State Perinatal Mental Health Initiative Report 2003-2007

State Perinatal Reference Group & WA Perinatal Mental Health Unit

Prepared by the WA Perinatal Mental Health Unit

2007

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Citation: The citation below should be used when referencing this work: State Perinatal Reference Group and the Western Australian Perinatal Mental Health Unit (2007). State Perinatal Mental Health Initiative: Report 2003-2007. Perth: Department of Health WA. © Department of Health, State of Western Australia (2007). Copyright to this material produced by the Western Australian Department of Health belongs to the State of Western Australia, under the provisions of the Copyright Act 1968 (C’wth Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the WA Perinatal Mental Health Unit and the Department of Psychological Medicine, King Edward Memorial Hospital for Women, Western Australian Department of Health. The Department of Health is under no obligation to grant this permission. Please acknowledge the WA Department of Health when reproducing or quoting material from this source. Important Disclaimer: All information and content in this Material is provided in good faith by the WA Department of Health, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents, do not accept legal liability or responsibility for the Material, or any consequences arising from its use.

For further information contact: WA Perinatal Mental Health Unit 15 Loretto Street, Subiaco, WA. 6008 Phone: (08) 9340 1795 Fax: (08) 9340 1782 Email: wapmhu@health.wa.gov.au

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State Perinatal Mental Health Initiative

Report 2003 - 2007

State Perinatal Reference Group

&

Western Australian Perinatal Mental Health Unit

iii

CONTENTS

PERINATAL MENTAL HEALTH.......................................................................1 PERINATAL MENTAL HEALTH ACROSS CULTURES ..................................2

Perinatal mental health in Aboriginal communities ................................2 Perinatal mental health in culturally and linguistically diverse (CALD) communities ..........................................................................................2

PERINATAL MENTAL HEALTH IN WESTERN AUSTRALIA (WA) .................3 The Childbirth Stress and Depression Project (1995-98) ......................3

STATE PERINATAL MENTAL HEALTH INITIATIVE .......................................5 State Perinatal Reference Group...........................................................5 Organisational Structure ........................................................................5 Strategic Philosophy..............................................................................6

A POPULATION HEALTH APPROACH...........................................................8 Health Promotion in WA ........................................................................8

COORDINATION .............................................................................................9 State-wide Mapping – WA .....................................................................9 Website................................................................................................11 Representation and Consultation ........................................................12

RESEARCH ...................................................................................................13 CALD Research...................................................................................15

Service Model Development ..........................................................................18 Indigenous Service Model Development – Carnarvon Project.............18 Practical Support Service Model Development....................................21 CALD Service Model Development .....................................................24 Hospital at Home (H@H) Service Model Development .......................27

EDUCATION AND TRAINING........................................................................30 Edinburgh Postnatal Depression Scale (EPDS) Training ....................33 Aboriginal Health Worker (AHW) Training ...........................................38 Inaugural Perinatal Mental Health Symposium – Beyond the Boundaries ..........................................................................................40

RESOURCES.................................................................................................43 Resources for Aboriginal Communities................................................43 Resources for CALD Communities......................................................44 General Resources..............................................................................45

FINAL RECOMMENDATIONS.......................................................................46 Coordination ........................................................................................46 Research .............................................................................................47 Service Expansion Initiatives ...............................................................47 Education and Training........................................................................47

REFERENCES...............................................................................................49

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PERINATAL MENTAL HEALTH

It is well established that the year after giving birth is one of heightened vulnerability for women with regard to social and emotional adjustment and mental illness, especially mood disorders (Evans et al, 2001). One in five Australian mothers of full term infants experience a perinatal mental health disorder within the first year of delivery (Priest et al, 2005). However, many are not diagnosed or treated (Buist et al, 2005). Antenatal anxiety and depression occur frequently and often together and may lead to postnatal depression and anxiety (O’Connor et al, 2002; Heron et al, 2004). A small number of women will develop an acute psychotic illness (one in a thousand), which significantly increases their risk of harm to themselves or others (Chaudron & Pies, 2003).

Whilst recent developments have seen an expanded focus and interest in the broader field of perinatal mental health, historically, the study of childbirth and mental health has been largely limited to postnatal depression (PND) (Austin, 2004).

Women who are particularly at risk for perinatal mental health disorders are those with:

• A history of mental illness (particularly affective disorder);

• Limited emotional and social support;

• Stressful life events or losses;

• Change in role and identity;

• An unwanted or unplanned pregnancy; and

• Those women from a lower socioeconomic status

(O’Hara & Swain, 1996; Beck, 2001; Abou Saleh & Ghubash, 1997).

A recent UK study identifies perinatal mental health as the leading cause of maternal morbidity and suicide as the leading cause of maternal death (Oates, 2003).

An increasing body of literature now supports that maternal depression and other psychological disorders during the perinatal period negatively impacts on the infant, partner and other family members as well as the mother (Herring & Kaslow, 2002; Murray et al, 1999; Glover, 1997; Lovestone & Kumar, 1993). Disturbed maternal/infant attachment can result in a significant influence on the cognitive, emotional, social and behavioural development of the infant both short term and long term (Murray et al, 1999; Murray et al, 1996).

Management of PND consists primarily of psychosocial support and both individual and group psychological interventions (Milgrom et al, 1999; Pope et al, 1999). Whilst outcomes of these are varied, there is some evidence to support certainly the short term benefits of such intervention (Boath et al, 2005). There is some ambivalence around whether or not the presence of

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rituals around pregnancy, birth and early motherhood are protective or not (Horowitz et al, 2001; Matthey et al, 2002), however it is largely agreed that the strongest link between culture and positive birth outcomes is social support (Misri et al, 2000; Logsdon et al, 2000). For some women experiencing more severe perinatal mental health disorders, medication or hospitalisation may be required.

PERINATAL MENTAL HEALTH ACROSS CULTURES

Perinatal mental health in Aboriginal communities

There are extensive mental health problems such as high levels of depression anxiety, self harm and suicide, within Aboriginal communities throughout Australia including WA. Trauma and grief are linked strongly to the past history of loss and reinforced by current adversities such as significantly high levels of poverty, unemployment and physical and emotional health problems. This is further complicated by issues such as family violence, substance misuse and issues of inequality in the provision of and access to appropriate health and social services (Swan & Raphael, 1995; Parker & Ben-Tovim, 2002). In WA, Indigenous infant mortality rates were three times as high as rates for the non-Indigenous population (Trewin, 2007) and the proportion of mothers aged under 20 years was 23% in the Indigenous population, compared with only 5% of non-Indigenous mothers (Trewin & Madden, 2005).

Within these social complexities Aboriginal women play a central role in families, and as women and mothers face significant risk factors associated with emotional and social difficulties in adjustment during pregnancy and after they have given birth.

Indigenous people are less likely to engage with mental health services, due in large part to the potential for culturally inappropriate services that fail to embrace Indigenous concepts of health and wellbeing (Dudgeon, 2000).

There is a recognised need to raise awareness about perinatal mental health issues for Indigenous women, their families and health workers (Druett, 1994) and there is significant literature supporting the need for culturally appropriate mental health services for Indigenous communities.

Perinatal mental health in culturally and linguistically diverse (CALD) communities

Whilst the majority of research exploring cross cultural aspects of perinatal mental health disorders (predominantly PND) have been undertaken in Western countries (Oates et al, 2004; Kumar, 1994), those studies that have explored the prevalence of PND in non-Western cultures have largely reflected similar findings (Abou Saleh & Ghubash, 1997; Cox 1983; Lee et al, 2001; Niwatiwa et al, 1998; Danaci et al, 2002).

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Australia is a multicultural society, with emerging communities that include refugee and migrant populations. Factors relating to language, religion, culture, tradition and the refugee experience itself place these groups at high risk of mental illness, particularly depression (Chung, 2001; Minas et al, 1996). There has been limited research guiding culturally sensitive practice and the development of clinical services for CALD populations. Much of the research to date has collectively grouped individual communities within the studies. This aggregation of diverse individuals fails to reveal specific group differences and provides inaccurate description of specific cultural needs to service providers (Commonwealth Department of Health and Family Services, 1998; Thompson, 1997).

PERINATAL MENTAL HEALTH IN WESTERN AUSTRALIA (WA)

In 2005 there were 26, 538 births in WA (Gee et al, 2006). Given average statistics this indicates that around 5,300 women experienced a perinatal mental health disorder. State and service documents and anecdotal reporting identify a range of services in WA providing intervention and support for women and their families experiencing perinatal mental health problems. However high levels of fragmentation and limited service coordination all impact on service delivery (Thomas, 2006). Whilst there is acknowledgement both of the importance of the perinatal period and of the need for cross sector collaboration, multiple conflicting demands on services and clinicians mean that both are frequently operating with limited information flow between them (Thomas, 2006).

This potentially contributes to issues pertaining to service duplication and poor access and screening of high risk women (especially those from CALD and Indigenous communities) (Thomas, 2006).

The Childbirth Stress and Depression Project (1995-98)

The Childbirth Stress and Depression Project (1995-98) based at King Edward Memorial Hospital (KEMH) was funded through the National Mental Health Incentive and Reform Program. The project was deemed successful in its aim to “…assess, recommend and undertake a state-wide role in improving the delivery of services for Childbirth Mental Health in Western Australia (WA)”.

Following an initial series of consultations with health professionals and consumers across metropolitan and rural WA 17 recommendations were presented in the “Report on Childbirth Stress & Depression (Vol. 1): Developing State-wide Services” (Pope, 1995). Ten of these recommendations received funding.

