Perinatal Depression Screening and Management Program Within Primary Health Care in Hefei,Anhui: Lessons on Cross-Cultural and Mental Health Qualitative Research

Women in Anhui experience some of the highest rates of perinatal depression in Mainland China (Nisar et al., 2020). The design and delivery of a screening and management program has potential to reduce mental suffering as well as to benefit the children and families of perinatal women (Madigan et al., 2018). As rural-urban disparities in access to mental health providers and services persist in China (Wang et al., 2020; Yin et al., 2020), digital health technologies, including internet-based cognitive behavioral therapy, are well positioned to address these disparities and health system capacity issues (Zhang et al., 2021). Psychological and psychosocial interventions for perinatal depression have shown promise in China, but further cultural adaptation of psychotherapy (Ng et al., 2017) and implementation science research is needed to evaluate strategies to promote uptake of evidence-informed knowledge tools (Koç & Kafa, 2019; Ng et al., 2017).

In this commentary, we share insights gained from the cross-cultural qualitative research process involved in exploring stakeholders’ perceptions of a perinatal depression screening and management program in Hefei, Anhui (Premji et al., 2021). Our team comprised members from both China and Canada. Our principal team members each have over 25 years’ experience in perinatal health research in China and Canada, including leading longitudinal cohort studies of maternal psychosocial health as well as providing clinical and mixed methods design expertise. Perinatal women, policy makers, and health care staff participated in interviews and focus groups during a pilot study at the Ma’anshan Maternal and Child Healthcare Center, Ma’anshan city (Premji et al., 2021). Interviews were audio recorded, transcribed, translated to English, and back-translated to Mandarin Chinese. Institutional review board approval was obtained at four universities and all participants provided informed consent.

During this stage of the project, we were interested in understanding acceptability and feasibility from the perspective of women, partners, and family members seeking care. Qualitative research in China presents unique considerations including adapting to sociocultural and political norms, addressing self-censorship, and the importance of achieving guanxi (relationship) (Lawrence, 2022). Linguistic and cultural diversity within China as well as marked disparities in education, health literacy, and socioeconomic status in rural areas must also be considered (Liu & Zhang, 2019; Wang et al., 2020). Consequently, cross-cultural qualitative research within these contexts necessitates preparation and adaptation throughout the research process to respond to external factors, ensure participants’ safety, and achieve cultural integrity (Lawrence, 2022; Pelzang & Hutchinson, 2018).

A Focus on Guanxi and Power Relations

Guanxi refers to the connections and relationships of social life. A close and warm guanxi lays the solid foundation for almost all types of human interactions in Chinese society, especially in mainland China (Bian, 2002). Davies et al. (2003) underscored the importance of this idea: “without guanxi, one simply cannot get anything done” (p. 43). Therefore, building guanxi with others is an important social practice to reduce social distance and become more connected within encounters. Once you have built guanxi with a group, you have entered their circle and information sharing becomes more natural.

During our qualitative study, interviewers first met participants when they conducted the interviews, which is a standard practice in Western culture. This arrangement, however, may not have facilitated optimal negotiation of information during interviews when applied to the sociocultural context in Ma’anshan city. Researchers are the “data collection instrument” (Bourke, 2014, p. 2) in qualitative research and thus their personal, political, and social status affect the study process (Bourke, 2014). Without a well-established rapport with the interviewer, participants may position the interviewer as a member of an outer group and restrict their communication or limit the depth and breadth of information that they share. Xu et al. (2018) also suggested that the stigma associated with mental illness tends to be greater in populations with fewer years of education. Our interviews were conducted in a small county close to the capital city (i.e., Hefei) of Anhui province, where the overall education level is relatively low (安徽统计年鉴, 2020). The interviews asked questions related to perinatal depression, which may be considered a controversial and sensitive social topic for participants. For instance, when one participant, the husband of a pregnant woman, was asked to share his understanding and opinions about perinatal depression, he labeled perinatal depression a “horrible” illness. Moreover, women who experience depression, or their family members, may be reluctant to genuinely share their opinions or may have difficulty expressing their ideas depending on their constructions of depression. Furthermore, these constructions impact perceptions of assessment and treatment as well as health care–seeking behaviors. One participant described “seeing a psychiatrist or psychologist is stressful because [pregnant women] will be worried about being diagnosed with a mental illness.” Therefore, a strong guanxi with participants prior to interviews is a necessary step to engage participants in more interactive and sensitive conversations.

While initially reviewing interviews, we questioned whether some participants may have regarded the interviewer as a government official who worked for the hospital where the interviews took place, despite the interviewers introducing themselves as researchers independent of the hospital. Similarly, when participants were asked their opinions about the screening and implementation program, participants positioned themselves as followers of authority. For instance, during one interview, a participant stated: “You are in the same system, right?” China is a high-power distance country thus people with less power within an organization or society have greater acceptance of the established hierarchy and unequal power distribution (Zhou & Nunes, 2013). This contributes to societal order and may manifest in acquiescence rather than open discussion, questioning, or challenging people who hold higher power (Zhou & Nunes, 2013). In this case, the perception of considering the interviewer as a member from a higher power group may have contributed to self-censorship and the possible generation of what would be considered acceptable responses thereby impacting participants’ ability and willingness to express themselves candidly.

Concept Analysis as a Strategy

During our analysis, we noted the frequency with which the idea of “talking” was presented by participants. “Talking” has nuanced meanings within psychotherapy (Marx et al., 2017), and in China, the construct of “talking” may involve perceptions of mental illness being morally inappropriate thinking (Yu et al., 2018). Talking, therefore, may relate to correcting an individual’s fault by providing moral guidance to return respectful attitudes and sense of peace (Yu et al., 2018). We propose a concept analysis of “talking” within the sociocultural contexts of Hefei as a next step to provide a deeper and more nuanced understanding of how “talking” may be conceptualized by women and families engaged in a perinatal depression screening and management program. For instance, “talking” may involve various perceptions, intentions, responses, and interventions borne out of any combination of pathology, stigma, worry, safety concerns, presence, empathy, and understanding. In addition, “talking” in these contexts is situated within broader forces of collectivist social and cultural norms, which accentuate group harmony over individual interests (Hofstede, 2011). Further exploring how women and families envision “talking” as a means to support perinatal women experiencing depression would help adapt program components to and optimize providers’ roles to specific sociocultural contexts.

Implications

This commentary describes our team’s experience conducting qualitative analysis in a cross-cultural and perinatal context in Mainland China. This project provided learning opportunities for our team to discover that studying perinatal mental health in China through Western lenses had some subtle but profound cultural implications. Our experiences underscore the various complexities that shape access to and interpretation of participants’ knowledge in a cross-cultural context. Sociocultural constructions of mental health in China, guanxi, and power relations are likely to shape data collection and analysis for similar projects. We highlighted the value of culturally nuanced approaches, concept analysis, and the importance of probing in cultivating in-depth and authentic discussions with participants. The strategies we have suggested may be useful to researchers who plan and conduct cross-cultural mental health research, as well as clinicians and stakeholders who undertake cross-cultural implementation science research.