Implementing WHO Thinking Healthy Program in A Population of Iranian Pregnant Women with Depression and its Impact on Infant Outcomes

doi:10.21203/rs.3.rs-3901039/v1

Download PDF

Research Article

Implementing WHO Thinking Healthy Program in A Population of Iranian Pregnant Women with Depression and its Impact on Infant Outcomes

https://doi.org/10.21203/rs.3.rs-3901039/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

Maternal depression during pregnancy and after delivery can affect the mother's relationship with the baby as well as the physical growth and development of the child. The purpose of this study was to investigate the effect of Thinking Healthy Program (THP) of the World Health Organization (WHO) which is an evidence-based intervention for the treatment of depression in in pregnant women, on infant outcomes up to 6 months after birth.

Method

This interventional study was conducted on 80 depressed pregnant women, completing all relevant questionnaires from August 2021 to March 2022, in Tehran, Iran, who were randomly divided into 2 groups of 40 participants in intervention (THP provided by healthcare liaisons) and control group (receiving routine care), and followed up to 6 months after delivery. Beck, Edinburgh, Ages & Stages Questionnaires (ASQ) were completed for all participants, and anthropometric indices of the newborn, child development, breast feeding, and gastrointestinal infections were assessed in the infants.

Result

In the 80 infants studied, weight at birth (3249.5 vs. 3042.5gr, P-value: 0.03), weight difference (birth- 4 months; 4354 vs. 4084 g, p-value: 0.02), height difference (4–6 months; 3 vs. 1 cm, P-value: 0.001), head circumference difference (4–6 months; 2 vs. 1 cm, P-value: 0.001), and ASQ score at 6 months of age (290 vs. 265, P-value: 0.001) were higher in the infants of the intervention group. Diarrhea (10% vs. 52.5%, P-value: 0.001) and respiratory infections (7.5% vs. 40%, P-value: 0.001) were less frequent, and 6 months exclusive breastfeeding rates (85% vs. 27.5%, P-value: 0.001) were higher in the intervention group; thus showing the effectiveness of THP.

Conclusion

This program led to the promotion of infant outcomes in the field of growth and development, and showed that this program can be implemented in Iran's health system and is effective for improving the health of children.

Pregnancy

Healthy Program

Cognitive Behavioral Therapy

Postpartum

Depression

Infant

1. Implications for policy-makers

Publishing the localized version of the healthy thinking program of the World Health Organization and sending it to all health centers that offer services for pregnant women.
Training health workers, excluding psychologists, in the program through workshops to ensure that a majority of them are fully knowledgeable about its content.
Training health liaisons by trained health staff.
Screening pregnant women for depression during pregnancy using valid tools in a suitable and serene environment.
Training health workers to properly manage pregnant women during pregnancy care visits, or if feasible, providing services by health liaisons under the supervision of trained health workers.

2. Implications for public

For This study focused on pregnant women with depression who underwent an educational intervention that lasted until 6 months after giving birth. The results showed that this intervention effectively helped the mothers, leading to an improvement in their mood and a reduction in depression. The mothers' relationship with their baby, as well as their family, improved. Furthermore, the decrease in maternal depression had a positive impact on the physical and intellectual development of the child. It was observed that these mothers were able to successfully breastfeed for up to 6 months after delivery, which is highly beneficial for both the mother and the child. The intervention also provided these mothers with essential training on sexual health during pregnancy and postpartum. These mothers had a higher rate of natural childbirth, which is considered much safer than cesarean section. Overall, this intervention significantly contributed to the well-being of the mother, baby, and family.

Assessment and treatment of depression in adults is usually challenging. Depression has been identified as the "evil of the 21st century" due to generational effects, and it is inferred that this "evil" may have been exacerbated by the COVID-19 pandemic ⁽¹⁾. Postpartum depression (PPD) is common, debilitating, and treatable ⁽²⁾. The prevalence of postpartum depression in low- and middle-income countries is much higher than in high-income countries ⁽³⁾. In a recent meta-analysis, this rate was even higher and varied from 18–25% in low- and middle-income countries (LMICs) ⁽³⁾. In a systematic review conducted in 2019 in Iran, the prevalence of gestational depression was between 11.8% and 24.98% ⁽⁴⁾. In addition to maternal pain and suffering, prenatal depression was also associated with increased premature birth, low birth weight, poor breastfeeding, more bouts of diarrhea, and poor cognitive development in infants ⁽⁵⁾.

