Risk and resilience: a mixed methods investigation of Aboriginal Australian women's perinatal mental health screening assessments

Investigating Protective and Risk Factors and Predictive Insights for Aboriginal Perinatal Mental Health: Explainable Artificial Intelligence Approach

BACKGROUND

Perinatal depression and anxiety significantly impact maternal and infant health, potentially leading to severe outcomes like preterm birth and suicide. Aboriginal women, despite their resilience, face elevated risks due to the long-term effects of colonization and cultural disruption. The Baby Coming You Ready (BCYR) model of care, centered on a digitized, holistic, strengths-based assessment, was co-designed to address these challenges. The successful BCYR pilot demonstrated its ability to replace traditional risk-based screens. However, some health professionals still overrely on psychological risk scores, often overlooking the contextual circumstances of Aboriginal mothers, their cultural strengths, and mitigating protective factors. This highlights the need for new tools to improve clinical decision-making.

OBJECTIVE

We explored different explainable artificial intelligence (XAI)-powered machine learning techniques for developing culturally informed, strengths-based predictive modeling of perinatal psychological distress among Aboriginal mothers. The model identifies and evaluates influential protective and risk factors while offering transparent explanations for AI-driven decisions.

METHODS

We used deidentified data from 293 Aboriginal mothers who participated in the BCYR program between September 2021 and June 2023 at 6 health care services in Perth and regional Western Australia. The original dataset includes variables spanning cultural strengths, protective factors, life events, worries, relationships, childhood experiences, family and domestic violence, and substance use. After applying feature selection and expert input, 20 variables were chosen as predictors. The Kessler-5 scale was used as an indicator of perinatal psychological distress. Several machine learning models, including random forest (RF), CatBoost (CB), light gradient-boosting machine (LightGBM), extreme gradient boosting (XGBoost), k-nearest neighbor (KNN), support vector machine (SVM), and explainable boosting machine (EBM), were developed and compared for predictive performance. To make the black-box model interpretable, post hoc explanation techniques including Shapley additive explanations and local interpretable model-agnostic explanations were applied.

RESULTS

The EBM outperformed other models (accuracy=0.849, 95% CI 0.8170-0.8814; F1-score=0.771, 95% CI 0.7169-0.8245; area under the curve=0.821, 95% CI 0.7829-0.8593) followed by RF (accuracy=0.829, 95% CI 0.7960-0.8617; F1-score=0.736, 95% CI 0.6859-0.7851; area under the curve=0.795, 95% CI 0.7581-0.8318). Explanations from EBM, Shapley additive explanations, and local interpretable model-agnostic explanations identified consistent patterns of key influential factors, including questions related to "Feeling Lonely," "Blaming Herself," "Makes Family Proud," "Life Not Worth Living," and "Managing Day-to-Day." At the individual level, where responses are highly personal, these XAI techniques provided case-specific insights through visual representations, distinguishing between protective and risk factors and illustrating their impact on predictions.

CONCLUSIONS

This study shows the potential of XAI-driven models to predict psychological distress in Aboriginal mothers and provide clear, human-interpretable explanations of how important factors interact and influence outcomes. These models may help health professionals make more informed, non-biased decisions in Aboriginal perinatal mental health screenings.

Aboriginal young people's experiences of type 2 diabetes diagnosis, management and support: A qualitative study in the Kimberley region of Western Australia

ISSUES ADDRESSED

In Australia, Aboriginal and Torres Strait Islander young people in remote settings are most-affected by young onset type 2 diabetes (T2D). It is necessary to understand young people's experiences, including factors impacting on self-management, to improve models of care.

METHODS

A phenomenological methodology underpinned this qualitative study in Western Australia's Kimberley region. Two Aboriginal Community Controlled Health Services supported recruitment of seven Aboriginal young people aged 12-24 with T2D, who participated in interviews. A carer and health professional of one young person in each site were also interviewed and relevant medical record data reviewed to assist with triangulation of data. De-identified transcripts were inductively coded and a coding structure developed with oversight by a Kimberley Aboriginal researcher.

RESULTS

Young people reported varied experiences and emotions relating to a T2D diagnosis. Most recounted this was upsetting and some reported current negative impact on emotional wellbeing. Challenges with understanding and managing diabetes were highlighted, particularly regarding healthy eating, physical activity and medication. Family are a prominent source of self-management support, with the intergenerational impact of diabetes being evident for each participant. Positive relationships with health professionals, entailing continuity of care, were valued.

CONCLUSIONS

There are significant emotional and medical challenges for young people with T2D and their families. Recommendations from this work will contribute to the development of local resources and initiatives to improve diabetes-related support. SO WHAT?: Alongside broader efforts to support good health at the societal level, enhanced health education and family-oriented support structures including Aboriginal clinical staff for young people with T2D are needed.

Identifying psychosocial vulnerabilities in pregnancy: A mixed-method systematic review of the knowledge base of antenatal conversational psychosocial assessment tools

BACKGROUND

Early identification of psychosocial vulnerability among expectant parents through psychosocial assessment is increasingly recommended within maternity care. For routine antenatal assessment, a strong recognition exists regarding conversational assessment tools. However, the knowledge base of conversational tools is limited, inhibiting their clinical use.

OBJECTIVE

Synthesising existing knowledge pertaining to antenatal conversational psychosocial assessment tools, including identifying characteristics, acceptability, performance, effectiveness and unintended consequences.

