommended to nursing mothers, 32.2% rightly disagreed with this belief, and 19.8% were undecided. When questioned about the use of electroconvulsive therapy (ECT) for the treatment of postpartum depression, only 25.6% expressed a belief in its potential effectiveness, 40.5% disagreed, and 33.9% were unsure. Remarkably, the vast majority (99.2%) accurately acknowledged the recommendation of supportive counselling for moderate postpartum depression, whereas only 0.8% expressed disagreement.

A total of 74.4% of the participants accurately recognised that postpartum depression might manifest at any point within the first year after giving birth, whereas 25.6% held inaccurate beliefs. Regarding the assumption that postpartum depression exclusively affects females, 83.5% of respondents believed that it only affects females, whereas 16.5% disagreed with this notion. Furthermore, a significant majority of individuals (85.1%) were cognizant that postpartum depression impacts 10-20% of women. A minor fraction (3.3%) expressed disagreement with this statistic, while 11.6% expressed uncertainty.

Table 4.2 Knowledge Score

According to the data presented in Table 4.3, the respondents’ knowledge of postpartum depression can be categorised into three distinct categories. The majority of the participants comprised of 54 respondents (44.6%), exhibited a commendable level of expertise by properly answering between six and ten questions. Subsequently, 43 participants (35.5%) demonstrated exceptional knowledge and achieved a score of 11–15 correct answers. Another 24 (19.8%) participants were categorised as having inadequate or poor knowledge, as they provided only 0–5 accurate responses..

Table 4.3 Knowledge Level of Respondents

4.3 Score of Confidence/Belief

The confidence and belief scores for postpartum depression screening and management among respondents are presented in Table 4.4. A considerable proportion of respondents (14.9%) were unsure whether postpartum depression was a social stigma or not. Only a small percentage (3.3%) strongly agreed that it was social stigma, whereas 14.9% strongly disagreed. However, most respondents were divided, with 26.4% agreeing and 40.5% disagreeing, indicating a lack of consensus on whether postpartum depression is viewed as social stigma. When considering whether it was a cultural norm for mothers to discuss their depression with nurses, 14.0% of the respondents were unsure. A minority (9.1%) strongly agreed with this statement, whereas only 1.7% strongly disagreed. The majority (61.2%) agreed that cultural barriers might prevent open discussions about depression between mothers and nurses. However, 14.0% disagreed, indicating that some did not perceive it as a significant cultural issue.

Regarding the preference for alternative treatments among mothers with postpartum depression, 20.7% of the respondents were unsure. Only 5.8% strongly agreed with this preference, whereas 4.1% strongly disagreed. A substantial proportion (47.1%) agreed, indicating that many believed that mothers preferred alternative treatments, whereas 22.3% disagreed, indicating that a notable proportion did not see this preference. The necessity of screening for postpartum depression was strongly supported with only 5.0% uncertainty. A considerable proportion (43.0%) strongly agreed that screening was necessary, whereas 4.1% strongly disagreed. Additionally, 43.8% agreed, and only 4.1% disagreed, demonstrating broad support for the importance of screening. Opinions on whether screening takes too much time vary, with 22.3% were unsure and only 4.1% strongly agreed that it was time-consuming. A large proportion (10.7%) strongly disagreed with this statement and 14.9% agreed. However, a substantial proportion (47.9%) disagreed, indicating that most respondents did not consider the time required for screening a significant barrier.

There was a powerful sense of responsibility for screening among the respondents. Only 9.1% were unsure about this responsibility, while 33.1% strongly agreed, and 4.1% strongly disagreed. The majority (52.1%) agreed that it was their responsibility and only 1.7% disagreed, highlighting a strong commitment to screen for postpartum depression. Similarly, when it came to counselling for mothers with postpartum depression, 15.7% were unsure. A quarter (25.6%) strongly agreed that this was their responsibility, whereas 3.3% strongly disagreed with it. Close to half (47.1%) of the respondents agreed and 8.3% disagreed, indicating that most respondents felt responsible for providing counselling. The responsibility of referring mothers for further treatment is widely acknowledged, with only 0.8% being unsure. A substantial number of 43.8% strongly agree and 4.1% strongly disagree. More than half (51.2%) agreed, and no respondents disagreed, showing a strong consensus on the importance of referrals and that caring for mothers with postpartum depression was perceived as rewarding by many, with 16.5% being unsure. A quarter (26.4%) strongly agreed and 3.3% strongly disagreed. Almost half (49.6%) agreed and only 4.1% disagreed, suggesting that most found this aspect of their work to be fulfilling. Comfort for discussing depression among postpartum mothers was high. While 18.2% were unsure, 24.8% of the respondent strongly agreed that they were comfortable, and only 2.5% strongly disagreed. More than half (50.4%) agreed, and 4.1% disagreed, indicating overall comfort in these conversations. Confidence in recognising postpartum depression was notably high, with only 14.0% being unsure. A significant percentage (21.5%) strongly agreed that they were confident, while 3.3% strongly disagreed. The majority (60.3%) agreed, and only 0.8% disagreed, reflecting the high confidence levels among the respondents.

Confidence in counselling, however, shows room for improvement. While 29.8% were unsure, 14.9% strongly agreed that they were confident, and 2.5% strongly disagreed. Almost half (46.3%) agreed, while 6.6% disagreed, indicating moderate confidence in providing counselling.

Table 4.4 Belief and Confidence Score of Respondents

As shown in Table 4.5, there were both low and high confidence levels among respondents in screening for postpartum depression. Approximately 86.8% of the respondents agreed that screening for postpartum depression was necessary, and 85.1% believed that screening for postpartum depression was their responsibility. Additionally, 95.0% felt responsible for referring mothers with postpartum depression for further treatment, while 72.7% agreed that counselling these mothers was their responsibility. This high level of confidence extends to the aspects of comfort and recognition. For instance, 75.2% of respondents felt comfortable talking with postpartum mothers about depression and 81.8% were confident in recognising postpartum depression. Furthermore, many respondents found that caring for mothers with postpartum depression was a rewarding experience, with 76.0% expressing this sentiment.

