ACTAUNIVERSITATIS

UPSALIENSISUPPSALA

2020

Digital Comprehensive Summaries of Uppsala Dissertationsfrom the Faculty of Medicine 1657

Perinatal Depressive Symptomsamong Women in North-EasternThailand

Risk Factors, Support and Prevention

NITIKORN PHOOSUWAN

ISSN 1651-6206ISBN 978-91-513-0919-4urn:nbn:se:uu:diva-402419

Dissertation presented at Uppsala University to be publicly examined in Sal IX,Universitethuset, Biskopsgatan 3, Uppsala, Monday, 18 May 2020 at 09:15 for the degree ofDoctor of Philosophy (Faculty of Medicine). The examination will be conducted in English.Faculty examiner: Professor emerita Eva Nissen (Karolinska Institutet).

AbstractPhoosuwan, N. 2020. Perinatal Depressive Symptoms among Women in North-EasternThailand. Risk Factors, Support and Prevention. Digital Comprehensive Summaries ofUppsala Dissertations from the Faculty of Medicine 1657. 78 pp. Uppsala: Acta UniversitatisUpsaliensis. ISBN 978-91-513-0919-4.

Perinatal depressive symptoms among women remain a global burden. Improvements in self-efficacy among public health professionals (PHPs) in primary healthcare settings to detect andmanage perinatal depressive symptoms among women are needed.

The aims of this thesis were to: identify prevalence and risk factors associated withperinatal depressive symptoms among women; to explore and describe life situation andsupport among women with antenatal depressive symptoms (ADS) and their partners; and toimprove self-efficacy of PHPs in detection and management of perinatal depressive symptomsin Sakonnakhon province in Thailand. Qualitative and quantitative studies with different typesof data collection methods were used.

Study I determined prevalence of ADS and associated risk factors among 449 Thai womenin late pregnancy using the Edinburgh Postnatal Depression Scale (EPDS). The prevalence was46.8% and associated risk factors were insufficient money, being a teenager, low psychologicalwell-being, low self-esteem and low sense of coherence.

Study II explored and described life situation and support during pregnancy among womenwith ADS and their partners using semi-structured interviews. Four categories emerged: Havingobstacles in life, Facing life situation, Enhancing confidence and Dissatisfaction with help.

Study III determined risk factors associated with postpartum depressive symptoms at onemonth among 319 women and at three months among 276 women. Risk factors at one monthwere antenatal psychological well-being, non-exclusive breastfeeding, low personal income andcaregiver not a mother; risk factors at three months were unintended pregnancy, low personalincome/month, low self-esteem, low psychological well-being and low maternal competence.

Study IV evaluated a self-efficacy improvement programme (SIP) intended to increase PHPs’self-efficacy in efforts to detect and manage perinatal depressive symptoms among women.After the SIP, PHPs in the intervention group (n=33) had higher self-efficacy scores thanPHPs in the control group (n=33). Four categories emerged in qualitative evaluation: Havingconfidence, Changing knowledge and attitudes, Increasing perception of an important role, andIncreasing awareness of performed function.

Women who are at increased risk for perinatal depressive symptoms should be screened usingthe EPDS. Health care professionals should involve expectant fathers in ANC process. The SIPenhances PHPs’ ability to detect and manage perinatal depressive symptoms.

Keywords: Perinatal depressive symptoms, Edinburgh Postnatal Depression Scale, riskfactors, life situation, support, intervention programme, public health professionals

Nitikorn Phoosuwan, Department of Public Health and Caring Sciences, Caring Sciences,Box 564, Uppsala University, SE-751 22 Uppsala, Sweden.

© Nitikorn Phoosuwan 2020

ISSN 1651-6206ISBN 978-91-513-0919-4urn:nbn:se:uu:diva-402419 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-402419)

True success is not in the learning, but in its application to the benefit of

mankind.

His Royal HighnessPrince Mahidol of Songkla

List of Papers

This thesis is based on the following papers, which are referred to in the text by their Roman numerals.

I Phoosuwan, N., Eriksson, L., Lundberg, P. C. (2018). Antenatal

depressive symptoms during late pregnancy among women in a north-eastern province of Thailand: Prevalence and associated factors. Asian Journal of Psychiatry, 36:102-107. doi:10.1016/j.ajp.2018.06.012

II Phoosuwan, N., Manasatchakun, P., Eriksson, L., Lundberg, P. C. (2020). Life situation and support during pregnancy among Thai expectant mothers with depressive symptoms and their part-ners: A qualitative study. Accepted for Publication in BMC Preg-nancy and Childbirth. doi:10.1186/s12884-020-02914-y

III Phoosuwan, N., Manwong, M., Eriksson, L., Lundberg, P. C. (2019). Perinatal depressive symptoms among Thai women: A hospital-based longitudinal study. Nursing & Health Sciences, 2019:1-9. doi:10.1111/nhs.12669

IV Phoosuwan, N., Lundberg, P. C., Phuthomdee, S., Eriksson, L. (2020). Intervention intended to improve public health profes-sionals’ self-efficacy in their efforts to detect and manage peri-natal depressive symptoms among Thai women: A mixed-meth-ods study. BMC Health Services Research, 20:138. doi:10.1186/s12913-020-5007-z

Reprints were made with permission from the respective publishers.

Contents

Introduction ................................................................................................... 11 Perinatal period, perinatal depressive symptoms and consequences ........ 11 Magnitude of perinatal depressive symptoms .......................................... 13 Measuring of perinatal depressive symptoms .......................................... 14 Risk factors and perinatal depressive symptoms ...................................... 14 Life situation and support during pregnancy ............................................ 15 Thailand, health situation and perinatal healthcare services .................... 17 Framework ............................................................................................... 18

The Model of Social Determinants of Health ...................................... 18 Theory of Self-efficacy ........................................................................ 20

Rationale of the thesis ................................................................................... 22

Aims .............................................................................................................. 24 Specific aims ........................................................................................... 24

Methods and Materials .................................................................................. 25 Design ...................................................................................................... 25 Setting ...................................................................................................... 26

Sakonnakhon ....................................................................................... 26 Procedure .................................................................................................. 26

Study I and Study III............................................................................ 26 Study II ................................................................................................ 27 Study IV ............................................................................................... 28

Instruments ............................................................................................... 30 Study I and Study III............................................................................ 30 Study II ................................................................................................ 31 Study IV ............................................................................................... 31

Ethical considerations .............................................................................. 32 Analyses ................................................................................................... 34

Study I and Study III............................................................................ 34 Study II ................................................................................................ 36 Study IV ............................................................................................... 36

Results ........................................................................................................... 38 Study I and Study III – Perinatal depressive symptoms among Thai women ...................................................................................................... 38

Characteristics of the participants ........................................................ 38 Descriptions of ADS and psychosocial factors during late pregnancy 38 Risk factors associated with antenatal depressive symptoms .............. 39 Prevalence of and Risk factors associated with depressive symptoms at one month and at three months postpartum ..................................... 40 Changes in depressive symptoms at late pregnancy, at one month and three months postpartum ............................................................... 43

Study II – Life situation and support during pregnancy ........................... 43 Characteristics of the participants ........................................................ 43 Life situation during pregnancy ........................................................... 43 Support during pregnancy .................................................................... 45

Study IV – Self-efficacy Improvement Programme among public health professionals for detection and management of perinatal depressive symptoms ................................................................................ 45

Characteristics of the participants ........................................................ 45 The effectiveness of the SIP ................................................................ 46 Self-efficacy of PHPs after participation in the SIP ............................ 46

Discussion ..................................................................................................... 48 Social Determinants of Perinatal Depressive Symptoms among Thai Women ..................................................................................................... 48

Individual characteristics ..................................................................... 48 Individual lifestyle factors ................................................................... 49 Social and community networks .......................................................... 51 Living and working conditions ............................................................ 52 General social conditions ..................................................................... 53

Self-efficacy among Public Health Professionals for detection and management of perinatal depressive symptoms after participating in the Self-efficacy Improvement Programme ............................................. 53 Methodological considerations................................................................. 55

Validity and reliability ......................................................................... 55 Trustworthiness ................................................................................... 55 Strengths and limitations ..................................................................... 55

Clinical implications ..................................................................................... 58

Implications for future research .................................................................... 59

Conclusion .................................................................................................... 60

Svensk sammanfattning ................................................................................ 61

Thai sammanfattning (Summary in Thai) ..................................................... 64

Acknowledgements ....................................................................................... 66

References ..................................................................................................... 68

Abbreviations

ACOG American College of Obstetricians and GynaecologistsADS Antenatal Depressive Symptoms ANC Antenatal Care EF Expectant Father EM Expectant Mother EPDS Edinburgh Postnatal Depression Scale FGD Focus Group Discussion GHQ General Health Questionnaire GSE Generalised Self-Efficacy HCP Health Care Professional HIC PHP

High Income Country Public Health Professional

LMIC Low- and Middle- Income Country MoPH Ministry of Public Health, Thailand OR PDS

Odds Ratio Postnatal Depressive Symptoms

SHPH Sub-district Health Promotion Hospital SOC Sense of Coherence WHO World Health Organization

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Introduction

The time after confirmation of pregnancy until early parenthood is a joyful event for most parents (Ahlborg, Berg, & Lindvig, 2013). Most mothers have positive emotions (Geller, 2014), while others might have negative life situa-tion from numerous changes during this period of life, such as in relation to context and in social roles (Highet, Stevenson, Purtell, & Coo, 2014). Mental disorders, particularly depression, have been addressed as a negative conse-quence during pregnancy and after childbirth among women (Roomruang-wong & Epperson, 2011). In Thailand, Thai women during the perinatal pe-riod are offered screening for depression using a two-question non-specific tool, conducted by a health care professional as there are few mental health professionals (Kongsuk et al., 2017). Depressive symptoms remain prevalent and under-recognised. In order to increase mental healthcare engagement and surveillance among Thai women during the perinatal period, depressive symp-toms among women should be detected and managed (Kongsuk et al., 2017). Still, there is lack of research focusing on perinatal depressive symptoms, in-cluding magnitude and risk factors for the symptoms, and life situation and support among the couples (Roomruangwong & Epperson, 2011).

Perinatal period, perinatal depressive symptoms and consequences Antenatal period can be categorised into trimesters of pregnancy; the first tri-mester (from the first day of the last menstrual period until 13 weeks of ges-tation), the second trimester (14-27 weeks of gestation), and the third trimester (28 weeks of gestation until childbirth) (American College of Obstetricians and Gynaecologists [ACOG], 2004). Postnatal period ranges from immedi-ately after childbirth to six weeks after childbirth (World Health Organisation [WHO], 2010), but postnatal period for depressive symptoms can extend from childbirth to one year postpartum (ACOG, 2018). In addition, the perinatal period covers the antenatal period and postnatal period (WHO, 1992), and three months before and after childbirth are high-risk periods for having de-pressive symptoms (Bisetegn, Mihretie, & Muche, 2016; Boratav, Toker, & Kuey, 2016). In this PhD project, the perinatal period included the period from the third trimester of pregnancy to three months after childbirth.

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Perinatal depressive symptoms encompass antenatal depressive symptoms (ADS) and postnatal depressive symptoms (PDS) among women. These terms are used in this thesis. Perinatal depressive symptoms include depressed mood or feeling sad, loss of pleasure or interest, low appetite, difficulty sleeping, declined energy or fatigue, increase in purposeless physical activity, feeling guilty or self-worthless, poor concentration, and suicidal thoughts or at-tempted suicide (American Psychiatric Association, 2013). Depression during the perinatal period among women is diagnosed when women have depressive symptoms lasting at least two weeks (Highet et al., 2014).

During the beginning of the antenatal period, the onset of biological and hormonal changes among women takes place. The biological changes are ac-companied by psychological processes, such as preparation for motherhood. During this period, a psychopathology will influence both mother and foetus (Aslan et al., 2014), as well as the partner (Roomruangwong & Epperson, 2011). The hormonal changes are the results of physiological adaptation be-tween mother and foetus. These changes have effect on pregnancy outcomes (Kumar & Magon, 2012), and are associated with ADS (Highet et al., 2014). Differences in severity of ADS are associated with a significant stepwise in-crement in psychosocial disability (Mehta, Mittal, & Swami, 2014). Conse-quences of having ADS negatively influence growth, weight and nutritional status (Rahman, Iqbal, Bunn, Lovel, & Harrington, 2004), socio-emotional outcomes of infants (Garman, Cois, Tomlinson, Rotheram-Borus, & Lund, 2019), quality of life of the family in the future (Sadat, Abedzadeh-Ka-lahroudi, Atrian, Karimian, & Sooki, 2014), PDS (Tsao, Creedy, & Gamble, 2015), and paternal depression (Paulson & Bazemore, 2010). Untreated ADS disproportionately affect rural and low-income women (Jesse & Swanson, 2007).

After childbirth, many women experience postpartum mood disorders, in-cluding PDS (Anokye, Acheampong, Budu-Ainooson, Obeng, & Akwasi, 2018). Similarity of PDS is found in relation to ADS. PDS are common com-plications of childbearing among some women and are associated with poor mother-infant attachment and child development (Fitelson, Kim, Baker, & Leight, 2011), and with maternal self-efficacy (Zheng, Morrell, & Watts, 2018). It can be a result of sensitivity to hormone fluctuations. For instance, declining level of progesterone hormone in early postpartum period promotes insomnia, which is an onset of PDS (Pearlstein, Howard, Salisbury, & Zlot-nick Pearlstein, 2009). Further, the first 90 days after childbirth was found to be a time of increased PDS (Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen, 2006).

