Goff Sarah L, Moran Michael J, Szegda Kathleen, Fioroni Tina, DeBanate Mary Ann, Byatt Nancy
Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, 715 N. Pleasant St., Amherst, MA 01003 USA.
Institute for Healthcare Delivery and Population Sciences, University of Massachusetts Medical School-Baystate, 3601 Main St., Springfield, MA 01199 USA.
Implement Sci Commun. 2020 Jul 21;1:66. doi: 10.1186/s43058-020-00049-x. eCollection 2020.
Postpartum depression (PPD) affects approximately 25% of women in lower-income and racial/ethnic minority populations in the USA. Evidence-based interventions for PPD screening and treatment exist, but many women with PPD are not identified or are inadequately treated. To address this gap, the American Academy of Pediatrics recommends screening for PPD at routine preventive visits in the first 6 months of postpartum, but less than half of pediatricians do so. Small PPD screening studies have been conducted in pediatric practices serving average-risk women, but less is known about practices serving families with lower-income and/or racial/ethnic minority status (safety-net practices). Study objectives were (1) to develop and pilot test an adaptable PPD screening protocol in safety-net practices and (2) to test strategies for implementing the protocol.
The Consolidated Framework for Implementation Research was used for this two-phase pilot study. Phase I focus groups with pediatric providers and staff in four safety-net practices informed phase II development and implementation of a PPD screening and referral protocol. Feasibility measures included the percentage of eligible women screened and documentation of follow-up plans in the electronic health record at 1-, 2-, 4-, and 6-month preventive visits over 3 months. Implementation strategies were assessed for acceptability, appropriateness, and feasibility.
Focus group participants felt that (1) addressing PPD in the pediatric setting is important, (2) all clinical team members should be engaged in screening, (3) workflows and competing interests may present barriers, and (4) commonly used screening tools/approaches may not adequately detect depression in the population studied. During protocol implementation, screening rates increased from 75 to 85% for 324 eligible preventive visits and documentation of follow-up plans increased from 66 to 87%. Only 6.5% of women screened positive (EPDS ≥ 10). Minor adaptations to implementation strategies were recommended to improve acceptability, appropriateness, and feasibility.
Although developing and implementing an adaptable protocol for PPD screening in safety-net pediatric practices using external facilitation and a bundle of implementation strategies appear feasible, low positive screen rates suggest adaptations to account for intersecting patient, practice, and external policy contexts are needed to improve PPD screening effectiveness in these practices.
产后抑郁症（PPD）影响着美国低收入以及种族/族裔少数群体中约25%的女性。虽然存在基于证据的PPD筛查和治疗干预措施，但许多患有PPD的女性未被识别或治疗不充分。为了弥补这一差距，美国儿科学会建议在产后前6个月的常规预防性就诊时进行PPD筛查，但不到一半的儿科医生这样做。在为平均风险女性提供服务的儿科诊所中开展过小规模的PPD筛查研究，但对于为低收入和/或种族/族裔少数群体家庭提供服务的诊所（安全网诊所）的情况了解较少。研究目标是：（1）在安全网诊所中制定并试点测试一种可调整的PPD筛查方案；（2）测试实施该方案的策略。
本两阶段试点研究采用了实施研究综合框架。第一阶段，与四个安全网诊所的儿科医护人员进行焦点小组讨论，为第二阶段PPD筛查及转诊方案的制定和实施提供信息。可行性指标包括在3个月内1个月、2个月、4个月和6个月预防性就诊时接受筛查的符合条件女性的百分比，以及电子健康记录中后续计划的记录情况。对实施策略的可接受性、适宜性和可行性进行了评估。
焦点小组参与者认为：（1）在儿科环境中解决PPD问题很重要；（2）所有临床团队成员都应参与筛查；（3）工作流程和相互竞争的利益可能构成障碍；（4）常用的筛查工具/方法可能无法充分检测所研究人群中的抑郁症。在方案实施期间，324次符合条件的预防性就诊的筛查率从75%提高到了85%，后续计划的记录率从66%提高到了87%。只有6.5%的女性筛查呈阳性（爱丁堡产后抑郁量表≥10分）。建议对实施策略进行轻微调整，以提高可接受性、适宜性和可行性。
尽管利用外部促进措施和一系列实施策略，为安全网儿科诊所制定并实施一种可调整的PPD筛查方案似乎可行，但低阳性筛查率表明，需要针对患者、诊所和外部政策环境的交叉情况进行调整，以提高这些诊所中PPD筛查的有效性。