However, there were areas where confidence levels were notably lower. A significant proportion (70.2%) of the respondents viewed postpartum depression as a social stigma and 29.8% acknowledged cultural barriers that prevented mothers from discussing their depression with nurses. This indicates that while healthcare professionals recognise their responsibilities, societal and cultural factors still pose significant challenges. There was also mixed confidence regarding preference for alternative treatments, with 47.1% showing low confidence and 52.9% showing high confidence. Furthermore, 81.0% of respondents believed that screening for postpartum depression took too much time, which could have acted as a barrier to the effective implementation of these screenings. Some respondents (38.8%) had low confidence in providing counselling.

Table 4.5 Confidence Level among Respondents

4.4 Score of Practice Among Respondents

The data from Table 4.6 presents the practices of healthcare workers regarding postpartum depression (PPD) screening and management. Several questions were asked withvarious responses. A total of 9.9% of respondents reported seeing an average of 0-10 postpartum women every week. On the other end, another 9.9% stated that they had seen more than 40 postpartum women every week, representing the highest demand group. 5.0% of the participants provided care for 21-30 postpartum mothers each week, while another 5.0% attended to 31-40 mothers on a weekly basis. Variance in patient load suggests that clinics have different levels of exposure to possible instances of PPD.

Regarding the frequency of screening for postpartum depression, 74.4% of the participants stated that they seldom performed screens, while 25.6% admitted that they did not screen for PPD. This indicates a significant disparity in the regular screening techniques for PPD among the respondents, which might result in several instances being undetected. There was substantial variation in the date of PPD screening among the respondents. While 47.1% of respondents indicated frequent screening of postpartum mothers for depression,a group of 27.3% acknowledged infrequent or rare implementation of such tests. Significantly, only 18.2% consistently performed the screening, whereas a minute portion (0.8%) never conducted screening, indicating a lack of uniformity in the screening schedule. The criteria used by healthcare personnel to determine when to check for PPD varied similarly. According to 44.6% of respondents, screening was most likely to occur when a family member expressed concerns. Furthermore, 24.0% of individuals reported undergoing screening for depression based on observable symptoms, whereas 12.4% screened for a family history of psychiatric disease. Other conditions including those who were teens, single mothers, and those with low income had lower screening rates (6.6%, 4.1%, and 1.7%, respectively). Screening was infrequent for primigravida mothers (0.8%) and non-existent for those with unplanned pregnancies and multigravida (0%).

Of 121 respondents, 117 were acquainted with at least one screening tool for Postpartum Depression (PPD). About 42.1% were familiar with the Edinburgh Postnatal Depression Scale (EPDS), which is the most widely used instrument, whereas 28.1% were acquainted with the Postpartum Depression Screening Scale (PDSS), and only 4.1% and 0.8% of the respondents recognised the Beck Depression Inventory (BDI) and Patient Health Questionnaire (PHQ-9), respectively. This research suggests that although there is a certain level of awareness regarding screening tools, the information is not evenly spread across all instruments, which might potentially impact the consistency and efficacy of screening techniques.

Only 32.2% of the respondents reported identifying PPD cases, whereas the remaining 67.8% did not recognise PPD among their patients. This information pertains to the identification and counselling of women with PPD. Among the respondents, 70.2% did not provide counselling, whereas only 9.1% frequently provided counselling. This underscores the crucial need for delivery of mental health assistance for women in the postpartum period. Regarding referral of patients for additional therapy, these trends were equally concerning. The majority of respondents (69.4%) did not make referrals for additional treatment, while only 9.1% did so frequently and 6.6% did so consistently. Responders encountered substantial obstacles to effective PPD screening. Of the respondents, 62.8% said that the main obstacle was their mother’s reluctance to discuss depression. Furthermore, 57.9% of the participants emphasised that insufficient training in postpartum depression (PPD) screening was a serious hindrance, while 28.9% identified the lack of mental health services in their clinics as a barrier. Challenges were also identified in terms of time constraints (16.5%) and a lack of privacy for screening (16.5%). Concerning future procedures and training, there was a distinct inclination towards enhancing PPD screening among respondents. Among participants, 49.6% indicated a desire for additional training. Among these, 44.6% preferred workshops, 45.5% chose seminars, and 41.3% favoured continuing medical education (CME). Only a small proportion (9.1%) showed an interest in Internet-based learning and a strong connection with psychiatric posts.

Table 4.6 Practices among Respondents

*Multiple answer

4.5 Correlation of Sociodemographic Factors with the level of knowledge, confidence and practice

Table 4.7 shows the correlation coefficients (R-values) and p-values for the relationships between various sociodemographic factors and levels of knowledge, confidence, and practices regarding postpartum depression among the respondents. The correlation between the place of practice and knowledge scores was very weak (r = 0.0018) and not statistically significant (p = 0.9843). This finding suggests that knowledge about postpartum depression does not vary significantly across five clinics involved. Similarly, there was a weak positive correlation between age and the knowledge score (r = 0.1100). However, this was not statistically significant (p = 0.2297), indicating that the nurses’ age did not have a meaningful impact on their knowledge of postpartum depression. The correlation between gender and knowledge scores was weakly negative (r = -0.1040) and not statistically significant (p = 0.2561).

The correlation between race and knowledge scores was weakly negative (r= -0.0886) and not statistically significant (p = 0.3339), indicating that race did not significantly affect postpartum depression knowledge. Finally, the correlation between religion and knowledge scores was very weak (r = 0.0316) and not statistically significant (p = 0.7306), suggesting that religious affiliation does not significantly influence postpartum depression knowledge.