Psychological problems are partly based on faulty or unhelpful ways of thinking, which is based on learned patterns of unhelpful behavior. CBT treatment usually involves attempts to change thought patterns. It is also learning to recognize one's own mental deviations that cause problems and then reevaluate them based on reality and gain a better understanding of the behavior and motivation of others ⁽⁶⁾.CBT, administered in different formats, is an evidence-based intervention that has been recommended as the first psychological intervention for the treatment and prevention of prenatal depression ⁽⁷⁾. There have been reports on the effectiveness of psychosocial interventions administered by non-psychologist healthcare workers, such as health workers, nurses, healthcare liaisons, and midwives, over the past few years ⁽⁸⁾. The results of studies show the positive effect of educational interventions for health liaisons in various health-related issues, therefore, by conducting educational interventions for health liaisons, an important role can be played in the health of society⁽⁹⁾.

The Thinking Healthy Program (THP) is part of the World Health Organization (WHO) mental health Gap Action Programme (mhGAP), which has been translated into several languages and is being tested in several countries ⁽¹⁰⁾. This program includes one or two introductory sessions and 5 modules, which starts from the second trimester of pregnancy and continues until one year after the birth of the child. Each module consists of 3 sessions. In each module, the first session is devoted to "mother's personal health", the second session deals with "mother's relationship with child" and the third session with "mother's relationship with others". In every session of each module, the initial step involves identifying unhealthy thinking patterns in the mother. Subsequently, the mother undergoes training to replace these unhealthy thoughts with positive and healthy ones. Finally, the mother is given the opportunity to practice and demonstrate her newfound healthy thinking patterns.THP is an example of a CBT-based psychosocial intervention developed in Pakistan to be delivered by community health workers without prior training in mental health ⁽¹¹⁾. One of the most important features of this program is that non-psychologists can be trained to administer it under expert supervision, and the intervention can be integrated into primary and secondary healthcare ⁽¹²⁾. The translation, localization, and administration of the program in China in 2020 showed that THP is acceptable and transferable to the health and cultural context of China and that healthcare workers and nurses can be good providers of this program ⁽¹³⁾.

In Iran, there is a lack of mental health professionals in health centers who can cater to the needs of pregnant women suffering from depression, leading to a shortage of human resources in this area, since these workers are responsible for administering numerous psychological programs developed by the Ministry of Health and Medical Education (MoHME), it seems that pregnant women do not receive adequate optimal services in this context. The fact that Iran is under various economic sanctions and that the COVID-19 pandemic has exacerbated mental problems, means that the impact on the quality of mental health services received during pregnancy is now more severe than ever. Therefore, after the translation and localization of this program, healthcare liaisons were recruited to administer the program to pregnant women suffering from depression. The purpose of this study is to measure the effects of the implemented THP program in women with pregnancy depression, on infant outcomes in Iran.

Study procedure and participants

This study was an interventional study that was conducted from August 2021 to March 2022. The target population were depressed pregnant Iranian women in their 20 to 28 weeks of pregnancy who were followed up to 6 months after delivery. The intervention was carried out in healthcare centers and health stations located in the south of Tehran and affiliated with Tehran University of Medical Sciences. The South Tehran Health Center includes 29 healthcare centers, each covering two to five health stations ⁽¹⁴⁾. It also has four health houses, two counseling centers for behavioral diseases, and a specialized psychiatric center for primary health services. The health stations provide primary health services such as maternal care, infant care, school health, and nutrition; the healthcare centers, however, provide medical, dental, psychological, and environmental health services in addition to the former ⁽¹⁵⁾. Each health station covers up to 12,500 people. Services for pregnant women are provided by a healthcare provider (midwife) with a bachelor's degree. In most healthcare centers, there is a psychologist who provides psychological services to children, adolescents, pregnant women, and older adults ⁽¹⁶⁾.

