Innovation summary

Perinatal depression is a significant public health priority in many low and middle income countries (LMICs) that is associated with poor child outcomes and high rates of prevalence1. In Metropolitan Lima, an estimated 28% of women in healthcare settings present with depressive symptoms during pregnancy2. The mental health treatment gap in LMICs compounds the problem of allocation of resources within perinatal depression care2.

In response to a call for more task-shifting approaches to the issue, Partners in Health is bridging this mental health service gap by implementing the Thinking Healthy Programme (THP) in Peru. The innovation resulted from consultations with other community-based mental health programs in Rwanda and Bolivia. THP materials were adapted to suit the context of each site and Community Health Agents in Peru were trained in its delivery. The pilot phase included 10 women in their third trimester and non-specialist Community Health Agents delivered the THP sessions in participant homes under the supervision of mental health specialists. 

Impact summary

  • Ten pregnant women participated in the Thinking Health pilot
  • There was a significant reduction in baseline scores for perinatal depression after re-screening three months after the intervention
  • A total of 26 Community Health Agents were trained in two Thinking Healthy training workshops
  • A total of 82 Thinking Healthy sessions were delivered in participants’ homes by Community Health Agents

"I am happy that mothers [can] understand me and we work together as a team"

-- Jesús, Community Health Agent

Innovation details

Research has shown that the stress of daily life, especially during pregnancy and childbirth, can affect the thinking and attitude of many mothers, making it difficult to meet the multiple demands of child-care1. An intervention for women in this situation can be very effective since research has shown that with the right support, the vast majority of mothers can change these negative patterns into very effective patterns for the optimal development of the baby2.

In low and middle income countries, approximately 20% of mothers suffer from postpartum depression3. The World Health Organization (WHO) recommends integrated and responsive social and mental health care, as well as the application of promotion and prevention strategies to address this issue3.

Partners in Health Peru implemented the WHO’s Thinking Healthy program as a pilot in pregnant women of the Maternal and Child Health Program to receive comprehensive care from the third trimester of pregnancy and with the support of Community Health Agents.

  • Thinking Healthy is an evidence-based intervention that addresses priority mental health conditions, such as perinatal depression.
  • It uses Cognitive Behavioral Therapy strategies to bring about changes in the symptoms and functioning of mothers.
  • It can be administered by community health agents (who have a similar role to community health workers) as it does not require prior knowledge of mental health care or specialized experience in the field.
  • Thinking Healthy helps to change unhealthy ways of thinking through the use of images and can help the person to modify their image in a more positive or positive way
  • Three areas are considered: personal health, the mother's relationship with the baby and the relationship of the mother with her environment
  • The duration of the intervention is 16 sessions and it works from the third trimester of pregnancy to 10 months after the birth of the baby

Key drivers

Sustainability

  • The intervention was conducted in collaboration with the Ministry of Health of Peru, which ensures its sustainability over time.

Ownership

  • It is an intervention delivered by people in the community (Community Health Agents), which gives them ownership and helps the intervention reach more people in the community.

Professionalism

  • Supervision and constant monitoring by professionals ensure that the sessions are delivered according to the training of community agents.

Challenges

Lack of resources for the target population

  • Pregnant women with depression struggle with accessing mental health care in this setting. Addressing this problem by bringing mental health care to the community was one of the rationales behind implementing this pilot.

Funding

  • The program faced challenges in integrating the intervention within Peruvian Guidelines for support to scale-up. One of the reasons was because it was the first implementation of the intervention within the Peruvian setting and it was difficult to secure funding.

Continuation

  • Given that the pilot yielded positive results, the Maternal and Child Health Program has obtained new funds from GCC Canada to scale up this intervention.
  • In 2018, Partners in Health Peru will extend the Thinking Healthy initiative to 60 pregnant women with depression in the northern area of Metropolitan Lima.
  • New training activities have been planned to support the next stage of Peru’s Thinking Healthy implementation.

Partners

Partners in Health - Peru

Evaluation methods

  • Pregnant women were enrolled in the program after being screened on the PHQ-9 and EPDS questionnaires (primary tools).
  • Screening was administered every three months in order to check on the participants’ mental health status.
  • Community Health Agents completed monitoring sheets for the sessions. These were used to reinforce care, provide additional support and ensure the high quality of implementation for the intervention.
  • Each Community Health Agent received at least one visit from a supervisor.
  • Monthly meetings were held with the Community Health Agents to analyze the strengths and limitations experienced through implementation.

Cost of implementation

An analysis of costs was not conducted for this pilot, however the estimated cost of implementing Thinking Healthy was low as the intervention was administered through Community Health Agents who live and work in the intervention area. The materials used are also freely accessible through WHO’s online resources (manual for psychological management of perinatal depression).

Impact details

  • This intervention was administered to 10 pregnant women in the third trimester of pregnancy.
  • None of the women who had depression at baseline screened positive for depression at the end of the intervention.
  • A total of two 4-day trainings on Healthy Thinking were conducted. The first training was attended by 6 Community Health Agents, while the second was attended by 20 Agents as well as personnel from the Ministry of Health, Social Security and Pan American Health Organization (PAHO).

References

  1. Maselko J et al. (2015) Effect of an early perinatal depression intervention on long-term child development outcomes: follow-up of the Thinking Healthy Programme randomized controlled trial. The Lancet Psychiatry, 2(7): 609-617
  2. Aramburu P et al. (2008) Prevalencia y factores asociados a depresión posparto en mujeres atendidas en establecimientos de salud del primer nivel de atención en Lima Metropolitana, junio 2004. Revista Peruana de Epidemiologia, 12(3)
  3. Zhong Q et al. (2014) Comparative performance of patient health questionnaire-9 and Edinburgh Postnatal Depression Scale for screening antepartum depression. Journal of Affective Disorders, 162: 1-7.
  4. Ancaya LC. (2013) Situación de la mortalidad materna en el Perú, 2000-2012. Revista Peruana de Medicina Experimental y Salud Publica, 30(3): 461-464
  5. Perú, Ministerio de Salud. (2009) Plan Estratégico Nacional para la Reducción de la Mortalidad Materna y Perinatal 2009-2015.

Research

Tools

Multimedia
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Country

Peru

Affiliated organizations

Partners In Health

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