There was a weak negative correlation between the clinic and confidence scores (r = -0.0856), but this was not statistically significant (p = 0.3505). This finding indicates that confidence levels in managing postpartum depression did not vary significantly across clinics. Similarly, there was a weak positive correlation between age and the confidence score (r = 0.1020). However, this difference was not statistically significant (p =

0.2654), suggesting that age did not significantly influence confidence levels in handling postpartum depression. The correlation between sex and confidence scores was weakly negative (r = -0.0902) and not statistically significant (p = 0.3252), indicating that sex did not significantly affect confidence levels in relation to postpartum depression. There was a weak positive correlation between race and confidence score (r = 0.1140). However, this difference was not statistically significant (p = 0.2132), suggesting that race does not significantly influence confidence in the management of postpartum depression. The correlation between religion and confidence scores was weak (r = -0.0414) and not statistically significant (p = 0.6521), indicating that religious affiliation did not significantly influence confidence in handling postpartum depression.

There was a very weak positive correlation between the clinical and practice scores (r = 0.0238), which was not statistically significant (p = 0.7959), suggesting that practices related to postpartum depression did not vary significantly across clinics. The correlation between age and practice scores was weakly negative (r = -0.0652) and not statistically significant (p = 0.4771), indicating that age did not significantly influence postpartum depression. There was a weak negative correlation between gender and practice scores (r = -0.0526), which was not statistically significant (p = 0.5668), suggesting that gender did not have a significant impact on the practice levels of postpartum depression. The correlation between race and practice scores was very weak (r = 0.0257) and not statistically significant (p = 0.7796), indicating that race did not significantly influence practice levels of postpartum depression. There was a weak positive correlation between the religion and practice scores (r = 0.1077). However, this was not statistically significant (p = 0.2396), suggesting that religious affiliation did not significantly influence practice levels of postpartum depression.

Note: The total number of respondents (N) is 121. Certain questions allowed respondents to select more than one option, which may have resulted in the sum of responses exceeding 121.

Table 4.7: Correlation between Sociodemographic Factors and Levels of Knowledge,

4.6 Discussion

4.6.1  Demographic Analysis

Demographic analysis of respondents plays a crucial role in situating the study within the context of the population under investigation. Of the 121 participants who completed the survey, Klinik Kesihatan Bayan Lepas received the most responses (26.4%). These findings indicate that Klinik KesihatanBayan Lepas likely has a greater number of nurses employed in the Maternal and Child Health (MCH) unit, suggesting a greater ability to provide maternal and child health services.

However, the representation of Klinik Kesihatan Seberang Jaya  was the lowest, accounting for only 16.5% of responses. Although Seberang Jaya had fewer participants, this did not necessarily indicate a lower total number of nurses in the area. However, this implies that the level of participation from Seberang Jaya in this survey was lower than that of other clinics.  Considering the number of responses, it is probable that Klinik Kesihatan Bayan Lepas has a higher workload, which puts more pressure on healthcare staff. A greater number of nurses often implies that the clinic handles a larger number of patients, which is associated with the need for additional resources and time allocated to postpartum care such as screening and managing depression. Nevertheless, the survey did not provide clear data regarding the clinic with the highest count of Staff Nurses (SN) in the MCH unit nor did it directly assess the workload in terms of patient-to-nurse ratios. The increased response rate from Bayan Lepas may indicate a greater workload. However, without precise statistics on patient volume or nurse staffing levels, the actual amount of strain can be inferred only from survey participation. This detailed distribution ensures that the sample proportionally represents the nurse population across the selected clinics, thereby maintaining balanced coverage and maximising the utility of the sample size for effective analysis [31].

4.6.2 Age and Experience

The age distribution revealed a predominance of–30-39 years (43.8%) and 40-49 years (49.6%) age groups, suggesting a workforce rich in professional experience. This could be particularly beneficial, as senior employees in the healthcare sector might possess enhanced diagnostic capabilities for conditions such as postpartum depression owing to their extensive work experience [32].  Conversely, the lower representation of the 18-29 age group (1.7%) and the 50-59 age group (4.8%) indicates a potential gap in the influx of young professionals into the profession or could reflect the retirement or transfer of older professionals to administrative roles.

4.6.3 Gender Distribution

The gender distribution among the respondents was female (100%), which is typical in the nursing and healthcare industries, particularly in maternal and child healthcare. This gender disparity may influence attitudes towards postpartum depression, as female healthcare workers (HCWs) may have personal or vicarious experiences that their male counterparts do not share [66].

4.6.4 Cultural and Religious Context

The racial and religious composition of the respondents, with 88.4% Malay and 89.3% Muslim, closely mirrors the general population ratio in Malaysia. This cultural and religious homogeneity is significant, as commonly held cultural and religious beliefs can impact both the attitudes and perceptions of professionals and patients regarding mental disorders such as postpartum depression [67].

4.6.5 Marital and Familial Status

A significant majority of the respondents (91%) were married, which could enhance their empathy and responsiveness to familial and postnatal challenges. Furthermore, all respondents had children, with the most common family size being two or three children. This personal experience with child-rearing might improve their understanding and identification of the difficulties associated with the postpartum period [68].

