Theme one: I do my best, but I doubt that it’s enough.

Theme one incorporates three emerging themes: “I was about to say become friends, but it’s the wrong word”- describing the need to establish an open and trusting relationship; “My job is to put another perspective to them”–elucidating strategies in increasing health literacy, promoting mental health and identifying sings of PPD in immigrant mothers, and “You don’t want to make things worse”–expressing the HCPs doubts of their own ability in identifying and supporting immigrant women with PPD.

“I was about to say become friends, but it’s the wrong word”. Five studies [36,38,39,41,42] present findings related to HCPs’ strategies to establish an open and trusting relationship with the immigrant mother, strategies which were needed in order to be able to interpret her mood all the time [38,41].

Trust was seen as the core for getting the mother to be a partner in care and to act on given advice [41]. Besides receiving the immigrant mothers with compassion, dedication and genuine desire to learn more about their culture and understand their situation, being available, receptive and responsive whenever the migrant mother sought help were emphasized as important for building trust [39].

“that they feel that I welcome them as I welcome any fellow human being and that I don’t look down on them or think that they are different, but that we … I was about to say become friends, but it’s the wrong word … but that we have a good relationship. That they feel they are liked and that I listen to them. I think that’s the main thing […] then they trust me […] that’s how I think it works.” [39, p. 741]

Continuity of caregivers was considered as critical in order to be able to build trust, improve symptom monitoring and encourage disclosure of symptoms [36,38,42]. Longer appointments were seen as facilitating for building a relationship and thereby for the woman to feel more comfortable with discussing sensitive issues [41,42]. In two studies, it was suggested that building trust could take longer with immigrant women [39,41]. This was partly due to mothers sometimes lacking understanding of provider confidentiality and fear that it would not be maintained, especially if the HCP was a cultural peer [41]. Another reason was related to expectations of care, where immigrant women had other anticipations of care compared to indigenous women who saw it more like a matter of course [39]. Conditions for building trust were also affected by challenges with communicating through interpreters [39,41].

“My job is to put another perspective to them”. All studies [35–42] contributed to presenting the HCPs’ strategies for identifying signs of PPD in immigrant mothers [5,34,37–39,41], increasing mental health literacy [36,42] and promoting mental health [40].

Flexibility in length of appointments was identified as a facilitator of effective assessment of migrant mothers’ mood [41], which in general was considered more difficult compared to indigenous mothers because of limited mental health literacy and different views of the concept of PPD [35,39,41].

It was a common perception among the HCPs that the concept of PPD was not recognized in some cultures [35,37–39], or at least the condition was not recognized as a “medical” problem [36]. Somatic presentation of “symptoms”, such as headache and back pain [35], and bodily visions of distress as static movements, looking tired and slouching, arouse suspicion among the HCPs [35,39]. Having a stiff facial expression and poor eye contact in combination with an empty sad blank look were specifically reflected on when assessing a mother’s mood. Behaviors such as being a little absent and quiet, not giving information and being in a constant hurry at visits, or alternatively worried and anxious and constantly seeking help, were further interpreted as signs of PPD [39].

Acting as the “navigator” in helping immigrant mothers to become aware of the condition, of different available services, helping them to connect and also to refer them if needed was seen as an important part of the HCPs’ work [41,42].

“My job is to put another perspective to them–this is another explanation for your symptoms in terms of a psychological model of distress.” [35, p. 270]

Any conversations about mental health were perceived as important for planting a seed in the woman’s mind for future reference [42]. Interventions such as mobile applications, social media, community campaigns in local media and handing out multilingual information sheets on PPD were seen as valuable in order to increase mental health literacy in immigrant mothers and make it easier for them to disclose their feelings [36,40,41] and thereby support their help-seeking [35–39]. Mental health was further promoted by the HCPs by arranging social networking through parental program activities [39,40].

“You don’t want to make things worse”. Six studies [35,36,38–41] contributed to describing the HCPs’ feelings of lacking cultural competence and doubts in their own ability to identify and support immigrant women with PPD [36,39,41].

Working with immigrant mothers meant having to deal with complex social realties that included issues that arose from housing difficulties, spousal relationship, illness of supernatural origin and having to find a way through this to uncover a path that would help the mothers [35]. Not feeling professional in caring for this population led to fear of missing mothers with signs of PPD [36].

‘‘it can be tough if you’re not really sure that you truly understand the situation… you might not feel competent in a cross-cultural setting …you don’t want to make things worse.” [36, p. 98]

Some HCPs felt that they would benefit from training in cultural competence [38–41], while others did not think that it would help. They meant that the only solution for developing self-efficacy in their own ability to identify and support immigrant women with PPD were through clinical experience and open-mindedness [36].

Theme two: I can find no way forward.

Three emerging themes characterized the second theme; “A document that non-English speaking women don’t necessarily understand”–describing how the HCPs adapted the challenging screening procedure to the best of their ability; “trying to communicate […] through a translator […] feels like … an exercise in futility”–elucidating lacking a common language as a major perceived difficulty, “They go underground with their symptoms”–expressing cultural understanding of PPD as a barrier and perceived as the reason for many of the challenges connected to performing effective screening.

