Acondicionamiento y cimentación  1. Movimiento de tierras

The findings that address each of the three research questions that were formulated in the introduction will be discussed here in brief.

Research question #1

What is the prevalence rate of psychological distress during pregnancy among women who receive antenatal care at primary health care centres, and what are the associated risk factors?

Chapter 3 of this thesis sought to answer this question. In the last two decades, several studies have investigated the prevalence rates and predictors of postnatal CMDs, primarily depression. Recently, researchers have increasingly focused on antenatal CMDs, also largely on depression. In South Africa, prevalence rates of symptoms associated with CMDs range between 21%, as measured with a screening instrument (Brittain et al., 2015), to 47% in rural areas, as measured by a diagnostic tool (Rochat et al., 2011). Very few have sought to investigate broader, dimensional definitions of mental health problems during this period. Using a range of methods, all samples were drawn from localised sites, such that results are difficult to generalise to broader populations. The findings from this study contribute to closing that gap by reporting on the prevalence of general psychological distress, along with the

associated risk and protective factors, among pregnant women who presented for antenatal care at all 11 MOUs in the Western Cape.

Of the 664 women who completed the study’s survey, 38.6% were found to be psychologically distressed, as measured by the SRQ-20. Factors associated with increased risk for antenatal psychological distress were found to include low SES; being the victim of physical abuse and/or rape in the previous three months; having given birth; and, complications during a previous delivery when compared to women pregnant for the first time. Protective factors included increasing age; having a high school education; having a partner who is supportive of the pregnancy; not having a partner at all compared to having an unsupportive partner; higher overall social support; being in the second semester of pregnancy compared to the first; and substance use, particularly alcohol and other drug use.

Research question #2

What perceptions do pregnant women have of mental illness during the perinatal period, including their beliefs about causes and views on the most effective treatments?

Chapter 4 of this thesis addressed this question. The limited data available concerning MHL among pregnant women comes from HI contexts and has shown that pregnant women often have difficulty differentiating CMD symptoms from the experience of being pregnant (Bilszta et al., 2010; Henshaw et al., 2013; Highet et al., 2011; Hübner-Liebermann et al., 2012). South African studies of MHL are also limited and none have focused on women in the perinatal period. This is the first South African study to explore the perceptions that pregnant women have of perinatal mental illness. 263 pregnant women completed a questionnaire after having been presented with one of five possible vignettes, portraying disorders including: panic disorder, substance abuse, schizophrenia, as well as ante- and postnatal depression.

The results from this study showed that more than three quarters of respondents (77.4%) did not identify the signs and symptoms described in the vignettes as characteristic of mental illness. More than half of all participants (57.5%) were of the view that all the disorders depicted were “typical of a weak character”, while stress was the most widely held explanation for symptoms of all disorders. Significantly, compared to postnatal depression, antenatal depression was perceived by more respondents to be a “normal response”. Almost two thirds of respondents considered the antenatal and postnatal symptoms of depression to be “typical

of a weak character”. Where treatment was concerned, participants were most confident in the therapeutic potential of psychological services, especially consulting with a counsellor or social worker. These were closely followed by lifestyle and self-help options as the most endorsed means to addressing psychiatric symptoms during pregnancy. Notably, seeking help from a spiritual or religious advisor was comparably as popular among participants as seeking help from a psychologist or social worker.

Research question #3

Is a modified PST intervention to reduce symptoms of psychological distress among women presenting for antenatal care in primary health care settings, delivered by a Registered Counsellor, feasible and acceptable; and, what are the preliminary mental health outcomes of said intervention?

Chapters 5 and 6 answered the third and final research question. To date there has been good evidence to support task shifting approaches to integrating mental health services into primary care in South African settings (Spedding et al., 2015). However, nearly all interventions have made use of lay counsellors or CHWs to deliver interventions. As yet, no studies have investigated the utility of the RC professional category to deliver services in PHC settings. PST has been shown be an effective intervention for reducing psychological distress and depression (Sorsdahl et al., 2014; van’t Hof et al., 2011), however, to the best of our knowledge there have been no studies examining the feasibility or effectiveness of PST for reducing depression in the perinatal period.

Chapter 5 focused on the 22 intervention participants who completed the pre- and post- intervention interviews, by investigating their preliminary responses to the three-session PST intervention, in addition to exploring their perceptions of the intervention’s feasibility and acceptability. Preliminary responses to the primary outcomes saw significant reductions in CMD symptoms, as measured by the EPDS, as well as symptoms of psychological distress, as seen in the SRQ-20 scores. Corresponding reductions in impaired functioning in the dimensions of work, social life, and family responsibilities were also noted. Where problem solving skills were concerned, ‘negative problem orientation’ and ‘avoidant style’ of problem solving were significantly reduced. Participants largely felt that the intervention was feasible and acceptable. At the heart of its acceptability was the opportunity to talk confidentially to a non-judgmental and empathic person about their problems. The intervention materials also

made a significant impression on many of the participants, with the booklet serving as an extension of the therapeutic process and a placeholder for the intervention itself. Factors that were identified by participants as representing potential barriers to the intervention included lack of transport or money, work commitments and stigma.

Chapter 6 was concerned with the intervention’s feasibility and acceptability from the perspectives of 6 key stakeholders who had varying degrees of involvement with the project. The stakeholders felt that the intervention was helpful to patients and a valuable resource for the facility to have. Some expressed concern about how stigma associated with mental illness might be a barrier to patients who need mental health care. To the staff, the project’s value seemed to lie primarily in the support it provided in managing emotionally distressed patients. Having a resource to refer patients to appeared to provide overburdened staff with some relief. None of the stakeholders reported that the screening and referral procedures added to their workload, although there were some indications that it might have. Some stakeholders felt detection of psychological problems among patients was compromised without mental health screening. Staff felt that a walk-in counselling service would serve to improve future interventions.