The 10 funded/implemented recommendations included: the establishment of a postnatal depression team based at KEMH, facilitation of inter-disciplinary communication via local reference groups, community education and

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professional training programs, extension of antenatal/parent education, development of antenatal and postnatal screening protocols and accompanying guidelines, development of antenatal and postnatal information packages for all childbearing women (nb. additional funds required for ATSI and CALD populations), improvement of early discharge planning (including guidelines for the provision of home-help/support), support for the development of self-help groups, and establishing a 24-hour freecall telephone number for crisis/emergency care and parenting advice/support.

The implementation process, results and future recommendations were presented in a second report entitled “Report on Childbirth Stress & Depression (Vol. 2): Implementing State-wide Initiatives” (Watts & Pope, 1998). Future recommendations included: the establishment of a centre of excellence comprised of clinicians and researchers with expertise in the field, the convening of a Central Reference Group, continuation of work on the Clinical Practice Guidelines (Watts & Pope, 1998), further development of services for women with childbirth-related mental health problems, revision of the antenatal and postnatal assessment protocols (in conjunction with the Clinical Practice Guidelines), implementation and evaluation of the “Home Sweet Home” parent education program, facilitation of at least three health professional training workshops for childbirth related mental health per year, liaisons with universities and relevant professional bodies to ensure all health professional education include childbirth related mental health, continued printing and distribution of information booklets and packs for the community, allocation of ongoing funds to the Postnatal Depression Support Association, ongoing facilitation of community education sessions, and funding of programs for Aboriginal and non-English speaking backgrounds.

Although these future recommendations were developed almost 10 years ago many are still pertinent today. In fact 7 of the 12 recommendations made by Watts and Pope (1998) have been acted upon by the State Perinatal Mental Health Unit over the past four years.

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STATE PERINATAL MENTAL HEALTH INITIATIVE

State Perinatal Reference Group

Funding for perinatal mental health in WA was provided by the State Government as an election commitment in response to a clearly identified need to address the needs of women and their families experiencing perinatal mental health issues in WA. The State Perinatal Reference Group (SPRG) was created to guide the planning, development, implementation and evaluation of key initiatives undertaken within the strategy.

The group brings together a cohort of professionals from a range of mental health disciplines and service providers. The SPRG has representation from a number of organizations who have demonstrated leadership over an impressive history of service provision in the state including:

• Women’s Health Service;

• King Edward Memorial Hospital Department of Psychological Medicine;

• Ngala;

• Child and Community Health; and

• Postnatal Depression Support Association.

In addition to the organizational experience available to the members, there is a depth of specialized community and professional expert knowledge in the group. Practitioners with specializations in the fields of infant and adult mental health, transcultural mental health, psychiatry, child and community health and population health bring a wealth of clinical, medical obstetric and service delivery knowledge to the SPRG (Thomas, 2006).

In order to ensure the needs of priority and minority groups are addressed and that planning, delivery and evaluation of initiatives are directed by all primary stakeholders for perinatal mental health the SPRG has representation from government and non-government organizations, rural, CALD populations, Indigenous services, and women’s health services.

Organisational Structure

Initially the organisational structure of the State Initiative consisted solely of one paid staff member (State Coordinator) with an administrative position created in 2005. The small organisation structure of 2 paid staff minimized administrative and bureaucratic expense associated with the initiative and enabled funding to be directed to primary objectives. However, it also significantly slowed the pace at which change could be enacted and limited the number of initiatives that could be undertaken. It was decided by SPRG that an expansion of the organisational structure was required in order to meet the growing demands being placed upon the service, particularly in relation to education, training and research.

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The WA Perinatal Mental Health Unit (WAPMHU) forms the operational centre for the SPRG and currently comprises of the following staff:

• State Coordinator;

• Education and Training Officer;

• Research Officer;

• Project Officer; and

• Administrative Assistant

Strategic Philosophy

Mission

To promote optimum mental health and wellbeing for all families in WA during the perinatal period.

Vision

Effective promotion and coordination of activity ensuring women and their families are adequately prepared, resourced and supported to enjoy optimal mental health during the perinatal period (Thomas, 2006) based on the following:

• That all families in the state will have equal access to support systems that are empowering and based on local needs; and

• That a state-wide perinatal mental health service exists coordinated by a multidisciplinary group including representation by:

� Indigenous services;

� CALD services;

� Consumers;

� Community representatives; and

� Key service providers.

Operating Principles

Initiatives undertaken by the SPRG are based upon the following principles:

• Effective health provision underpinned by evidence based research and best practice.

• Recognition of the perinatal period as a critical life stage affecting health throughout life span across the population.

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• Long term health planning must consider trans-generational health impacts to be effective (cost-wise and in impact).

• A strategy built on respect for the value of community-based participatory approaches.

• Respect for human rights, cultural and religious diversity.

• International human rights recognition of increased needs of mother, child and family during the perinatal period.

• Valuing cohesiveness, coordination and collaboration between stakeholders.

In responding to the needs of women and their families in WA, four principal areas have been identified within the strategy:

• Coordination;

• Service Expansion and Development;

• Education and Training; and

• Research.

Progress in each of these areas is directed by a subcommittee, with feedback from the SPRG and implemented by the WAPMHU. Coordination of initiatives is undertaken by the State Coordinator.

Coordination

Aim: To provide improved access to services for women and their families and enhance partnerships between services, by improved service coordination and inter-service collaboration. This will be achieved through the systematic development, implementation and evaluation of policies, procedures and referral pathways to guide clinical practice and promote partnerships, and the development of a central resource website/multimedia facility.

Service Expansion

Aim: To extend the range of services in both specialist clinical and community areas of delivery, prioritising on capacity building to ensure useful, practical and sustainable outcomes.

Education and Training

Aim: Workforce training and education will provide staff with improved skills to assess and treat women, facilitating promotion, prevention and early intervention measures that enhance the emotional and psychological well being of mother, infant and partner.

Research

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Aim: Community consultation and rigorous qualitative and quantitative research informs and guides all aspects of service coordination, capacity building and education and training. Particular emphasis is placed on the provision of culturally sensitive and relevant services and interventions that reflect the needs of CALD, Aboriginal and Torres Strait Islander (ATSI) and rural and remote area communities.

A POPULATION HEALTH APPROACH

Population health has been identified by the World Health Organisation (WHO) as the most advanced and cost effective model for health provision (Freeman & Miller, 2001; Murray et al, 2002). Internationally, the WHO endorses effective health promotion and illness prevention through the implementation of strategies that promote a sense of attachment to family and community, a sense of cultural identity and ethnic pride and prioritise access to social support networks and supportive relationships.

Health Promotion in WA

In Australia, the Mental Health Promotion and Illness Prevention Policy (2002) prioritises the identification of appropriate partnerships, the clarification and strengthening of communication, and supports the development of evaluation methods to review the effectiveness of interventions. It recognises the early years of life as critical in providing intervention that will promote the development and future wellbeing of children. As such, cost effective initiatives such as Early Years, Healthy Start and the LIFE framework have been initiated by the Australian Federal and State Governments (Thomas, 2006).

Likewise, the National Mental Health Plan (2003-2008) states that:

“Interventions to promote mental health and reduce the impact of mental health problems and mental health illness must be developed relevant to the needs of population groups”

and that

“new models of service delivery and improved interventions that are more responsive to diversity of the need should also be developed and evaluated for their effectiveness and cost effectiveness.”

With respect to perinatal mental health the Beyondblue Perinatal Mental Health Consortium (2007) based their National Action Plan firmly within a health promotion and early intervention framework. Key areas identified include training and workforce development; universal, routine psychosocial assessment and pathways to care.

Rationale

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Prevention of depression and other perinatal mental health disorders may be achieved through the promotion of certain healthy behaviours that act to protect individuals from experiencing risk factors for depression (Park, 2003). Protective factors that act to reduce the risk for postnatal depression include a parent’s possession of confidence in their abilities as a parent, good social support systems, and a subjective sense of wellbeing and life satisfaction (Park, 2003). Focussing on developing protective factors for the prevention of depression is also in alignment with population health approach of conceptualising mental health in positive, rather than negative terms

The existing evidence base suggests that providing accessible services to women during the perinatal period protects children during the critical first three years of development by ensuring their caregivers receive appropriate care and assistance. The research supports the population health position in advocating a focus on health and wellbeing throughout life and recognizing the perinatal period as a critical life period for mental health and reducing disparities between sub-populations (Health Canada, 1998; McCain & Mustard, 2002).

COORDINATION

Since the strategy commenced, consultation with local services and communities has been undertaken to inform and guide key considerations. In addition, informal cross-cultural service comparisons have been implemented to observe and compare services in other parts of Australia and overseas. This has enabled a comprehensive understanding of current and future directions in clinical management and service delivery, and established a solid foundation on which to build and coordinate current and future service development, educational and training initiatives.

State-wide Mapping – WA

In 2004, a state wide mapping of perinatal mental health services and consultation with a range of community clinicians were undertaken. The areas of focus included:

• Assessment and treatment of women with perinatal mental health issues; and

• Strengthening community based networks and support for women and families (i.e., culturally sensitive local frameworks).