4.6.6  Professional Roles and Experience\

The employment positions of Respondents were predominantly Community Nurses (38.8%), Registered Nurses (25.6%), and Staff Nurses (19.8%). These roles are typically at the forefront of patient care and preliminary diagnoses, indicating that surveys are directly involved in daily patient interactions [69]. Most of the respondents had substantial work experience, with the majority having 6–20 years of experience. This mature workforce is likely to have extensive knowledge about maternal and child health

4.6.7 Educational Background

The educational background of the respondents highlights a well-rounded foundation in nursing and maternal health, with a significant portion holding either a diploma (33.1%) or a certificate, commonly referred to as “sijil” (33.9%) in nursing. The inclusion of “sijil” holders in this workforce is particularly noteworthy, as it reflects the critical role that these certified nurses play in the healthcare system, often providing essential frontline care. Their certification indicates a solid grasp of practical nursing skills, which are vital in day-to-day patient care, especially in maternal and child health settings [70].

4.6.8 Awareness and Confidence

An impressive 97.5% of respondents affirmed that they had been educated about postpartum depression. However, regarding research objective 2 on evaluating the confidence levels of nurses in executing PND screening protocols, the research findings showed that nurses’ confidence in applying this knowledge varied, indicating the challenges in translating knowledge into practice. This gap underscores the need for ongoing training and support to boost confidence in postpartum depression management.

The phenomenon of high awareness and varied confidence among nurses concerning postpartum depression (PND) screening protocols was not unique to this study. Similar trends have been observed in various healthcare settings, where education on mental health conditions does not always equate with practical proficiency. For instance, research conducted in urban healthcare centers has shown that while educational programs effectively raise awareness, they do not consistently enhance the confidence needed for practical application unless paired with hands-on training and supportive supervision [33].  This suggests that mere theoretical knowledge might be insufficient unless reinforced by practical experience and mentorship.

Thus, the implications of these findings are significant. Enhancing nurse confidence through additional training and support not only empowers nurses but also potentially increases the quality of care provided to new mothers [34].  facilitating early detection and intervention in PND. This approach could lead to better health outcomes and improved patient satisfaction, underlining the need for a holistic training approach to bridging the gap between knowledge and practice in nursing education.

4.6.9 Knowledge of Postpartum Depression

The findings regarding the respondents’ knowledge of postpartum depression provided valuable insights into the first research objective, which assessed nurses’ knowledge of postpartum depression. A significant majority (74.4%) correctly identified that postpartum depression could occur at any time within the first year after delivery, indicating good fundamental knowledge. However, there was a notable deficiency in recognising the impact of the condition on males, with 83.5% incorrectly perceiving it solely as a female issue. This suggests a need for education to help healthcare providers identify postpartum depression in all parents irrespective of gender.

Findings on postpartum depression align with broader research on mental health education in the medical profession. The literature often highlights a general awareness of postpartum depression but points to persistent oversight regarding its occurrence in males [35].  Therefore, the implications of this deficiency are significant. By not fully understanding that postpartum depression can affect both parents, healthcare providers may miss critical opportunities for intervention and support of at-risk male parents. Male partners with PPD may also affect their wives’ mental states and children and need to be referred to a specified team. Research indicates that paternal postpartum depression is often associated with maternal postpartum depression and can exacerbate maternal mental health challenges [71]. Additionally, paternal depression has been linked to adverse emotional and behavioural outcomes in children [72].Educating nurses and other health professionals on the inclusive nature of postpartum depression is crucial. This can lead to more comprehensive screening and support strategies, ensuring that new parents have access to the mental health resources they need, thus promoting a more inclusive approach to maternal and paternal mental healthcare [37].

4.6.10 Prevalence and Risk Factors

Awareness of the prevalence of postpartum depression, aligning with the first research objective, was high, with 85.1% of respondents correctly identifying its impact on 10–20% of women of childbearing age. This awareness is crucial for reducing the stigma and promoting early management. However, misunderstandings regarding the prevalence and risk factors persist, highlighting the need for comprehensive training that includes detailed prevalence data and risk factor education.

This high level of awareness of the prevalence of postpartum depression among respondents mirrors the trends observed in other regions where educational initiatives have successfully heightened recognition of the condition’s widespread nature.

However, similar studies have also reported persistent gaps in the understanding of specific risk factors, reflecting a common challenge across healthcare settings [38].

Therefore, it is crucial to understand the implications of this persistent misunderstanding. Understanding the full scope of the risk factors for postpartum depression is vital for effective screening and early intervention. Enhancing the quality of training programs to include a more detailed exploration of risk factors could empower health care providers to identify and support at-risk individuals more effectively. This approach not only aids in early detection, but also plays a significant role in the broader effort to destigmatise mental health issues associated with childbirth, promoting a healthier start for families.

4.6.11 Symptom Recognition

Addressing the first research objective, 70.2% of respondents correctly understood that postpartum blues persisting for more than two weeks could indicate depression, and gaps in knowledge about the timeline and symptoms of postpartum depression were evident. For example, only 79.3% correctly identified the first three months postpartum as the most common time for postpartum depression, and many were uncertain about specific symptoms. This finding suggests a need for more focused education regarding the symptoms and timeline of postpartum depression. The partial understanding of the timeline and symptoms of postpartum depression among study participants reflects a common trend in mental health literacy across the healthcare sector. Research from a similar study in a community healthcare setting in Australia highlighted that while general awareness of postpartum depression was high, detailed knowledge of its symptoms and critical periods was lacking [39]. This issue is often attributed to the generalised nature of mental health education, which may not delve deeply into specific disorders, such as postpartum depression.

Thus, the implications of these knowledge gaps are significant. Accurate symptom recognition is crucial for timely and effective intervention for postpartum depression. To this end there is a necessity to carry out specialized educational intervention programs that are aimed at disclosing the specifics of postpartum depression. Such programs should be specifically aimed at addressing the identified gaps in knowledge, training and retraining of nurses that work in MCH facilities. Such a concept would ensure that such healthcare professionals are up to date with the latest literature, management strategies, and evidence-based practices for the diagnosis and treatment of postpartum depression thus enhancing the support given to affected mothers as well as the overall health outcomes of the patients involved [73].