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Magnitude of perinatal depressive symptoms ADS and PDS are the most common mental disorders during the perinatal period, affecting women all over the world (Roomruangwong & Epperson, 2011). The magnitude of ADS and PDS can vary depending on methods of detection, timing and target population. From a recent systematic review, overall pooled prevalence of women having perinatal depressive symptoms was about 12%, and the prevalence was significantly higher in women from Low- and Middle- Income Countries (LMICs) in comparison to women from High- Income Countries (HICs), 19% vs 9% (Woody, Ferrari, Siskind, Whiteford, & Harris, 2017).

A meta-analysis shows that the prevalence of ADS among HICs is between 7% and 13% (Bennett, Einarson, Taddio, Koren, & Einarson, 2004). In a sys-tematic review including LMICs, it is demonstrated that the overall prevalence of ADS is 15.6% (Fisher et al., 2012), and ADS among Asian women is about 20% (Roomruangwong & Epperson, 2011). ADS differ between HICs and LMICs, for example, 3% among Swedish women (Rubertsson, Wickberg, Gustavsson, & Rådestad, 2005) and 18% among women in Bangladesh (Nasreen, Kabir, Forsell, & Edhborg, 2011). Moreover, the prevalence of ADS increases during the period of pregnancy. For instance, the prevalence of ADS in the first trimester is <25%, whereas it is about 28% in the second trimester and >65% in the third trimester (Biratu & Haile, 2015). The third trimester seems to be a risk period producing ADS among women (Bisetegn et al., 2016). In addition, a recent study conducted in southern Thailand demon-strated that 21% of pregnant women experienced ADS (Limlomwonse & Liabsuetrakul, 2006). However, currently little is known about the exact prev-alence of ADS in other regions of Thailand.

The rates of PDS are also different between countries and depending on what months after childbirth are considered. The global pooled prevalence of having PDS is 17.7% (Hahn-Holbrook, Cornwell-Hinrichs, & Anaya, 2018), whereas the average prevalence of having PDS in Asian countries from a sys-tematic review is about 22% (Roomruangwong & Epperson, 2011). For ex-ample, the prevalence of PDS among mothers in Nepal at 2 months postpar-tum is 30% (Giri et al., 2015), while among Turkish mothers at 3-6 months postpartum it is 48% (Boratav et al., 2016). A longitudinal study from Thai-land revealed that 17% of women experienced PDS early postpartum (Lim-lomwonse & Liabsuetrakul, 2006), while a cross-sectional study revealed that 10% of Thai women were diagnosed with postpartum depression (Liabsuetrakul, Vittayanont, & Pitanupong, 2007). PDS seem to be less com-mon than ADS (Andersson, Sundström-Poromaa, Wulff, Åström, & Bixo, 2006) and are slightly higher in Asian countries than in western countries (Roomruangwong & Epperson, 2011). However, the magnitude of PDS also depends on how depressive symptoms are measured (Norhayati, Hazlina, Asrenee, & Emilin, 2015).

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Measuring of perinatal depressive symptoms There are many accepted instruments evaluating symptoms of perinatal de-pression, i.e. clinical diagnostic and screening tools. The clinical diagnostic tools, such as structured clinical interview tools show a lower prevalence of having depression in comparison to screening tools, but have not been used for secondary prevention (Norhayati et al., 2015). The ACOG (2018) recom-mended that women should be screened for depressive symptoms during the perinatal period using a valid instrument, and the Edinburgh Postnatal Depres-sion Scale (EPDS) published is the most widely accepted screening scale in the perinatal period worldwide. For example, the EPDS was tested among postpartum women within three months after childbirth in a community set-ting (Cox, Holden, & Sagovsky, 1987), and the instrument has recently been used among women during the antenatal period in Asia, Africa and Europe (Limlomwonse & Liabsuetrakul, 2006; Kerstis, Engstrom, Edlund, & Aarts, 2013; Bisetegn et al., 2016).

The EPDS is a simple and quick self-reported questionnaire containing only 10 items, where each item can generate scores between 0-3 and a total possible score is between 0 and 30. It was originally developed to screen for postnatal depression during the first three months after childbirth (Cox et al., 1987), but nowadays it has also been used in the antenatal period (Bisetegn et al., 2016). The EPDS has been validated in several studies and shown high sensitivity and specificity and confirmed that EPDS screening accuracy in di-agnosing depression is satisfactory (Kozinszky & Dudas, 2015). A Thai ver-sion of the EPDS has previously been validated among postnatal women, and a cut-off value of 10 provides a good sensitivity of 60% and specificity of 90% (Pitanupong, Liabsuetrakul, & Vittayanont, 2007). It has also been used among women during pregnancy and after childbirth (Limlomwonse & Liabsuetrakul, 2006), and has been tested in the antenatal period in a north-eastern province of Thailand (Phoosuwan, Eriksson, & Lundberg, 2017).

Risk factors and perinatal depressive symptoms Many risk factors associated with perinatal depressive symptoms among Asian women have been investigated. They can be grouped into socio-demo-graphic, psychosocial and obstetric factors.

Socio-demographic risk factors associated with both ADS and PDS in-clude: being a teenager (Lau & Wong, 2008), low education and being house-wives (Ege, Timur, Zincir, Geckil, & Sunar-Reeder, 2008). Being unmarried (Limlomwonse & Liabsuetrakul, 2006), alcohol consumption and smoking (Chen, Chan, Tan, & Lee, 2004) have also been found to be risk factors asso-ciated with ADS among women, whereas lack of knowledge about infant care (Ege et al., 2008), religion (Limlomwongse & Liabsuetrakul, 2006), and low

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household income (Ege et al., 2008; Nasreen, Edhborg, Petzold, Forsell, & Kabir, 2015) are risk factors associated with PDS among women.

Psychosocial factors have also been connected with both ADS and PDS, such as having a history of depression and intimate partner violence (Aslan et al., 2014; Nasreen et al., 2011; Nasreen et al., 2015). Low marital satisfaction (Zeng, Cui, & Li, 2015), low self-esteem (Jesse, Kim, & Herndon, 2014), low psychological well-being (Bassi et al., 2017), low sense of coherence (Kerstis et al., 2013), lack of social support from partner and family (Ege et al., 2008; Gausia, Fisher, Ali, & Oosthuizen, 2009; Liabsuetrakul et al., 2007; Zeng et al., 2015), high marital conflict (Lau & Wong, 2008), and negative attitude towards current pregnancy (Limlomwonse & Liabsuetrakul, 2006) are ex-pected to be potential risk factors associated with ADS. Psychosocial prob-lems associated with increased risk for PDS include maintained maternal roles (Zheng et al., 2018) and baby feeding problems (Roomruangwong, Withaya-vanitchai, & Maes, 2016).

Obstetric factors contributing to depressive symptoms among pregnant and postpartum women are nulli- or primiparity (Ege et al., 2008; Fisher et al., 2013), unplanned pregnancy (Aslan et al., 2014; Ege et al., 2008; Lau & Wong, 2008) and giving birth to a female baby (Dindar & Erdogan, 2007; Gausia et al., 2009). Being in the third trimester of pregnancy is a risk factor associated with experiencing ADS (Gausia et al., 2009), while having a his-tory of abortion (Dindar & Erdogan, 2007), normal childbirth, unintended pregnancy and breastfeeding (Ege et al., 2008; Roomruangwong et al., 2016) are obstetric factors influencing PDS among women.

Life situation and support during pregnancy The transition to motherhood is a process characterised by fluctuations, mov-ing from a known to an unknown situation (Mercer, 2004). Expectant mothers (EMs) may feel like having a positive event (Ahlborg et al., 2013; Geller, 2014). However, depression is also experienced by EMs during the transition to motherhood (Roomruangwong & Epperson, 2011), as well as stress and anxiety (Rallis, Skouteris, McCabe, & Milgrom, 2014). If EMs are depressed, they may feel unsecure about their new situation; thus, they need to understand more about their maternal health (Bennett, Boon, Romans, & Grootendorst, 2007). It has also been reported that urban women in a LMIC experience high stress and depression during their pregnancy (Bloom, Glass, Curry, Hernan-dez, & Houck, 2013). Whilst women from rural areas may not reveal their negative life situation, e.g. feelings of sadness and depression to professionals or family because they fear being labelled ‘crazy’ or being reported to social services as unfit mothers (Jesse, Dolbier, & Blanchard, 2008). Therefore, in-formation support is often provided during the pregnancy period, through e.g. antenatal care (ANC), in order to make pregnant women and their partners

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develop more confidence in their parenthood (Persson, Kvist, Fridlund, & Dykes, 2011). However, some EMs are dissatisfied with the antenatal support they receive because health promotion strategies provided during pregnancy seem to limit their lifestyle behaviours (Edvardsson et al., 2011). Many EMs also describe that they get low support from their partner and therefore they need peer support from other women (Raymond, 2009). In contrast, some EMs express that their husband and their female relatives are the main providers of their emotional, instrumental and informational support (Thornton et al., 2006).

Amongst expectant fathers (EFs), transition to fatherhood has been de-scribed as an emotional roller coaster, i.e. tension between different feelings about EFs’ future as fathers (Asenhed, Kilstam, Alehagen, & Baggens, 2014), which also is an important aspect to focus on. EFs may have to take on several roles, such as father’s and provider’s roles during the transition (Habib, 2012). Hence, they may have mixed feelings, being happy and being worried about their transition (Poh, Koh, Seow, & He, 2014). If they are depressed, they may experience lack of control and power. They may also experience a gap be-tween their expectations and their realities (Edhborg, Carlberg, Simon, & Lindberg, 2016). Social support from social network can give EFs a feeling of calm and security for their child and parenthood (Bäckström et al., 2017), but the best support for EFs is their partner (Widarsson, Engstrom, Tydén, Lundberg, & Hammar, 2015). Expert guidance to fruitful and accurate infor-mation may help the construction of an identity during fatherhood and strengthen their fatherhood role (Pålsson, Persson, Ekelin, Hallstrom, & Kvist, 2017). Also, the information given before birth affects the early postnatal pe-riod for new fathers (Persson, Kvist, Fridlund, & Dykes, 2012). However, many EFs are dissatisfied with the health promotion provided by healthcare professionals (HCPs) during the antenatal period because the health promo-tion is not suitable for them (Edvardsson et al., 2011). Therefore, a father’s involvement during pregnancy may positively influence health outcomes for himself, his partner and his child (Plantin, Olukoya, & Ny, 2011). Even if the fathers want to be involved from the beginning of pregnancy, they often feel ignored by HCPs (Deave, Johnson, & Ingram, 2008; Well, 2016). The im-portance of focusing on both parents’ experiences in order to strengthen them as individuals, parents and families has also been addressed in previous re-search (Fletcher, Vimpani, Russel, & Sibbritt, 2008). Hence, antenatal HCPs have an important role in including both parents in the preparation (Persson et al., 2011, 2012) and should focus on the whole family (Widarsson et al., 2015).

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Thailand, health situation and perinatal healthcare services Thailand, an Upper-Middle-Income Country (The World Bank Group, 2016), is situated in the Southeast Asia region with approximately 70 million popu-lation. Thailand is divided into 76 provinces and four regions: southern re-gion, central region (which includes Bangkok Metropolitan region), northern region and north-eastern region. These regions differ in terms of topography, economy, and social and cultural patterns. In addition, each province contains a number of districts, and each district consists of several sub-districts. Nearly 93% of the Thai people declare themselves to be Buddhists (WHO, 2015a).

In terms of the health situation in Thailand, the life expectancy at birth is 78 years for females and 71 years for males. Depression is the third disease burden among all females based on years of life lost due to disability (YLDs), but it is the main cause of YLDs among females aged 30-59 years (Interna-tional Health Policy Programme Foundation, 2017). A recent report has esti-mated that more than 1.5 million Thai people experience depression, and the prevalence of major depressive disorders among women is 3% and that among men is 1.7% (Department of Mental Health of Thailand [DMH], 2015).

In Thailand, healthcare services are provided by private and public sectors. The private sector includes private hospitals and private clinics, where many of them are situated in Bangkok and urban areas. There are over 400 private hospitals in the private sector (Sakunphanit, 2006). The public sector involves sub-contracted primary care centres and public hospitals, where the hospitals have different levels: advanced hospital level, standard hospital level, medium hospital level and small hospital level. Each hospital has several primary care centres, which are currently called Sub-district Health Promoting Hospitals (SHPHs). In each district in Thailand, there is at least one government hospital from one of the levels, and each sub-district has one or two SHPHs (Table 1).

Health promotion, disease prevention and control, rehabilitation and gen-eral primary care are the focuses at SHPHs. These tasks are provided by HCPs, i.e. public health professionals (PHPs), a nurse/midwife and a public health assistant. PHPs have a bachelor’s degree in public health; moreover, they are responsible for disease prevention and control, and for health promotion. A nurse/midwife has a bachelor’s degree and is responsible for nursing practice and treatments. A public health assistant with a diploma in public health may assist the nurse/midwife and the PHPs with dental and community public health tasks (Public Health Administrative Division, 2016).

