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Table 3 Recommendations for implementation of perinatal mental health screening in women of refugee background

From: Factors affecting implementation of perinatal mental health screening in women of refugee background

Behavioural determinant

Behavioural change techniquesa

Examples to support health professionals (HPs)

Examples to support women


Information regarding behaviour, outcome

Provide information for HPs regarding rationale for screening; clinical guidelines and evidence-practice gap; appropriate EPDS administration, scoring and actions; and PTSD screening

Provide information (e.g. culturally appropriate group sessions, translated printed materials) at earlier appointments about perinatal mental illness, routine screening, and MHS


Goal/target specified: behaviour or outcome

Increasing skills: problem solving, decision making, goal setting

Rehearsal of relevant skills

Organisation to set target of routine screening; individual HPs to set targets for skills attainment

Provide training for HPs regarding identification and prioritisation of refugee health needs; appropriate use, scoring and actions to EPDS; and cultural competence (including approach to mental health and managing family members)

Provide opportunities to practise skills


Social/professional role and identity

Social processes of encouragement, pressure, support

Involve refugee health nurse, bicultural worker, perinatal mental health nurse and senior staff to support referral

Balance inter-disciplinary approach with clear delineation of roles

Ensure clear communication between antenatal and postnatal services and identify women already receiving mental health care


Beliefs about capabilities

Increasing skills: problem solving, decision making, goal setting

Social processes of encouragement, pressure, support

Provide training for HPs (i.e. sensitive administration of trauma screening tool, management of women at risk of suicide or self-harm)

Engage staff by communicating the rationale for screening and benefits for women


Beliefs about consequences

Persuasive communication

Information regarding behaviour, outcome

Provide information for mental HPs regarding the provision of refugee appropriate mental health care (e.g. practical advice about managing symptoms)

HPs to normalise screening; provide culturally appropriate mental health information at earlier appointments; manage expectations regarding referrals; and communicate professionalism of interpreters and usefulness of follow-up mental health care

Environmental context and resources

Environmental changes (e.g. objects to facilitate behaviour)

Select the most appropriate time(s) to screen with input from HPs administering the EPDS (e.g. second antenatal visit and again in third trimester). Allow HPs discretion to screen earlier or later or to forgo screening if guided by MHS already involved in care

Management to work with HPs to allow appropriate appointment length and flexibility to manage disclosures and make immediate referrals

Map MHS in the area and confirm capacity and sustainability of services prior to implementation

Incorporate rigorously translated screening tools into routine maternity care

Provide skilled, onsite, female interpreters for common refugee languages and standardised instructions for appropriate EPDS translation

Screen in a private setting

Provide advice around transport

Social influences

Social processes of encouragement, pressure, support

Ensure a ‘go-to’ or support person for HPs (e.g. refugee health nurse, senior staff, psychiatry liaison), regular team meetings and debrief opportunities

Ensure continuity of care

Include referral pathways to social work, women’s groups and language services

HPs to explain to family members what screening and potential follow-up involves; however screening to be undertaken privately

Behavioural regulationb

Planning, implementation

Prompts, triggers, cues

Establish robust referral pathways, feedback mechanisms to confirm receipt of referrals, communication channels between services, and clear documentation at all stages of pathways

Clearly communicate pathways (e.g. flowcharts) and contact numbers for to HPs

Establish various pathways for different needs while minimising referral points

Use on-site services where possible (e.g. social worker)

  1. HP health professional, EPDS Edinburgh Postnatal Depression Scale, MHS mental health services
  2. aBehaviour change techniques recommended by Michie et al.’s matrix [34] and deemed to be relevant to this setting
  3. bBehaviour change techniques listed for Action planning in Michie et al.’s matrix [34] have been used here interchangeably with Behavioural regulation given the likeness between the domains