Key recommendations made by the document which have guided the development of initiatives undertaken by SPRG and WAPMHU include:

Partnerships

• Develop collaborative partnerships with a broad range of stakeholders

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• Actively seek out partnerships with organisations across the spectrum to facilitate a collaborative/community development approach to creating and improving services

Data Collection

• Negotiate with Child and Community Health Division regarding frameworks for data collection pertinent to perinatal mental health

Service Provision

• Work with other agencies to develop outreach services, outreach midwifery and support/treatment programs for families

• Develop culturally appropriate models of care for ATSI and CALD communities

• Develop models for assessment, treatment and referral (for metro and rural/remote)

• Work with local services to improve coordination of service delivery

Training

• Develop comprehensive training program for wide spectrum of health professionals

• Provide multifaceted training for GPs on assessment and management

Information Dissemination

• Investigate best ways to deliver information for women/families from varying cultural backgrounds and levels of literacy

• Develop a website clearinghouse for material regarding perinatal mental health

ATSI Health Services

• Incorporate best practice principles including using preferred definition of health and working with communities to establish priorities/directions

• Promote programs reducing family violence, child abuse, substance abuse and infant mortality

• Support initiatives promoting cultural self-determination

Support Groups

• Examine the possibility of a support network for rural/remote areas that uses web-based or telehealth structure

• Facilitate expansion of PNDSA (i.e., into major regional centres and outlying metro areas)

Further Research

• Incidence and management of perinatal mental health issues in rural/remote Australia

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• The relationship between physical conditions and perinatal mental health (e.g., anaemia, gestational diabetes)

• The role of local government, Child Health Nurses and GPs in perinatal mental health

• All aspects of ATSI and CALD perinatal mental health

Website

In 1996 Pope and Watts recommended a central perinatal mental health information resource would benefit families in WA. More recently the state-wide perinatal mental health service mapping (Gallegos, 2004) highlighted the need for information that was easily accessible for women and their families in WA and suggested the development of a consumer website.

A part-time website manager was employed to develop the content for the website in consultation with consumers and clinicians. The first stage of a perinatal web site/multimedia facility has been completed, combining audio visual information that addresses a range of topics for mums, dads and family/friends and provides a comprehensive central resource for the community.

Resources available include:

• A comprehensive database of perinatal mental health services state-wide;

• Consumer information for mums, dads and families;

• Different perinatal mental health topics; and

• Video streamed information.

Due to restrictions in site development and resources, there have been challenges associated with the development of the website. It is hoped that the second stage of the consumer website will incorporate interactive components that will enable communication and online support for women and their families who may have difficulties accessing services in person. However, progress in this area will be guided by ethical and medicolegal considerations associated with online interactive sites in the context of mental health service provision. Understandably there are concerns with regards to risk management and implications for clinical practice. As such development will depend on government health legislative recommendations.

A service provider website is planned and will include service database; management and clinical guidelines for health promotion, screening, early intervention and management for perinatal mental health issues; and information on CALD and Indigenous perspectives on management of perinatal mental health. This information will assist health professionals in delivering culturally sensitive and appropriate care for women and their

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families experiencing perinatal mental health issues. The site will also include an online education and training resource and support, and translated versions of the Edinburgh Postnatal Depression Scale (EPDS) with guidelines for use to ensure access for clinicians state-wide.

Representation and Consultation

During the four years of the State Perinatal Initiative, a significant component of the service has involved contribution to key documents and forums. This has involved participation in a number of local, state and national committees including:

• beyondblue perinatal mental health – Pathways to Care;

• Swan Adult Mental Health Centre;

• Child and Adolescent Mental Health Services;

• Perinatal Mental Health Professional Association; and

• Regional and local perinatal mental health reference groups.

Input has been provided to a range of local, state and national documents including:

• beyondblue: the national depression initiative, Perinatal Mental Health Consortium, National Action Plan;

• WA maternity services;

• Clinical Guidelines for Case Management of Female Mental Health Clients in relation to Reproductive and Pregnancy Needs;

• Perinatal Depressive and Anxiety Disorders – State wide Obstetric Unit, Women and Newborn Health Service; and

• Early Childhood and Parenting Support Service Scoping Study.

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RESEARCH

Background

Since the commencement of the initiative, rigorous qualitative and quantitative research has informed and guided all aspects of service coordination, capacity building and education and training. This has enabled identification of the specific needs of the community, and gaps in service provision, to be translated into improved and sustainable services/opportunities for women and their families in WA. Particular emphasis has been placed on research into the provision of culturally sensitive and relevant services, and interventions that reflect the needs of CALD, ATSI and rural and remote area communities.

Given the rapid development of the research component of the State Perinatal Mental Health Initiative, existing infrastructure was found to be insufficient to meet the expanding research demands. Subsequently, various options have been explored over the past four years to ensure a cost effective, efficient and rigorous approach to perinatal mental heath research in WA is undertaken.

In September 2005 a partnership was established between the SPRG and WA Combined Universities’ Centre for Research for Women (CRW) to jointly manage the first set of perinatal research projects funded by State Perinatal Mental Health. It was envisaged that this would facilitate partnerships with the universities in WA and provide opportunity for collaborative approaches to research between tertiary institutions and service providers.

Four research projects were undertaken under these auspices, with some providing the basis for future service model development initiatives.

A rigorous strategic planning process was undertaken in collaboration with Dr K. Thomas from Curtin University. This process included a planning day, with members of the SPRG directed through a course of activities and discussions by Dr Thomas, with the objective of developing a critical strategic plan for perinatal mental health in WA. As a result of this process a 51-page document was prepared for SPRG members by Dr Thomas and has been used as a reference point for subsequent SPRG discussion and decision making.

Exploring the Postnatal Experiences of Iraqi Arabic Speaking Migrant Women and the Provision of a Support Group Intervention was completed by researchers at Curtin University in 2007. The results of this project are now informing the development of an on-going support group for Iraqi women funded by the WAPMHU.

Managing Work and Motherhood: Implications for Perinatal Mental Health was a research project completed by Dr D. Gallegos from the Centre for Social and Community Research, Murdoch University in 2007. A number of thought provoking recommendations were made by the author. Recommendations regarding the use of the internet for information provision and support for

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working mothers were particularly noteworthy and may be incorporated in future development of the WAPMHU websites.

The fourth, and final, research project grant was awarded to Dr Lynn Priddis from Curtin University, to pilot a video based parenting program, called Tuned in Parenting, at Ngala Family Resource Centre. The positive results of this pilot project paved the way for further refinement and evaluation of the program and a Telstra grant has subsequently been awarded to Dr Priddis and Ngala to continue this work.

Challenges

Although the partnership between the SPRG and CRW was initially contracted for a period of 10 months from September 2005 to July 2006 it was envisaged that the collaboration would continue. With three of the four research projects incomplete, and thus requiring continued administrative support, contract renegotiations commenced in February 2006 and continued throughout March, April and May.

The elongated negotiation process was in large part due to SPRG concerns regarding the previous lack of service delivery by the CRW. That is, there was agreement by the SPRG that despite a substantial amount of money having been paid to the CRW there was still a great deal of work and responsibility regarding research matters being carried by the WAPMHU State Coordinator. These concerns were raised with CRW during negotiations and safeguards discussed.

During the renegotiation process the SPRG had also been discussing the option of appointing a Research Officer, to oversee the conclusion of the existing research projects and meet the evolving research requirements of the service expansion initiatives being developed by the SPRG.

The decision was eventually made by the SPRG not to enter another contract with CRW. In the end this decision was influenced more by the changing research requirements of the SPRG rather than previous service provision issues.

Current Status

The initial allocation of funds to the four areas of: service expansion, education and training, co-ordination, and research, has since been reallocated by the SPRG according to the emerging requirements of the WAPMHU service expansion initiatives. That is, funding previously quarantined and made available for the administration and carrying out of individual research projects (as above) has been committed to research that will instead inform, support and evaluate the current and future service expansion initiatives of the WAPMHU. As such, the services of the CRW were

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no longer required and a part-time Research Officer position was created within the WAPMHU.

It was decided that the role and function of the research subcommittee will inform and prioritise the research activities being conducted as part of the service expansion initiatives and that this will be achieved via close collaboration between the Research Officer, State Coordinator and Research subcommittee.

Each of the WAPMHU service expansion initiatives aims to provide a high quality service to a high priority population, with the intention that the service (if shown to be successful) will continue. In order for the SPRG to make informed decisions about future funding allocation, each initiative needs to be guided by existing research and thorough evaluative processes must be built into each initiative. Results of evaluation processes will thus be used to direct on-going development of the service and/or the termination of that service.

Incorporating research within this framework has enabled a comprehensive understanding of current and future directions in clinical management and service delivery, and established a solid foundation on which to build and coordinate current and future service development, educational and training initiatives.

Should funding become available for additional research in the future, the Research subcommittee will review any incoming research proposals and make recommendations to the SPRG so as to enable them to make fully informed decisions in a timely manner. Priority will be given to research topics in the priority areas (i.e., CALD, Indigenous and rural populations).

CALD Research

A qualitative study was undertaken to explore the social and emotional wellbeing of women from emerging communities in WA.

Rationale

There has been limited research guiding culturally sensitive practice and the development of clinical services for CALD populations. Much of the research to date has collectively grouped individual communities within the studies. This aggregation of diverse individuals fails to reveal specific group differences and provides inaccurate description of specific cultural needs to service providers (Commonwealth Department of Health and Family Services, 1998; Thompson, 1997).

Similarly, when defining the implication for clinical practice amongst different populations, consideration needs to be given to cultural explanations of mental illness. Some societies define mental illness from a spiritual and religious perspective that contrast with Western approaches emphasising psychological

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factors, life experiences and the impact of stress on an individual’s response (Commonwealth Department of Health and Family Services, 1998). Gallegos (2004) highlighted areas of particular concern.

• Community health nurses often use personalised contact, but limited time availability impedes the building of trusting relationships with CALD women who present with several barriers including language, culture, traditions as well as trust issues.

• The perception that mental health issues are taboo in many cultures prevents ease of discussion with the women when raised by health professionals.

• A lack of culturally appropriate perinatal mental health resources for women and their families.

In addition Pope and Watts (1996) and more recently Gallegos (2004) identified a lack of cultural awareness amongst clinicians delivering intervention to women and families during the perinatal period.

Framework

A qualitative study utilising ethnographic research methodology was undertaken (Down et al, 2007). Iraqi, Sudanese and Ethiopian populations were selected to participate in focus groups. The participating women had arrived in Australia in the last ten years and had a child aged three years or younger who was born in Australia. Key questions were developed in consultation with bilingual workers and group discussions addressed issues pertaining to the comparison of experiences during pregnancy and postpartum between country of origin and Australia and recommendations for support and intervention. The discussions were recorded on audiotape, translated, transcribed and key themes extracted. Participants were invited back for a second focus group in order to validate findings and provide feedback.