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Table 1. Public hospital levels in Thailand

Level of hospitals Number of hospitals Main focus Sub-district health promoting hospital

10,277 hospitals Health promotion, disease prevention and control

Small hospital 692 hospitals Treatments by general physicians Medium hospital 123 hospitals Treatments by specific physicians Standard hospital 48 hospitals Treatments by special physicians Advanced hospital 33 hospitals Treatments by sub-special

physicians Source: Public Health Administrative Division (2016)

Since 2002, Thailand has been fully launched to the Universal Healthcare Coverage scheme to increase healthcare accessibility for the Thai people who have no employment or in vulnerable groups at a cheaper cost (30 baht, which is <1 USD) per visit (Panpiemras, Puttitanun, Samphantharak, & Thampanish-vong, 2011). Recently, an exemption to payment was implemented covering all pregnant women receiving ANC services at a public hospital where they register (Ministry of Public Health [MoPH], 2017). ANC services include car-ing for maternal health and screening of pregnancy-related diseases and child malfunction, such as gestational diabetes during pregnancy and ADS (MoPH, 2013). Both in a hospital and a SHPH, pregnant women receive screening test for depression by HCPs at ANC clinic once during pregnancy by a two-ques-tion screening tool for general population (called 2Q) developed by the Min-istry of Public Health of Thailand (MoPH, 2013). Women who are at risk for depression based on the screening can be referred for diagnosis and treatment by a general practitioner (MoPH, 2015; Kongsuk et al., 2017).

Framework In this thesis, the Model of Social Determinants of Health (Dahlgren & White-head, 1991; 2007) and the Theory of Self-efficacy (Bandura, 1977; Bandura, 1986) are used as conceptual frameworks in order to explain perinatal depres-sive symptoms among women and to design an intervention programme, self-efficacy improvement programme for detection and management of perinatal depressive symptoms, targeting PHPs.

The Model of Social Determinants of Health The model conceptualises the relationship between determinants of health and categorises them into several structural layers from proximal to distal sectors according to the individuals (Figure 1) (Dahlgren & Whitehead, 1991). There

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are four layers and each layer is connected to another closed layer. This model is widely used as one of the most effective illustrations of health determinants.

Figure 1. The Model of the Determinants of Health (Dahlgren & Whitehead, 1991)

According to the model, individuals are placed in the centre, which possesses age, sex and constitutional characteristics that influence their health. The next closed layer is the individual lifestyle factor layer, which encompasses actions taken by individuals, such as their choice of relaxation methods and consump-tion of alcohol and smoking. Next, the social and community network layer which includes mutual support from family, friends, neighbours and their lo-cal community. The layer of living and working conditions includes material and living conditions under which people live and work, which are determined by various sectors such as housing, healthcare services, working condition and employment (Dahlgren & Whitehead, 2007). These conditions influence the ability of a person to maintain health (WHO, 2007). Finally, general social condition layer involves the major structural environment, such as culture or policy (Dahlgren & Whitehead, 2007) that prevails in the overall society (WHO, 2007).

To conclude, several factors influence the individuals’ health. These factors can be classified into layers in order to hierarchically understand what deter-minants are related to the individuals. In this thesis, the determinants of health are applied to discuss women’s mental health during the perinatal period.

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Therefore, different layers of this model are used to discuss the research find-ings of this study.

Theory of Self-efficacy The Theory of Self-efficacy was initiated by Bandura (1977). In order to change an individual’s behaviour, the individual is expected to enhance effi-cacy expectations, and the behaviour may generate a good outcome if the in-dividual is served outcome expectations. The efficacy expectations are prod-ucts from perceived self-efficacy, and the outcome expectations depend on magnitude, generality and strength of the individual. There are four major sources of information that contribute to the efficacy expectations, i.e. mastery experiences, social modelling, social persuasion, and individual’s physical and emotional states (Bandura, 1986). The Theory of Self-efficacy is concep-tualised in Figure 2.

Figure 2. Diagram of the Theory of Self-efficacy

In order to explain Figure 2, the mastery experience component includes achieving success in situations that require personal effort, and is perceived as the most influential source for self-efficacy (Bandura, 2004). Social modelling is referred to as vicarious experience from other persons who are similar to the individual and succeed in their roles. Social persuasion refers to verbal persuasion to reinforce and encourage the individual positively. Individual’s

Individual Behaviour Outcome

Efficacy Expectations Outcome Expectations

Perceived self-efficacy: Mastery experiences

Social modelling Social persuasion

Physical and emotional states

Magnitude Generality Strength

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physical and emotional states refer to non-verbal persuasion from other per-sons to the individuals.

Perceived self-efficacy is defined as an individual having a belief in own capacity to succeed. An individual who has strong self-efficacy may challenge him/herself to enhance personal well-being and increase ability to accomplish difficult goals and tasks (Bandura, 1994). Conversely, an individual who has low self-efficacy may doubt their own capability and set fewer goals com-pared with the one having strong self-efficacy. An individual with low self-efficacy may have decreased commitment to do what is planned, and be stressed and depressed (Bandura 1993, 1994). Self-efficacy is related to self-judgement of one’s ability to perform specific actions, and has more specific domain than self-concept or self-esteem (Margolis & McCabe, 2004; Pajares, Johnson, & Usher, 2007).

Many interventions try to change and maintain individuals’ behaviours, particularly among HCPs, where four sources of information for perceived self-efficacy of the Theory of Self-efficacy have been integrated into such in-terventions. For example, a training programme conducted among HCPs demonstrated that an intervention programme could improve self-efficacy to provide HIV/AIDS care after participation (Kamiru, Ross, Bartholomew, McCurdy, & Kline, 2009), while another study showed that an educational programme containing self-efficacy sources increased self-efficacy among psychiatric nurses working in mental health hospitals (Zaki, 2016).

Self-efficacy can be measured by how individual’s beliefs generalise ac-cording to tasks and situations, i.e. generalised self-efficacy (GSE) and task-specific self-efficacy (SSE). Both denote beliefs about individual’s ability to reach desired outcomes, but the constructs differ in the scope, i.e. the general self-efficacy is defined as individuals’ perception of their ability to perform actions in different situations, and SSE focuses on a specific domain (Chen, Gully, & Eden, 2001). More importantly, the GSE is positively connected to the need for achievement (Chen, Gully, Whiteman, & Kilcullen, 2000), and positively influences SSE (Chen et al., 2001).

Several instruments have been created and show degree of applicability and acceptability to measure perceived self-efficacy. There are two recognised in-struments developed for self-efficacy. Sherer et al. (1982) developed a 17-item questionnaire for clinical and personality research on expectations that individuals carry into new situations. Later, the GSE Scale was constructed by Schwarzer and Jerusalem (1995) to assess a general sense of perceived self-efficacy for general adult population. It has ten items where each item has four scales, and a higher score indicates higher self-efficacy. It is widely accepted with 33 language translations, including Thai. An adjusted version of the scale has been used in this study to evaluate self-efficacy among PHPs for detection and management of perinatal depressive symptoms by following the recom-mendations for constructing SSE (Bandura, 2006).

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Rationale of the thesis

Worldwide, mental disorders affect 40% of disability-adjusted life years among the population, with women, in particular, affected more than men (Whiteford et al., 2013). Women’s mental health is important, and problems with mental health often seem to be ignored by women and HCPs. Improving women’s mental health is closely linked to the new Sustainable Development Goals (SDGs), on the reduction of premature mortality by promoting mental health and well-being by 2030 (United Nations, 2017). Women, during the perinatal period, are in a high-risk group for having depressive symptoms (Kongsuk et al., 2017). Three-month phases immediately before (Bisetegn et al., 2016) and after childbirth (Boratav et al., 2016) are highly significant pe-riods for perinatal depressive symptoms among women. There are many neg-ative consequences from having perinatal depressive symptoms for both women and their partners (Roomruangwong & Epperson, 2011), and child de-velopment (Rohanachandra, Prathapan, & Wijetunge, 2018). Therefore, risk factors for depressive symptoms among women during the perinatal period need further exploration. Moreover, EMs with ADS and their partner might have mixed life situation during pregnancy. In Thailand, there are few studies about perinatal depressive symptoms and its risk factors (Roomruangwong & Epperson, 2011).

Self-efficacy among HCPs to detect and manage perinatal depressive symptoms is also essential (Kongsuk et al., 2017), whereas current healthcare services among Thai women in the perinatal period are available and afforda-ble for all (Panpiemras et al., 2011; MoPH, 2017). In Thailand, PHPs at SHPHs mainly provide health promotion and disease prevention, while nurses/midwives provide ANC and treatment. Specific screening for perinatal depressive symptoms has not been carried out for Thai women. Therefore, this preventive action could be a routine task for a PHP. Although highlighted as important, how perinatal depressive symptoms can be prevented often seem to be neglected, in terms of research, practice and preventive programmes (Fisher et al., 2012; Kongsuk et al., 2017). To bridge this knowledge gap, there is need for more research focusing on the associated factors and changes of depressive symptoms among Thai women during the perinatal period, and on exploring what life situation and support EMs with ADS and their partners have. PHPs at primary healthcare settings are responsible for detection and management of perinatal depressive symptoms among women. An interven-tion programme, such as self-efficacy improvement programme for detection

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and management of perinatal depressive symptoms in order to train PHPs needs to be developed and implemented. This could demonstrate important information on the effectiveness of the self-efficacy improvement programme among PHPs. Targeting the north-eastern region of Thailand, the largest re-gion where Thai people live (WHO, 2015a), would generate increased knowledge to guide how perinatal depressive symptoms among women can be detected and managed in advance.

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Aims

The overall aims are to identify prevalence and risk factors associated with depressive symptoms among Thai women during the perinatal period, to ex-plore and describe life situation and support during pregnancy among EMs with depressive symptoms and their partners, and to improve self-efficacy of public health professionals for detection and management of perinatal depres-sive symptoms.

Specific aims are: - To determine the prevalence of ADS and associated risk factors among Thai women in late pregnancy (Study I). - To explore and describe life situation and support during pregnancy among EMs with depressive symptoms and their partners in the last trimester of preg-nancy (Study II). - To determine risk factors associated with PDS among Thai women, and in-vestigate differences in depressive symptoms at late pregnancy, at one month and three months postpartum (Study III). - To develop and evaluate an intervention programme intended to increase PHPs’ self-efficacy in efforts to detect and manage perinatal depressive symp-toms (Study IV).

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Methods and Materials

Design In this thesis, different designs, both quantitative and qualitative methods, have been used in order to get a more comprehensive understanding of the studied problems (Creswell & Clark, 2010; Patton, 2015). All studies were based on primary data gathered from the same study setting in north-eastern Thailand. An overview of the methods used in the studies included in the the-sis is shown in Table 2.

Table 2. The study designs, data collection, participants, and analyses used in the thesis

Study Design Data collec-

tion Participants Analyses

I Quantitative (Cross-sec-tional)

Question-naires

449 pregnant women who received ANCs in late pregnancy

Multiple logistic regression

II Qualitative (Explorative and Descrip-tive)

Semi-struc-tured inter-views

54 informants: 27 EMs with ADS and 27 partners of EMs

Content analysis

III Quantitative (Longitudinal)

Question-naires

449 pregnant women at late pregnancy, 319 women at one month and 276 women at three months postpartum

Multiple linear regression, and paired t-tests

IV Quantitative (Randomised controlled trial [RCT]) Qualitative (Explorative)

Question-naires Focus Group Discussions (FGDs)

33 PHPs participated in the intervention group and 33 PHPs participated in the control group 23 PHPs in the intervention group participated in 4 FGDs

Multiple linear regression Content analysis

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Setting Sakonnakhon The north-eastern region is the largest region in Thailand; it includes 20 prov-inces (Piayura & Ayuwat, 2012) with approximately 20 million inhabitants. Sakonnakhon is a province in the upper north-eastern region, and it has 18 districts with a total population of about 1.1 million people. In Sakonnakhon there are 18 public hospitals, one military hospital, one private hospital and 164 SHPHs (Sakonnakhon Provincial Statistic Office, 2016). The province was purposively selected for this research project because it has high number of annual childbirths, is comprised of both rural and urban areas, and has sev-eral levels of health facilities, which was suitable for this project in terms of quantity and distribution of participants. Figure 3 shows the map of Sa-konnakhon and the 18 districts located therein.

Figure 3. Map of Sakonnakhon and 18 districts (Retrieved from http://www.lu-angpumun.org)

Procedure Study I and Study III In Study I and Study III, women were consecutively recruited from seven se-lected hospitals in Sakonnakhon, where the hospitals have high number of an-nual childbirths in each hospital level (one advanced-level hospital, two me-dium-level hospitals, and four small-level hospitals). Sample size calculation

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for Study I was based on χ2 = 3.841, N = 12,421, proportion = 0.5, power calculation = 80% (Wayne, 1995) and P = 0.5, percent of control exposed = 50%, and Odds Ratio [OR] = 3.54 (Joseph, Fleiss & Myunghee, 2004). Sam-ple size for Study III was suggested by Hair, Black, Babin, and Anderson (2010) who found that having 10 participants was suitable for testing each possible risk factor. There were 25 expected risk factors. All calculations were set at a 95% level of significance. An attrition rate was considered for Study I and Study III, resulting in enrolment of 449 participants. Pregnant women at the selected hospitals were approached. The inclusion criteria were: pregnant women (1) being in the late pregnancy period (between the 28th and 37th week of gestation); (2) receiving ANC in the selected hospitals during the period of data collection and (3) willing to participate in the study. The exclusion crite-ria were non-Thai citizens and self-reporting a psychiatric problem. Pregnant women who met the criteria were asked to answer the questionnaire voluntar-ily at three occasions, i.e. late pregnancy (T1), one month (T2) and three months (T3) after childbirth. Data collection process is shown in Figure 4.

