Health Promotion: Post Natal Depression

The issues of health and health promotion initiatives have gained much significance in the recent past. Stephens (2008:5) comments that from a social perspective health are understood as much more than a matter for individual experience and responsibility; health behaviour is seen in terms of relationship with others and health is structured by society.” World HealthOrganisation(WHO) constitution of 1948, defines health as a state of complete, physical, social and mental well-being, and not merely the absence of disease or infirmity. It also adds that health has been considered less as an abstract state and more as a means to an end which can be expressed in functional terms as a resource which permits people to lead an individually, socially and economically productive life, with respect to health promotion. (WHO, Geneva, 1986). WHO recognizes the spiritual dimension of health and regards health as a fundamental human right and states that the basic resources for health should be accessible for all people. According to WHO, health promotion represents a comprehensive social and political process, which not only embraces actions aimed at strengthening the skills and capabilities of individuals, but also acts toward changing social, environmental and economic conditions so as to alleviate their impact on public and individual health. It’s also the process of enabling people to increase control over the determinants of health and thereby improve their health (WHO official website)

The concept of social determinants of health needs to be considered while discussing health and health promotion initiatives. According to a study conducted by Bambra et.al(2008), the wider social determinants of health were listed out as water and sanitation, agriculture and food, health and social care services, unemployment and welfare, working conditions, housing and community, education and transport.

The term health promotion has variously been used to refer to a social movement, an ideology, a discipline, a strategy, a profession, and a strategy or field of practice delineated by commitment to key values(Keith and Tones, 2010).According to O’Donnell (2009), health promotion is the art and science of discovering the synergies between their core passions and optimal health enhancing their motivation to strive for optimal health and supporting them in changing their life style to move toward a state of optimal health, which is a dynamic balance of emotional, social, spiritual and intellectual health. Tones and Tilford (2009) is of the opinion that health promotion as a quasi-political movement and professional activity can be described as militant wing of public health. At a general level health promotion has come to represent a unifying concept for those who recognize the need for change in the ways and conditions of living to promote health (Fleming and Parker, 2006).

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Post natal depression

Postnatal depression is one of the most discussed topics in health today. This assignment discusses postnatal depression in detail, considering the significance it has and the risks associated with Postnatal depression, among the women in the United Kingdom. There has been a growing international recognition of postnatal depression as a major public health concern (Oates et.al, 2004). The government policy (Department of Health, 2004) recognises that the mental disorders during pregnancy and the post natal period can have serious consequences for individual women, their partners, babies and other children. Perinatal psychiatric disorder is one of the leading causes of maternal morbidity and is the leading cause of maternal mortality in the UK (Confidential Enquiries into Maternal Deaths, 2001).NICE (2007) observes that the mental disorders which occur during pregnancy and the postnatal period can seriously affect the health and wellbeing of a mother and her baby, as well as for her partner and other family members. This condition is a form of maternal morbidity that affects about one in eight women from diverse cultures and is a leading cause of maternal mortality(Dennis, 2009).Dennis(2009) also comments that postnatal depression can also have serious consequences for the health and well being of the family as the infants and children are particularly vulnerable to it – impaired maternal-infant interactions can have an impact on the cognitive, social ,emotional and behavioural development of the children.

According to the latest reports it is estimated that approximately 75000 women within the United Kingdom are affected by postnatal depression (Hanley and Hanley, 2009).Craig (2008) comments that postnatal depression has been various defined as non-psychotic depression occurring during the first six months, the first four weeks and the first three months post partum; but recently three months postpartum was suggested in the United Kingdom. There have been many views by various authors about postnatal depression. Wheatley (2006) comments that postnatal depression affects between 10 and 20 percent of women who have had babies, and it causes distress at a time when there is every reason for happiness. Wheatley (2006) adds that the symptoms vary from person to person as for some symptoms can be mild and for other women, it can lead to serious consequences including bouts of depression. However, the case of postnatal depression which is serious enough to warrant treatment percentage is between 7% and 35%. Dalton and Holton (2001) defines that postnatal depression is one of the symptoms of a serious mental condition known as postnatal illness. They opine that postnatal illness covers a range of afflictions which range from sadness to infanticide which start after child birth. The disorders associated with postnatal illness are blues, postnatal depression, puerperal psychosis and infanticide or homicide. Dalton and Holton (2001, p.3) defines postnatal depression as the first occurrence of psychiatric symptoms severe enough to require medical help occurring after childbirth and before the return of menstruation’. They add that it does not include the blues, and excludes the condition of those who have previously sought psychiatric help because of other psychiatric illnesses such as schizophrenia, manic depression, depression or drug abuse. Feeney (2001) is of the view that although the symptom of postnatal depression is dysphoric (depressed) mood, this state is also accompanied by other symptoms like extreme fatigue, strong feelings of guilt, disturbance of sleep and loss of appetite.