Outcomes

Key findings supported those found in previous studies, with women finding motherhood extremely challenging in a new country. Many were used to extended community and family networks in their country of origin which was markedly different to the social support available to them in WA. The absence of social support and traditional rituals resulted in increased feelings of isolation and loss and was accompanied by stress associated with issues about changes in traditional/ gender roles and responsibilities in the family.

A number of perceived gaps and barriers to existing pathways to care were highlighted and reflected those found in the literature, including language barriers and limitations in the provision of culturally appropriate information. Specifically there was significant anxiety about caesarean sections. The

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majority spoke little or no English and experienced difficulties navigating the health and support systems available to them. Many wished for informal support networks to provide them with links/ support from other mothers.

Future Recommendations

Based on the existing literature and the information gained from our research with CALD communities in WA, there are some key implications for clinical practice for consideration by service providers.

• Collaboration to ensure culturally sensitive intervention incorporates aspects of Western intervention with the cultural practices mothers value. By merging components of cultural practice with standard clinical practice, the stress experienced by new mothers may be reduced (Posmontier & Horowitz, 2002; Down et al, 2007).

• Education and training strategies to increase cross cultural awareness and considerations for clinicians and service providers (Posmontier & Horowitz, 2002; Thompson, 1997; Down et al, 2007).

• Promote community collaboration to encourage recognition of cultural rituals and traditions, and acknowledge the individuality of women within a cultural context (Rice et al, 1999; Down et al, 2007; Thompson, 1997).

• Provision of support or self help groups to enable shared experiences and development of coping strategies (Chan et al, 2002), and consideration of the provision of drop-in centres for mothers (Thompson, 1997) and outreach service for “harder to reach” women (Chan et al, 2002; Down et al, 2007).

• Ensuring health promotion encompasses realistic expectations of motherhood and differences in health care systems (Posmontier & Horowitz, 2002) and facilitates education related to early recognition and help seeking behaviour (Chan et al, 2002; Down et al, 2007) using culturally appropriate resources (Rice et al, 1999; Down et al, 2007).

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Service Model Development

Commitment to service expansion has been a priority for the SPRG since commencement. However there have been challenges that have arisen in this area. Given that funding was initially for four years only, there were appropriate concerns expressed by the SPRG, service providers and the community about the ethical implications of establishing services short term, with time limited funding. With this in mind, initial service expansion projects were undertaken in a “service capacity building” framework. These provided valuable extension to existing services, with a focus on short term “pilot style” intervention.

In 2006, funding was made recurrent and planning and development was initiated to establish longer term sustainable community based initiatives. Given the extent of identified need for perinatal mental health services in WA and the limited funding available under the auspices of the SPRG, it was decided that a service model development approach be undertaken to service expansion. As such service models have been developed in collaboration with key stakeholders incorporating rigorous evaluation frameworks and with a view to establishing demonstrated models of best practice. At completion of successful evaluation the information gained from these services will be used as a platform for further funding applications to facilitate replication throughout WA.

Indigenous Service Model Development – Carnarvon Project

There is a recognised need to raise awareness about perinatal mental health issues for Indigenous women, their families and health workers (Druett, 1994). There is also significant literature supporting the need for culturally appropriate mental health services for Indigenous communities and evidence supporting the implementation of a well-designed trial of a culturally appropriate intervention in WA for Indigenous women and their families.

Aims

• Raise awareness of perinatal mental health issues among Indigenous communities;

• Provide support to existing service infrastructure;

• Establish support networks for women during the perinatal period;

• Provide education and information to service providers and the wider community; and

• Establish innovative and culturally appropriate approaches for achieving the above aims.

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Rationale

• The SPRG has identified Indigenous communities as a priority, and thus the provision of funding to develop and trial a perinatal mental health service framework has been endorsed.

• This framework will extend and support the existing services delivering support to women and their families during the perinatal period in Carnarvon (Central West region of WA).

• It is important that mental health services for Indigenous populations acknowledge existing frameworks for healing within Aboriginal communities – combining traditional with Western characteristics and grounded in community based models of care which build on strengths and improves on areas of weakness (Minniecon et al, 2003).

• The available evidence supports the implementation of a well-designed trial of a culturally appropriate intervention in WA for Indigenous women and their families, which recognises the following:

� The need to provide adequate and appropriate education, support services and care (Minniecon et al, 2003; Druett, 1994); encompassing trans generational networks enhancing emotional support and information for mothers (Vicary, 2002).

� The importance of including Indigenous Health Workers in the consultation process for service delivery (Westerman, 1997); and

� The importance of community self-management, ownership, and capacity building in relation to research/evaluation and in maintaining therapeutic engagement and intervention (Vicary & Andrews, 2001; Westerman, 2002).

Framework

Having engaged the community in consultations to determine preferences for the service, the Carnarvon service will be modelled to incorporate the following:

• A combination of Indigenous and non-Indigenous staff who provide a mix of a mix of primary health promotion strategies and a tertiary case management and treatment;

• A role in community health education and promotion, including culturally sensitive and visually strong educational/promotional materials (featuring Aboriginal images and language easily understood by the target audience);

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• A role for the mothers and grandmothers of adolescent girls in a school-based educational program;

• Ongoing consultation (both in town and in the community) with women regarding the service framework to ensure suitability;

• An informal style, including an outreach component to maximise service access and engagement;

• The combination of traditional and spiritual components with western medicine in service provision;

• An overall focus on the need to build trust and increase confidence and self esteem of young Aboriginal girls (through education, support and self help groups); and

• Capacity to provide additional support for the smaller number of women requiring more intensive help.

Qualitative and quantitative data will be collected prior to the service being implemented (i.e., baseline), again 12 months into the project, and at the completion of the 2-year pilot to evaluate performance against expected outcomes. Evaluation measures include:

• A purpose designed ‘Postnatal Women’s Questionnaire’;

• Focus groups;

• A purpose designed ‘Health Professionals Questionnaire’;

• Mapping of perinatal specific services and health promotion strategies available/employed within the local community; and

• Administrative records maintained by local service providers (i.e., Carnarvon Aboriginal Medical Service, Carnarvon Mental Health Service, and Carnarvon Hospital).

Evaluation reports will be generated by the SPRG Research Officer and State Coordinator following data collection and analyses at baseline, 12-months into service delivery, and at completion of the pilot period. Analyses of baseline data is currently in progress, preliminary results indicate low levels of perinatal knowledge/awareness among local service providers and that aboriginal women experiencing symptoms of anxiety and depression during the perinatal period may not be seeking/receiving professional help.

Outcomes

Highlights

• Service and community partnerships have been established with local lead agents identified

� State Indigenous Mental Health Services;

� Carnarvon Hospital; and

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� Gasgoyne Mental Health Service.

• Education and training (based on informal needs analysis with local clinicians and service providers) undertaken with representation from many of the local services

• Anecdotal reports of increased awareness of perinatal mental health in the local community

• Information about cultural perspectives on perinatal mental health gained from focus groups undertaken with Aboriginal women from the local community

• Baseline evaluation undertaken to establish a benchmark for evaluation framework.

• Service model developed in collaboration with local service providers and community and supported by both.

Challenges

• Operational issues related to recruitment process resulting in extended delays for advertising service positions – this potentially will have an impact on support and commitment generated amongst local community

• Limited flexibility in government process to accommodate cultural issues identified both by community and service providers (e.g., complexity of application documents may act as a significant deterrent to individuals who are interested in applying for the positions).

• Addressing issues pertaining to local community politics has required sensitivity and close collaboration with stakeholders to limit the impact these potentially may have on the service development.

Current Status

The service is envisioned to be operational and receiving clients in 2008.

Future Recommendations

If evaluation results show that the service is effective, consideration will be given to writing funding proposals to enable replication of similar service models elsewhere in WA. Funding will continue for the service in Carnarvon.

Current and future models for Indigenous communities may require adjustment to reflect the needs of different communities. Likewise the service model in Carnarvon may require changes in order to be flexible to the needs of the community.

Practical Support Service Model Development

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In reviewing the literature, it was found that many researchers have reported a strong association between perceptions of low social support and high EPDS scores – indicating depressive symptomatology. The review also revealed that various dimensions of social support, including practical help, have been proposed as one of the means to reducing postnatal depression. On the basis of this literature review, the SPRG came to a consensus that allocation of funding for a practical support service was a priority.

Aims

The practical support service aimed to target one rural and one metropolitan site to enable comparison between two locations and to address the needs of a rural community. The service would also be provided (through funding from SPRG) by an external agency and would provide the following:

• Domestic assistance;

• Basic childcare;

• Guidance and support for mothers to develop practical skills (including time management, prioritising/goal planning, problem solving, etc); and

• Guidance and support to establish a domestic/childcare routine so that when the service withdraws, the mother is better equipped to manage with practical tasks.

Rationale

• The foundation of most home visitation programs rests on social support theory (Langford, et al., 1997; Norbeck, 1981) which emphasises the important links between receiving emotional, practical, and informational social support and having good psychological health.

• Mothers who receive greater levels of instrumental, emotional and/or informational support from others postpartum show higher maternal sensitivity than mothers who do not have access to such support (Broom, 1994; Han 2002; Kivijarvi et al., 2004; Shin et al., 2006).

• Various dimensions of social support, including practical help, have been proposed as the means to decrease childbirth complications and postnatal depression (Affonso et al., 1991; Cutrona & Troutman, 1986; Da Costa, et al., 2000; O’Hara 1986; Oakley et al., 1990; Wolman et al., 1993).