Figure 4. The enrolment process of participant selection

Study II This study targeted the same hospitals as mentioned in Study I and Study III. A purposive sampling guided the selection of participants. The participants

197 women

18 Hospitals in Sakonnakhon

Advanced hospital level

1 Hospital

Medium hospital level

3 Hospitals

Small hospital level

14 Hospitals

129 women 123 women

449 participants (during late pregnancy, T1)

319 participants (at one month postpartum, T2)

276 participants (at three months postpartum, T3)

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were EMs and their partners. The criteria for selecting EMs were: (1) having received ANC in one of the selected hospitals in the last trimester of pregnancy (28-37 weeks gestational age), (2) having depressive symptoms (i.e. a score of ≥7 from the Thai version of the EPDS, which previously was suggested as a suitable cut-off for identification of Thai women’s depressive symptoms by Pitanupong et al. (2007)), and (3) being willing to participate in this study. EMs were excluded if they (1) did not live with their partner at time of data collection and (2) reported a history of mental illnesses. EFs who were part-ners of the selected EMs were asked to participate voluntarily in individual interviews. The researcher (NP) received a list of EMs from nurses/midwives at each hospital and screened EMs in the last trimester of pregnancy by using the EPDS. EMs having EPDS score of ≥7 and their partners were asked to participate voluntarily. Recruitment continued until there was no new infor-mation from interviews. Data were collected during May and June 2017 using two semi-structured interview guides.

Semi-structured interviews were carried out in Thai by three Thai native researchers. In order to make participants feel comfortable, female researchers were assigned to interview EMs, while the male researcher (NP) interviewed EFs (Galle et al., 2019). Convenient place and time for interviews were chosen by the participants. Each EM and EF was interviewed separately to disclose personal life situation and information. Each interview was digitally recorded and lasted about 60 minutes.

Study IV This study selected PHPs who worked in the hospitals of three levels in six districts of Sakonnakhon (see Figure 4), where the districts have high number of childbirths each year. Sample size was calculated for a randomised con-trolled trial (RCT) (Chow, Shao, & Wang, 2003), with standard deviation (SD) = 4.3, mean difference = 1.1, superiority margin = 4, power calculation = 80% and a set of 95% level of significance. A minimum requirement was 28 participants per each group, where due to loss of follow-up, 33 PHPs for the intervention and 33 PHPs for the control groups were included in Study IV. PHPs in the selected districts were approached and informed in writing about the purpose of the study and their rights to participate in the study. Eli-gible PHPs were those who worked in the selected districts and were willing to participate in the study. In total, 134 PHPs agreed to participate, signed the consent form and completed the questionnaire for baseline data (T1). Exclu-sion criterion was PHPs who could not fully participate in the study. There were 66 PHPs randomly allocated for the intervention (n=33) and control (n=33) groups. Those in the intervention group were asked to participate in the self-efficacy improvement programme (SIP), whereas those in the control group worked with their routine tasks (Figure 5) .

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Figure 5. Recruitment and data collection processes for Study IV

Self-efficacy Improvement Programme (SIP) The SIP was developed by the researchers and based on the Theory of Self-efficacy (Bandura, 1977; Bandura, 1986). It is comprised of two parts: (1) one day of theory and (2) four weeks of practice.

The one day of theory was conducted at the Sakhonnakhon Provincial Pub-lic Health Office. The content focused on knowledge of, motivation for and outcome of detection and management of perinatal depressive symptoms in four interactive lectures held by three experts for eight hours. A manual for psychosocial management from the World Health Organization (2015b) trans-lated into Thai by NP, guidelines for detection and management of perinatal depressive symptoms developed by the research group, and a questionnaire containing the Thai EPDS screening tool for women during the perinatal pe-riod (Phoosuwan et al., 2017; Pitanupong et al., 2007), psychological well-being questions (Nilchaikovit, Sukying, & Silpakit, 1996), self-esteem ques-tions (Wongpakaran & Wongpakaran, 2012a) and sense of coherence ques-tions (Antonovsky, 1987) were also introduced to the participants.

The four weeks of practice was initiated after the one day of theory. The participants in the intervention group were asked to practice with at least two women (one pregnant woman and one woman after childbirth) in their com-munity/SHPH using the manual, guidelines and questionnaire presented in the day of theory. They were given material for practice, such as copies of ques-tionnaire. NP supervised each participant once by phone, and all participants by mobile applications (Facebook and Line) and by face-to-face visit if the participants requested.

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Instruments Study I and Study III The questionnaire, used in Study I and Study III, contained eight parts (I-VIII). It was tested for content validity by three experts and for internal consistency among 30 pregnant women in another province nearby Sakonnakhon before data collection started (Cronbach’s alpha for the questionnaire was 0.75).

Part 1: Socio-demographic characteristics. This part was constructed by NP. It consists of questions about age, religion, education, occupation, marital status, personal income, personal expense, family income, self-defined family economic status, family type, pregnancy planning, family history of psychiat-ric problems, alcohol consumption, smoking habit and obstetric data (i.e. gra-vidity, parity and abortion). Additional questions for Study III concerned mode of delivery, co-habitation after childbirth, child’s gender, child’s feed-ing, child’s caregiver and child’s birth weight.

Part 2: Edinburgh Postnatal Depression Scale (EPDS). A Thai version of the EPDS (Pitanupong et al., 2007) was used. It has ten items and each item has four options. A score from zero to three can be generated for each item, and a total possible score is between 0-30. In Study I, a score of ≥10 indicated that women had depressive symptoms (a sensitivity of 60% and specificity of 90% by Pitanupong et al., 2007), and in Study III a higher score showed a higher number of depressive symptoms. The Cronbach’s alpha for this part was 0.83.

Part 3: General Health Questionnaire (GHQ). This is a 12-item question-naire developed by Goldberg (1972), and a Thai version of the questionnaire was used (Nilchaikovit et al., 1996). Each item has four options and generates a score of zero or one. A total possible score is between 0 and 12. In Study I, a score of ≥2 indicated that women had low psychological well-being and a score of zero or one indicated women had high psychological well-being (Goldberg (1972) recommended the cut-off). In Study III, a higher score meant women had lower psychological well-being. The Cronbach’s alpha for this part was 0.83.

Part 4: Sense of Coherence (SOC) Scale. This is a 13-item questionnaire developed by Antonovsky (1987). It was forward-backward translated into Thai for research purpose. Each item provides a score between one and seven, and a total score ranges between 13 and 91. In Study I, a SOC score <55 was considered low and >54 was considered high (cut-off defined by mean), whereas, in Study III, a higher score of SOC meant the women had a higher SOC. The Cronbach’s alpha for this part was 0.79.

Part 5: Self-esteem Scale. This is a 10-item questionnaire constructed by Rosenberg (1965), and a Thai version (Wongpakaran & Wongpakaran, 2012a) was used. Each item has four options, where each option can provide a score between zero and three, and a total possible score is 30. In Study I, a score

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<20 and >19 was considered low and high (cut-off defined by mean). In Study III, a higher score implied the women had higher self-esteem. The Cronbach’s alpha for this part was 0.54.

Part 6: Dyadic Adjustment Scale. This is a 14-item questionnaire (Spanier, 1976) and was forward-backward translated into Thai. A total score ranges from 0 to 69. In Study I, a score of ≥48 was considered as having high marital satisfaction, whereas a score of ≤47 was considered low (cut-off defined by mean). In Study III, a higher score indicated having a higher marital satisfac-tion. The Cronbach’s alpha for this part was 0.72.

Part 7: Perceived Social Support Scale. This is a 12-item questionnaire (Zimet, Dahlem, Zimet, & Farley, 1988), and a Thai version of the scale (Wongpakaran & Wongpakaran, 2012b) was used. The score ranges between one and seven in each item. In Study I, it was categorised into low (a score of <35), medium (a score of 35-60) and high (a score of ≥61) women’s social support, suggested by the tool developers (Zimet et al., 1988). In Study III, a higher score meant women had greater social support. The Cronbach’s alpha for this part was 0.86.

Part 8: Parenting Sense of Competence Scale. This has 17 items and each item can provide a score between one and six, resulting in a total possible score of 102 (Gibaud-Wallston & Wandersman, 1978). A Thai version of the scale (Suwansujarid, Vatanasomboon, Gaylord, & Lapvongwatana, 2013) was used. In Study I, a total score of ≥65 indicated having high maternal compe-tence and a total score <65 indicated having low maternal competence (cut-off defined by mean). In Study III, higher score indicated greater maternal competence. The Cronbach’s alpha for this part was 0.57.

Study II Two semi-structured interview guides (one for the EMs and one for the EFs) about life situation and support during pregnancy were developed based on literature and experiences of researchers. It was tested on two couples in an-other upper north-eastern province of Thailand and adjusted with minor cor-rections of language and wording before data were collected. The questions in the interview guides were open-ended. The interview questions are presented in Table 3.

Study IV A questionnaire was used for four time-points. The questionnaire consisted of two parts: socio-demographic and self-efficacy assessment parts. The socio-demographic part was developed by the researchers and comprised of age, gender, marital status, education level, experience of mental health training, years working at the SHPH, and size of the SHPH. The self-efficacy assess-ment part used a Thai version of self-efficacy questionnaire (Sukmak,

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Sirisoonthon, & Meena, 2001), originating from the Generalised Self-Efficacy Scale (Schwarzer & Jerusalem, 1995). After receiving permission to use the Thai version of the questionnaire, the questionnaire was adjusted with minor correction of wordings for measuring of self-efficacy among PHPs for detec-tion and management of perinatal depressive symptoms according to recom-mendations for constructing SSE (Bandura, 2006). This was a ten-item ques-tionnaire, scoring from one to four in each item. The total score ranged be-tween 10 and 40, where a higher score indicated greater self-efficacy. It has been tested for content validity by three experts, and for internal reliability in 30 PHPs in another province before use (Cronbach’s alpha coefficient=0.959).

An interview guide was used for FGDs in order to let PHPs in the interven-tion group describe their self-efficacy for detection and management of peri-natal depressive symptoms after participation in the SIP. It was constructed by the researchers and contained open-ended questions. The first FGD was used as a pilot test (Krueger & Casey, 2009) and adjusted with a minor cor-rection of wording. The interview guide is presented in Table 4.

Ethical considerations Ethical approval was sought and granted from the ethics committees in Thai-land (SWDCPH2017-003) and in Sweden (Dnr 2016/544) before data collec-tion for all studies (I-IV) were initiated. The directors of the provincial public health office and of the seven hospitals, and the heads of district public health offices approved the study plan and gave permission to carry out the studies. All participating women in Study I and Study III received oral and written information about the study before signing a consent form at the ANC clinic where they received services. EMs with depressive symptoms and EFs in Study II received both oral and written information about participation in the study before signing a consent form at their place of interview. All participat-ing PHPs in Study IV received information in writing about the study before signing a consent form.

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Table 3. Interview guide used in Study II

Background questions 1. Gender 2. Age 3. Education 4. Marital status 5. Employment 6. Personal income per month 7. Number of years (months) of live together 8. Type of family 9. Number of children 10. History of child delivery

Interview about life situation and support Pregnant women -How have you felt during your pregnancy? -What are your feelings about the new life situation as you soon will get with a newborn baby? -What feelings and events have had an effect on your relationships with your hus-band/partner, children, family, friends or work colleagues? Please give examples. -Has your mood been going up and down during your pregnancy? If yes, please give examples of situations in which your mood has been going up and/or down. -What do you think would help (have helped) you cope with your situation? -What roles do you think expectant parents should have during the pregnancy pe-riod? Please describe. -What kinds of support and service do you need during your pregnancy (hus-band/partner, family, friends, healthcare, etc.)? Please describe. -Is there something else that you would like to tell me or that I should know? Husbands/partners -How have you felt during your wife’s/partner’s pregnancy? -What are your feelings about the new life situation you will soon get with a new-born baby? -What feelings and events have had an effect on your relationships with your wife/partner, children, family, friends or work colleagues? Please give examples. -Has your mood been going up and down during your wife’s/partner’s pregnancy? If yes, please give examples of situations in which your mood has been going up and/or down. -What do you think would help (have helped) you cope with your situation? -What roles do you think expectant parents should have during the pregnancy pe-riod? Please describe. -What kinds of support and service do you need during your wife’s/partner’s preg-nancy (wife/partner, family, friends, healthcare, etc.)? Please describe. -Is there something else that you would like to tell me or that I should know?

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Table 4. The interview guide used in Study IV

1. What are your experiences of meeting women with antenatal depressive symptoms in your community/health centre?

2. Please share your experiences from participating in the one-day lecture on theory of the self-efficacy improvement programme (SIP).

3. Please share your experiences from participating in the four-week field practice of the SIP.

4. How has your knowledge, attitude, and self-efficacy changed after you participated in the SIP?

5. For evaluation purpose, please give your opinion of the SIP. 6. Is there something we did not discuss that you would like to add to the

programme?

Analyses Study I and Study III Data were entered and analysed using the SPSS programme version 24.0. De-scriptive statistics were performed. Inferential statistics were conducted using multiple logistic regression analyses in Study I, and multiple linear regression analyses in Study III (Rosner, 2010). A 95% confidence interval (CI) and a 0.05 significant level were used for both studies. Hypothetical directed acyclic graphs (DAGs) (Suttorp, Siegerink, Jager, Zoccali, & Dekker, 2015) were constructed from reviewed literature, to define possible risk factors for both ADS and PDS among Thai women (Figure 6a, b).