Hanzak (2005) attributes the occurrence of postnatal depression to three factors; biological, psychological and social causes. She lists out some of the possible reasons for postnatal depression as history of disturbed early life, loss of own mother, current marital or family conflicts, infertility and investigations for four or more years , loss of a previous pregnancy, adoption or fostering, high medical anxieties over the pregnancy, admission to hospital for longer than one week over the last three months of pregnancy ,major upheavals or stress over the last three months, emergency Caesarean section, neonatal illnesses, hormonal changes and personal or family history of depression

Walsh (2009) comments that the occurrence of postnatal depression is linked with birth experience. Parker (2009) had earlier opined that if the birth was traumatic, there are high chances for postnatal depression. Epidemiological factors of poverty, social class and low income influence the chances of postnatal depression (Gale and Harlow, 2003). Walsh (2009) puts forward a view that postnatal depression can affect fathers and children and hence it’s important to maintain communication and interaction between family members.

Cox and Holden (2001) are of the opinion that the consequences of maternal depression are costly not only on a personal level, but also in terms of money and personnel level as well. They put forward an interesting point that when there is contact between professionals and mothers is high detection of postnatal depression is very low and that the failure to diagnose depression may be attributed to short appointments, a physical orientation of care and an emphasis on the baby’s rather than the mother’s well being. Most cases of postnatal depression can be dealt with at primary care level with monitoring by the family doctor and interventions by primary care staff (Cox and Holden, 2001).

Health promotion models and approaches

Dahlgren and Whitehead (1991) had proposed that the factors which influence health are multidimensional and suggests a model which illustrates the wider determinants of health. The main factors according to them are general socioeconomic, cultural and environmental conditions, living and working conditions, social and community influences, individual lifestyle factors, age, sex and hereditary factors.

The model depicts individuals as central characters, who are influenced by various other determinants, which play a major role in influencing their health factors.

Source: Dahlgren and Whitehead (1991)

Another model which is widely discussed with relation to health promotion is the stages of change model. Bunton et.al(2000) proposes that the transtheoretical or stages of change model has greatly influenced health promotion practices in the United States of America, Australia and the United Kingdom since the late 1980s.The stages of change model was focused on encouraging change for people with addictive behaviour. People go through several stages when trying to change behaviour (Naidoo and Wills, 2000). Fertman (2010) asserts that behaviour change occurs in stages and that a person moving through these stages in a very specific sequence constitutes the change. According to this model, there are five stages of change, which are listed as pre contemplation, contemplation, preparing for change, making the change and maintenance.

The health belief important model is a well known theoretical model, which emphasises the role of beliefs in decision making. This model which was proposed by Rosenstock(1966) and modified by Brecker(1974) proposes that whether or not people change their behaviour will be influenced by an evaluation of its feasibilities and the comparisons of its benefits weighted against the costs.

Evans et.al (2005) comments that the major three health promotion approaches are the behaviour change approach, the self-empowerment approach and the collective action or community development approach. They add that these approaches have different goals and adopt different ways to achieve their goals and propose different criteria for their evaluation, though they have a common aim to promote good health and to prevent the effects of ill health. Each of these approaches has a unique understanding of the origins of health and health behaviour and subsequently of their objectives in health promotion and these three approaches are mutually complimentary. (Victorian Health Promotion Foundation, 2004).

NICE (2007) defines behaviour change as “the product of individual or collective human actions, seen within and influenced by their structural, social and economic context””.

Resnicow and Waughan (2006) comment that the study of health behaviour change has historically been rooted in a cognitive-rational paradigm. The models such as social cognitive theory, the health belief model, the transtheoretical model have viewed behavioral change as an interaction of factors such as knowledge, attitude, belief etc (Rimer and Lewis, 2002; Baranowski et.al, 2003).It has been suggested by the evidences that behavior change occurs in stages or steps and that movement through these stages is cyclical involving a pattern of adoption, maintenance, relapse and readoption over time. It has been suggested by the evidences that behavior change occurs in stages or steps and that movement through these stages is cyclical involving a pattern of adoption, maintenance, relapse and re adoption over time(Di paitro and Hughes, 2003)..

