Rev. Latino-Am. Enfermagem
Original Article
2016;24:e2675 DOI: 10.1590/1518-8345.0982.2675
www.eerp.usp.br/rlae
Barriers to access to treatment for mothers with postpartum depression in primary health care centers: a predictive model1
Pablo Martínez2 Paul A. Vöhringer3 Graciela Rojas4
Objective: to develop a predictive model to evaluate the factors that modify the access to treatment for Postpartum Depression (PPD). Methods: prospective study with mothers who participated in the monitoring of child health in primary care centers. For the initial assessment and during 3 months, it was considered: sociodemographic data, gyneco-obstetric data, data on the services provided, depressive symptoms according to the Edinburgh Postpartum Depression Scale (EPDS) and quality of life according to the Short Form-36 Health Status Questionnaire (SF36). The diagnosis of depression was made based on MINI. Mothers diagnosed with PPD in the initial evaluation, were followed-up. Results: a statistical model was constructed to determine the factors that prevented access to treatment, which consisted of: item 2 of EPDS (OR 0.43, 95%CI: 0.20-0.93) and item 5 (OR 0.48, 95%CI: 0.21-1.09), and previous history of depression treatment (OR 0.26, 95%CI: 0.61-1.06). Area under the ROC curve for the model=0.79; p-value for the Hosmer-Lemershow=0.73. Conclusion: it was elaborated a simple, well standardized and accurate profile, which advises that nurses should pay attention to those mothers diagnosed with PPD, presenting low/no anhedonia (item 2 of EPDS), scarce/no panic/fear (item 5 of EPDS), and no history of depression, as it is likely that these women do not initiate treatment.
Descriptors: Depression, Postpartum; Health Services Accessibility; Primary Health Care.
1
Supported by Iniciativa Científica Milenio, Chile, process # IS130005 and by Fondo Nacional de Desarrollo Científico y Tecnológico, Chile, process
2
Doctoral student, Escuela de Psicología, Universidad de Santiago de Chile, Santiago, Chile. Assistant Researcher, Departamento de Psiquiatría y
3
PhD, Associate Professor, Departamento de Psiquiatría y Salud Mental, Hospital Clínico, Facultad de Medicina, Universidad de Chile, Santiago,
4
PhD, Full Professor, Departamento de Psiquiatría y Salud Mental, Hospital Clínico, Facultad de Medicina, Universidad de Chile, Santiago, Chile.
# 1130230. Salud Mental, Hospital Clínico, Facultad de Medicina, Universidad de Chile, Santiago, Chile. Chile.
Martínez P, Vöhringer PA, Rojas G. Barriers to access to treatment for mothers with postpartum depression in primary health care centers: a predictive model. Rev. Latino-Am. Enfermagem. 2016;24:e2675. [Access ___ __ ____]; Available in: ____________________. DOI: http://dx.doi.org/10.1590/1518-8345.0982.2675
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Rev. Latino-Am. Enfermagem 2016;24:e2675
Introduction
Metropolitan Region (MR), Chile (n=120). It was selected the health unit of PHC that registered the
Postpartum depression (PPD) is a public health
highest number of health attendances of children in the
problem worldwide(1). It is the most common psychiatric
past 2 months, in each of the six Health Services of the
condition postpartum(2) and there is extensive material
MR, according to administrative data of the Ministry of
on the degree of disability that it is likely to cause to
Health, in the period from January to September, 2012.
the mother(3), its association with the delay in child
In this way, the sample consisted of six municipal health
development and behavior disorders in adult life of the
units of PHC of the MR, Chile. This due to the fact that
descendants(4).
the administrative data from the Ministry of Health are
In Chile, studies using standardized diagnostic
not broken down by month.
criteria reported a prevalence of PPD of about 20%
During the months of January and February 2013, it
in the primary health care (PHC) of public health
was consecutively recruited those mothers participating
system(5). In contrast, a study using the Edinburgh
in the child health monitoring, from two to six months
Postpartum Depression Scale (EPDS), validated in
postpartum, at the selected health units. After routine
Chile(6), indicated that 41.3% of mothers who are
examination, the study researchers included those
assisted in clinics are affected by severe depressive
mothers that have signed an informed consent, over
symptoms between 2 and 3 months postpartum(7),
18 years old, without intellectual disability and could
that is, at risk of PPD.
be contacted by telephone. All the women agreed to
Although a significant proportion of mothers who
participate voluntarily.
use the APS are at high risk and the importance of
A week later, a structured interview was carried
maternal and child health leads to a greater number
out by phone (initial diagnosis), which assessed:
of visits to health centers in this period, depressive
sociodemographic antecedents, gynecological-obstetric
disorders are not usually detected and treated(8), despite
and perinatal data, depressive symptoms, according to
the availability of effective treatments(9).
the Edinburgh Postpartum Depression Scale (EPDS)(7), promoted
confirmation of current diagnosis of Major Depressive
a early detection of PPD, recommending the adoption
Based on that, the Ministry of Health
Postpartum Episode (PPD), according to the structured
of the universal screening in the PHC, so that the EPDS
psychiatric interview MINI(12) and quality of life, according
is applied by nursing professionals in the follow-up of
to the SF-36 Health Status Questionnaire(13).
(10)
children and women at postpartum period. However, treatment rates remain low. In this regard, the national literature has evidenced the presence of barriers to access to health services for depressed mothers and the need for trainnig of human resources in the PHC in order to ensure a greater commitment to the ministerial guidelines and tighter monitoring of women at risk(11). It is considered that the construction of a predictive model to identify the factors that modify the access to treatment may be useful in reducing the failures in the treatment of PPD, by focusing on the use of human resources available in the public health system, and
The final sample used for collection and analysis of data in this study included only women in which PPD has been confirmed, according to MINI, in the initial diagnosis.
Definition of dependent variable After
three
months,
the
medical
records
of
users with PPD (follow-up evaluation) were reviewed, considering as no access to treatment: if no provision of mental health consultation was recorded in the health unit after the initial diagnosis (dichotomized variable).
Definition of independent variables
specifically, strengthening the role of nurses in detecting PPD during routine examinations. There are no studies in the local context that have investigated that aspect at present. The aim of this study was to develop a predictive model to evaluate the factors that modify the access to treatment for PPD in PHC.
Method This is a prospective cohort study. The sampling
To determine the predictors of no access to treatment in women with PPD in PHC, a review of the available literature was performed(14-21). Accordingly, the following variables were selected as potential predictors: age, marital status, education, current occupational status, who lives in the household, number of children, planning of the last pregnancy, help in caring for the baby, history of previous treatments of depression, depressive symptoms (total score of EPDS and score in each item
consisted of all health units of PHC located in the
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Martínez P, Vöhringer PA, Rojas G. of the instrument) and quality of life (according to the
Results
dimensions of the SF-36). All variables that were significant with p