4.6.12 Misconceptions and Treatment

Misconceptions regarding treatment of postpartum depression are also prevalent. For instance, 44.6% incorrectly believed that all mothers with postpartum depression required antidepressants and 47.9% assumed that no antidepressants were safe during breastfeeding. These misconceptions could hinder effective treatment and management of the condition, emphasising the need for accurate information and training on treatment options. It is for this reason that a proper education regarding the use of antidepressants is crucial in responding to some of the issues raised concerning antidepressants use, especially where properly prescribed and managed, are critical in the management of postpartum depression. Making sure that the healthcare providers are informed on the benefits and possible risks of using antidepressants and other forms of treatment to patients will help them offer the best treatment plan to patients [74].

4.6.13 Confidence and Beliefs

In conjunction with the second research objective, the assessment of confidence and beliefs regarding postpartum depression among healthcare workers revealed mixed understandings that could directly impact the care provided to the affected women. A significant number of respondents (70%) perceived mental disorders as stigmatised, which could deter open discussion about postpartum depression. This stigma, coupled with cultural and social expectations, poses a critical barrier to effective communication and intervention.

The interplay of stigma and varying levels of confidence in discussing postpartum depression highlighted in this study resonates with the findings from other healthcare contexts. In view of this, the following are findings that point towards this kind of difficulty, which is global in nature. The implications of these findings are as follows: stigma is not only a determinant of healthcare workers’ willingness to discuss postpartum depression with patients, but also influences their self-confidence regarding these cases [39]. This underlines the necessity for practising interventions aimed at eradicating existing prejudice towards mental health among members of healthcare occupations, as well as the public. Addressing stigma and increasing confidence through staff, training, and cultural changes could help provide better and more sensitive care for women with postpartum depression [32].

4.6.14  Screening and Management Practices

The practice assessment highlighted significant gaps and barriers in current healthcare practices related to screening and management of postpartum depression. Despite the recognition of the importance of screening, with 86.8% supporting its necessity, practical barriers such as time constraints and lack of established protocols hinder regular screening. The low frequency of screening, inconsistent timing, and limited familiarity with screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) and Postpartum Depression Screening Scale (PDSS) underscores the need for standardised screening protocols and comprehensive training

4.6.15 Barriers to Effective Screening

The study established that there are several significant barriers that hampers the proper screening and management of postpartum depression, thus the need to enhance the approach. Some of the most important barriers included inadequate awareness of the postpartum depression screening process and inadequate training and experience that may cause missed or inaccurate diagnoses. Moreover, the fact that there is uncertainty in determining the next course of action once a screening result has been obtained does not help the situation and just makes healthcare providers shy away, or mothers who require support [75]. Lack of time is another factor, which can be regarded as a problem of practice while working in the clinical environment; in such circumstances, healthcare professionals may not have time to consider other non-life-threatening medical conditions while evaluating patients for mental health problems [76]. Adding to these challenges is the cultural taboo that prevents many mothers from reporting depressive symptoms, or experiencing depression for fear of being sidelined or ostracised, which leads to under-diagnosis and delayed treatment.

To overcome these barriers, it is therefore require a system approach. A new model of delivering mental health care that will see specialists offer the services within the primary care setting would be useful in ensuring that postpartum depression receives a similar attention as other medical issues [77]. This integration would also make it easier for the people in need of mental health services to access professionals in the field. In addition, there should be private areas within clinics so that mothers can freely discuss issues concerning their mental health without the feeling that everybody around them can overhear them. Another measure includes ensuring that enough time is dedicated more so for mental health screening during the appointments so that providers are able to complete their assessments without feeling the pinch of time. Such changes, in addition to other strategies such as education and training of health care providers on screening techniques and procedures to be followed after screening, are important in enhancing early diagnosis and treatment of PDMP, hence improving the wellbeing of mothers and their families.

4.6.16  Training and Future Practices

The study highlights a strong willingness among healthcare workers to improve their practices, particularly in the area of postpartum depression management, which is a positive indicator for future advancements in care. A majority of the respondents said they require more training, and this shows that they recognize their deficits in certain areas. This recognition is important as it portrays a positive outlook to the need for professional practice advancement as well as the guarantee of improved maternal care to women who are affected by postpartum depression. The differences in the choice of training types, with the seminars’ and workshop appearing as the most preferred, indicate that the healthcare workers prefer applied and participatory trainings which include practical components and actual hands-on approach [78].

As such, it is imperative to build on this openness to learning by offering the healthcare workers tools and encouragement to improve their competencies. To increase the chances of success it will be important for the training programs to be customized to best suit the healthcare providers. However, ongoing education should not only be in form of single sessions but a form of continuing professional development that ensures that the healthcare workers are update on best practice of postpartum depression care [79]. Establishing frequent and easily available continuing education, medical facilities can promote the culture of learning that results in improved approaches to detection and treatment of postpartum depression [80]. This will in turn go a long way in improving the health of these mothers and their families, and reignite discussion on the importance of well-trained healthcare workers in maternal and child health care.

CHAPTER 5: CONCLUSION

5.1 Study Limitations

This study has several limitations that should be considered when interpreting the findings. The cross-sectional design provides a snapshot of current practices and knowledge but cannot establish historical learning or the effects of recent training. This design limits the ability to determine causality between sociodemographic factors and the levels of knowledge, confidence, and practice. Therefore, although correlations can be observed, definitive conclusions regarding the cause-and-effect relationships remain speculative.

Additionally, the study relied on participants’ self-reports, which may have introduced response bias. Participants may tend to overreport socially desirable behaviours and underreport socially undesirable behaviours. This response bias can skew the data, leading to an inaccurate representation of the true knowledge, confidence, and practices of the healthcare workers involved.

