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Abstract
Introduction The estimated prevalence of postpartum depression (PPD) worldwide, in China, and Shanghai is 17.2%, 18.0% and 23.2%, respectively. In 2021, Shanghai housed a population of 3.2 million childbearing-age migrant women, most of whom migrated to the city with their husbands for economic reasons. There is a general lack of help-seeking behaviour for mental disorders in China due to the perceived risk of social stigmatisation. In Shanghai, 70% of women did not seek professional help for perinatal mental health problems. We aim to gather information from multiple perspectives, such as the migrant women with PPD and perinatal depression (PND), their caregivers, health service providers and communities, to understand the help-seeking behaviour of postpartum migrant women with PPD or PND in China.
Methods and analysis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework for Scoping Reviews will guide this review. A bilingual research librarian developed a comprehensive search strategy to retrieve published and unpublished English and Chinese studies involving factors influencing women’s PPD or PND help-seeking behaviour in China. This literature includes perceptions, views, patterns, acceptance and refusal, tendencies, probability, service accessibility and utilisation, and facts. We will search PubMed, Embase, Web of Science and CINAHL for English literature and CINKI for Chinese literature. Backward and forward snowball approaches will be used to identify additional relevant papers from the reference lists of selected papers. Two independent reviewers will screen the title and abstract and review the full text of selected papers to identify eligible articles for data extraction. We will build a Microsoft Access database to record the extracted data. The results will be presented in tables and a causal map to demonstrate the relationships between extracted variables and help-seeking behaviours for PPD and PND. A conceptual simulation model will be formulated based on the information from the literature to validate the logic of the relationships between variables, identify knowledge gaps and gain insights into potential intervention approaches. Experts and stakeholders will be invited to critique and comment on the results during group model building (GMB) workshops in Shanghai. These comments will be essential to validate the findings, receive feedback and obtain additional insights.
Ethics and dissemination The literature review component of our study does not require ethical approval because the information and data collected will be obtained from publicly available sources and will not involve human subjects. Our collaborating research partner, International Peach Maternal Child Hospital, obtained the IRB approval (GKLW-A-2023-020-01) for screening and enrolling participants in GMB workshops. Stanford University received IRB approval under protocol number 67 419. The full review will be presented at a relevant conference and submitted to a peer-reviewed scientific journal for publication to report findings.
- Literature
- Behavior
- China
- Postpartum Women
- Protocols & guidelines
- Decision Making
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STRENGTHS AND LIMITATIONS OF THIS STUDY
Using a causal map helps readers visualise the relationships between the factors of aspirin uptake and adherence and the relationships among factors.
Due to scant studies in Shanghai, we included studies in other geographical areas, which may hinder the generalisability of the findings to Shanghai.
The review also includes studies about perinatal depression. However, help-seeking behaviour might be different during pregnancy and post partum.
Definitions for postpartum depression and help-seeking behaviour are limited in the literature. Hence, this study does not specify the inclusion and exclusion criteria for postpartum and perinatal depression and help-seeking behaviour.
Introduction
Postpartum depression (PPD) is characterised by the onset of depressive symptoms within approximately a week after childbirth, including intense feelings of sadness, anxiety and despair, which may persist for up to a year or more.1 The estimated prevalence of PPD worldwide, in China, and Shanghai is 17.2%, 18.0% and 23.2%, respectively.2 3 Data are scarce on the prevalence of PPD among migrant women in China despite their growing numbers; in Guangzhou, the prevalence of PPD among migrant women was 34%.4 A recent meta-analysis reports that the prevalence rates for perinatal depression (PND), mood disorders that occur during and after childbirth,5 range between 11% and 55% in 23 regions in China.3
In 2021, Shanghai housed a population of 3.2 million childbearing-age migrant women, most of whom migrated with their husbands for economic reasons.6 ‘Migrant women in our study refers to the floating population without permanent residency certificates (‘hukou’) in the city where they work and live for more than 6 months of the year. The terminology ‘floating population’ is unique to China because the definition is conceptualised according to the places of hukou registration.7 These individuals’ hukou are still registered under the administrative area of their hometown. Without a hukou—a certificate that proves the permanent residence of an individual—in Shanghai, migrant women lack the rights and benefits to access healthcare, social services, offspring education and housing. These migrant women could be more susceptible to PPD than local residents because they have to adapt to a new environment, master a new language, follow new societal rules and regulations, and obey different norms for social interactions and lifestyles. Additionally, migrant women lack social support and thus endure disempowerment and loneliness.8
There is a general lack of help-seeking behaviour for mental disorders in China due to the perceived risk of social stigmatisation. Few frameworks exist to define help-seeking behaviour clearly. We adopt the definition of ‘help-seeking behaviour’ in the mental health context from Rickwood and Thomas9—‘Help-seeking is an adaptive coping process that is the attempt to obtain external assistance to deal with a mental health concern.’ Our study includes three types of help: formal, informal and self-help. In Shanghai, 70% of women did not seek professional help for mental health problems.10 11 Women who scored between 1 and 4 in the self-reported WHO Composite International Diagnostic Interview questionnaire (11%) prefer WeChat subscription-based online help (38.5%) and online consultation (30.8%). However, the barriers, facilitators, providers’ and patients’ behaviours, interactions among health system building blocks and the policies that affect women’s help-seeking behaviours and service provision for PPD among migrant women in Shanghai (or elsewhere in China) remain unexplored. Scant evidence due to a lack of clinical diagnosis of PPD and reluctance among women to access care hinders knowledge needed by professionals and policy-makers to build mental healthcare capacity to treat PPD. The objective of this scoping review is to gather information from multiple perspectives, such as the migrant women with PPD and PND, their caregivers, health service providers and communities, to understand the help-seeking behaviour of migrant women with PPD or PND in China.