The inclusion criteria for this study were: depressed pregnant women in 20 to 28 weeks of pregnancy with no prior or present psychiatric disorders that require medical intervention such as schizophrenia, bipolar disorder, etc. based on psychiatrist/psychologist diagnosis, singleton pregnancy, Iranian citizenship, minimum reading and writing literacy, absence of chronic diseases, access to a smartphone and WhatsApp use. The required evaluations were made by examining the mothers' health records, posing questions to the mothers, and recruiting the psychologist to diagnose any mental illnesses in the mother. The exclusion criteria were: unwillingness to participate in the study, adverse events (death of a close relative, severe accidents, etc.), stillbirth, or infant death.

To recruit eligible pregnant women, the researcher was provided with an inventory of pregnant women and their phone numbers by the authorities in charge, and made phone calls and briefed the candidates on the program, then the Beck’s Depression Inventory-II (BDI-II) andThe Edinburgh Postnatal Depression Scale(EDPS) were sent to them through WhatsApp application. The researcher then reviewed the completed questionnaires, and if the mothers scored 13 or higher on EDPS (17), and 16 or higher on BDI-II (18), they were considered as depressed, and were invited to participate in the study. If the mothers were willing to participate, an informed consent form was completed by each of them.

Health Liaisons

In Iran's health system and in urban and rural health centers, there are people with the title of health liaison. These people cooperate with health centers on a voluntary basis. Health liaisons are periodically trained by midwives and health care workers in health centers to perform some of the tasks assigned to them. The main activities of the health liaisons include: covering up to 50 households, identifying people who need health care in the covered households, regular attendance in public education classes, identifying and following up the health problems of the neighborhood and reporting them to the officials of the health center, conveying educational material and messages to households and other members of society, group participation in cultural and social artistic activities.

According to the protocol of the World Health Organization, the implementation of THP should be done by people who are not experts in the field of psychology, because its goal is to fill the gap in mental health services and integrate them into primary health care at the lowest cost in low- and middle-income countries. This program has been carried out in different countries with the same method and has been successful

To administer the program, the researcher went to the health centers, and obtained the list of health liaisons from the relevant official and the liaisons who were qualified (minimum diploma education, high motivation and good service record) were selected, and contacted; while introducing the work and program, they were asked to declare their readiness if they wanted to cooperate. Then, healthcare liaisons received 10 sessions of training in the form of group discussion, role playing, question and answer, etc. under the supervision of a psychology professor and the researcher who had completed a CBT course and 80 hours of online training offered by an experienced psychologist. After the end of the course, their competence was determined through the ENACT checklist and the intervention was started by them. Also, continuous monitoring of their performance was implemented.

After obtaining permission from the original developers of ENACT (ENhancing Assessment of Common Therapeutic Factors) for translating and using their tool, the researcher received the latest version of this tool and carried out the standard procedures of its localization for Iran. This checklist was used to check the competence of the healthcare liaisons for administering THP, and those who scored 70% or higher ⁽¹⁹⁾ were deemed eligible.

Intervention

The mothers in the intervention group (n = 40) received the WHO's THP, which has been localized in Iran and some changes have been made in it, and is an evidence-based intervention with CBT strategies ^{(11, 20, 21)}. The intervention was performed from the second trimester of pregnancy and lasted up to 6 months after delivery in the form of 4 modules: the first module consists of 4 sessions during pregnancy, each of the second, third and fourth modules were administered in 3 sessions with intervals of 2 to 4 weeks in the postpartum period. Due to the COVID-19 pandemic conditions, the program was implemented online through WhatsApp application by five healthcare liaisons. This group also received the MoHME protocol for the care of depressed pregnant women in addition to the routine care provided to pregnant women by healthcare workers.

The intervention consisted of a face-to-face introductory session in which the mothers were given a health calendar plus training on it; there were also four virtual training modules using WhatsApp, the first module was conducted from the second trimester of pregnancy to the 40th week of pregnancy, or delivery (four sessions), and the other three modules were presented until six months post-partum; the 2nd, 3rd, and 4th module at 2, 4, and 6 months after birth respectively (each module was covered over three sessions). The intervention was administered by video calls on WhatsApp.

After the diagnosis of depression, the mothers in the control group (n = 40) were introduced to a female healthcare worker to administer the MohME protocol devised for depressed pregnant women, and the researcher conducted a follow-up on the conclusion of these sessions. The control group also received routine pregnancy care by healthcare workers.