According to NICE (2007) the attempts to promote or support behaviour change take a number of forms, which are activities which can be delivered at a number of levels, ranging from local, one to one interactions with individuals to national campaigns. NICE(2007) divides interventions into four main categories as policy-such as legislation ,education or communication-such as one to one advice, group teaching or media campaigns, technologies-such as the use of seat belts, breathalyses , resources-such as leisure centre entry, free condoms or free nicotine replacement therapy.

According to the Victorian Health foundation (2004) the behavioural approach focuses on implementing interventions to change or remove behavioural health risk factors. Interventions from this perspective are targeted at a particular behavioural risk factor associated with a particular negative health outcome, and they target a population performing the behavioural risk factor and endeavour to promote health through various strategies. However, Craig et.al (2008) adds that behaviour change interventions are generally complex to design, deliver and evaluate.Michie (2008) states that more investment in developing the scientific methods for behavioural change studies is essential. Behavioural science is relevant to all phases of the process of implementing evidence-based health care; development of evidence through the primary studies, synthesizing the findings in systematic reviews, translation of evidence into guidelines and practice recommendations and implementing these recommendations in practice(Michie,2008).

Dunn et.al (2006) proposes that Item Response modeling (IRM) can be used to improve the psychometric methods in health education and health behaviour research and practice. They add that IRM is already being adopted to improve and revise quality of life questionnaires. However Masse et.al (2006) comments that a number of issues seem to stunt the application of IRM methods, as they list out the following issues

(i) Lack of IRM applications in the context of health education and health behavior research; (ii) lack of awareness as to what IRM can do beyond assessing the psychometric properties of a scale; (iii) lack of trained psychometricians trained in our field.

It is to be noted that the behaviour change approach came under criticism from various quarters. The major criticisms pointed out by Marks et.al(2005) were the inabilities to target the major socio-economic causes of ill health, possible incompatibilities of the top-down recommendations with community norms, values and practices, the assumption of a direct link between knowledge attitudes and behaviour and the assumption of homogeneity among the receivers of health promotion messages.

Post natal depression-Current significance and ethical considerations

Post natal depression is a matter of serious concern in the current age, as many women are being affected by it. Almond (2010) comment that post natal depression can be deemed a public health problem as the effects of it are known to go beyond the mother and it also affects the partner and the child. He adds that it can lead to infanticide as well as maternal death by suicide and according to evidences, all countries are faced with the challenge of postnatal depression, and the most affected countries are the low and middle income countries. The NICE guidelines for the clinical management of antenatal and postnatal mental health (2007) have observed the risks associated with postnatal depression. Ramchandani (2005) concurs to it and observes that the postnatal depression in fathers can have long-term consequences for the development of their child, on behavioural and emotional aspects. A study entitled “The children of the 90’s “by Bristol University in 2008, had found that post natal depression in fathers can have long lasting psychological effects on their children. A notable observation in this study was that the boys born to depressed fathers are twice as likely as other boys to have chances of developing behavioural problems by the age of three and a half.

It is essential to look into the long term consequences posed by the problem. Ramchandani (2008) points out that the conduct problems at the age of three to four years are strongly predictive of serious conduct problems in the future, increased criminality and significantly increased societal costs. The quotes by Ramchandani points out the threats posed by the depression among the fathers of new born babies. The impact of postnatal depression can be highly detrimental to a society, as proved by the recent unfortunate happening of a depressed teacher killing her baby in Exeter, as a result of the depression.

Policy drivers

There have been lots of developments over the last few years in policy on the mental health and women’s services (NICE, 2007). NSF for Child Health and Maternity was published in 2004 and is a 10 year programme that is aimed at the long term and sustained improvement in children’s health. Setting standards for health and social services for children, young people and pregnant women, the NSF aims to ensure fair, high quality and integrated health and social care from pregnancy to adulthood (NHS, 2007). NICE(2007) lists out the four main strands of policy relevant to antenatal and postnatal mental health as National service frameworks(NSFs), (particularly the mental health NSF,NSF for children young people and maternity services),policy to ensure equal access to responsive mental health services( especially services that meet needs of women, people from minority ethnic groups), public health policy and policy on commissioning and delivering health care and social care services in the community and the policy concerned with strategies for improving mental health services.