DESIGN

Mixed-method systematic review based on searches in CINAHL, PubMed, Embase, PsycINFO, Cochrane and Scopus. 20 out of 5394 studies were included and synthesised with a convergent integrated approach using a thematic analysis strategy.

FINDINGS

We identified seven antenatal psychosocial assessment tools that partially or completely utilised a conversational approach. Women's acceptability was high, and tools were generally found to support person-centred communication and the parent-health care professional relationship. Evidence regarding effectiveness and performance of conversational tools was limited. Unintended consequences were found, including some women having negative experiences related to assessment of intimate partner violence, lack of preparation and lack of relevance. High acceptability was reported by health care professionals who considered the tools as valuable and enhancing of identification of vulnerability. Unintended consequences, including lack of time and competencies as well as discomfort when assessment is very sensitive, were reported.

CONCLUSIONS

Evidence regarding conversational tools' effectiveness and performance is limited. More is known about the acceptability of conversational tools, which is generally highly acceptable among women and health care professionals. Some unintended consequences of the use of included conversational tools were identified.

Resilience and mental health among perinatal women: a systematic review

OBJECTIVE

This review aimed to assess the current evidence on the relationship between resilience and mental health employed in response to the impacts of mental health.

METHOD

This review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). The protocol of this review was registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023470966). Three authors searched peer-reviewed articles using several electronic databases, including Scopus, PubMed/MEDLINE, Psych Info, EMBASE, and Web of Science, from September to October 2023 and included all the studies from any time until November 1, 2023. The review included all eligible quantitative observational and qualitative studies, irrespective of geographical boundaries.

RESULT

Depression, anxiety, and post-traumatic stress disorders were found to be the most common, but not the only, mental health disorders during the perinatal period, and higher maternal resilience during perinatal periods was found to reduce mental health disorders. It was also found that pregnant women were more resilient to mental health disorders than postpartum women. Tolerance of uncertainty and a positive cognitive appraisal, women's self-behavior and family functioning, and protective psychosocial resources such as dispositional optimism, parental sense of mastery, self-esteem, gratitude, and forgiveness were found to be the most common mechanisms of resilience among perinatal women. Older age, having an adolescent partner, family income, and distress were found to affect resilience.

CONCLUSION

Noting that women's resilience is an important tool to prevent perinatal mental health disorders, maternal healthcare providers need to counsel perinatal women on resilience-boosting mechanisms, such as applying self-behavior and having social support or close family relationships. It is recommended to counsel or provide psychosocial interventions for the woman's companion or partner to give strong support for the woman in each of the perinatal periods.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=470966, identifier CRD42023470966.

Mixed-methods study exploring health service access and social support linkage to the mental well-being of Canadian Indigenous pregnant persons during the COVID-19 pandemic

OBJECTIVES

This study aimed to explore how the unprecedented stressors associated with the COVID-19 pandemic may have contributed to heightened levels of depression and anxiety among pregnant Indigenous persons, and identify protective individual-level factors.

DESIGN

The current study used a mixed-methods design including standardised questionnaires and open-ended response questions. Using hierarchical regression models, we examined the extent to which COVID-19-related factors of service disruption (ie, changes to prenatal care, changes to birth plans and social support) were associated with mental well-being. Further, through qualitative analyses of open-ended questions, we examined the coping strategies used by pregnant Indigenous persons in response to the pandemic.

SETTING

Participants responded to an online questionnaire consisting of standardised measures from 2020 to 2021.

PARTICIPANTS

The study included 336 self-identifying Indigenous pregnant persons in Canada.

RESULTS

Descriptive results revealed elevated rates of clinically relevant depression (52.7%) and anxiety (62.5%) symptoms among this population. 76.8% of participants reported prenatal care service disruptions, including appointment cancellations. Thematic analyses identified coping themes of staying informed, social and/or cultural connections and activities, and internal mental well-being strategies. Disruptions to services and decreased quality of prenatal care negatively impacted mental well-being of Indigenous pregnant persons during the COVID-19 pandemic.

CONCLUSIONS

Given the potential for mental well-being challenges to persist and long-term effects of perinatal distress, it is important to examine the quality of care that pregnant individuals receive. Service providers should advance policies and practices that promote relationship quality and health system engagement as key factors linked to well-being during the perinatal period for Indigenous persons.

Exploring Mental Health Presentations in Remote Aboriginal Community Controlled Health Services in the Kimberley Region of Western Australia Using an Audit and File Reviews

The study aims to explore the role of mental health care in remote Aboriginal health services in the Kimberley region of Western Australia and provide a more nuanced understanding of the patients presenting for care, their needs, and the clinical response. Little is currently known about primary health care presentations for mental health, suicide, and self-harm for remote dwelling Aboriginal residents of the Kimberley region, despite high rates of psychological distress, self-harm, and suicide across the area. This study was progressed through a retrospective, cross-sectional audit of the electronic medical records system used by three remote clinics to explore the interactions recorded by the clinics about a patient's mental health. In addition, an in-depth file review was conducted on a stratified purposive sample of 30 patients identified through the audit. Mental ill-health and psychological distress were found to be prominent within clinical presentations. Psychosocial factors were frequently identified in relation to a patient's mental health presentation. Optimizing patients' recovery and wellness through service improvements, including an enhanced mental health model of care, is an important next step.