• Despite the now widespread acknowledgment of the importance of social support to women’s psychological health during the perinatal period, the effectiveness of social support interventions during pregnancy and postpartum is unclear.

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• From the limited RCT literature available, there are reports that intensive social support does have a positive impact on women’s psychological functioning (Navaie-Waliser, et al., 2000).

• Given the potential for a practical support service to impact positively on women’s psychological health during the perinatal period, implementing a trial of such in WA is warranted, with the proviso that a well-designed evaluation process is built into the trial.

Framework

Recognising the diverse range of service operations, the SPRG advertised for expressions of interest (EOI) in order to ascertain the interest in, and canvass the range of possibilities relating to the provision of a Practical Support Service.

Outcomes

Highlights

• Much interest was generated by the call for EOIs both in rural and metropolitan areas. Many parties indicated they would support the initiative (through receiving/providing referrals etc) regardless of who was the successful tender applicant and would also keep an eye out for future SPRG funding to enhance their services.

Challenges

• A number of interested parties were only able to provide service in one area (either metropolitan or rural, but not both).

• Communicating the necessity of a rigorous evaluation framework was also a challenge, and only two of the five EOI respondents demonstrated the capacity to meet the requirements of SPRG.

Current Status

The service is envisioned to be operational from February 2008.

Future Recommendations

If evaluation results show the service is effective, particular focus should be placed on expanding the current service into other rural communities.

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CALD Service Model Development

Based on information gained from reviewing the literature and research undertaken within WA (Down et al, 2007), women from CALD backgrounds clearly stated a wish for a culturally appropriate support service that combined Western and traditional approaches to intervention for women during the perinatal period. The SPRG endorsed the development of a perinatal mental health service model for women from CALD backgrounds to be trialled over two sites in Perth.

Aims

• Increase the level of psycho-social support provided to CALD mothers and mothers-to-be

• Increase the awareness of perinatal mental health issues within the CALD community

• Increase the ability of women in the CALD community to navigate social and health providers, such as obstetric, postnatal, mental health and community services

• Increase the women’s level of ‘comfort’ in interacting with these services resulting in greater confidence to access them in the future

• Identify and encourage the practice of cultural traditions that have a positive impact in mother-child social and emotional wellbeing.

• Foster the development of CALD women leaders.

Rationale

• By merging components of cultural practice with standard clinical practice the stress experienced by new mothers may be reduced (Posmontier & Horowitz, 2002, Down et al, 2007)

• Promotion of community collaboration that encourages recognition of the importance of cultural rituals and traditions and acknowledges the individuality of women within a cultural context (Rice et al, 1999; Down et al, 2007; Thompson, 1997).

• Provision of support or self help groups to enable shared experience and development of coping strategies (Chan et al, 2002) and consideration of the provision of a drop-in centre for mothers (Thompson, 1997) and outreach service for “harder to reach” women (Chan et al, 2002; Down et al, 2007).

• Ensuring that health promotion encompasses discussion of realistic expectations of motherhood and differences in health care systems (Posmontier & Horowitz, 2002; Down et al, 2007) and facilitate education related to early recognition and help-seeking behaviour

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(Chan et al, 2002; Down et al, 2007) using culturally appropriate resources (Rice et al, 1999; Down et al, 2007).

Framework

The WAPMHU approached preferred service providers Gosnells Women’s Health and ISHAR (who were already committed to the area of CALD perinatal mental health) to establish partnerships in the development of psychosocial support groups for women from CALD backgrounds. Pilot projects based on the focus groups had also previously been undertaken with the Sudanese and Iraqi communities. New service model frameworks, based on evaluations from the pilot projects, were developed for the three communities respectively.

The model for intervention is based on the templates previously developed by ISHAR Multicultural Centre for Women’s Health and Curtin University, funded and approved by the SPRG. However, it is recognised that while the model will incorporate psychotherapeutic components, those women requiring intensive intervention will be referred on to other appropriate resources (e.g., Transcultural Mental Health Services).

A capacity building program will be incorporated into service provision for all groups and will promote the establishment of local groups supported/facilitated by local organisations. This component will promote the sustainability of the service as suitable women from the community are identified and groomed to lead the group and will assist women in navigating health and welfare systems. Intervention plan, progress reports and annual report will respond to key performance indicators (KPI) agreed upon.

The following outcomes, based on the objectives stated above will be evaluated by appropriate qualitative and quantitative methodologies:

• An increased level of social support provided to CALD mothers and mothers-to-be

• An increased awareness of perinatal mental health issues within the each community

• An increased ability by women in the three communities to navigate social and health providers, such as obstetric, postnatal, mental health and community services

• An increased level of women’s ‘comfort’ in interacting with these services

• An greater level of maternal/infant attachment, parenting and child well being skills

• The creation of a de facto extended family within the community to support women within the perinatal phase of their lives

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• Greater ability of mainstream services in the perinatal mental health area to provide a quality outcome for this client group

KPIs have been developed by the WAPMHU. These are incorporated into a more detailed project plan in subsequent refinements of the project arising from consultation with the SPRG and the CALD communities.

The baseline evaluation will be conducted during the implementation phase, approximately 2 to 3 weeks prior to the start of groups. A baseline evaluation report will be prepared with the assistance of the WAPMHU.

Evaluation data will then be routinely collected at the completion of each 10 week period. The final evaluation will be conducted at the completion of the first year of funding. All data will then be collated and analysed by the WAPMHU to ascertain the impact of the group interventions on the emotional, social and physical wellbeing of the women.

Based on the outcome of the evaluation, a decision will be made about continuing the projects in the second year in a seamless manner.

Outcomes

Highlights

• Strong partnerships have been formed between WAPMHU, Transcultural Mental Health, community health, ISHAR, Gosnells Women’s Health and communities. This has enabled the exchange of valuable information and has begun the process of establishing trust with local communities.

• A service model has been developed with support and endorsement of both community and local service providers.

Challenges

• Engagement with communities and establishment of trust understandably takes time, as such processes have been extended longer than expected

• Recruitment to the positions may be challenging given there are limited bilingual individuals with the required expertise to facilitate groups with some understanding of social and emotional health issues

• Establishing an evaluation framework that meets government reporting requirements and is culturally appropriate has been difficult and has been developed within funding limitations. Specific considerations include costs associated with translations and back translations necessary in qualitative research.

Current Status

Service model envisaged to be implemented in 2008.

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Future Recommendations

If evaluation results show that the service is effective, consideration will be given to writing funding proposals to enable replication of similar service models elsewhere in WA.

Current and future models for CALD communities may also be adjusted to reflect the new and emerging groups of high need. If (as is hoped) the proposed groups self generate a support network for women in the community, focus may then be shifted on to other “at risk” populations who may have less support available.

Hospital at Home (H@H) Service Model Development

A review of relevant literature by the WAPMHU revealed there is a considerable body of research evidence showing that ‘hospital in the home’ is a safe and feasible alternative to hospital admission for many individuals with acute psychiatric disorder, and one they and their carers/relatives generally prefer. It became clear there is adequate research evidence to justify the provision of hospital at home for ‘at risk’ families during the perinatal period. Furthermore, the SPRG had a unique opportunity to conduct a perinatal specific hospital at home trial as part of the current Psychiatric Emergency Team (PET) hospital at home trial and in collaboration with the Mother Baby Unit, to provide much needed and valuable research evidence.

Aims

Hospital at Home (H@H) aimed to provide an alternative to hospital care to mental health patients by providing intensive treatment at home. Treatment at home was provided to patients who would otherwise be admitted voluntarily to a mental health hospital. Treatment at home aimed to maintain the individual’s normal functioning and normal social roles as much as possible during a period of acute mental illness.

Clients were primarily those with severe mental illness who were having an acute episode or who are in crisis during the perinatal period (pregnancy through to 3 years postpartum). Target population included those women who have:

• Major depressive or anxiety disorder;

• Increased risk of relapse of existing bipolar disorder or schizophrenia; or

• Been discharged from hospital and require initial intensive support back in the community.

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Rationale

• There is currently limited service provision specific to meeting the perinatal mental health needs of those women in WA who are experiencing more severe and/or acute mental illness during this time.

• It was proposed that H@H would provide an important bridge in the gap in services between hospital admission and community services, enabling a greater number of women to be maintained within the community and providing an increased level of support for those community services and GPs to provide longer term support for women experiencing perinatal mental health difficulties.

• In Australia the National Mental Health Policy (Australian Health Ministers, 1992) recognised the benefits of and need for an increased focus on community based mental health services.

• In the 2004 report A Health Future for Western Australians: Report of the Health Reform Committee, the recommendations were once again put forward for initiatives aimed at supported accommodations and unnecessary hospital admissions to be avoided through the provision of better community and home-based care.

• The WA H@H trial began admitting patients in March 2006 and has steadily increased its ‘virtual’ bed usage (current capacity of 4 patients/beds per day). Results of qualitative evaluation indicate that patients, carers and health professionals have embraced the service. Quantitative evaluation has demonstrated significant bed cost savings.

Framework

The perinatal H@H was intended initially to be a six month pilot project with the aim of decreasing the pressure on the utilisation of beds in the new mother and baby unit. The SPRG funded the employment of 1 FTE level 2 community mental health nurse on contract, to work with the existing team to provide a seven day service and extend the capacity of the service to provide six virtual beds, whilst maintaining the requirements for after hours safety standards.

It was envisaged that all staff employed at H@H would be involved in the care of women with perinatal mental health issues and as such a comprehensive training program was developed in issues specific to this area to support clinicians working with the client group.

Further detail pertaining to the H@H service framework is available on request.