In Study I, the dependent variable was having depressive symptoms (the EPDS score ≥10). Independent variables were socio-demographic factors: age, religion, education, occupation, marital status, personal income, personal expense, family income, self-defined family economic status, family type, pregnancy planning, alcohol consumption, smoking habit, number of preg-nancy and number of abortion, and psychosocial factors: psychological well-being, sense of coherence, self-esteem, dyadic adjustment, social support and maternal competence. In the first step, each independent variable was included in a univariate logistic regression analysis. Thereafter, significant independent variables (p<0.05) were used from univariate analyses retained in the multi-variate logistic regression analysis using the enter method (inserting all sig-nificant independent variables into the analysis at the same time). The strength of association was assessed using adjusted OR and 95% CI.

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(a)

(b)

Figure 6. Hypothetical directed acyclic graph for possible risk factors for (a) Ante-natal Depressive Symptoms and (b) Postpartum Depressive Symptoms among Thai women

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In Study III, there were two main analyses: (1) an analysis for the first model for the EPDS scores at one month postpartum and the second model for the EPDS scores at three months postpartum as dependent variables, and (2) an analysis for differences in the depressive symptom scores during late preg-nancy and at one month and three months postpartum. In the first model, the independent variables were socio-demographic and psychosocial factors, sim-ilar to the independent variables in Study I. All independent variables were included in univariate linear regression analysis. Furthermore, the significant independent variables (p<0.05) remained in the multivariate linear regression analysis using a stepwise method (inserting all significant independent varia-bles into the analysis at the same time presented only significant variables for the model). In the second model, all independent variables in the first model and additional variables from socio-demographic and psychosocial factors at one month postpartum were inserted in a univariate linear regression analysis. Furthermore, the significant variables (p<.05) from the univariate analyses re-mained in the multivariate linear regression analysis using the stepwise method. Each multivariate linear regression analysis was controlled by age and a history of ADS. Both models presented the strength of association using Beta and 95% CI. In addition, dependent sample t-test was applied for differ-ences in the depressive symptom scores.

Study II The interviews were transcribed verbatim by NP before analysis. Data were subjected to an inductive qualitative content analysis (Graneheim & Lundman, 2004). Each Thai transcription was read and re-read several times by three Thai researchers who separately analysed the data. Data from EMs and their partners were first analysed separately as two data sets; thereafter, the data were analysed together according to the aim of the study by focusing on the couples. Meaning units were created from participants’ descriptions. Then, meaning units were condensed and coded. Thereafter, similar codes were grouped into sub-categories and similar sub-categories were grouped to-gether, resulting in a descriptive level of the content called category. Four Thai transcriptions from two couples were translated into English and back. The English transcriptions, sub-categories and categories were rechecked by an-other researcher who is not Thai native. Finally, the results were discussed and consensus was reached on final categories and sub-categories. The results were reported to the participants, who agreed with them.

Study IV Study IV used both quantitative and qualitative analyses. Descriptive analysis was performed, whereas baseline data and self-efficacy scores between par-ticipants in the intervention and control groups were compared using tests of

37

significance as Pearson chi-square, Fisher’s exact and independent sample t- tests. Multiple linear regression analysis was performed, the main exposure was participation in the SIP, the outcome was the self-efficacy scores at T4, and age, gender, marital status and number of working years were adjusted as confounding factors. Self-efficacy scores among participants in the interven-tion group at different times were compared using paired sample t-test. All analyses were set with the level of significance at 0.05 and 95% CI was used.

The qualitative analysis applied an inductive content analysis (Elo & Kyn-gas, 2007). First, the recorded FGDs were transcribed verbatim and quality was checked by NP (Krueger & Casey, 2009). The analysis was performed for three phases: preparation, organising and reporting. Preparation phase was a selection of sentences and manifest contents to prevent fragmentation of words and maintain results close to the transcriptions. This was done by two Thai native researchers who separately read the transcriptions several times for familiarisation. The organising phase comprised of two processes: an open coding for notes and headings were written during reading transcriptions, and a creation of categories where they were generated and grouped from written notes and headings into categories. The reporting phase was done when the two researchers agreed upon categories, and another non-Thai researcher agreed upon categories after reading an example of English transcriptions from the original transcriptions. Final categories were reported to the FGD participants after agreement between the three researchers was reached.

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Results

Study I and Study III – Perinatal depressive symptoms among Thai women Characteristics of the participants During late pregnancy, 463 pregnant women were approached, 451 pregnant women (451/463 responses, 97%) answered the questionnaire, and 449 preg-nant women were eligible for Study I (T1) analysis (two participants were excluded from the 451 responses because one is not a Thai citizen and one reported having a psychiatric problem). At one month (T2) and three months (T3) postpartum, 319 (out of 449, 71%) and 276 (out of 449, 61%) participants were included in the analyses.

At T1, almost half of the participants (47.4%) were 20-29 years old, while 17.7% of the participants were less than 20 years old. About one-third (31.0%) of the participants graduated from a secondary school and 42.2% were primip-arous. The majority of the participants had a personal income (60.6%) and expenses (80.5%) per month that were ≤9,000 baht (approximately 300 USD).

At T2, 17.3% of eligible participants were less than 20 years old and 85% of the participants graduated with less than a bachelor’s degree. About 66% of the eligible participants had a personal income/month that was ≤9,000 baht, and more than four-fifths (81%) of the participants had personal expenses per month that were ≤9,000 baht. In addition, the main mode of delivery was nor-mal (71.3%) and most of the eligible participants exclusively breastfed their children at one month postpartum (83.3%).

At T3, almost one-fifth (18.5%) of the eligible participants were less than 20 years old and 85.1% of the participants graduated with less than a bache-lor’s degree. The majority of the eligible participants had a personal income and expenses per month that were ≤9,000 baht (68.1% and 81.0%, respec-tively).

Descriptions of ADS and psychosocial factors during late pregnancy The prevalence of ADS among participants was 46.8% (95% CI 42.3-51.4). Amongst the participants, three-fourths (75.9%) had high psychological well-

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being and 53.1% had high SOC. More than three-fifths (63.6%) of the partic-ipants had low self-esteem and 52.9% had low dyadic adjustment. A majority of the participants had high level of total social support (63.4%), and more than half of the participants (52.7%) had low maternal competence.

Risk factors associated with antenatal depressive symptoms Risk factors tested in the univariate analysis were sociodemographic charac-teristics, obstetric and psychosocial factors, and there were many significant risk factors associated with ADS as shown in Table 5.

Table 5. Risk factors associated with antenatal depressive symptoms tested in the univariate analysis

Sociodemographic Characteristics

Obstetric factors Psychosocial factors

Age* Gestational week Psychological well-being* Education level* Parity Sense of coherence* Religion Abortion Self-esteem* Occupation* Marital satisfaction* Marital status Social support* Personal income/month* Maternal competence* Personal expense/month Family income/month Money status* Family type Pregnancy planning Alcohol consumption Smoking habit* * statistically significant at 0.05 level Note: all were categorical variables In multivariate analysis, significant risk factors associated with ADS remained as shown in Figure 7. Women aged less than 20 years were at higher risk of having ADS in comparison with those aged 30-39 years (OR 2.58, 95% CI 1.14-5.84). The pregnant women who did not have enough money had in-creased risk of ADS in comparison with those having enough money in a bank account (OR 2.71, 95% CI 1.22-6.05). Other psychosocial risk factors for ADS were low psychological well-being in comparison with high psycholog-ical well-being (OR 3.12, 95% CI 1.75-5.58), low self-esteem in comparison with high self-esteem (OR 2.08, 95% CI 1.24-3.49) and low SOC when com-pared with high SOC (OR 1.82, 95% CI 1.12-2.95). Non-significant risk fac-tors associated with ADS were religion, education, occupation, marital status, personal income and expense per month, family income per month, family

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type, pregnancy planning, alcohol consumption, smoking habit, gestational week, parity, marital satisfaction, social support and maternal competence.

Figure 7. Risk factors associated with Antenatal Depressive Symptoms among the participants

Prevalence of and Risk factors associated with depressive symptoms at one month and at three months postpartum The prevalence of PDS at one month and at three months postpartum were 22.4% (95% CI 17.5-27.5) and 22.5% (95% CI 17.5-27.5), respectively. EPDS scores at one month and three months postpartum represented depressive symptoms at one month and three months postpartum. There were many sig-nificant risk factors associated with increased EPDS scores at one month (Model 1) and at three months (Model 2) postpartum in univariate analyses as shown in Table 6.

In multivariate analyses, significant risk factors associated with increased EPDS scores at one month and three months postpartum remained as shown in Figure 8. Women with higher antenatal psychological well-being scores (β=0.314, 95% CI 0.292-0.326), with non-exclusive breastfeeding (β=0.166, 95% CI 0.106-0.226), with low personal income/month (β=0.139, 95% CI 0.008-0.197; <300 USD/month vs. ≥300 USD/month), and a caregiver other than a mother (β=0.119, 95% CI 0.051-0.186) were risk factors associated with increased EPDS scores at one month postpartum.

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Table 6. Risk factors associated with increased Edinburgh Postnatal Depression Scale Scores at one month and at three months postpartum tested in univariate anal-yses

Sociodemographic characteristicsa

Obstetric factorsa

Psychosocial factors At one month postpartum b

At three months Postpartum b

Age* Parity Antenatal psychological well-being*

Antenatal psycho-logical well-being**

Education level Abortion Antenatal sense of coherence

Antenatal sense of Coherence

Marital status* Mode of childbirth

Antenatal marital satisfaction*

Antenatal marital satisfaction**

Occupation Antenatal self-esteem*

Antenatal self-esteem**

Personal income/month*,** Antenatal social support* Antenatal social support**

Personal expense/month Antenatal maternal competence*

Antenatal maternal competence**

Family income/month Psychological well-being at one month postpartum**

Money status Sense of coherence at one month post-partum**

Family type Self-esteem at one month postpartum**

Pregnancy planning** Marital satisfaction at one month post-partum**

Alcohol consumption Total social support at one month post-partum**

Co-habitation after Childbirth

Maternal compe-tence at one month postpartum**

Child’s feeding* Child’s caregiver*,** Child’s gender * statistically significant at 0.05 level for the analysis at one month postpartum ** statistically significant at 0.05 level for the analyses at three months postpartum Note: a=categorical data; b=numerical data

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Figure 8. Risk factors associated with increased Edinburgh Postnatal Depression Scale (EPDS) scores at one month and three months postpartum among the partici-pants

Women with higher one month postpartum psychological well-being scores (β=0.401, 95% CI 0.386-0.416), with lower one month postpartum self-es-teem scores (β=0.190, 95% CI 0.181-0.199), with unintended pregnancy (β=0.144, 95% CI 0.106-0.772), with low personal income/month (β=0.138, 95% CI 0.077-0.199; <300 USD/month vs. ≥300 USD/month), and with lower one month postpartum maternal competence scores (β=0.123, 95% CI 0.121-0.125) were risk factors associated with increased EPDS scores at three months postpartum.

Non-significant risk factors associated with increased EPDS scores at one month and three months postpartum were: education, occupation, marital sta-tus, personal expense per month, self-perceived insufficient money, family in-come per month, family type, alcohol consumption, parity, history of abortion, sense of coherence during late pregnancy, marital satisfaction during late pregnancy and social support during late pregnancy. Planned pregnancy, self-esteem during late pregnancy and maternal competence during late pregnancy did not influence EPDS scores at one month postpartum, whereas non-exclu-sive breastfeeding, caregiver not a mother, mode of childbirth, co-habitation after childbirth, and child’s gender did not influence EPDS scores at three months postpartum.

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Changes in depressive symptoms at late pregnancy, at one month and three months postpartum

Mean EPDS scores reduced significantly from late pregnancy to one month postpartum (p<.01). The scores were unchanged from one month postpartum to three months postpartum (p=.26), as shown in Figure 9.

Figure 9. Changes in the Edinburgh Postnatal Depression Scale scores among the participants

Study II – Life situation and support during pregnancy Characteristics of the participants In total, 27 couples were included in the study. The age range of EMs was 16-41 years and that of EFs was 17-50 years. Many EMs had no work during pregnancy, while most EFs had non-permanent employment. The EPDS scores of selected EMs ranged from seven to twenty-three points.

Life situation during pregnancy From the analysis, two categories and seven sub-categories emerged about life situation during pregnancy among EMs with ADS and their partners. They are presented in Table 7 and described below.

9.74

6.47

6.68

0

2

4

6

8

10

12

Late pregnancy One monthpostpartum

Three monthspostpartumEd

inbu

rgh

Post

nata

l Dep

ress

ion

Scal

e sc

ores

Time points

p<.01

p=.26

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Table 7. Categories and sub-categories about life situation during pregnancy among EMs with depressive symptoms and their partners

Categories Sub-categories Having obstacles in life Decreased dignity because of economic insufficiency

Fear of health problems, childbirth and an abnormal child

Worry about partner’s behaviour

Uncomfortable with in-law family members

Facing life transition Need to prepare for a secure family

Dealing with different life events

Accepting changes in life

Having obstacles in life. There were four sub-categories in this category, which were: Decreased dignity because of economic insufficiency; Fear of health problems, childbirth and an abnormal child; Worry about partner’s be-haviour and Uncomfortable with in-law family members. The participants (both EMs and EFs) described having problems in their lives during preg-nancy. All of the EMs with depressive symptoms and their partners expressed that economic burdens became an obstacle in their lives in many ways. For example, EMs gave up their work because of pregnancy and EFs needed to secure more money for the new family member. Some EMs expressed that they were afraid of not being in good health and giving birth to an abnormal child. EMs were also worried about partners’ behaviours, such as extramarital sex and drinking. Additionally, some EMs felt uncomfortable with in-law family members, such as living with the mother-in-law. EFs were afraid of physical risk behaviour of pregnant women, such as too much physical activ-ity and engaging in hard work.