The screening for postnatal depression is highly talked about in the field of psychology and medicine today. Currie and Radematcher (2004) argues that pediatric providers are aware of the prevalence of postnatal depression and its effect on new born babies. However, there have been arguments for and against screening for postnatal depression and hence the practitioners should consider them carefully (Coyne et.al, 2000). The view proposed by Chauldron et.al (2007) is that from the legal and ethical standpoints and the perspective of feasibility, the benefits of screening outweigh the risks. However, they add that, the implementation must be seen as an iterative process, and implementing the screening for post natal depression in a systematic and comprehensive approach is critical to the ultimate well-being of children and families.Basten (2009) proposes that more studies in the field of psychotherapeutic research and psychological areas are required. This is in conformance with the observation by De Tychey ,Briancon et.al, 2008) that the diagnostic techniques need to be improved for both caregivers and sufferers through education and the communication should be promoted, focusing on the fostering of parenting skills as a preventive measure against Post Natal Depression.(de Tychey, Briançon et al. 2008).

One of the recent studies by Norman et.al (2010) has found out that exercise can help women in combating postnatal depression and that the specialised routines could help new mothers decrease the chances of depression by upto 50 percent.

Partnership working

Partnership working is a very important term in the current health and social care system in the United Kingdom. Partnership working can be defined as a system where two or more disciples work collaboratively to deliver optimal care to an individual (NHS, 2007). In the context of post natal depression partnership working refers to working in partnership with the team involved in the mother and the newborn baby, which includes pediatricians and obstetricians(Byrom et.al,2009) .Douglas(2008) points out that partnership working is recognised as the most effective way of improving social care services. Department of Health (2006) had stressed that the action to improve health and care services will be underpinned through working in partnerships between individuals, communities, business, voluntary organizations, public services and government.Butt(2008) argues that partnerships have international appeal as a means to integrate health and social services in response to the realisation that both sectors serve populations whose complex needs cannot be met adequately through segmented approaches. Partnership working with women having mental health problems can be a challenging task (Department of health, 2008).

According to NICE (2007) the impact of partnership working is a function of a number of features of joint working and it is possible to categorise partnerships along a number of descriptive variables such as membership, structures, leadership, agendas and organisational cultures. Previous studies have shown that the working of people involved in the care of women with post natal depression, a trusting partnership can be developed between carers, patients and professionals, which will be beneficial to all. Feeney et.al (2001) had proposed that working in partnerships with families is an essential component of effective programming in the early developmental stages of children. Hence partnership working holds a very important role in the post natal period as, it would be able to relieve the emotional stress which many women go through.

It was observed by NICE (2007) that developing trust and accommodating relationships within facilitating partnerships is imperative to the attainment of partnership goals, and issues of process are highly important building blocks to success.Sorin (2002) comments that there are many reasons to establish partnerships and asserts that the family is the most significant influence on the mother’s post natal health as well as the child’s development and well being. Sorin( 2002) adds that partnerships that develop to address fear and other emotions can work towards understanding appropriate expression of these emotions, which include learning words to describe the emotion using forms like music ,talking to others .

A report on safety in maternity services published by King’s fund (2008) emphasises the significance of team work and collaboration in ensuring the safety of mothers and babies and points out that effective team work can increase safety, whereas poor teamwork can be detrimental to the safety. The report proposes several solutions to resolve the difficulties in team work. The main suggestions include ensuring clarity about the objectives of the team and roles and that there is effective leadership among the group and clarity in procedures for communication is present (Byrom et.al, 2009).

It is important to look into the barriers which affect the concept of partnership working. Lester et.al(2008) comments that there are barriers to closer working in partnerships, which include cultural differences, the time factor which is required to create and maintain relationships and recognition of the advantages of remaining a small and autonomous organisation.

Conclusion

This essay has critically analysed the effect of the behavioural change approach intervention of postnatal depression to address the needs of women who are more at risk in the United Kingdom. Various factors which lead to postnatal depression have been explained in the essay. It can be concluded that postnatal depression is to be seriously taken care of, and that the impact of postnatal depression can have serious consequences for society. The various health promotion models have portrayed the linkages between beliefs and behavioral changes. The essay has pointed out the importance of partnership working in improving the conditions of mothers and newborn babies. Effective working in partnerships can go a long way in alleviating the concerns of the mothers and improving the mental health of the new born babies, as they play a very important role in framing the future characteristics of the new born babies. A recent study by the University of Leicester has found out that women are less likely to become depressed in the year after childbirth if they have an NHS health visitor who has undergone additional mental health training. These findings point out the fact that postnatal depression can be effectively tackled with external help. The studies about postnatal depression and the concept of partnership working have been very effective in improving the health care system in the United Kingdom and hence serve as an interesting topic for future researches in the field.