Innovation summary

Perinatal depression is a public health priority associated with high prevalence and poor child development. In high income countries (HICs), the value of total lifetime costs of perinatal depression has been estimated to be over $100,000 USD per woman with the condition.1 In low income countries (LICs) where perinatal depression affects 1 in 5 women, this is compounded by a greater mental health treatment gap overall, especially for perinatal depression.2 Thus immediate call for task-shifting to narrow this treatment gap.

As existing health workers are a finite and overburdened resource, there is a need for task-shifting to narrow the treatment gap3. This poses a challenge to scaling up evidence-based perinatal mental health interventions like the WHO adopted Thinking Healthy Programme (THP).

SHARE’s key innovation is to move the boundaries of task-shifting further by using peers (lay women) to deliver THP. Community based peers are an untapped human resource with the potential to address a key barrier to scalability of task-shifting.

Currently, the major research objective of SHARE is to implement and test a variation of the Thinking Healthy Programme for mothers with depression.4 The Thinking Healthy Programme-Peer delivery (THPP) variation features:

  • Culturally-appropriate psychological treatment based on the principles of cognitive behavioral therapy (CBT)
  • Community-level service delivery by lay volunteers
  • Supervision and quality assurance by existing cadres of health workers

Impact summary

  • 6700 pregnant women screened for depression out of a population of 2 million
  • 70 Peers trained in delivering the THPP intervention
  • 420 depressed women receiving THPP 

“In every session I used to ask her [woman participating in THPP] about her mood and her daily routine. She used to tell me what she had done, how she had taken care of her baby. This makes me realize that she is following my suggestions. Moreover the improvement in her says it all”

– A Peer delivering THPP to a depressed woman

Innovation details

The major research objective of the SHARE project is to implement and test the THPP, a variation of the Thinking Healthy Programme (THP) originally developed in Pakistan. It incorporates cognitive and behavioral techniques such as active listening, collaboration with the family and non-threatening inquiry into the family’s health beliefs through challenging beliefs and if necessary offering substitutes for some of these through alternative information. Starting from pregnancy till 6 months postnatal. THPP delivers an established psychological treatment that reduces the burden of depression in mothers in South Asia using an innovative, feasible, effective and sustainable community-based approach. 

The training for Peers is brief (5-7 days) and can be conducted by non-specialists with some experience of using THP in their work. A cascade model of training and supervision has been developed whereby a specialist supervises a number of non-specialist trainers through distance, and the non-specialist trainers cascade this training to the peers.

The primary innovation in the SHARE-THPP approach is the use of peers, who are lay women/peers with no prior health training. The delivery and content of THP are adapted to be:

  • Deliverable by peers (local mothers) in the community
  • Feasible, acceptable, affordable and effective for delivery in varied settings in South Asia
  • Scalable – using a cascade model of training and supervision

SHARE-THPP is adapting and evaluating the intervention for scale-up in two different settings in India and Pakistan:

  • Community-based rural population in Rawalpindi, Pakistan
  • Facility-based urban population in Goa, India

The major difference between the trials is that in Goa, interventions will be delivered one-on-one by peers. In Pakistan, the intervention includes a group session format and is delivered as part of the established village based “Lady Health Worker” program.

An embedded sub-component of this research is the Shared Research project. The Shared Research project is a cross collaborative Hub activity which aims to identify barriers and facilitators to task sharing of mental health services, with the objective of informing future replication and scaling up of services beyond the study sites.

Perceptions of barriers and facilitators to task sharing will be looked at from various perspectives, including those of the trial participant, spouse, peer supervisor and other health professionals. Focus group discussions and in depth interviews will be carried out, and based on the identified barriers and facilitators, tools will be developed. These tools could be used to monitor and evaluate the impact that barriers and facilitators have on task sharing services at scale up.