Facing life transition. This category had three sub-categories: Need to pre-pare for a secure family, Dealing with different life events and Accepting changes in life. Both EMs and EFs described that they needed to have a secure family and ways to solve problems. For instances, they described a need to prepare materials and room for the new baby and a need to relax by them-selves, by going out of the house, when being in a bad mood. Both EMs and EFs also felt they would meet a new role, for example, a role of mother or of the head of the family.

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Support during pregnancy There were two categories and four sub-categories related to support during pregnancy among EMs with ADS and their partners. They are shown in Table 8 and described below. Table 8. Categories and sub-categories of support during pregnancy among EMs with depressive symptoms and their partners

Categories Sub-categories Enhancing confidence Getting encouragement from surrounding persons

Receiving assistance from social networks

Dissatisfaction with support

Needing better healthcare services

Insufficient involvement by the family

Enhancing confidence. This category had two sub-categories: Getting encour-agement from surrounding persons and Receiving assistance from social net-works. EMs and EFs described that they got support from persons surrounding them such as family members, in terms of materials or consultation. They also received assistance from social networks, such as online network groups and HCPs.

Dissatisfaction with support. It had two sub-categories: Needing better healthcare services and Insufficient involvement by the family. EFs described that they needed a better support by increasing the involvement of EFs in the ANC process. They also expressed that they were less involved in the family.

Study IV – Self-efficacy Improvement Programme among public health professionals for detection and management of perinatal depressive symptoms Characteristics of the participants There were 66 participants in this study, where 33 PHPs were in the interven-tion group and 33 PHPs in the control group. Additionally, 23 PHPs in the intervention group participated in 4 FGDs (FGD1 (n=4), FGD2 (n=8), FGD3 (n=6) and FGD4 (n=5)).

At baseline (T1), mean age (SD) of participants in the intervention group was 32.21 (7.60) and of PHPs in the control group was 40.12 (10.26). The average (SD) working years of participants in the intervention group was 7.19 (5.38) and of participants in the control group was 11.52 (7.03). These were

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significant different characteristics between participants in the intervention and control groups, whereas other characteristics of participants were similar between the groups, e.g. marital status and self-efficacy scores.

The effectiveness of the SIP Study IV revealed that after participation in the SIP (T4), the participants in the intervention group had higher self-efficacy scores than those in the control group (β = 3.26, 95% CI 1.10-5.42, p=.004).

Amongst participants in the intervention group, the self-efficacy scores sig-nificantly increased from after the one-day of theory (T3) to T4 (p<.05), while the scores among participants in the control group significantly declined from baseline (T1) to T4 (p=.002).

Self-efficacy of PHPs after participation in the SIP Four categories emerged and are described below: Having confidence, Chang-ing knowledge and attitude, Increasing perception of important role, and In-creasing awareness of performed function.

Having confidence. Before participating in the SIP, PHPs mainly worked to address disease prevention and control, not depressive symptoms among women during the perinatal period. After the SIP, the participants described that they got guidelines for detection and management of perinatal depressive symptoms and how to work in practice, and they were supervised during their practices by NP. Using materials from the SIP, some participants practiced with two women (one pregnant woman and one woman after childbirth), while some practiced with three women (pregnant and after childbirth). As a result, PHPs had confidence to advice women, screen women for perinatal depressive symptoms, and explain to their colleagues about perinatal depressive symp-toms among women.

Changing knowledge and attitude. The PHPs described their limited knowledge and attitude related to perinatal depressive symptoms before par-ticipating in the SIP. The participants mentioned that interactive lectures from the SIP provided them new knowledge related to perinatal depressive symp-toms and positive attitude towards working with detection and management of perinatal depressive symptoms. They mentioned that they paid more atten-tion to perinatal depressive symptoms than before.

Increasing perception of important role. The PHPs described their percep-tion of the preventive role. After the SIP, the participants perceived that the most important tasks of PHPs were detection and management of perinatal depressive symptoms among women in communities. They also mentioned that the SIP should be distributed to all PHPs so they could all have the same level of knowledge and could help other professionals.

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Increasing awareness of performed function. The PHPs described their concerns about service functions in their SHPHs and how they planned to manage in their SHPHs, such as using the EPDS presented in the SIP to screen for perinatal depressive symptoms by PHP in the SHPH.

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Discussion

Based on the findings of the research project, it is evident that the prevalence of ADS and PDS among women in the study setting was high. Many socio-demographic and psychosocial factors were significantly associated with ADS and PDS at one month and three months, e.g. teenage pregnancy and lower psychological well-being. Further, women with ADS and their partners ex-pressed both positive and negative life situation and support during the preg-nancy period. The PHPs had increased self-efficacy scores after participation in the SIP for detection and management of perinatal depressive symptoms. The SIP could also demonstrate other outcomes from participation, such as changing knowledge and attitude among participating PHPs after the SIP. Re-lating these findings to theoretical frameworks could generate ideas for future improvements upon detection and management of perinatal depressive symp-toms among women. Therefore, this discussion is based on the Model of So-cial Determinants of Health (Study I, Study II and Study III), and the Theory of Self-efficacy (Study IV).

Social Determinants of Perinatal Depressive Symptoms among Thai Women Individual characteristics Findings from Study I and Study III connect to the Model of Social Determi-nants of Health (Dahlgren & Whitehead, 1991; 2007), in which individual characteristics influence health, i.e. depressive symptoms among women dur-ing the perinatal period.

In Study I, it was found that pregnant teenagers less than 20 years of age had 2.6 times higher risk for ADS in comparison to pregnant women who were 30-39 years old. In Study III, unintended pregnancy was a risk factor for in-creased EPDS scores at three months postpartum. These findings are con-sistent with many previous studies. For examples, a study from Hong Kong found that Chinese women with a younger age had increased risk of having ADS (Lau & Wong, 2008), and a longitudinal study conducted in Turkey found that unplanned pregnancy was a significant risk factor for PDS (Boratav et al., 2016). In the Thai context, premarital pregnancy is not acceptable and pregnant teenagers may have to leave their school to prepare to become a

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mother (Sriyasak, Almqvist, Sridawruang, Neamsakul, & Häggström-Nordin, 2016). Moreover, women in the north-eastern region of Thailand are perceived to have less value after leaving school (Muangpin, Tiansaward, Kantaruksa, Yimyam, & Vondeheid, 2010). On the contrary, recent studies found that ad-olescents believed in living together before getting married (Ounjit, 2015), and contraceptive use among reproductive women was quite low (Panyava-ranant, Santibenchakul, & Jaisamrarn, 2015). These results might explain why teenage pregnancy and unintended pregnancy were risk factors associated with ADS and increased EPDS scores at three months postpartum. However, in Study I and Study III no association was found between the number of preg-nancies and perinatal depressive symptoms. In Thailand, during the perinatal period, women are treated if they have a positive screening for depressive symptoms and they can access to mental health services on timely basis (Kongsuk et al., 2017). Thus, women may not have these symptoms during early pregnancy and late pregnancy (Fisher et al., 2013).

Individual lifestyle factors Individual lifestyle factors are actions taken by individuals, including attitudes (Dahlgren & Whitehead, 2007), resulting in having depressive symptoms among women both during pregnancy and one month and three months after childbirth. Lifestyle behaviours are modifiable, and healthier lifestyle behav-iours may reduce depressive symptoms among women during the perinatal period.

In Thailand, the consumption of alcohol is widely accepted as a social ac-tivity, recreation and interaction among people (Assanangkornchai, Sam-Angsri, Rerngpongpan, & Lertnakorn, 2010). In particular, it is embedded in the north-eastern culture (Moolasart, 2011). This might explain why the preg-nant women with depressive symptoms in Study II expressed negative feel-ings regarding their partner’s drinking behaviour. However, in Study I and Study III, no association was found between women’s alcohol consumption and depressive symptoms during the perinatal period. The reason may be that many pregnant women stopped drinking when they were pregnant and some were non-drinkers. This is in line with a recent survey in Thailand, showing that 40% of women are non-alcohol drinkers and about 90% of men are alco-hol drinkers (Wakabayashi et al., 2015).

Actions taken by a mother during the early postpartum period are associ-ated with the EPDS scores. In Study III, non-exclusive breastfeeding and care-giver other than a mother were risk factors associated with increased EPDS scores at one month postpartum, while lower maternal competence was a risk factor associated with increased EPDS scores at three months postpartum. Many studies have previously demonstrated that actions taken by a mother are connected to each other; breastfeeding could promote mother-child bonding, and prevent PDS (Borra, Iacovou, & Sevilla, 2015; Safadi, Abushaikha, &

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Ahmad, 2016), whereas women who care for the baby by themselves during the early postpartum period might have increased their maternal self-efficacy and been less depressed (Zheng et al., 2018). Therefore, exclusive breastfeed-ing and mother-based care should be nationally promoted, e.g. well-prepared educational programmes during late pregnancy and early postpartum (van Scheppingen, Denissen, Chung, Tambs, & Bleidorn, 2018).

There are different views about sexuality between Thai men and women. Thai men are perceived to have a higher sex drive, while Thai women are viewed to be more in control of their sexual feelings (Thianthai, 2004). Also, in Thailand it has been reported that many Thai males have extramarital sex (Chongsiri & Yamarat, 2014), and young teenagers continue to think that sex-uality is a private issue (Ounjit, 2015). These reasons can explain why women with ADS in Study II were so worried about their partners’ sexual behaviour.

Psychological well-being was a potential risk factor found in both Study I and Study III. In Study I, prevalence of women with low psychological well-being during late pregnancy was 2.4 times higher than general Thai population (Hanklang, Ratanasiripong, Naksranoi, Sathira-Anant, & Patanasri, 2018). Women during the antenatal period seemed to decrease their psychological well-being; this is why low psychological well-being was a risk factor associ-ated with ADS in Study I. Other studies demonstrated that low psychological well-being among pregnant women is correlated with high EPDS score (Bassi et al., 2017), and it is a risk factor for postpartum disorders (Robertson, Grace, Wallington, & Stewart, 2004). Hence, women who have low psychological well-being need to prepare themselves to become a mother (Haga et al., 2012), at least understanding that they are parents (Naphapunsakul, Prateepchaikul, Taboonpong, & Punthmatharith, 2007). If this is not possible, a long-term con-sequence after childbirth might be a reduction of life satisfaction and psycho-logical well-being (Pollmann-Schult, 2014).

Self-esteem is one potential factor found in the research project, which has affected depressive symptoms among women during the perinatal period. In Study I, low self-esteem among pregnant women doubled the risk of experi-encing ADS in comparison with women having high self-esteem, whereas in Study III a lower self-esteem score at one month postpartum among women increased EPDS scores at three months postpartum. These findings are in line with several other studies. For example, Leigh and Milgrom (2008) indicated that low self-esteem is a predictor of antenatal depression, and lower self-es-teem increases the number of symptoms (Jesse, Walcott-McQuigg, Mariella, & Swanson, 2005). Women may think that being a mother is difficult for them (Liamputtong, Yimyam, Parisunyakul, Baosoung, & Sansiriphun, 2004), which destroys their self-esteem. In order to have higher self-esteem, they have to increase their self-evaluation during pregnancy (Ju-young & Yoon-ji, 2013) or increased responsibility from their partners might increase the self-esteem among the women (Macola et al., 2010).

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Low SOC was found to be a risk factor for ADS among women in Study I. Women with low SOC may not manage stressful situations very well and they may think their lives are difficult (Antonovsky, 1987). To improve their SOC, HCPs need to promote pregnant women’s mental health using intervention programmes (Suzuki, Sekizawa, Tanaka, Okai, & Kinoshita, 2016), e.g. the Cognitive Behavioural Therapy (WHO, 2015b). However, in Study III, no as-sociation was found between women’s SOC and increased EPDS scores at one month and three months postpartum. This might be because the participants had improved their SOC from late pregnancy to the first trimester after child-birth. Previous studies show that if improvement is not met, women might have high parental stress (Hildingsson, 2017) and depressive symptoms (Ker-stis et al., 2013) after childbirth.

In conclusion, actions taken by women (e.g. mother-based care) and their partners (e.g. extramarital sex), and women’s psychosocial factors (e.g. psy-chological well-being) during the perinatal period, are associated with perina-tal depressive symptoms. Therefore, women during the perinatal period should have support from people outside their family, e.g. a PHP in the pri-mary care setting or a community leader to prevent perinatal depressive symp-toms.