Although the sample size was representative of many healthcare workers in Penang, it may not capture the full range of approaches and experience of all healthcare workers. This is particularly pertinent in diverse fields such as healthcare, where individual experiences and approaches can vary significantly. The exclusive focus on public health clinics in Penang further limits the generalisability of the results. Healthcare practices and resources can vary widely between the public and private sectors and across different regions. Thus, the findings of this study may not be applicable to other regions or private health care facilities in Malaysia.

Furthermore, the study population predominantly consisted of Malay and Muslim healthcare workers. Although this reflects the demographic composition of the region, it may restrict the generalisability of our findings to other ethnic and religious populations. The cultural context in which health care workers operate can significantly influence their knowledge, confidence, and practices, particularly in areas related to mental health.

Although this study provided valuable insights into the current state of knowledge, confidence, and practices related to postnatal depression screening among healthcare workers in Penang, its limitations highlight the need for future research to adopt more comprehensive and diverse methods.

5.2 Future Recommendations

Future research should focus on longitudinal studies to assess the changes in knowledge, confidence, and practice over time, particularly after training. Longitudinal studies should provide a more comprehensive understanding of the long-term impact of training programs and other initiatives aimed at improving screening for PPD. Expanding this research to include private healthcare settings and other regions in Malaysia would offer a broader view of PPD screening practices nationwide. Including a more diverse sample in terms of race, religion, and cultural background will help us better understand how these factors influence attitudes and practices related to PPD.

Considering the observed knowledge gaps and inconsistent confidence levels among nurses in performing postnatal depression (PND) screenings, it is evident that tailored educational programs are imperative. These should not only focus on the fundamental issues of PND but should also go further and cover what is germane to the actual skills required to perform adequate screening and management of PND. The integration of full-fledged modules that include all symptoms, risk factors, and strategies for patient interaction can significantly increase the effectiveness of healthcare workers. For instance, incorporating a (Mental Health First Aid Course) into the training curriculum could prepare nurses with adequate knowledge to offer the first response to a person with mental health problems such as PND [40].

The creation of awareness and involvement in the community is vital in the fight against stigma and screening for PND. Campaigns should be aimed at raising awareness of the topic and encouraging discussions on mental health; this approach can make both healthcare practitioners and patients more comfortable discussing issues such as PND. Online e learning modules can also be used as a cost-effective way to provide refresher information and knowledge to nurses, while making the latest guidelines and practices readily available.

Additionally, the implementation of clinically tested and short screening measures such as the Whooley questions and PHQ-2 should be underlined. These tools are not only easy to use and time-saving but also help in early detection, which is important in the case of childhood diseases [41].  To ensure the consistency of the process of screening for PND among different healthcare facilities and to make sure all the nurses who are to screen patients for possible PND are equipped with the corresponding knowledge, regular training sessions concerning the effective use of the tools mentioned above should be conducted.

Collectively, the purpose of all the proposed recommendations is to narrow the gap between what is known in theory and how they can be implemented in practice to improve the quality of care for postpartum women [42]. This way, by raising the level of knowledge of healthcare providers, implementing guidelines for screening, and raising awareness of the community, one can expect nurses’ self-confidence and ability to manage PND to rise. This will improve the health status of mothers and their families and highlight the importance of effective and unintermittent medical training.

5.3 Conclusion

Despite the existence of Malaysian guidelines that mandate screening for postnatal depression (PND) among all postpartum mothers, significant gaps in adherence to these guidelines persist. Bridging this gap necessitates a multifaceted approach, including enhanced training for healthcare providers, creating supportive work environments, establishing standardized screening protocols, and ensuring effective resource allocation. Implementing these strategies will enable health clinics to improve their adherence to guidelines, resulting in better identification and management of PND, ultimately enhancing maternal mental health outcomes.

The findings of this study revealed a notable knowledge deficit among nurses in Penang, alongside challenges in their practices and confidence regarding PND screening. While there is a general awareness of PND, misunderstandings and other obstacles continue to impede effective care. This study underscores the importance of continuous education for healthcare personnel, aimed at improving PND screening and care provision. Addressing these educational and practical gaps through targeted training, increased awareness among healthcare providers, public education, and systematic changes within practice settings will significantly benefit mothers experiencing PND, as well as their families and the broader society. By doing so, maternal and child health in Malaysia can be substantially improved.

Future strategies should remain focused on addressing the ongoing gaps in knowledge, confidence, and practices among healthcare providers in Penang concerning PND. By adopting the recommended measures, healthcare systems will be better equipped to meet the needs of mothers during one of the most vulnerable periods of their lives, thereby enhancing the overall health and well-being of both mothers and their families.