The healthcare liaisons administering the program were regularly and daily supervised by the experienced psychologist and the researcher by holding face to face meetings or getting feedback and reporting daily performance from health liaisons; during the intervention, various meetings were held with them to examine the problems and challenges they encountered.

Sampling, randomization, and blinding

Healthcare centers were selected from the south of Tehran by using a table of random numbers. The participants were selected by simple convenience sampling through the researcher’s visit to healthcare centers and health stations and preparing a list of eligible pregnant women with the help of the health workers in charge. After a phone call to the pregnant women and a brief explanation on the study, the candidates were registered if they orally consented to participate. After registering the participants and getting the depression score based on the scores of the questionnaires, their written consents were obtained, and they were randomly assigned to the experimental or control groups using a table of random numbers (Random Allocation). Randomization was performed by a researcher who was not involved in the registration of the participants. The experimental group participants were randomly divided among five healthcare liaisons. It was not possible to blind the healthcare liaisons or the participants in the experimental group, but the healthcare liaisons had no contact with the randomization team or the control group.

Follow-up

Women who did not wish to continue participating in the study, or experienced stillbirth or infant death or needed drug treatment (and were treated according to the protocol of the Ministry of Health) were excluded. Intervention sessions were conducted by health liaisons with prior coordination with pregnant mothers according to the THP program via WhatsApp. If the mother was not ready for the meeting, scheduling was promptly organized with the mother as soon as it was possible. In each meeting, the tasks related to the health calendar were checked by the interventionist through WhatsApp (provided by the mother). A group of mothers was formed on WhatsApp, and through this, mothers expressed their questions or their feelings and thoughts. The supervisor also participated in this group and provided answers and guidance to the mothers if needed. At the end of the first module which was 4 sessions and continued for every 2 to 4 weeks from the second trimester of pregnancy until delivery, the participants of both groups completed BDI-II and EDPS once more.

After delivery, the newborns’ anthropometric measurements were recorded in both groups from their health cards. The infants’ status in terms of jaundice, respiratory problems and hospitalization was also examined.

The second module was held from 2 weeks to 2 months after delivery in 3 sessions with an interval of 2 to 4 weeks, and the third module was conducted from 2 months to 4 months after delivery with an interval of 2 to 4 weeks. At the end of the third module (4 months after birth), the infant measurements at four months of age were recorded from the health cards, and their parents completed the ASQ at four months. At six months of age, the infants’ measurements, exclusive breastfeeding, experience of at least one bout of diarrhea (diarrhea defined as three or more loose diarrheal stools over 24 hours) and respiratory diseases were recorded, and ASQ was completed by the parents again.

In general, in this study after the recruitment of 80 pregnant women with depression and their random allocation to the two groups, THP was administered by healthcare liaisons with the continuous supervision of a psychology professor and the researcher. The introductory session was held in person, and 13 sessions were offered online to 40 mothers in the intervention group; and the mothers of both groups completed the questionnaires during and after the intervention, and the data obtained were then analyzed (Flowchart 1).

Sample size

In a 2005 study ⁽²²⁾, Hosseinisazi et al. obtained the mean and standard deviation of the BDI-II score in pregnant women as 11.43 ± 7.57. Using this score, with a confidence level of 5% and power of 80%, the sample size was estimated as 40 mothers per study group.

Statistical analysisdepression

This instrument consists of ten items. The response options range from low to high severity (items 1, 2, 4) or vice versa (items 3, 5, 6, 7, 8, 9, and 10) and are scored from 0 to 3 depending on the severity of the symptoms. The total score is calculated by summing the scores of the items and can range from 0 to 30. Mothers scoring above the threshold of 13 suffer from different degrees of depression ⁽²³⁾ According to Montazeri' study, Cronbach's alpha of the Persian version of EPDS was almost acceptable for all the women. Cronbach's alpha coefficient was 0.77 (for reliability testing) at time point 1 (6–8 weeks postpartum) and 0.86 at time point 2 (12–24 weeks postpartum) ⁽²⁴⁾.