The task of developing an evaluation framework was a complicated one, due in large part to the delayed opening of the in-patient perinatal mental health facility (i.e., the Mother Baby Unit). In response to the uncertainty regarding the capacity of the yet unopened Mother Baby Unit to be involved in the trial

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and thus the evaluation, three evaluation design options were presented for consideration. With the Mother Baby Unit not yet operational at the time of implementation, evaluation option B, the non-experimental one-group pre-test-post-test design was selected. This design would allow for the evaluation of outcomes in terms of patient symptomatology and patient/family satisfaction with the Hospital at Home service. The decision was made to incorporate both quantitative and qualitative measures within this design.

Outcomes

Highlights

• Raising the profile of the Hospital at Home service amongst perinatal specific services;

• Provision of perinatal training to staff;

• An increase in staff awareness of the specific needs of perinatal patients admitted to Hospital at Home;

• The development of an evaluation framework; and

• The fostering of a closer working relationship between Hospital at Home and the recently opened Mother Baby Unit.

Challenges

• Despite a 6-month trial period, the number of perinatal specific referrals to the Hospital at Home team was extremely low. Thus at the conclusion of the 6-month trial period the only available evaluation data was for the one perinatal patient referred to the Hospital at Home team during the final 3-months of the trial and the final evaluation subsequently became a case study. Further details of this case study are outlined in the Perinatal Hospital at Home Evaluation Report.

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Current Status

Subsequent to the withdrawal of WAPMHU funds to the Hospital at Home trial a meeting has been held between management of the Mother Baby Unit, Hospital at Home and WAPMHU. This meeting was arranged by the WAPMHU with the aim of fostering a collaborative working agreement between the Hospital at Home team and the Mother Baby Unit.

Discussions were extremely positive and staff training days have been tentatively arranged to increase awareness in both services of treatment models being used, with the ultimate goal being an amalgamation of models to enable patients to be transferred form one service to another with minimal disruption to treatment.

Future Recommendations

Continued support for H@H staff by way of education and training as required.

EDUCATION AND TRAINING

Education and training has been identified as one of the four key components of the State Perinatal Mental Health Initiative. Given the state-wide scope of the initiative and limited funding and resource capacity, it was recognised that a clear understanding of the education and training needs of clinicians and service providers was required to enable training and development activities to be targeted, planned and managed based on priority to meet the overall strategy objectives.

In order to address this issue the SPRG endorsed the following activities:

• Funding of a state-wide mapping of perinatal mental health services in WA (Gallegos, 2004) including identified training needs

• Extensive formal and informal consultation with clinicians and service providers throughout the state

• Extensive formal and informal consultation with women and families from WA aimed at identifying perceived gaps in service (to assist directing priority training areas)

• Review of the literature pertaining to education and training in different areas of perinatal mental health

• Attendance to State, national and international conferences in which education and training pertaining to perinatal mental health was identified as a key priority

The information gained highlighted the following areas of priority with respect to education and training and advocated the development of a comprehensive

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training framework, for a wide spectrum of health professionals working with women and their families during the perinatal period. This reflected the education and training needs identified previously by Pope and Watts (1996) in WA and supported conclusions drawn in the literature for the need for further training to facilitate a streamlined and consistent approach to management of women and their families during the perinatal period (Cox & Holden, 2003).

Aims

• To develop, review and deliver training programs addressing skills development in the screening, early identification and management of perinatal mental health disorders.

• To develop, review and deliver training programs addressing skills in promoting parental infant attachment.

• To develop, review and deliver specific training modules on perinatal mental health issues as indicated by training needs analysis, clinician request, service requirement or policy.

• To liaise with service providers in the assessment, development, facilitation and evaluation of training programs to support service expansion.

• To encompass cultural considerations for Indigenous and CALD communities in all education and training initiatives.

• To assist in the promotion of the State Perinatal Mental Health Strategy within the clinical and broader community via education and training initiatives.

Target Audience

• Clinicians working within government and non-government organisations which provide health-related services;

• General Practitioners; Consumers; and

• Carers.

Developing training programs

There is increasing recognition of the need to provide training programs of high quality and relevance within the field of health care and medicine and to ensure that these programs have a sound educational foundation (Schneider, 1994; Viau, 1994).

Training is defined as the systematic acquisition of skills, rules, concepts or attitudes that result in improved performance (Goldstein, 1993). Adult training

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and education programs need to be framed within a process of learning and development, creating a design that meets the needs of the organisation and targeted participants (Bozionelos and Lusher, 2002). There is value in using techniques such as experiential learning (role play etc) that promote shared experience and allow understanding of social interactions that arise in the midst of solving a problem (Feinstein et al, 2002).

In the development and delivery of any training initiative, it is essential to incorporate a comprehensive evaluation and feedback system to enable the redesign and adjustment of the program based on organisational and participant’s perspectives and needs (Bozionelos and Lusher, 2002; Arnone, 1998). Lingham et al (2006) argue this should address issues such as whether such evaluations yield useful information for the organisation and members. Information gained should include not only training process, but also feedback from participants in terms of content and applicability of such programs.

Training structure and delivery is implemented with consideration of the needs of service providers in WA. This includes:

• Accessibility to training and education programs, particularly for rural clinicians and service providers

• Time and resource limitations

• Staff turnover

• Range of different services and multidisciplinary clinicians

In response to some of these challenges the following approaches have been utilised:

• Intensive short course provision has been found to be effective in developing new skills and improving standards of care while maximising the effective use of limited training time (Harris et al, 1994).

• Train the Trainer approach – enables expansion of the knowledge and capacity of community based organisations to train key leaders and constituents to deliver training locally. It is generally cost effective (Ross, 1990; Neef, 1995); promotes a culture of information sharing and reflection among the team as the model encourages trainer-trainee dialogue (Bennett, 1987); and promotes a greater uptake of new information which is demonstrated by peers rather than by an “expert” (Bandura, 1997). Disadvantages include promotion of divisions within teams between those who are the chosen trainers and those who are the chosen trainees; poor trainer selection; and too little time spent on training processes (Rolheiser et al, 1999).

All training packages developed by the WAPMHU adhere to the following principles outlined by Lingham et al (2006):

• Designing and training initial program;

• Launching and evaluating the initial program;

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• Designing quantitative measures based on feedback from phase two; and

• Ongoing training and evaluation.

Edinburgh Postnatal Depression Scale (EPDS) Training

The SPRG identified that while there was a public health campaign encouraging early identification of women with maternal mental health disorders, there was a lack of skills development options for health professionals working with women in this area. Given the estimated number of women who experience perinatal mental health mood disorders, the importance of early intervention in the diagnosis and management of perinatal mental health has been widely researched and documented (Milgrom et al, 1999; Cox & Holden, 2003). There is evidence that health professionals can improve the detection of maternal and paternal mental health disorders by using clinical skills and experience in conjunction with a screening questionnaire such as the EPDS.

Aims

The four hour module aimed to provide a professional development option for health professionals working with families during the perinatal period. It was designed to assist health professionals and others in the use of the EPDS.

Rationale

The EPDS was originally developed by Cox, Holden and Sagovsky (1987) to enable health professionals to screen mothers for postnatal depression. The EPDS is recommended for use both during pregnancy and postpartum (Murray & Cox, 1990). The EPDS is a self report scale consisting of ten statements and is available in a number of different languages, though not all versions have been validated against standard psychiatric measures. It has demonstrated high reliability and specificity as an indicator of significant depressive symptomology.

Health professionals across the Perth metropolitan area and some WA rural areas are incorporating the EPDS as a screening tool in standard postnatal visits. This has resulted in earlier detection and treatment of maternal mood disorders.

Effective use of the EPDS requires training. Research has shown that only 30-40% of women who obtain high scores on the EPDS are actually recognised as having problems by their hospital or community nurse if they are not correctly trained in the use of the EPDS (Holden, 1991; Coyle & Adams, 2002, Hatton et al, 2006; Armstrong & Small, 2007).

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Framework

Funding was allocated to train 22 trainers from throughout WA, taking into consideration geographic location and access to other trainers for support – 12 positions were allocated to rural regional locations, ten positions to metropolitan locations. Selection criteria were established to assist in trainer selection. This included a high level of experience working in perinatal mental health and mandatory support from service/manager.

All selected trainers attended a two day training course (structure described below), with access to regular supervision from the State Perinatal Mental Health Unit and Education and Training Officer, and peer discussion via face to face contact, email, and video conferencing when available.

The initial 2-day training programs were held in August/September 2005, with positive feedback from participants. Analysis in Dec 06 revealed that there had been significant reduction in trainers available to continue with the EPDS module, especially in the metropolitan area. This was attributed to employment movement, loss of managerial support to complete training sessions, ill-health, and migration. This resulted in NMMH having 1 trainer available to continue with rollout of EPDS training across the entire region, and that several regional areas were below core capacity. 1 further train the trainer session (2-days) for 11 participants was planned and delivered targeting areas of need in March 2007. Currently, there are 26 EPDS trainers providing training around Western Australia.

The Program

Train the Trainer Program

The training program is two days duration and combines the development of practical teaching skills incorporating principles of adult learning and emphasising the importance of group management skills, within a perinatal mental health framework context. This is achieved through a highly experiential training framework using case scenarios, role play to facilitate skills development with an emphasis on the problem centred nature of the task and the skill being developed (Moss, 1997).

Trainers are then taught the structure and content of the four hour EPDS module. Attainment of objectives is achieved by employing highly interactive instructional strategies which involve the trainees in significant rehearsal of core knowledge and application of that knowledge in an instructional setting.

Analysis of teaching strategies via self and peer group evaluation and discussion are also an integral feature of the course. Nature of training tasks are problem centred to ensure that training skills are never separate from the workplace needs of the trainees.

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A training manual provides a comprehensive overview of the principles of adult learning, together with detailed information on the use and misuse of the EPDS in screening and management for perinatal mental health disorders. The training resource contains a range of additional resources such as DVDs, literature review, etc.

The trainers are introduced to the comprehensive evaluation framework and how the evaluation process informs and guides module development.