Methods and analysis
This scoping review adopts the framework suggested by the Joanna Briggs Institute Manual for Evidence Synthesis,12 with the conceptual framework initially proposed by Arksey and O’Malley,13 revised by Levac et al 14 and enhanced by Peters et al.15 This review will include the following six steps proposed by Peters et al,12 with modifications that align with the purpose of our study. This study’s planned start and end dates are June 2024 and May 2025, respectively.
Step 1: formulate research questions
The broad question that directs this review is: What are the relevant factors and their causal relationships that influence the help-seeking behaviour of migrant women with postpartum or perinatal depression in China?
Step 2: identify relevant studies
The inclusion and exclusion criteria follow the population-concept-context framework (table 1).
Population-concept-context framework (inclusion and exclusion criteria) for study selection
Search strategy and source of evidence selection
A comprehensive search strategy was developed by a bilingual research librarian to retrieve published and unpublished studies in English and Chinese. We will employ a two-step search strategy. Initial searches in PubMed (English literature) and CNKI, a Chinese academic journal database, were performed to identify relevant articles. Subsequently, we will manually search the references in selected papers to identify additional pertinent papers (‘snowballing strategy’) after reviewing all literature from the first literature search. The keywords that describe relevant articles in the initial search were listed and used to develop a full PubMed search below. The search strategy was subsequently customised and modified, consisting of all keywords and index terms using Boolean operators for Embase, Web of Science, CINAHL and CNKI (Chinese National Knowledge Infrastructure). Table 2 shows the number of papers retrieved from multiple databases and to be screened. We will snowball the literature backward and forward. Backward snowballing refers to searching the reference lists of selected papers. Then, we will discern literature that cites the selected papers (forward snowballing). The reviewers will contact the authors of selected papers for further information when necessary.
Databases and number of potential English papers (1 January 2000–18 August 2023)
PubMed query
(experience*[tiab] OR ((help*[tiab] OR support*[tiab] OR communit*[tw] OR social[tiab] OR treat*[tiab] OR therap*[tw]) AND (seek*[tiab] OR asked[tiab] OR access*[tw] OR refus*[tw])) OR “refusal to treat”[mesh] OR “treatment refusal”[mesh] OR “grounded theor*“[tw] OR “Patient Acceptance of Health Care”[Mesh] OR “Health Services Accessibility”[MAJR] OR “Adaptation, Psychological”[MeSH] OR “Interview, Psychological”[mesh] OR “help seeking behavior”[mesh] OR phenomeno*[tw] OR qualitative Research[mesh] OR qualitative[tw] OR interview*[tw] OR ethno*[tw]) AND (“Depression, Postpartum”[Mesh] OR “postpartum depression”[tiab:~3] OR “post partum depression”[tiab:~3] OR “postnatal depressi*” OR “post natal depressi*” OR “perinatal depression”[tiab:~3] OR “perinatal depressive”[tiab:~3] OR “antenatal depression”[tiab:~3] OR “antenatal depressive”[tiab:~3] OR “antepartum depression”[tiab:~3] OR “antepartum depressive”[tiab:~3]) AND (“China”[tw] OR China[mesh] OR Shanghai OR (China[AD] AND (China[tw] OR China[mesh] OR Chinese[tw] OR Shanghai))) NOT (“convergent validity” OR protocol[ti] OR validation[ti]) AND (english[Language] OR chinese[Language])
Step 3: select eligible studies
Both English and Chinese studies identified with the above search strategies that satisfied the inclusion criteria (table 1) will be imported to Covidence, a literature review software (http://covidence.org) for title and abstract screening. The reference lists of all included articles will be searched to identify additional studies.
The review team comprises nine people with diverse backgrounds, including system modelling, human biology, nursing, public health, and maternal and child health (table 3). Reviewer 1 will screen the titles and abstracts of the English references from the initial search. Subsequently, reviewers 1–3 will review the full text of the selected English papers to extract variables. Reviewers 1 and 4 will screen the titles and abstracts of the Chinese references from the initial search, followed by full-text review by reviewers 1 and 5–8. We will snowball the reference lists of the selected English and Chinese papers. Because this review aims to formulate a causal map and simulation model, snowballing will facilitate the search for papers that provide theoretical and macro perspectives. Thus, reviewer 1 will manually search the reference lists after completing the first data extraction stage. The differences between reviewers’ decisions will be discussed with reviewer 10.