Social and community networks Support during pregnancy has been addressed as a preventive factor for post-partum depression (Morikawa et al., 2015). Study I and Study III show that social support, marital satisfaction, and size of a family were not risk factors associated with depressive symptoms during the perinatal period. The expla-nation may be that women continued to get support after getting pregnant. In study II, most pregnant women and their partners described that they received physical, economic, and informational support from their family, friends, neighbours, community and HCPs, which enhanced their confidence. How-ever, some expectant parents felt that it was difficult to live with their in-law family and to be included as a member of the family. Stressful family relation-ships have previously been seen in some Asian cultures (Roomruangwong & Epperson, 2011), such as the relationship between pregnant women and par-ents-in-law in China (Lau & Wong, 2008). Pregnant women in Study II were afraid and worried about health, childbirth and complications because of in-formation they had received from HCPs and other women’s experiences. This is supported by several studies (Jha, Larsson, Christensson, & Svanberg, 2017; Rishworth, Bisung, & Luginaah, 2016; Rondung, Thomten, & Sundin, 2016) showing that depressive symptoms are associated with having fear of child-birth. Although this project did not measure fear of childbirth, it might be as-sociated with ADS among women in the current study population. In addition, some EFs addressed that health services should be improved, in terms of providing enough information about maternal and child health and including

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this information in the process of maternal care. Some studies show that father involvement is needed at ANC clinics, and fathers often feel invisible at the clinics (Widarsson, Kerstis, Sundquist, Engstrom, & Sarkadi, 2012; Widarsson et al., 2015). It could be implied that there are gaps between ex-pectations of the expectant parents about HCPs in terms of information and involvement. HCPs in ANC clinics need to be informed about these issues in order to help them improve the situation.

Living and working conditions ADS and PDS among women are global problems, particularly in Asian coun-tries, e.g. 18% among pregnant women in Bangladesh (Nasreen et al., 2011) and 48% among postpartum women in Turkey (Boratav et al., 2016). The variation might come from several factors, including contextual factors and times during the perinatal period. In Study I and Study III, the prevalence of ADS was rela-tively high and that of PDS at one month postpartum reduced significantly and remained at the same level to three months postpartum. In previous surveys, the prevalence of major depressive disorders among Thai women in general was found to be three per cent (DMH, 2015), and depression among Thai female adolescents in a slum community using the CES-D screening tool was 40% (Somrongthong, Wongchalee, & Laosee, 2013). A prospective study conducted in southern Thailand (Limlomwonse & Liabsuetrakul, 2006) showed a declin-ing trend of prevalence from late pregnancy (20%) to 6-8 weeks postpartum (17%), which is similar to the results in Study I and Study III. Further, the au-thors of that study meant that the prevalence might have been lower because the study was conducted in a city. This may indicate that living conditions and sit-uations of the participants in Study I and Study III, who were from the city cen-tre and different local areas of Sakonnakhon, may have contributed to the high prevalence of ADS and PDS among the participants. Women in north-eastern Thailand usually leave their jobs in the big cities and move back to their home town to have their delivery when they become pregnant. This is a migration that may contribute to a higher prevalence of ADS and PDS in this study setting compared to other regions Thailand.

One potential factor addressed in accordance with depressive symptoms in Study I, Study II and Study III was economy. Amongst women, low economy was found to be a risk factor for ADS (Study I) and to be an obstacle for EMs, particularly when they stopped working because of pregnancy (Study II). Fur-ther, low personal income per month was found to be a risk factor for increased EPDS scores at one month and three months postpartum (Study III). It has been shown that a majority of the women participating in Study I and Study III also had an income lower than Thai minimum income (National Wage Committee, 2016). For women in the north-eastern region of Thailand, it is considered normal to go back to their hometown before childbirth (Coyle &

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Kwong, 2000). A financial constraint increases the risk for women to experi-ence depressive symptoms (Hanklang, Kaewboonchoo, Morioka, & Plernpit, 2016) and it is also a burden for EFs, e.g. when having a non-permanent in-come and at the same time having the expectation of being a leader providing support for their whole family (Chirawatkul et al., 2012). Findings from Study I, Study II and Study III demonstrate that if women’s personal income/month remains insufficient, effect of the imbalanced economy may contribute to de-pressive symptoms among women not only during late pregnancy, but also lasting at least during the first trimester after childbirth. Therefore, family planning including economic issues should be taken into account.

Caesarean section as a part of healthcare services at childbirth may contrib-ute to PDS among women (Ahmed, Alalaf, & Al-Tawil, 2012). However, the findings of Study III showed that the mode of childbirth did not give depres-sive symptoms to postpartum women. The reason may be the fact that Thai-land offers all women the right to deliver a child in a public hospital free of charge (Panpiemras et al., 2011; MoPH, 2017). Also, this may be because a nurse/midwife at a Thai labour room provides enough information related to childbirth, because lack of information may make women feel depressed (Widarsson et al., 2012).

General social conditions In this research project, the child’s gender is seen as part of the social condi-tion. The findings in Study II showed that child’s gender preference was not addressed by pregnant women with depressive symptoms and their partners, and child’s gender was not a risk factor for increased EPDS score at one month and three months postpartum in Study III. These findings differ from a sys-tematic report showing that pregnant women who are depressed prefer having a son and child’s gender produces depression (Roomruangwong & Epperson, 2011). This might be because in Thailand, there is no policy limiting the num-ber of children in a family like in China (Hesketh & Xing, 2005). Moreover, in the north-eastern Thai culture, couples usually prefer having many children in their families. Therefore, there is no problem if the couple get a boy or a girl because they still have chance to have a baby of their own desire.

Self-efficacy among Public Health Professionals for detection and management of perinatal depressive symptoms after participating in the Self-efficacy Improvement Programme The Theory of Self-efficacy has been developed by Bandura (1977) in order to describe how to improve an individual’s behaviour. Screening for perinatal

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depressive symptoms is essential (ACOG, 2018), and it can be proceeded by a PHP (Mutamba, van Ginneken, Smith, Wandiembe, & Schellenberg, 2013). The SIP in Study IV has been developed based on the four sources of infor-mation from the Theory of Self-efficacy (Bandura, 1977; Bandura, 1986) aim-ing at improving the self-efficacy among PHPs in detecting and managing perinatal depressive symptoms in the research project.

In Study IV, it was found that PHPs who participated in the SIP had signifi-cantly higher self-efficacy scores in comparison with those who routinely worked with their ordinary tasks. Among PHPs who participated in the SIP, they also in-creased their self-efficacy scores after their full participation in the programme. These findings are in line with other studies finding that HCPs in government settings need more training in order to improve their self-efficacy in caring for people (Zaki, 2016), and that an intervention containing self-efficacy sources of information can improve self-efficacy among people (Lee, Avis, & Arthur, 2007). Bandura (1977) pointed out that four main sources of information (e.g. perfor-mance accomplishment) could increase efficacy expectations, and the expecta-tions could improve a behaviour. In Study IV, PHPs in the intervention group received the contents related to all sources of information about the Theory of Self-efficacy (Bandura, 1977) in the one-day of lectures. They had a chance to practice at their SHPH and in their community during the four weeks after the day of theory, together with supervision. Both the day of theory and the field practice might make PHPs in the intervention group have higher self-efficacy scores than those in the control group.

In Study IV, the results also showed that after full participation in the SIP, PHPs highlighted having confidence, changing knowledge and attitude, in-creasing perception and increasing awareness of performed function. These highlighted statements came after they practiced in their communities/SHPHs for four weeks, with supervision provided by an expert. This is supported by the Theory of Self-efficacy (Bandura, 1977; Bandura, 1986) and previous studies that increasing awareness is connected to the self-efficacy (Tsuei et al., 2017) and capacity and work performance may come after a full course on self-efficacy (Zaki, 2016).

It could be said that the SIP based on the Theory of Self-efficacy increased not only self-efficacy among PHPs for detection and management of perinatal depressive symptoms but also enhanced their confidence, changed their knowledge and attitude, increased perception of their important role and in-creased their awareness of their performed function for detection and manage-ment of perinatal depressive symptoms after full participation in the SIP.

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Methodological considerations Validity and reliability All studies concerned external and internal consistencies (Drost, 2011). The questionnaire used in Study I and Study III had been approved for face validity by similar pregnant women in a province nearby Sakonnakhon, and for con-tent by PhD-qualified instructors in universities. A reliability test for the ques-tionnaire used in Study I and Study III was carried out among pregnant women close to the study setting, with a good value (Cronbach’s alpha ≥ 0.7) (Nun-naly, 1978) for the whole questionnaire. Considering the different parts of the questionnaire, only the self-esteem and parenting sense of competence scales had the lowest values (Cronbach’s alpha = 0.5). In Study IV, the questionnaire used was tested for its content by three experts (Content Validity Index > 0.80) and for internal consistency among 30 PHPs in another province close to Sa-konnakhon before data collection (Cronbach’s alpha ≥ 0.9), with good values (Brown, 1996; Nunnaly, 1978).

Trustworthiness Trustworthiness (Lincoln & Guba, 1985) has been taken into consideration. First, the creditability of results was established, e.g. by various characteristics of informants, such as depressive symptoms with different scores of EPDS (Study II), and feedback analysis results shown to the participants (Study II and Study IV). Second, detailed descriptions of the data and methods, e.g. study settings and methods of analysis in Study II and Study IV (Elo & Kyn-gas, 2007; Graneheim & Lundman, 2004) could demonstrate transferability. Third, dependability was increased by using interview guides (Study II) and a FGD guide (Study IV), researchers separately analysed the data followed by joint discussion (Study II and Study IV), and external audit was done in a seminar with other researchers not involved in the research project (Study II). Fourth, confirmability was ensured as the results were strengthened by using researchers with expertise in qualitative method, nursing/midwifery and pub-lic health perspectives (Study II and Study IV).

Strengths and limitations There are several strengths to this study project. The number of participants in Study I, Study III and Study IV was based on statistical calculations (Chow et al., 2003; Wayne, 1995), which was applicable to other settings in Thailand. The participants in Study I and Study III came from several hospital levels, and those in Study IV came from several SHPH sizes, which could minimise a clustering effect (Delamater, Shortridge, & Messina, 2013) from the selec-tion of the hospitals/SHPHs (i.e. demonstrating homogeneity within each level

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of hospitals and heterogeneity between levels of hospitals). The informants in Study II had varieties of characteristics which was suitable for a qualitative study (Lincoln & Guba, 1985), e.g. residing in rural and urban areas, with different levels of education and wide range of the EPDS scores of EMs. Fur-ther, participants in the intervention and the control groups in Study IV were quite similar at baseline. Therefore, the effect of the SIP could be well demon-strated.

The combination of study designs is also a strength (Creswell & Clark, 2010; Patton, 2015; Polit & Beck, 2012). Study I was a cross-sectional study, which could provide prevalence and associated factors for ADS. Initial results guided the design of further investigations. Study II was a qualitative study, where the results from the study could explain in depth what life situation and support during pregnancy among EMs with ADS and their partners were. Study III was a longitudinal study and its findings could illustrate risk factors associated with increased EPDS scores at one month and at three months post-partum, and illustrate changes of the EPDS scores at late pregnancy, and at one month and three months postpartum. In Study IV, both quantitative and qualitative methods were used, and the findings could show not only statistical differences between participants in the intervention and control groups, but also other outcomes were identified after participation in the SIP, such as awareness of performed function for detection and management of perinatal depressive symptoms.

Another strength is the validated instruments that were used (Pitanupong et al., 2007). The EPDS is a standardised tool used internationally. It has been used during the perinatal period and has continued to be used until recent years. For example, it has been used longitudinally from pregnancy to six weeks after childbirth among Swedish women (Cato et al., 2019) and to six months after childbirth among women in Turkey (Boratav et al., 2016). The Thai version of the EPDS used in Study I, Study II and Study III has been tested for content and internal consistence before data collection. Although the questionnaire used in Study IV was originally from the Generalized Self-efficacy Scale, it had been modified following the recommendations of con-structing SSE (Bandura, 2006), to make it suitable for assessment of SSE among PHPs for detection and management of perinatal depressive symp-toms. It has also been tested for validity and reliability before the data collec-tion. In addition, interview guides used for Study II have been piloted in sim-ilar population in a province nearby Sakonnakhon.

There are also limitations in this research project. First, all studies were conducted in a north-eastern province of Thailand, and the results might differ from other provinces and regions of Thailand. Second, in Study I, the EPDS has never been validated for Thai pregnant women, so NP decided that women with EPDS ≥10 were considered having ADS, because this cut-off provides a sensitivity of 60% and a specificity of 90% for Thai early postpartum women (Pitanupong et al., 2007). This cut-off could affect the prevalence of ADS and

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PDS and the sensitivity and specificity of disease detection. Furthermore, in Study II, women with EPDS ≥7 were included because they marginally had minor and/or major depressive symptoms in the late antenatal period. Third, some parts of the questionnaire used were translated for the first time by re-searchers who were not native English speakers, i.e. SOC scale and Dyadic Adjustment Scale; thus, the translation could be inaccurate. Fourth, EMs in Study II were in the third trimester of pregnancy and had a partner; hence, the results do not refer to other trimesters and single EMs. Also, EFs in Study II have not been evaluated for depressive symptoms, EFs’ depressive symptoms could also affect EMs. Last, some factors might also be a risk, but they could not be investigated in Study I and Study III due to difficulties with data col-lection and sensitive topics, e.g. domestic violence.

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Clinical implications

The results showed that the prevalence of ADS and PDS was high. There were many risk factors associated with ADS and increased EPDS scores at one month and three months postpartum. There was a combination of life situation and support during the pregnancy period among EMs with ADS, and their partners, and the SIP seemed to be beneficial in increasing self-efficacy scores of PHPs for detection and management of perinatal depressive symptoms. The implications for clinical practices are as follows.

First, an internationalised standardised tool, the EPDS, for depressive symptoms among women during the perinatal period shall be used at least twice; once during pregnancy and once at one month after childbirth, as the depressive symptom scores were connected between time points, i.e. late preg-nancy, one month and three months after childbirth (Study I and Study III). The EPDS should be recommended as the screening tool both during preg-nancy and postpartum periods.