Access to supervision and peer discussion makes up a significant component of the training package, with the trainers given opportunity to discuss clinical and training matters of interest and relevance to their region.

4-hour Module

The module consists of several key features, including a power point presentation on the EPDS and it’s use and potential misuse, an opportunity for clinicians to complete the screening tool; role-plays; discussion on appropriate referral pathways; and two videos’ (Caring for the Family’s Future and Getting to Know You) with an overarching focus on shared experience and experiential learning.

The course structures incorporate the following components:

• Clear aims and objectives

• Provision of comprehensive high quality resource material including written and audiovisual information

• A highly experiential training framework using case scenarios, role play to facilitate skills development with an emphasis on the problem centred nature of the task and the skill being developed (Moss, 1997)

• Incorporated comprehensive evaluation framework

• Access to supervision and peer discussion

The aims of the training are to enhance health professional’s ability to identify women who may be at risk of or are experiencing mental health disorders during the antenatal and postnatal periods by:

• Providing a brief overview of perinatal mental health and understanding of the historical development of the EPDS;

• Demonstrating the benefits of using the EPDS;

• Raising awareness of the misuses of the EPDS; and

• Teaching health professionals how to administer the EPDS with greater understanding, confidence and ability.

Outcomes

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Highlights

• The EPDS Train the Trainer has proved highly successful, with over 250 clinicians from throughout the state having received training.

• There are a total of 26 EPDS trainers, covering all regions of WA.

• Preliminary results indicate that there has been a significant positive impact, on average, on clinical practice and appropriate use of the EPDS (see Chart One below).

• Workshop evaluations have consistently rated ‘good’ or ‘excellent’.

Chart One:

Question Key:

I have confidence in administering the EPDS.

I understand when the EPDS can be administered to antenatal women.

I understand when the EPDS can be administered to postnatal women.

I have confidence in scoring the EPDS.

I have confidence in interpreting the score.

I have understanding of how the EPDS can be misused.

I have knowledge of referral pathways.

I have knowledge of parent infant attachment.

Challenges

• A dedicated central program officer is required to coordinate ongoing support of trainers and the program. This role has included the identification of suitable training venues, booking dates, coordinating training requests, and providing regular support and research

• The package must be carefully structured to support varying levels of expertise and confidence

EPDS Training Participants Average Self Ratings (Pre & Post)

0.0

1.0

2.0

3.0

4.0

5.0

1 2 3 4 5 6 7 8

Question

Rat

ing

(out

of 5

) Differencebetween pre &post trainingscore

Pre-training score

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• Referral pathways included managing political and systemic issues

Current Status

The train the trainer framework has been established to include ongoing mentorship and supervision for the regional trainers, provided by WAPMHU (primarily the education and training officer). This supportive infrastructure includes the provision of individual and group supervision, made available through VC to rural practitioners. Peer supervision is closely affiliated with the interactive nature of the course and ensures that there is a regular exchange of ideas and experiences both within peer groups and between trainees and trainers (Malkin, 1994). Anecdotally many trainers have cited that the provision of this infrastructure has enabled them to maintain their role as trainers.

Support and supervision is offered to trainers via several means including an opportunity to “debrief” after their initial training session with the Education Officer or WHS staff; peer support through joint training sessions within their local regions; individual support via email or phone to the Education officer; or group support via regular meetings or VC link-up. Regular provision of information in the form of relevant articles, reports and research are also provided to trainers to assist in their skills development. Whilst the benefits of such regular contact are the continuing levels of enthusiasm and dedication to the project from the trainers, and a commitment to the ongoing training needs of WA, the resources required to maintain it are significant, particularly in the investment of time from WAPMHU.

Future Recommendations

• Ongoing review to inform future training requirements.

• Evaluate how services have incorporated knowledge into practice (e.g., are outcomes improved? Has the training made a difference for women and families?)

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Aboriginal Health Worker (AHW) Training

The SPRG has identified Aboriginal women, their families and communities as a priority population. Minniecon et al (2003) and Druett (1994) have recognised that to ensure better outcomes for Indigenous women during the perinatal period, adequate and appropriate education, support services and care must be provided. Swan and Raphael (1995) have also recommended that AHWs have prescribed education in Aboriginal mental health. As such, the WAPMHU has sought to develop and deliver an education module specifically designed for AHWs to address issues pertaining to the perinatal mental health of Aboriginal communities.

Aims

The AHW training module aimed to be culturally appropriate and flexible in its approach to delivery, while also providing a comprehensive introduction to perinatal mental health and ways to support women and families.

Rationale

Indigenous mental health in general has been revealed as an extensive problem (Dudgeon 2000). It is essential that AHWs are involved in the provision of mental health services, as it has been noted that the Aboriginal community recognises the employment and training of AHWs is particularly beneficial (Pacza et al 2001).

AHWs are in a prime position to raise awareness of perinatal mental health in the Aboriginal community and to detect and coordinate the care of women and their families. As such, it was considered essential to provide the necessary training to support AHWs in this role.

In 2005, a steering committee was established, with Indigenous representation from various government and non-government agencies. The purpose of this steering committee was to guide the process and development of information and training resources for AHWs. The steering committee facilitated the consultation and participation of AHWs in one full day workshop. From this, levels of knowledge and priority areas for education and training were identified which would be helpful in the detection and management of postnatal depression for Aboriginal women and their families.

Framework

The module was designed as an introduction to perinatal mental health, which would build on existing knowledge and experiences of Health Workers and acknowledge the Aboriginal cultural context.

Topics covered included:

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• Common perinatal mental health problems and identifying signs and symptoms;

• Cultural beliefs and practices pertaining to pregnancy, motherhood and mental health;

• Risk and protective factors for perinatal mental disorders;

• The impact of perinatal mental health problems on families;

• Ways to help and support families (including encouraging good relationships with the baby);

• The role of AHWs as part of a multidisciplinary team addressing perinatal mental health; and

• Ways AHWs can take care of themselves while providing perinatal mental health care to communities.

The training is presented in an interactive workshop style, allowing much group based discussion and activities (including role plays and case-studies). To ensure a flexible yet tailored approach, discussions and activities are directed such that participants can recognise and contribute what they already know from their personal, cultural or professional experiences. Participants can then apply this existing knowledge to understanding the more specific details/definitions of perinatal mental health, as recognised by other (Western) health professionals.

Outcomes

Highlights

• The training module has been implemented twice at Marr Mooditj Aboriginal Health Training College – once each with Certificate III and Certificate IV Aboriginal Primary Health Care students.

• Verbal feedback received from both staff and students of the college has been extremely positive.

• The verbal feedback from students is supported in the formal written evaluations, which indicate the sessions were well organised and relevant, the information was useful, the workshop was set at an appropriate pace, not too easy or too difficult, and the workshop was enjoyable.

• Feedback from Marr Mooditj staff has also been affirmed in two written letters.

• From the input received during the module development and the feedback from the workshops, it appears that perinatal mental health is a topic of great interest for Aboriginal people and the opportunity to learn more on the subject is greatly valued.

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Challenges

• It was important to have a Project Officer dedicated to the task of developing the module. This task required much consultation and follow-up for input.

• Developing an effective communication strategy to obtain input on module development from stakeholders was difficult. It was often necessary to use multiple and varying strategies to obtain necessary feedback and information (including phone calls, emails, group meetings and individual meetings).

• Due to the amount of and methods for consultation, the project was quite time-intensive.

• Delivery of the training workshop is somewhat difficult with no Aboriginal Liaison Officer as part of our WAPMHU team. In this respect, the “Boodjarri Business” DVD and support from State Indigenous Mental Health is helpful.

Current Status

The AHW training has been run twice at Marr Mooditj Aboriginal Health Training College – once each with Certificate III and Certificate IV Aboriginal Primary Health Care students.

Further training is planned at Marr Mooditj, including with students completing the Diploma of Aboriginal Mental Health Care and the Diploma of Enrolled Nursing (expected to be implemented late 2007 and early 2008 respectively).

A request was also made to adapt the workshop for presentation to Aboriginal Mentors as part of Uniting Care West’s “Our Mob, Our Kids, Our Community” program. This workshop was conducted in mid October 2007.

Future Recommendations

• Develop a Train the Trainer format for this module:

� Potential to decrease amount of time WAPMHU staff required to deliver training

� Potential to provide Indigenous trainers

• Implement the training module via teleconference

• Adapt the module for non-Indigenous health professionals who work with Aboriginal communities

Inaugural Perinatal Mental Health Symposium – Beyond the Boundaries

The ‘Beyond the Boundaries’ symposium and pre-symposium workshop were both coordinated by the WAPMHU as a means of promoting perinatal mental

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health to the broader WA health sector, highlighting the achievements of the SPRG and WAPMHU as a Department of Health initiative.

Aims

• Offer clinicians the opportunity to participate in research-based education sessions;

• Highlight the achievements of WA perinatal mental health clinicians and researchers to both a national and international audience;

• Promote Perth as a vibrant, “centre of excellence” in the field of perinatal mental health; and

• Offer local clinicians and researchers an opportunity to network and learn improved methods of working with this client group.

Rationale

Perinatal mental health researchers and clinicians continue to ‘move beyond’ the narrow concept of postnatal depression (PND), expanding their focus to include the broad spectrum of disorders across the perinatal period, including anxiety, depression and psychosis.

Subsequently, with many diverse and exciting initiatives are taking place in WA and a wide variety of client groups, the WA Perinatal Mental Health: Beyond the Boundaries Symposium was held to provide a forum for people working in the field of perinatal mental health to promote, share and discuss past, present and future projects.

Framework

Workshop

The WAPMHU presented a half-day workshop with Dr Stephen Matthey on ‘Evaluating Outcomes in Clinical Practice’. With the understanding that for many clinicians, the idea of using evaluation measures in their practice is regarded with minimal enthusiasm, this workshop offered all clinicians the opportunity to learn how to make evaluation useful and relevant to their clinical practice, and explored the concept of Clinical Significance.