Review team
Step 4: extract and chart data
After the first full-text review stage in step 3, reviewers 1–3 will review the English studies once more and extract data independently. Reviewers 1, 4 and 5–8 will review the full text of the Chinese literature selected in step 3 again and will extract data independently. The extracted data will be recorded in a customised form developed with Microsoft Word (online supplemental appendix 1). The form captures basic information about each paper, such as the title, authors, year, journal, keywords, abstract, study population, variables, categories of variables, relationships with help-seeking behaviour and reasons for exclusion. These data will be imported to a Microsoft Access Database (online supplemental appendix 2) specifically built for this study. We plan to share the database alongside the future manuscript for use by other researchers.
Supplemental material
Supplemental material
The data presentation of our study differs from the framework proposed by Peters et al.12 We will present the variables extracted from the literature in a causal map. The causal map will display factors influencing the ‘probability of seeking help’ among migrant women. We also infer the positive or negative relationships between factors and dependent variables from the literature. A relationship is considered positive if an increase in a factor leads to an increase in the probability of seeking help for PPD or PND. If the increase in the factor leads to a decrease in the dependent variable, the relationship is negative. An example of the causal map is presented in online supplemental appendix 3.
Supplemental material
Step 5: build a simulation model to identify knowledge gaps
This step will also deviate from the framework proposed by Peters et al. We will synthesise the variables and relationships from the causal map to build a system dynamics (SDs) simulation model. SD is a modelling and simulation approach that allows the integration of variables from multiple sectors and levels. These variables and the relationships among them form a system within which various stakeholders, including the providers, community members and migrant women, interact. These bidirectional or multidirectional interactions give rise to the complexities of women’s decisions to seek help. An SD model consists of a set of differential and algebraic equations that specify the relationships between variables.16 The definitions of variables and relationships in the SD model are logical, clear and precise. When we encounter ambiguity, we make assumptions in the model. Later in the process, we invite experts’ inputs to fill the knowledge gap and validate the model. An operational SD model can be used to project the future trends of help-seeking behaviours among migrant women. The model may also be used to experiment and design strategies to promote help-seeking. An example of a simplified SD model can be found in online supplemental appendix 4.
Supplemental material
Step 6: collate, summarise and report the results
We will present the review results in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart and PRISMA framework for Scoping Reviews checklist. Presentation of extracted data will include the following headings: author, year of publication, study type, study population, primary objective(s), factors and the relationships with the probability of seeking help (dependent variables) and the polarity of the relationships (positive or negative).
The findings of this review will also include a full summary of the evidence, an overview of concepts and types of evidence available, limitations and study conclusions. Thematic and narrative approaches will also be incorporated for the analysis of quantitative and qualitative studies. The review team will identify gaps in the literature and highlight implications for future research.
Step 7: consultation
We aim to conduct group model building (GMB) workshops in Shanghai, China, by the end of 2025. Migrant women with and without PPD and providers will be invited to critique and comment on the results of this review. Obtaining comments from the system’s actors allows us to validate the findings, receive feedback and get additional insights into the findings and potential interventions to increase help-seeking.
Patient and public involvement
No patients are involved in searching and reviewing the literature. International Peach Maternal Child Hospital (IPMCH) will screen the postpartum women returning for check-up after 42 days postdelivery using the Edinburgh Postnatal Depression Scale. 15 women who meet the criteria for PPD and 5 without PPD will be invited to participate in the GMB workshops in Shanghai. Additionally, eight healthcare workers will enrol in the GMB workshops. These patient and non-patient participants will review our findings and share their perspectives to improve our understanding of the system that influences migrant women’s decisions to seek help for PPD.
Ethics and dissemination
The literature review component of our study does not require ethical approval because the information and data collected will be obtained from publicly available sources and will not involve human subjects. However, we have obtained the IRB approval (GKLW-A-2023-020-01) from our collaborating research partner, IPMCH to screen patients and conduct GMB workshops in the IPMCH. Stanford University received IRB approval under protocol number 67419 to conduct GMB workshops in IPMCH. The full review will be presented at a relevant conference and submitted to a peer-reviewed scientific journal for publication.
Discussion
The objective of this scoping review is to gain insights into the decision-making process of migrant women with PPD or PND to understand the factors that influence their intention to seek help. Synthesising and mapping the variables from the literature may potentially define the boundary of the system that affects migrant women’s help-seeking behaviour. We will also distill the causal pathway of the women’s decision-making processes to design recommendations for stakeholders to promote help-seeking among this subpopulation.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
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Footnotes
X @gdarmsta
Contributors YJL and GLD conceptualised and designed the study. YJL drafted the initial manuscript. GLD obtained funding, and together with YJL, AT, RK, CW, YC and HL reviewed the manuscript. All authors read and approved the final version of the manuscript.
Funding This study is funded by a Seed Grant (SPO-270628) from the Stanford Center for Innovation in Global Health.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.