“A document that non-English speaking women don’t necessarily understand”. Six studies [36–40,42] contributed to describing how the HCPs adapted the screening procedure to the best of their ability, but still it was perceived as challenging [39,42].

Attitudes towards performing screening with the EPDS were in general positive [38–40,42] as the EPDS allowed for more focused discussion around mental health [42] but opinions differed somewhat [36,37]. Executing the screening procedure was considered challenging and the HCPs adapted it to their best ability to make it possible for the immigrant mother to fill out the EPDS depending on her literacy level, access to a translated validated questionnaire in the mother’s own language and the interpreters’ skills [39]. Introducing audio versions of the EPDS to women with low literacy level were suggested for making it possible to complete the questionnaire independently [42]. It was also emphasized how the mother’s educational level affected her ability to understand and fill out the EPDS [37,39,42]. The HCPs tried to normalize the screening by talking about it at earlier appointments and describing it as routine and useful [38]. Many HCPs experienced that immigrant mothers tended to interpret the statements literally [37].

“The [EPDS] is a document that non-English speaking women don’t necessarily understand … plus when you literally translate something like: “do things get on top of you?” the literal translation is: “Is there something on top of your head?” and it’s like, what’s that got to do with anything? Yes, I carry water on top of my head. I carry things on my head, because that’s what I do in Africa. Yes, everyday things get on top of my head.” [37, p.651]

The HCPs were aware of that the EPDS items could be interpreted differently in different cultures and needed further explanation and clarification [38–40,42]. Concerns were raised about the cultural sensitivity and terminology of the EPDS [36,37], for example if mothers who experienced war and persecution could perceive the statements as insensitive or inappropriate [37].

Access to translated screening questionnaires was important, but the literal translations of the EPDS were in some cases considered inadequate [38,40]. Especially the Arabic and Turkish versions of the translated validated questionnaires were perceived as lacking in their translation from the original English version [39].

“[…] trying to communicate […] through a translator […] feels like … an exercise in futility”. All studies described the difficulties of lacking a common language and having to rely on an interpreter as a major perceived barrier to performing effective screening [35–42].

Using an interpreter when screening for PPD was considered helpful but not ideal [37,39,41,42]. The HCPs were dependent on the interpreters’ ability to translate and convey the EPDS, as well as their capacity to translate mothers’ answers in a nuanced and exact way [37,39]. They found that it was hard to apply their regular conversational technique during the clinical interview [39], and having to discuss something as subtle and complicated as emotions through an interpreter aroused frustration [36].

“In my experience, trying to communicate with a woman suffering from PPD through a translator [sometimes] feels like … an exercise in futility.” [36, p.95)].

The HCPs also described other circumstances related to the interpreter which could influence the screening, such as the interpreter’s understanding and acceptance of the sociocultural norms within the mother’s country of origin and the host country [35,37]. If the mother did not trust the interpreter’s confidentiality [37–39] or the interpreter became too friendly [40] she could become apprehensive about disclosing symptoms [35–39]. Likewise, using an interpreter of the opposite sex was perceived as problematic since the mothers then might experience further stigmatization [40] and for this reason the HCPs preferred using on-site female interpreters [38,40]. Altogether the HCPs experienced an uneven quality in the interpreters’ work [38,39] and standardized instructions to the interpreter regarding PPD screening were suggested [38].

“They go underground with their symptoms”. In all studies cultural understanding of PPD was seen as a barrier and the reason for many of the challenges connected to performing effective screening [35–42].

The HCPs spoke of the stigma which existed around mental illness in many cultures, which made the mother unable or unwilling to speak about her mood and accept her own feelings [36,37,41], as did having a poor understanding of PPD [35].

“The impact is that they go underground with their symptoms…so then you are less likely to talk about what you’re feeling.” [41, p. 194]

The HCPs reflected on the fact that even if mothers were able to identify and accept their distress and wanted help, they felt compelled to hide it since they feared being shunned by the family and of bringing shame on the family [36–38]. As a result, the HCPs felt that mothers tended to choose “good” answers in the screening, conveying a positive message of being treated well by the husband, since “bad” answers attracted unwanted attention, implying that the husband did not fulfil his role [37]. Even if the HCPs tried to avoid it situations when the woman completed the questionnaire together with her husband occurred, if an interpreter was unavailable and she was unable to read [2].The HCPs attempted to handle the situation by normalizing mood disorders and trying to get the opportunity to perform screening without the presence of the extended family [41]. Lacking spousal support and validation of the need to seek help was highlighted as barrier to accessing care [36]. Even if the husband seemed positive to his wife wanting or needing support [37] the HCPs knew that many immigrant families kept mental ill-health in the family and did not view professional assistance as a first-line health intervention [39–40]. Another concern which the HCPs had to deal with was mothers’ fear of speaking about depressive symptoms with a person in authority [36,39,40]. There was a general belief among immigrant families that the baby then would be taken away by the Child Protective Services if the parents suffered from mental illness [36].