The literature on barriers and facilitators to task sharing has been reviewed and qualitative data from the formative research examined to identify potential barriers and facilitators across various domains such as logistical, structural, attitudinal and stigma related barriers and facilitators. Topic guides for focus group discussions and in depth interviews are being developed and data collection will begin from the first quarter of 2016.

Continuation

This study has the potential to make a major contribution to reducing the treatment gap and improving health outcomes for depressed mothers in peri-urban settings in South Asia. THPP will advance our knowledge of the extent to which task-sharing can be implemented through lay persons in India and Pakistan, offering a potential opportunity to access a vast untapped human resource for mental health care and addressing a major barrier – the lack of human resources in the formal health sector– to scaling up mental health services in low-resource settings. Triangulating findings of this study with the findings of the concurrent trial evaluating the THPP has the potential to produce results that will be generalizable to the entire region. The knowledge gained could be instrumental in influencing the mental and maternal health policy agenda in the region.

Partners

SHARE is one of the National Institute of Mental Health (NIMH) Collaborative Hubs for International Research on Mental Health. Since 2011, SHARE has brought together a network of sixteen collaborating organizations across South Asia in partnership with academic leaders in global mental health. A five-year program (2011-2016), SHARE aims to reduce the mental health treatment gap in South Asia by generating evidence, building capacity and fostering the uptake of research into policy and practice. The key partners in implementing the goal of SHARE are:

Funder

Evaluation methods

Randomized control trial (RCT) results from Pakistan published in Lancet 2008, demonstrated the effectiveness of the original Thinking Healthy Program (THP) delivered by community health workers (called Lady Heath Workers) in treating perinatal depression and improving infant health like reduced diarrheal episodes and increased vaccine coverage.

SHARE-THPP is now evaluating the effectiveness of THPP, which is delivered by lay peer counsellors, in achieving similar outcomes. We are also evaluating the cost effectiveness of THPP

In Goa, India, the trial design is an individual RCT (as interventions are delivered in an individual format). In Pakistan, the design is a cluster RCT (as interventions include group sessions and are delivered by village-level peers working in close collaboration with existing community health workers i.e the Lady Health Workers).

Both THPP trials are scheduled to end March 2017.

The Capacity Building Component of SHARE in the form of Studentships, Fellowships, Super Course Lectures, Distance Learning Course, Research in Humanitarian Context Course offered for the entire region is already showing impact in the form of junior and mid-level researchers exposed to this are going on to do PhDs and being taken up in other research projects carried out in the region.

SHARE has developed 2 new courses and supported participation of 37 researchers/public health professionals in 5 short courses. In order to build the advance research skills, 8 fellowships were awarded and 3 of these fellows have been successful in winning grants to scale up their fellowship study in the region.

SHARE team maintains a career tracking record of all students and fellows associated with capacity building program and support them through their career development.

SHARE researchers and fellows have published 11 papers in high impact journals. two of these publications were led by SHARE fellows. Early career researchers associated with SHARE were involved and mentored in writing of most of these academic papers. 6 of the SHARE researchers have enrolled for advance research degrees under mentorship of Senior SHARE members.

SHARE core team has facilitated creation of local research networks in Afghanistan and Pakistan to support institutes that lack mechanisms for training  and mentoring in mental health research

Cost of implementation

Costing data will be made available following the conclusion of the trial.

Impact details

Impact data will be made available following conclusion of the trial.

References

  1. Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, Holmes W. (2012) Prevalence and determinants of common mental disorders in women in low- and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization, 90:139-149G
  2. Bauer A, Knapp M, Parsonage M. (2016) Lifetime costs of perinatal anxiety and depression. Journal of Affective Disorders, 192:83–90
  3. Jaskiewicz W, Tulenko K: Increasing community health worker productivity and effectiveness: a review of the influence of the work environment. Hum Resour Health 2012, 10(1):1478-4491
  4. Rahman A et al. (2008) Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet, 372: 902-909.

Research

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Associates

Vikram Patel Co-PI
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