Second, life situation and support during pregnancy among EMs with ADS and their partners were found (Study II). HCPs in ANC clinics should include both EMs and EFs in their services as both need support from HCPs, such as information related to maternal and child health. HCP at ANC clinics should also provide intervention programmes for women having depressive symp-toms, e.g. education or cognitive programmes so that EMs with ADS are of-fered mental health promotion.

Third, many risk factors are associated with EPDS scores concerning ADS and PDS (Study I and Study III). HCPs who are responsible for the detection and management of perinatal depressive symptoms of women, such as PHPs, should screen and manage depressive symptoms when pregnant women come to receive ANC services at ANC clinics or SHPHs, e.g. offering education and method of relaxation to pregnant women with low psychological well-being, pay more attention to pregnant women who are teenagers and who demon-strate an economic burden.

Fourth, the SIP could increase self-efficacy scores of PHPs for detection and management of perinatal depressive symptoms (Study IV). Therefore, demonstrating the SIP to other settings and other professionals might be of great interest. PHPs in other provinces and other professionals, like nurses/midwives may understand and provide assistance in detecting and managing perinatal depressive symptoms in women holistically and effi-ciently.

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Implications for future research

The EPDS screening tool would be beneficial for screening for depressive symptoms during the perinatal period, and it has already been translated into Thai. Unfortunately, it has not been validated against clinical diagnosis for pregnant women. Therefore, validation of EPDS among pregnant women is necessary. Thereafter, the EPDS can be used in Thailand and might be bene-ficial for pregnant women and HCPs.

Although this research project was conducted during the perinatal period, it was only during a high-risk period for perinatal depressive symptoms among women, i.e. between three months before and after childbirth. To conduct re-search during a longer period in different regions of Thailand, a longitudinal study covering the first trimester of pregnancy to one year after childbirth (Bi-setegn et al., 2016; Nasreen et al., 2015) would be of great interest and could provide clearer evidence and aetiology of the perinatal depressive symptoms for Thai women.

Currently, there is no screening for depressive symptoms among EFs in Thailand. Research related to the use of screening tool for depressive symp-toms and risk factors associated with depressive symptoms among EFs should be done. For example, EPDS should be tested and validated among EFs, and a longitudinal study should follow up EFs who have a pregnant partner, from her first trimester of pregnancy to one year postpartum. Results might be ben-eficial, not only for EFs themselves but also for their partners and HCPs to develop public health interventions in the future.

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Conclusion

In this research project, prevalence of ADS and PDS among the Thai women was quite high. The EPDS scores decreased from late pregnancy to one month postpartum and remained on the same level until three months postpartum. Psychological well-being and economic burdens (i.e. insufficient money and low personal income/month) were predominant risk factors contributing to having depressive symptoms both during late pregnancy and after childbirth at one month and at three months. Socio-demographic and psychosocial fac-tors that increased risks of having depressive symptoms during late pregnancy were teenage pregnancy, low self-esteem and low sense of coherence. Non-exclusive breastfeeding and having a caregiver other than a mother were risk factors associated with increased EPDS scores at one month postpartum, whereas risk factors associated with increased EPDS scores at three months postpartum were unintended pregnancy, and lower self-esteem and maternal competence scores at one month postpartum. EMs with ADS and their part-ners had mixed life situation and support during period of pregnancy. HCPs at an ANC clinic should involve EFs and provide information to EFs. EPDS should be used twice during the perinatal period: once during pregnancy and once at one month postpartum. Women who are at increased risk for ADS and PDS should be screened for depressive symptoms during pregnancy, referred for diagnosis, and provided treatment to reduce the risk of ongoing depressive symptoms during the postpartum period. SIP, an intervention programme based on the Theory of Self-efficacy, was proved to increase self-efficacy scores among PHPs in primary care settings for detection and management of perinatal depressive symptoms. This programme also increased PHPs’ confi-dence, changed their knowledge and attitude, increased their perception of im-portant role, and increased their awareness of performed function for detection and management of perinatal depressive symptoms among women.

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Svensk sammanfattning

Depressiva symtom under den perinatala perioden, dvs före, under och efter förlossning, är fortfarande ett globalt problem. Depressiva symtom före (ADS) och efter (PDS) förlossning kan ge negativa långsiktiga konsekvenser för kvinnans och hennes familjemedlemmars livskvalitet. I Thailand råder det emellertid brist på forskning relaterad till depressiva symtom bland kvinnor under den perinatala perioden vad gäller symtomens förekomst och associe-rade faktorer samt livssituation och stöd under graviditeten. Förbättring av tilltro att själv kunna upptäcka och hantera perinatala depressiva symtom bland kvinnor behövs bland folkhälsoarbetare i primärvården. Detta dok-torandprojekt syftar till att (1) undersöka prevalens och riskfaktorer förknip-pade med perinatala depressiva symtom bland kvinnor samt skillnader i poäng efter användning av instrumentet EPDS (Edinburghs Postnatal Depression Scale) sent i graviditeten, en månad efter förlossning och tre månader efter förlossning, (2) utforska och beskriva livssituationen och stödet under gravi-ditet hos blivande mödrar med ADS och deras partners, samt (3) utveckla och utvärdera ett program SIP (Self-efficacy Improvement Programme) för för-bättring av tilltro till egen förmåga bland folkhälsoarbetare i primärvården att upptäcka och hantera perinatala depressiva symtom. Doktorandprojektet genomfördes i Sakonnakhon, en provins i nordöstra Thai-land där mer än 12 000 förlossningar sker varje år. Projektet består av fyra studier. EPDS har främst använts i studierna I, II och III, och ett frågeformulär om tilltro till egen förmåga har använts i studie IV. Projektet inkluderar både kvalitativa och kvantitativa studier och data insamlades med olika metoder. Studie I var en tvärsnittsstudie där vi undersökte prevalens och riskfaktorer förknippade med ADS bland 449 thailändska kvinnor. Multipel logistisk regression, Oddskvoter och 95% konfidensintervall (CI) tillämpades. Studie II var en kvalitativ studie där semi-strukturerade intervjuer användes för att utforska och beskriva livssituation och stöd under graviditet bland blivande mödrar med ADS (n=27) och deras partners (n=27). Data analyserades med kvalitativ innehållsanalys. Studie III var en longitudinell studie där enkäter användes för att undersöka förekomsten av riskfaktorer bland kvinnor förknip-pade med PDS en månad (n=319) och tre månader (n= 276) efter förlossning samt skillnader i depressiva symtom sent i graviditeten, en månad efter för-lossning och tre månader efter förlossning. Data analyserades med multipel linjär regression och parade t-test. Studie IV var en randomiserad kontrollerad studie för att utveckla och utvärdera SIP som var avsedd att öka tilltro till egen

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förmåga att upptäcka och hantera perinatala depressiva symtom bland folk-hälsoarbetare i primärvården. Enkäter besvarades av sådana folkhälsoarbetare i en interventions- och en kontrollgrupp (n=33 respektive n=33). Dessutom genomfördes fyra fokusgruppsdiskussioner bland folkhälsoarbetare i inter-ventionsgruppen (n = 23). Data analyserades med linjära regressioner, parade t-test och innehållsanalys. För alla kvantitativa analyser i studierna I, III och IV användes signifikansnivån 0,05. Förekomsten av ADS bland thailändska kvinnor var 46,8% (95% CI 42,3-51,4), medan förekomsten av PDS bland kvinnor en månad och tre månader efter förlossning var 22,4% (95% CI 17,5-27,5) respektive 22,5% (95% Cl 17,5-27,5). Lågt psykologiskt välbefinnande, otillräckligt med pengar, tonårs-graviditet, låg självkänsla och låg känsla av sammanhang var riskfaktorer för-knippade med ADS. Högre poäng för psykologiskt välbefinnande under sen graviditet, icke-exklusiv amning, låg personlig månadsinkomst och annan vårdgivare än mamman var riskfaktorer förknippade med ökade EPDS-poäng en månad efter födseln. Riskfaktorer förknippade med ökade EPDS-poäng tre månader efter förlossning inkluderade oavsiktlig graviditet, låg personlig må-nadsinkomst, högre poäng av psykologiskt välbefinnande, självkänsla och mödrars kompetens en månad efter födseln. Blivande mödrar och deras partners lyfte fram olika frågor som rör livssituat-ion och stöd under graviditeten: (1) hinder i livet, (2) möta livets övergång, (3) förbättra självförtroendet och (4) missnöje med stöd. Paren beskrev till exempel hinder när det gäller ekonomi, rädsla för hälsoproblem och för att få ett onormalt barn samt partnerns beteende. De fick ofta stöd från familjemed-lemmar och sociala nätverk, men vissa var missnöjda med stödet från sjukvår-den. Till exempel önskade partnern att få mer hälsoupplysning och vara mer involverad. Tilltro till egen förmåga bland folkhälsoarbetare i primärvården att upptäcka och hantera perinatala depressiva symtom ökade efter deltagande i SIP och var högre än hos folkhälsoarbetare som inte deltog i SIP. Deltagande i SIP ledde till ökat självförtroende, ökad kunskap, förändrad attityd, ökad insikt om viktig roll i primärvården samt ökad medvetenhet om utfört arbete. Studiens resultat tyder på att kvinnor som har ökad risk för ADS och PDS bör undersökas för depressiva symtom under graviditeten samt hänvisas för att få diagnos och behandling som minskar risken för depressiva symtom efter för-lossning. Sjukvårdspersonal vid ANC-klinik bör involvera och informera part-nern. Ett träningsprogram bland folkhälsoarbetare i primärvården med syfte att öka tilltro till egen förmåga att upptäcka och hantera perinatala depressiva symtom rekommenderas. Ett sådant träningsprogram bör introduceras även hos andra yrkesgrupper, som sjuksköterskor och barnmorskor, samt i kontex-

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ter utanför Sakonnakhon. Fortsättningsvis behöver en longitudinell studie ge-nomföras bland blivande mödrar och deras partners som täcker tiden från gra-viditetens första trimester till ett år efter barnets födelse. Studien bör innefatta en validering av EPDS bland blivande fäder och depressiva symtom bland dessa.

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Thai sammanfattning (Summary in Thai)

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Acknowledgements

This work was carried out at the Department of Public Health and Caring Sci-ences, Uppsala University, Sweden. The opportunity to do my PhD studies was granted by Kasetsart University Chalermprakiat Sakonnakhon Province Campus, Thailand. I would like to express my deepest gratitude to everyone who has supported and inspired me throughout the process.

All participants from Study I, Study II and Study III who had participated in my studies, your valuable responses and experiences during the perinatal pe-riod are of benefit, not only for other couples in Thailand, but also for the improvement of mental health services both in Thailand and worldwide. Fur-ther, thanks to all PHPs who answered questionnaire for Study IV and those who participated in the intervention programme. Your participation and re-sponses demonstrate that PHPs in Thailand do work to detect and manage perinatal depressive symptoms. Pranee C. Lundberg, my main supervisor, for your engagement since the first time I sent an e-mail to Uppsala University for application. You have helped and encouraged me to reach the admission requirements for a foreigner like me. That was the beginning engagement and it has lasted even until now. Also, thank you for helping me with the data collection, especially since not too many supervisors would like to go to a research setting in a country far away. You have spent time to go and stay there, taking at least five days each trip, and about three hours each way by car. Further, thanks to Professor Bengt Lundberg who agreed with this support. Bengt has helped me with so many things, not just tasks related to my PhD study, but also with basic living items, such as accommodation and transportation support in Sweden. There were many shared times and activities. Leif Eriksson, my co-supervisor, for your engagement in my PhD studies since the beginning. You have shared your fruitful discussions with me during the time. Also, thank you for your generosity and encouragement as well as trav-elling to the research setting, which is a difficult province to reach and time-consuming for transportation.

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Professor Katarina Hjelm, who is not only the head of the research group of caring sciences at the department, but also my co-supervisor who has sup-ported me and made my study process as smooth as possible. Dr Passakorn Ongarj, who is the dean of the Faculty of Public Health, Kaset-sart University Chalermprakiat Sakonnakhon Province Campus, Thailand, where I work. Thank you very much for your assistance during the time I have studied for my PhD, including support and management of my PhD plan. Also, thanks to my colleagues at the faculty for your encouragement and con-tinuing cooperation during the time. Thank you very much to the Department of Public Health and Caring Sci-ences, for supporting me all the things a PhD student needs. Also, thanks to the Caring Sciences research group members, studying here has been like liv-ing with my family, including meetings, Fikas and seminars. Thanks to the many people who have helped me with data collection and man-agement since my PhD project was initiated, including Mr Santisuk Chaimongkol who works for maternal and child health promotion at the Sa-konnakhon Provincial Public Health Office. Also, great thanks to staff and directors at the Sakonnakhon Public Health Provincial Office and hospitals where data were collected. They have helped and facilitated the collection of the data tremendously. Finally, the greatest thanks to my family. My parents, Amnart Phoosuwan and Kamjai Phoosuwan, the first and second persons who have always supported me since I was born with studying, working and living. My brother Pakorn Pusuwan, for providing emotional and family support during the time I have been away from my hometown, Angthong, Thailand. Natthida Phoosuwan, my wife, who is the third person who has encouraged me to study abroad. Words of encouragement also come from Koranat Phoosuwan, my daughter. Either online or offline, she always talks to me and activates me to go to school like her. Moreover, thanks to my in-law family members (Family Phinyosap), who always take care of me, my wife, my daughter and my family.

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