Beck’s Depression Inventory-II (BDI-II)

The new version of this self-report 21-item inventory aims to measure depression in adults and adolescents 13 years or above. The psychometric analysis of BDI-II in Iran showed that the items and components can diagnose and evaluate the severity and degree of depression well. The scores in this inventory range from 0 to 3 based on four options (0–3), indicating the absence of a symptom to the greatest severity of that symptom ⁽²⁵⁾. In Iran, the intraclass correlation coefficient of this inventory was 0.81. Its internal consistency was 0.93 based on Cronbach's alpha and 0.64 based on the split-half method ⁽²⁶⁾.

The ENhancing Assessment of Common Therapeutic Factors (ENACT): As part of a mental healthcare program in Nepal, ENACT was developed by Kohrt et al. to measure counselors' competenc ⁽²¹⁾. ENACT measures a set of common factors identified as therapeutic competencies and skills that seem to be necessary for proper counseling in any evidence-based intervention. This tool was first used in Nepal, Liberia, and Uganda ^(27–29). ENACT has 15 items with four levels: (1) Unhelpful or potentially harmful behaviors, (2) No basic skills or some but not all the skills, (3) All basic skills, and (4) All basic and advanced skills. Each level is a set of observable behaviors that help operationalize each level for each competence item ⁽³⁰⁾.

The Ages & Stages Questionnaire (ASQ): ASQ contains questionnaires for children aged four to 60 months, which are filled out by the parents or caretakers and includes five domains: Communication, gross motor, fine motor, personal-social, and problem-solving. ASQ can be filled out by those with a low level of literacy as well. Each item has three options for response (yes = 10, sometimes = 5, not yet = 0) –only one of which should be selected ⁽³¹⁾.

Out of the 479 mothers who were contacted by the researchers, 202 responded, 90 matched the criteria for pregnancy depression, and finally 80 agreed to participate in the study (Fig. 1). Table 1 presents the demographic characteristics of the two groups. According to Chi-square test, there were no significant differences in the demographic characteristics between the two groups. Therefore, it can be inferred that the study groups were homogeneous in terms of mother’s age, education, and occupation, parity, number of children, problems in previous pregnancies, history of depression before pregnancy, planning for the current pregnancy, unintended pregnancy, pre-pregnancy counseling, and attending pregnancy courses.

Table 1

Distribution of demographic characteristics and pregnancy status in the 2 study groups (n = 80)
Variable		Intervention (n = 40) N (%)	Control (n = 40) N (%)	P-value (Chi-square test)
Age(Year)	15–19	(2.5)1	2 (5)	0.39
	20–29	(45)18	(42.5)17
	30–39	(52.5)21	(42.5)17
	40–49	0	(10)4
Education	Elementary	(5)2	(5)2	0.32
	Junior high	(15)6	(32.5)13
	High school	(50)20	(37.5)15
	University	(30)12	(25)10
Occupation	Housewife	(92.5)37	(82.5)33	0.17
Occupation	Employed	(3.7)3	(17.5)7	0.17
Parity	1–3	(92.5)37	(95)38	0.36
	4–6	(7.5)3	(2.5)1
	7–8	0	(2.5)1
No. of children	0	(60)24	(40)16	0.96
	1–3	(37.5)15	(60)24
	4–8	(2.5)1	0
Problems in previous pregnancies	No	(47.5)19	(42.5)17	0.65
Problems in previous pregnancies	Yes	(52.5)21	(57.5)23	0.65
History of depression before pregnancy	No	(92.5)37	(85)34	0.28
History of depression before pregnancy	Yes	(7.5)3	(15)6	0.28
Planning for the current pregnancy	No	(30)12	(35)14	0.63
Planning for the current pregnancy	Yes	(70)28	(65)26	0.63
Unintended pregnancy	Intended	(72.5)29	(67.5)27	0.10
	Unintended by the man	0	(10)4
	Unintended by the woman	(2.5)1	(7.5)3
	Unintended by the couple	(25)10	(15)6
Pre-pregnancy counseling	No	(75)30	(67.5)27	0.45
Pre-pregnancy counseling	Yes	(25)10	(32.5)13	0.45
Attending pregnancy courses	No	(77.5)31	(80)32	0.75
Attending pregnancy courses	Yes	(22.5)9	(20)8	0.75
Depression screening in the current pregnancy	No	(82.5)33	(85)34	0.76
Depression screening in the current pregnancy	Yes	(17.5)7	(15)6	0.76

The mean birth weight in the two groups was significantly different, and the infants in the intervention group weighed more than the control group at birth, but the difference was not significant between the two groups in terms of height and head circumference at birth. Moreover, weight gain at 4 months differed significantly between the intervention and control groups, and the children in the intervention group gained more weight than those of the control group, but the difference in head circumference and height was not significant between the two groups at the age of 4 months. The difference was significant between the two groups in terms of height and head circumference at 6 months, and the values were higher in the intervention group than the controls (Table 2).