REFERENCES

1. O’Hara MW, Swain AM. Rates and risk of postpartum depression: A meta-analysis. Int Rev Psychiatry. 1996;8(1):37-54.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington DC: American Psychiatric Association; 2013.
3. Field T. Postpartum depression effects on early interactions, parenting, safety practices: A review. Infant Behav Dev. 2010;33(1):1-6.
4. Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, management of mood disorders in pregnant, postpartum women. Obstet Gynecol. 2011;117(4):961-977.
5. Giallo R, Dunning M, Hayes L. Maternal postnatal mental health, later emotional-behavioural development of children: The mediating role of the mother-child relationship. Child Care Health Dev. 2014;40(3):327-36.
6. Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers, maternal treatment preferences: A qualitative systematic review. Birth. 2006;33(4):323-331.
7. Ahmad NA, Silim UA, Rosman A, Mohamed M, Chan YY, Kasim NM, et al. Postnatal depression, intimate partner violence: A nationwide clinic-based cross-sectional study in Malaysia. BMJ Open. 2018;8(5)
8. Garapathi VS, Sani MA, Rahman RA, Ramli A. Challenges in the management of perinatal mental health: A study on healthcare providers’ perspectives. BMC Health Serv Res. 2023;23(1):567.
9. Raaj S, Hassan N, Zainal NZ. Maternal mental health in Malaysia: Bridging gaps in practice, policy. Asian J Psychiatr. 2023;80:103348.
10. Ministry of Health Malaysia. Clinical Practice Guidelines (CPG) for the Management of Major Depressive Disorder. Putrajaya: Ministry of Health Malaysia; 2019.
11. Kang PS, Mohazmi M, Ng YM, Liew SM. Nurses’ knowledge, beliefs, practices regarding the screening, treatment of postpartum depression in maternal, child health clinics: A cross-sectional survey. Malays Fam Physician. 2019;14(1):18-25.
12. Clarke JR, Gibson M, Savaglio M, Navani R, Mousa M, Boyle JA. Digital screening for mental health in pregnancy, the postpartum period: A systematic review. Arch Womens Ment Health. 2024;27(4):489-526.
13. Bell L, Feeley N, Hayton B, Zelkowitz P, Tait M, Desindes S. Barriers, facilitators to the use of mental health services by women with elevated symptoms of depression, their partners. Issues Ment Health Nurs. 2016;37(9):651-9.
14. Byatt N, Levin LL, Ziedonis D, Moore Simas TA, Allison J. Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review. Obstet Gynecol. 2015;126(5):1048-58.
15. Shorey S, Chan SWC, Chong YS, He HG, Tam WWS. A systematic review of the correlates of postnatal depression among Asian women. Midwifery. 2018;56:166-78.
16. Eberhard-Gran M, Eskild A, Tambs K, Samuelsen SO, Opjordsmoen S. Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta Psychiatr Scand. 2001;104(4):243-9.
17. Rosenstock IM. The Health Belief Model, preventive health behavior. Health Educ Monogr. 1974;2(4):354-86.
18. Sidebottom AC, Vacquier M, LaRusso E, Erickson D, Hardeman R. Perinatal depression screening practices in a large health system: identifying the current state, assessing opportunities to provide more equitable care. Arch Womens Ment Health. 2021;24:133-144.
19. Thomas S, Beh LS, Nordin RB. Health care delivery in Malaysia: Changes, challenges, champions. J Public Health Afr. 2011;2(2).
20. Raaj S, Verghese V, Tharmaseelan M, Duffy R, Sinnadorai NKS. Perinatal mental health in Malaysia: understanding the treatment gap, recommendations for the future. BJPsych Int. 2023;20(1):9-12.
21. Raghavan R, Brown B, Horne F, Kumar SR, Barrett A, Dasan C, et al. Stigma, mental health problems in an Indian context: Perceptions of people with mental disorders in urban, rural, tribal areas of Kerala. Int J Soc Psychiatry. 2023;69(2):362-9.
22. Abdollahi F, Lye MS, Md Zain A, Ghazali S, Zarghami M. Postnatal depression, its associated factors in women from different cultures. Iran J Psychiatry Behav Sci. 2011;5(2):5-11.
23. Ahad AA, Sanchez-Gonzalez M, Junquera P. Understanding, addressing mental health stigma across cultures to improve psychiatric care: A narrative review. Cureus. 2023;15(5)
24. Alimuddin AS, Mohd Shukor NA, Soh SY, Suainbon R, Mahmud AA, Abdul Samad FD, et al. Mind Matters: A Critical Look at Malaysia’s Postnatal Depression Policy for Women’s Mental Health. Womens Health Rep (New Rochelle). 2023;4(1):381-386.
25. Arefadib N, Cooklin A, Nicholson J, Shafiei T. Postnatal depression, anxiety screening, management by maternal, child health nurses in community settings: a scoping review. Midwifery. 2021;100:103039.
26. Banerjee D, Arasappa R, Chandra PS, Desai G. “Hear me out”: experiences of women with severe mental illness with their healthcare providers in relation to motherhood. Asian J Psychiatry. 2021;55:102505.
27. Bit-Lian Y, Woei-Ling T, Nachiappen SJ, Jajali NFM. Factors Affecting Participation of Registered Nurses in Continuing Nursing Education among selected private hospitals in Penang, Malaysia. Malays J Nurs. 2022;14(2):82-89.
28. Clatworthy J. Effectiveness of antenatal interventions to prevent postnatal depression in high-risk women. J Affect Disord. 2012;137(1-3):25-34.
29. Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment: a prospective study. JAMA. 2006;295(5):499-507.
30. Corrigan CP, Kwasky AN, Groh CJ. Social Support, Postpartum Depression, Professional Assistance: A Survey of Mothers in the Midwestern United States. J Perinat Educ. 2015;24(1):48-60.
31. Cowell W, Colicino E, Askowitz T, Nentin F, Wright RJ. Fetal sex, maternal postpartum depressive symptoms: findings from two prospective pregnancy cohorts. Biol Sex Differ. 2021;12(1):1-10.
32. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786.
33. Fisher J, de Mello MC, Patel V, Rahman A, Holton S, Holmes W. Prevalence, determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: A systematic review. Bull World Health Organ. 2012;90(2):139-149H.