Symposium

The symposium was held on 29 August 2007 at the Duxton Hotel. Key features of the day included:

• A keynote presentation by Dr Stephen Matthey on Prevention Strategies for Postnatal Distress;

• Seven half-hour presentations, featuring both a consumer and a clinical focus; and

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• A discussion panel on the topic of Indigenous perinatal mental health, questioning the appropriateness of mainstream services.

Outcomes

Highlights

• Both the symposium and the pre-symposium workshop were hailed as a huge success. Anecdotally, as well as in formal feedback, participants found both events to be interesting and valuable professionally and personally.

• Responses from the symposium feedback questionnaires revealed that 78% of participants indicated the event had been useful to them in their work either ‘a lot’ or ‘extremely’ and 61% indicated the event had increased their knowledge in a similar way.

• In addition, 46% and 37% of respondents to the symposium feedback questionnaire said the event increased level of confidence and competence (respectively) in clinical practice ‘a lot’ or ‘extremely’.

Challenges

• Although deemed to be such a success, the event was extremely time intensive with regard to preparation and coordination.

• Anticipated attendance was lower due in part to the chronic staff shortage presently being experienced in WA, which resulted in staff requests for leave to attend the symposium being denied. This remains on ongoing issue for education and training as heavy clinical demands on clinicians reduces the ability to attend events.

Future Recommendations

• In future, an event such as the ‘Beyond the Boundaries’ Symposium and pre-conference workshop could be held bi-annually. Alternately, the WAPMHU could focus greater attention to attending other external conferences and symposia in order to promote perinatal mental health to the broader WA health sector.

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RESOURCES

Resources for Aboriginal Communities

A number of key recommendations for resource development were gained from literature reviews, workshops, community consultation and focus groups undertaken with Indigenous communities and service providers throughout WA. Emphasis was given to the need for culturally appropriate resources that reflected the unique experiences of Indigenous women and their families within their cultural context. In response to these identified needs the following resources were developed in collaboration and consultation with community women and Indigenous service providers.

Boodjarri Business: Maternal Mental Health Resource for Aboriginal Health Workers (Resource Booklet)

In 2005, a number of Aboriginal Health Worker (AHWs) attended a workshop during which identified levels of knowledge and priority areas pertaining to perinatal mental health in Aboriginal communities. One of the priorities identified was the need for an information resource for health professionals which would be helpful in the detection and management of postnatal depression for Aboriginal women and their families.

In response to this identified need, Boodjarri Business – Maternal Mental Health Resource for Aboriginal Health Workers was produced. The 34 page booklet provided definitions of key perinatal mental health issues, symptoms, risk factors, the impact on families, while also providing suggestions of ways to work with women and their families who are affected by perinatal mental health problems.

200 copies were distributed in 2006 and initial informal feedback has been very positive. A reprint is in process with adjustments based on feedback from those who have been using it. This has included AHWs, other Aboriginal health services and Marr Mooditj Aboriginal Health Training College. Boodjarri Business has provided the basis from which AHW training modules have been developed in partnership with Marr Mooditj. A formal evaluation of the resource will be incorporated as part of the AHW training module evaluation.

Boodjarri Business – Yarning about feelings after baby (DVD)

This DVD provides an overview of the experience of perinatal depression from the perspective of two Aboriginal women and includes information on symptoms, risk factors, treatment and accessing pathways to care.

The DVD aims to:

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• Raise awareness of perinatal mental health issues amongst women and their families; and

• Provide opportunity for discussion with mothers/families.

Boodjarri Business – Working with Aboriginal Mums, Babies and Families during the perinatal period (DVD)

This DVD provides information about cultural considerations and engaging Aboriginal mums and families who may be experiencing perinatal mental health issues. The information is given by a range of Aboriginal clinicians who work with families in the community.

Note: Both DVDs were produced in partnership with State Indigenous Mental Health Services. Since production of these two DVDs requests have been received for the production of further information DVDs targeting fathers, mothers in rural communities and teenage parents. Consideration of these requests will be given prior to future resource development.

Information Pamphlets

A series of consumer information pamphlets have been developed for Indigenous mums, dads and family members respectively. These contain information about perinatal mental health issues and provide guidance on how mothers and families can access help.

It is important to note that given the great cultural diversity of different communities throughout WA and Australia, that regional/cultural variations in any resource may mean that they are more or less appropriate for certain populations. The majority of resources have been developed for particular communities and as such may not reflect the thoughts or practical resources for all regional communities in WA. It is hoped that they may provide a template from which other health workers, service providers and communities may adapt their resources to suit their individual and /or local needs.

Resources for CALD Communities

You Are Not Alone (DVD)

During extensive consultation with CALD communities in Perth, women identified the need for culturally appropriate information/resources about social and emotional wellbeing during and service access during the perinatal period.

Three DVDS have been produced for the following communities:

• Ethiopian (Amharic)

• Sudanese (Dinka)

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• Iraqi (Arabic)

The DVDs provide an overview of the experience of perinatal depression from the perspective of women from each of the communities and includes information on symptoms, risk factors, treatment and accessing pathways to care. They also aim to:

• Raise awareness of perinatal mental health issues amongst women and their families; and

• Provide opportunity for discussion with mothers/families

Using the Edinburgh Postnatal Depression Scale (EPDS) Translated into Languages Other Than English (Resource file)

Developed by Community Health in partnership with the WAPMHU, this resource collates copies of the EPDS that have been translated into languages other than English and validated for use in screening. It will assist health workers to detect perinatal depression in both the antenatal and postpartum periods for women who have a first language other than English.

For each language there is specific information recommending cut off scores to use in screening. “Notes and summaries” of the validation research studies to guide the use of the translated EPDS.

General Resources

“Where to find Help” (Information booklet)

This pocket sized booklet aimed at families, provides contact details for key services state-wide pertaining to different areas of perinatal mental health. Since its development, several thousand copies have been printed and distributed and have been accessed by consumers, child health nurses, GPs, midwives, other health services, welfare, parenting and education services.

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FINAL RECOMMENDATIONS

Coordination

Clinical Guidelines for Perinatal Mental Health in WA

• Members of the SPRG and external service providers have indicated that provision of Clinical Guidelines would be extremely beneficial and considered a priority.

WA Perinatal Mental Health Policy

• Development of a policy document is considered crucial to cementing perinatal mental health on the political agenda both now and in the future.

• It is envisioned this document would highlight the following:

� The evidence available to support further service expansion and capacity building, including further services for CALD, Indigenous and rural/remote communities, as well as service model development for other ‘at-risk’ clientele (e.g., parents with anxiety disorders, teenage parents, families in which substance misuse and/or domestic violence is an issue)

� The demand for education and training to support health professionals

� The demand for perinatal mental health promotion and literacy in the community

� The need to work within a cross-sectoral framework to address perinatal mental health issues

Perinatal Mental Health Networks

• Given the recognised need to work across sectors in providing perinatal mental health services, networking channels should be formalised to enhance those relationships established through the SPRG and the partnerships established through service expansion initiatives.

• It is proposed that networks could be enhanced in the following ways:

� Provision of quarterly meetings/forums, hosted by WAPMHU and Coordination Subcommittee. These meetings/forums would provide an opportunity for service providers to gain and share information on a variety of perinatal mental health topics through themed presentations and guided discussions. Teleconferencing could also be utilised.

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Research

Publishing findings

• Many of the initiatives of the WAPMHU have gained recognition nationally as setting a benchmark in perinatal mental health, and with such recognition it becomes important to communicate successful strategies.

• In addition, the comprehensive research frameworks built into each initiative allow for comprehensive evaluation. The findings of the evaluations should be considered not only in the light of guiding future directions of the WAPMHU, but also as potentially influencing the directions of other perinatal mental health initiatives nationally and internationally.

• It is proposed that specific time is devoted to writing-up the results of evaluations for the purpose of submitting them to journals.

Guidelines for gathering evidence

• It is envisioned that the processes used in gathering evidence to support initiatives will be formalised in a set of guidelines.

• Creating these guidelines will maintain current processes for community consultation and gathering evidence as these processes will regularly come under review through quality assurance mechanisms.

Service Expansion Initiatives

• It is envisioned that the current service expansion projects will be used as a platform for future initiatives, either to build the capacity of current projects (i.e., extend into other locations, target groups, or serve greater numbers of women and families) or to be utilised as models for new initiatives.

• Populations to target for future initiatives will be outlined in the proposed policy document (as highlighted above).

Education and Training

Resources

• Perinatal mental health resource development has expanded greatly over 2007, becoming an area to which much staff time is devoted. As such, it is proposed that ‘Resources’ become a fifth principal area (alongside Coordination, Research, Service Expansion and Education and Training).

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• By creating this fifth principal area, resource development could potentially be guided by a SPRG subcommittee of its own, rather than being a subset of Education and Training (which is a large area without considering resources).

• Resource development requires some clear parameters surrounding it. There is the potential that, without containment, resources may begin to consume larger portions of funding than intended which may detract from the Education and Training budget.

• A clear evaluation framework should also be considered for monitoring and evaluating the success and uptake of resources developed.

Websites for consumers and health professionals

• It is envisioned that these central resources will be regularly update and modified in the future. This may extend to provision of online education and training modules for health professionals, online clinical guidelines, and further development of the multimedia component (e.g., podcasts with information/personal accounts from dads).

Training Modules

• It is proposed that a training module pertaining to anxiety in the perinatal period will be developed.

• It is envisioned that all current training modules and education opportunities will utilise video-conferencing facilities in order to target professionals in rural/remote areas.

• Further education and training needs will be identified and outlined in the proposed policy document.

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