Research question: What are the ethnoculturally defined patterns of help-seeking behaviours and decision-making and other predictive factors for therapeutic mental health care access and outcomes in respect of postpartum depression for immigrant women in Canada?
Goal 1. To increase understanding of the immigrant women’s decision-making influences (including pre-migration history) and the multiple contextual factors in respect of postnatal depression and access to effective postpartum depression
Goal 2. To identify and describe available screening and referral practices and support interventions that are effective in impacting upon clinical outcomes in respect of postnatal depression amongst immigrant women in Canada
The search and selection strategies draw upon established systematic review methods as outlined by the Centre for Reviews and Dissemination, and also incorporate recent guidelines for the selection and appraisal of grey literature. Two search and selection phases will be conducted (please see attachment). The first will largely consist of searching electronic databases and websites of relevant journals to identify empirical papers (primary research using working hypotheses (or research questions), which are tested using observations or experimentation) published in peer-reviewed journals. The second will target grey literature, and include select database searches, internet-based searches, review of reference lists, and email or phone contact with researchers and other stakeholders having subject expertise or interest. For phase 1, the following databases will be searched: Ovid MEDLINE 1946- and In-Process & Other Non-Indexed Citations, Ovid EMBASE 1974-, Ovid PsycINFO 1806-, EBSCOhost CINAHL, EBSCOhost Gender Studies, EBSCOhost SocINDEX, ISI Web of Science Science Citation Index, ISI Web of Science Social Sciences Citation Index, Scopus, CSA Sociological Abstracts. English and French articles will be sought, as published between 1990-2013.
There are no restrictions on study design since the methodology used for the synthesis of findings (narrative synthesis) is applicable to all forms.
Condition or domain being studied
Understanding the ethnocultural orientation of immigrant women in maternity is critical and contributes to successful integration of newcomers and social cohesion. Ultimately the issue is one of social justice in health care. A key aspect of this is the need for timely identification and treatment of postpartum depression among immigrant women and far reaching implications for the mother, child, and family. PPD symptomatology has a prevalence ratio of 2.42 (confidence interval 1.89-3.06) for recent immigrants as compared to Canadian-born women of European descent, and interventions for PPD symptomatology should target immigrant and adolescent mothers. Moreover, the aforementioned level of increased risk may be conservative since other studies have found relative risks for depressive symptomatology of four-to-five times for refugee and immigrant women, respectively, and an odds ratio of 2.97 (CI 1.70-5.17) for major PPD. Additionally, many of the existing screening tools for PPD have either some limitations when used in different cultural contexts or have not been tested for their cultural congruency. They may provide underestimates of the problem due partly to variations in interpetation of symptoms. Our narrative synthesis review of quantitative and qualitative empirical evidence will further (i) deconstruct the significant precursors of PPD and anxiety prevalence, (ii) establish why immigrant women have higher levels of PPD than Canadian-born women, and (iii) map out helping-seeking behaviour, decision making, patterns of stigmatization, and ethnoculturally defined patterns of behaviour.
Immigrant women in Canada will be included; we are including economic migrants and skilled workers, temporary foreign workers, documented and undocumented residents, refugee claimants, refugees, asylum seekers, and students in this defintion of immigrant.
The study populations will include women in their perinatal period (pregnancy to 1 year postpartum) although retrospective studies with outcomes and experiences related to this period will be included.
Women from all ethnocultural groups and countries of origin will be included, but there must be reference to their immigrant status rather than just ethnocultural identity (thus exclusion criteria).
Inclusion criteria: qualitative, quantitative and mixed-method research studies related to immigrant women's help-seeking behaviours and decision-making as well as other predictive factors for therapeutic mental health care access and outcomes in respect of postpartum depression.
Exclusion criteria: systematic reviews, case reports, opinion/commentary pieces will be excluded although reference lists of systematic reviews will be examined
There will often be comparison to Canadian-born women
The setting of the studies will be any of those which enable the investigators to study ethnocultural dimensions or various other predictive factors (including individual, family, community and health care system related factors) to prediction, identification, and treatment of postpartum depression.