34. Haughton B, Stang J. Population risk factors, trends in healthcare, public policy. J AcadNutr Diet. 2012;112(3 Suppl)
35. Holden L, Berger R, Zingarelli E, Siegel E. After-school program for urban youth: evaluation of a health careers course in New York City high schools. Inf Serv Use. 2015;35(1-2):141-160.
36. Horowitz JA, Cousins A, Heilemann MV, Milgrom J. Interventions for postpartum depression to improve parenting, infant health outcomes. Cochrane Database Syst Rev. 2013;10
37. Howell EA, Bodnar-Deren S, Balbierz A, Parides M, Bickell NA. Intervention to reduce postpartum depressive symptoms: A randomized controlled trial. Arch Womens Ment Health. 2014;17(1):57-63.
38. Jannati N, Farokhzadian J, Ahmadian L. The Experience of Healthcare Professionals Providing Mental Health Services to Mothers with Postpartum Depression: A qualitative study. Sultan Qaboos Univ Med J. 2021;21(4):554-562.
39. Kaneshiro NK, Mielenz TJ, DiClemente RJ, Wingood GM, Rose ES, Crosby RA. Predictors of repeat pregnancies among adolescent mothers: A review of the literature. J Adolesc Health. 2005;36(6):465-475.
40. Kornfeld E, Bair-Merritt M, Frosch E, Solomon BS. Postpartum depression screening practices, policies for pediatric primary care. JAMA Pediatr. 2013;167(10):1060-1066.
41. Kingston D, Austin MP, Heaman M, McDonald S, Lasiuk G, Sword W, et al. Barriers, facilitators of mental health screening in pregnancy. J Affect Disord. 2015;186:104-110.
42. Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD, DEPRESsion Screening Data (DEPRESSD) EPDS Group. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant, postpartum women: A systematic review, meta-analysis of individual participant data. BMJ. 2020;371
43. Logsdon MC, Wisner K, Pinto-Foltz MD. The impact of postpartum depression on mothering. J ObstetGynecol Neonatal Nurs. 2006;35(5):652-658.
44. Maleki M, Mardani A, Harding C, Basirinezhad MH, Vaismoradi M. Nurses’ strategies to provide emotional, practical support to the mothers of preterm infants in the neonatal intensive care unit: A systematic review, meta-analysis. Womens Health (Lond). 2022;18:17455057221104674.
45. Maru S, Msambichaka B, Machumi L, Bartlett JA, Kilawe CJ, Mushi D, et al. Impact of mHealth interventions on postpartum depression among women in Tanzania: A randomized controlled trial. J Affect Disord. 2021;278:61-67.
46. McCauley KM, Elsom SJ, Muir-Cochrane E, Lyneham J. Improving Mental Health Nursing Care through a Multidisciplinary Educational Intervention. Adv Ment Health. 2011;9(2):147-157.
47. Mitchum LD. Improving the Detection of Depression in Postpartum Mothers in Pediatric Primary Care. Ph.D. diss. Grand Canyon University; 2022.
48. National Institute for Health and Care Excellence (NICE). Antenatal, postnatal mental health: Clinical management, service guidance. NICE Guideline [CG192]. London: NICE; 2014.
49. Noor Ani A, Umi Adzlin S, Fatanah I, Baizury B, Majdah M, FazlyAzry AA, et al. Screening for perinatal depression: Should we do this? Malays J Med Sci. 2018;25(4):75-83.
50. Park SH, Weaver L, Mejia-Johnson L, Vukas R, Zimmerman J. Integrative literature review of patient turnover in inpatient hospital settings. West J Nurs Res. 2016;38(5):629-655.
51. Factors associated with the onset, timing, symptoms, and severity of depression were identified in the postpartum period. PubMed. Accessed [date].
52. Robertson-Hart SJ. Investigating Mental Health First Aid (MHFA) in the workplace. PhD diss. University of Manchester; 2020.
53. Rudolph JE, Zhong Y, Duggal P, Mehta SH, Lau B. Defining the representativeness of study samples in medical, population health research. BMJ Med. 2023;2(1)
54. Russell VL, Loo CE, Walsh A, Bharathy A, Vasudevan U, Looi I, et al. Clinician perceptions of common mental disorders before, after implementation of a consultation-liaison psychiatry service: A longitudinal qualitative study in government-operated primary care settings in Penang, Malaysia. BMJ Open. 2021;11(6).
55. Segre LS, Stasik SM, O’Hara MW, Arndt S. Listening visits intervention for depressed mothers in home visitation: a pilot study. J Community Psychol. 2010;38(5):561-566.
56. Smith TA, Gemmill AW, Milgrom J. Perinatal anxiety, depression: Awareness, attitudes in Australia. Int J Soc Psychiatry. 2019;65(5):378-387.
57. Stewart DE, Vigod SN. Postpartum depression: pathophysiology, treatment, emerging therapeutics. Annu Rev Med. 2016;67:231-243.
58. Sword W, Busser D, Ganann R, McMillan T, Swinton M. Women’s care-seeking experiences after referral for postpartum depression. Qual Health Res. 2008;18(9):1161-1173.
59. Teagle SE, Brindis CD. Perinatal screening for depression: practical suggestions for primary care practices. J Pediatr Health Care. 2008;22(3):204-212.
60. Thurgood S, Avery DM Jr, Williamson L. Postpartum depression (PPD). Am J Clin Med. 2009;6(2):17-22.
61. Ujang IR, Hamidi NA, Ab Hamid J, Awang S, Zulkifli NW, Supadi R, et al. The COVID-19 pandemic, disruptions to maternal, child health services in public primary care, Malaysia: A retrospective time-series analysis. BMJ Glob Health. 2023;8(11)
62. Wan EM, Lee DTS, Samad SBA, Din NC. Prevalence of postnatal depression, its associated factors among mothers in Kuala Lumpur, Malaysia: A cross-sectional study. Asia Pac Psychiatry. 2019;11(2)
63. Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, management of mood disorders in pregnant, postpartum women. Obstet Gynecol. 2011;117(4):961-977.
64. Zlotnick C, Miller IW, Pearlstein T, Howard M, Sweeney P. A preventive intervention for pregnant women on public assistance at risk for postpartum depression. Am J Psychiatry. 2006;163(8):1443-1445.
65. Horowitz JA, Cousins A, Heilemann MV, Milgrom J. Interventions for postpartum depression to improve parenting, infant health outcomes. Cochrane Database Syst Rev. 2013;10