Scale-Up of a Maternal Depression Intervention Through Technology in a Post-Conflict Area
To scale up the Thinking Healthy Programme in a district affected by multiple humanitarian crises
Application of technology assisted assessment, training and supervision tool to the Thinking Healthy Programme (an established evidence-based intervention)
Prevalence of maternal depression in low and middle income countries (LMIC) range between 18-25%.1 In Pakistan the mean prevalence of depression is 33%, with women at a greater risk than men.2 Untreated depression in pregnant women and/or mothers is of particular concern due to its adverse effects on the health of the mother and infant. Research has shown maternal depression to be linked with pre-term birth, low birth weight and undernutrition in the first year of life, higher rates of diarrhea, and early cessation of breastfeeding.3-5 Evidence based interventions for depression exist but there is slow progress in the “know-do gap”: the gap between what is known and what gets implemented in LMICs.6-8 The burden of illness can be reduced by narrowing this gap through scale up of proven interventions, however major barriers - costs, equity and quality concerns, service delivery issues, and the supply of additional human resources - often limit scale up of the proven interventions.9-10
The Thinking Healthy Programme (THP) is a cognitive behavior therapy (CBT)-based intervention for maternal depression, delivered by lady health workers (LHW).11 This innovation will scale up the THP, assisted by a technology-assisted assessment, cascade training and supervision (TACTS) system which:
- Diagnoses depression in the community
- Standardizes training so that a specialist trainer is not needed
- Allows specialists to supervise the LHW program supervisors remotely
- 80 community health workers and 4 community health supervisors were trained in treating maternal depression
- 12,000 women were screened for maternal depression using a door-to-door survey
- The cost evaluation shows a 37% reduction in training costs through the use of technology compared to training by specialists
“Training of LHWs has become difficult because of the regional conflict."
- LHW study participant
Region of Study
The study will be conducted in the district of Swat, which has been affected by multiple humanitarian crises including military operations in 2009 and floods in 2010. The health system is weak and fragile. The rationale for selecting this challenging area as the field site is twofold:
- Large parts of the world’s population are increasingly affected by humanitarian crises and research into delivery of effective interventions for this population is scarce
- By choosing a site with multiple challenges both at the community and health systems level the study will demonstrate proof of concept in the most difficult settings so it is generalizable to any setting
Objective and Innovation
The main objective of this study is to scale up the THP, a cognitive behaviour therapy (CBT)-based intervention for maternal depression, delivered by LHWs (non-specialists).11
In a recent meta-analysis commissioned by the World Health Organization (WHO), THP was shown to have the largest effect and has been adopted by the WHO for global dissemination through its mhGAP programme.6 However, a major challenge in scaling up of this evidence-based intervention is the provision of training and supervision at scale, especially in post-conflict areas with weak health systems. The study team aims to meet this challenge by providing a technology based solution. Building on the team’s previous work in this area, a technology-assisted assessment, cascade training and supervision (TACTS) system will be developed which will include:
- A technology assessment tool to diagnose depression in the community
- A tablet-based manual allowing standardized training to be delivered without the need for a specialist trainer
- A cascade training model whereby specialists supervise, from distance, the LHW program supervisors, who in turn, supervise the LHWs as part of their normal routine
The LHW Programme covers 85% of Pakistan’s rural population through 115,000 LHWs. Through this technological solution for their training and supervision, they have the potential to provide treatment to an estimated 5 million women in rural Pakistan with maternal depression.
The project will be implemented in two phases:
Phase 1 (months 0-12)
TACTS will be developed in partnership with technology experts at the Human Development Research Foundation. This will include the mobile-phone based detection tool, the tablet based training manual, and the cascade model of supervision. The instruments for evaluation of the system will also be developed.
Phase 2 (months 13-24)
Evaluation of TACTS in district of Swat Union Councils through a feasibility cluster trial.
Instability and Weak Health System
The unstable political situation and the weak health system may be a barrier to achieving the proof of concept. However, given existing collaborations and work, the team is confident that they will deliver the project in this challenging setting.
Use of IT technology developed for training and supervision has a great potential to be used in the health sector and the software technology developed will be transferable to other types of trainings. Dissemination of the technical software materials to international networks in health, social services and mental health consortiums will pave the way for future international partners to use these materials to deliver cost-effective, evidence and community based mental health interventions in other contexts.
The TACTS model will be shared with the WHO which will then be made available to other countries. Additionally through the team’s partnerships with other organizations, this model will be potentially implemented at scale in other post-conflict settings.
Feasibility Cluster Trial
TACTS will be evaluated in four union councils of the district of Swat through a feasibility cluster trial. A union council is the smallest administrative unit in a district, with a population of 15,000-25,000, covered by about 15-20 LHWs and a supervisor.
In the two intervention union councils, the TACTS system will be implemented through the LHW program. In the two comparison union councils, the THP will be delivered in the conventional way through detection of cases by traditional paper-pencil screening conducted by the LHWs, and specialist-led training and supervision.
Outcomes will include the rates of detection of depressed cases in the community, competency levels achieved by the LHWs in delivering THP, and the cost of delivery of the two models. The evaluation will be conducted by trained assessors who will be blind to the allocation status. Feasibility and acceptability of TACTS will be assessed through qualitative methods
Cost of implementation
Cost will be estimated at the end of the project
12000 women were screened for maternal depression using door to door survey. The original target was 6,000 women, of whom 2,000 would receive the THP intervention based on Pakistan's depression rate (33%).2
80 community health workers and 4 community health supervisors have been trained in treating maternal depression to cover a population of 1,26000. An RCT showed that community health workers trained through technology were as competent in intervention delivery skills as those who were trained by specialists.
There has been a 37% reduction in training costs through using technology as opposed to training by specialists.
- Fisher J et al. (2012) Prevalence and determinants of common perinatal mental disorders in women in low- and lower middle- income countries: a systematic review. Bulletin of the World Health Organization.
- Mirza I et al. (2004) Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. British Medical Journal, 328:794.
- Grote NK et al. (2010) A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Archives of General Psychiatry, 67(10):1012–1024.
- Surkan PJ et al. (2011) Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis. Bulletin of the World Health Organization, 89(8):608–615.
- Wachs TD, et al. (2009) Maternal Depression: A Global Threat to Children's Health, Development, and Behavior and to Human Rights. Child Development Perspectives, 3:51–59.
- Rahman A et al. (2013) Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis. Bulletin of the World Health Organization, 91:593–601.
- Eaton J et al. (2011) Scale up of services for mental health in low-income and middle-income countries. The Lancet, 378 (9802): 1592–1603.
- Pablos-Mendez A et al. (2006) Knowledge translation in global health. Journal of Continuing Education in Health Professions, 26:81–86.
- Mangham LJ. (2010) Scaling up in international health: what are the key issues? Health Policy and Planning, 25:85–96.
- Van Damme W. (2008) Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: how will health systems adapt? Social Science and Medicine, 66: 2108–2121.
- 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. The Lancet, 372: 902–909.