Ethnoculturally defined help-seeking behaviours and decision making Contextual factors in respect of postnatal depression and access to effective postpartum depression care
Effectiveness of screening and referral practices and treatment for postpartum depression in immigrant women
Timing of ethnocultural and contextual factors will be the lifetime of the participants
Timing of screening and referral practices would be during pregnancy and 0-6 months postpartum
Timing of treatment will be 0-12 months postpartum
Effect measures will be incidence, prevalence (and associated relative risk measures), duration of symptoms and treatment, patient acceptability and utilization and appropriateness of screening and treatment services.
Data extraction, (selection and coding)
Study abstracts will be screened using screening criteria (see below) and then full texts will be reviewed for selection based on their ability to answer the research question or contribute to the goals. The screening will be piloted for the first 100 citations, with the primary screener's decisions being confirmed by the first author and discrepancies brought to one or more other team members. After screening, at least 2 team members will select articles after full review, and discrepancies will be discussed by the entire team as possible. Reasoning for articles passing the screening stage but not selected will be documented.
Selected articles will be summarized in textual descriptions (narratives of study with sub-headings: Setting, Participants, Aim, Sampling and Recruitment, Method, Analysis, Results, ‘Thick’ or ‘Thin’ study, and quality appraisal outcome) and data will be extracted into several tables including one study description table and several related to study outcome themes. Further coding and synthesis will be performed usign Atlas.ti software which allows for PDF upload and provides numerous output tables. One reviewer will produce textual descriptions and extract data and another will verify all work. Identifiied themes will be discussed in team meetings.
Risk of bias (quality) assessment
The studies will be subject to quality appraisal using the tools (6 available) of the Centre for Evidence-Based Management and scores with reasoning will be discussed in the narrative synthesis Element 4. Studies of higher quality will be given higher weight in the narrative synthesis.
Strategy for data synthesis
Data synthesis will follow the narrative synthesis approach described by Popay and colleagues which has 4 elements:
1) Developing a theory of why and for whom
2) Developing a preliminary synthesis of findings of included studies
3) Exploring relationships in the data
4) Assessing the robustness of the synthesis
Several tools will be used with an emphasis on developing groupings/clustering based on themes and other study characteristics. Exploring relationships between the studies will be emphasized, and procedures such as ideas webbing and concept mapping will be completed.
Data will largely be synthesized at the aggregate level although some focus on different ethnocultural groups will be incorporated.
Analysis of subgroups or subsets
There may be some exploration of subgroups related to ethnocultural orientation but no statistical analysis will be performed on the data.
Multiple audiences will be targetted to optimize impact on policy and practice change throughout health service, public health, immigration and community sectors. Health care and community-based workshops will be offered, open access publications, fact sheets and research breifing papers will be produced. Team members will share findings & recommendations within their organizations and networks.
Contact details for further information
Rm 5-021A, Edmonton Clinic Health Academy (ECHA),
11405 87 Avenue,
Canada, T6G 1C9
Organisational affiliation of the review
University of Alberta, Edmonton, Canada
Dr Gina Higginbottom, University of Alberta Dr Myfanwy Morgan, King's College, UK Dr Joyce O'Mahony, University of Calgary Mrs Yvonne Chiu, Multicultural Health Brokers Co-operative Ms Mirande Alexandre, Citizenship and Immigration Canada Ms Marilyn Young, Alberta Health Services Ms Joan Forgeron, Alberta Health Services Ms Deb Kocay, Public Health Agency of Canada
Details of any existing review of the same topic by the same authors
Immigrant women's experience of maternity care services in Canada
Prospero Registration 2185
Anticipated or actual start date
01 March 2013
Anticipated completion date
28 February 2014
Final proposal submitted for funding from Canadian Institutes for Health Research - decision Feb 2013
Conflicts of interest
Other registration details
Subject index terms status
Subject indexing assigned by CRD
Subject index terms
Canada; Depression, Postpartum; Emigrants and Immigrants; Female; Humans; Postnatal Care; Women"s Health
Reference and/or URL for protocol
Date of registration in PROSPERO
28 September 2012
Date of publication of this revision
28 September 2012
Stage of review at time of this submission
Piloting of the study selection process
Formal screening of search results against eligibility criteria
Risk of bias (quality) assessment
PROSPERO This information has been provided by the named contact for this review. CRD has accepted this information in good faith and registered the review in PROSPERO. CRD bears no responsibility or liability for the content of this registration record, any associated files or external websites.