Table 2

Comparison of anthropometric characteristics of the infants at birth, 4 months, and 6 months of age among the two groups (n = 80)
Anthropometric Measurements	Intervention (n = 40)	Control (n = 40)	P-value
Weight at birth (g) Mean ± SD	3249.5 ± 468.6	3042.5 ± 390.75	0.03*
Height at birth (cm) Mean ± SD	49.58 ± 2.1	48.9 ± 1.8	0.15*
Head circumference at birth (cm) Mean ± SD	34.2 ± 1.3	33.7 ± 1.4	0.11*
Weight difference (birth vs. 4 months; g) Mean ± SD	4354 ± 767	4084 ± 554	0.02*
Head circumference difference (birth vs. 4 months; cm) Median ± IQR	8 ± 2.5	8 ± 2	0.39**
Height difference (birth vs. 4 months; cm) Mean+-SD	2.5 ± 14.8	2.1 ± 13.9	0.30*
Weight difference (4 vs. 6 months; g) Median ± IQR	1125 ± 850	1000 ± 475	0.95**
Height difference (4 vs. 6 months; cm) Median ± IQR	3 ± 2	1 ± 3	0.001**
Head circumference difference (4 vs. 6 months; cm) Median ± IQR	2 ± 1	1 ± 2	0.001**
* T-Test

** Mann-Whitney’s U-Test.

All infants showed an upward growth trend in anthropometric indices, but at all measurement stages (at birth, 4 and 6 months after birth), the measured indices were higher in infants of the intervention group than in the control group (Table 3).

	Weight at birth (g)	Weight at 4 months(g)	Weight at 6 months(g)	P-value*
Intervention(n = 40)	3249.5 ± 468.6	7603.5 ± 775.7	8722.5 ± 702.1	0.001
Control(40)	3042.5 ± 390.75	7127.5 ± 511.7	8087.5 ± 450.7	0.001
	height at birth(cm)	Height of 4 months	Height of 6 months	P-value*
Intervention(n = 40)	49.58 ± 2.1	64.4 ± 2.27	67.8 ± 2.12	0.001
Control(40)	48.9 ± 1.8	62.8 ± 1.5	64.3 ± 2.2	0.001
	Head circumference at birth	Head circumference at 4 months	Head circumference at 6 months	P-value*
Intervention(n = 40)	34.2 ± 1.3	42 ± 1.4	44.7 ± 1	0.001
Control(40)	33.7 ± 1.4	42 ± 0.86	43.1 ± 1.1	0.001
*Friedman Test

Infants' ASQ scores significantly increased in the intervention group from 4 to 6 months of age, but not in the control group. Also, the ASQ scores were significantly higher in the infants of the intervention group than the control group, both at 4 and 6 months of age. (Table 4)

Table 4

Comparison of the mean score of ASQ at 4 and 6 months of age in the infants of the two groups
Group	ASQ^& at 4 months Median ± IQR	ASQ^& at 6 months Median ± IQR	P-value
Intervention (n = 40)	277 ± 40	290 ± 25	0.002*
Control (n = 40)	260 ± 30	265 ± 30	0.068*
P-value	0.16**	0.001**	-
*Wilcoxon
**Mann-Whitney’s U-Test
ASQ; Ages & Stages Questionnaire

The incidence of respiratory infections, diarrhea, and exclusive breastfeeding from birth to 6 months differed significantly in the infants of the intervention group compared to the control group, and THP could thus reduce respiratory infections and diarrhea and increase exclusive breastfeeding rates in the infants (Table 5).

Table 5

Comparison of the frequency of acute respiratory infections, diarrhea, and exclusive breastfeeding at 6 months in the infants of the two groups
Variable		Intervention (n = 40) N. (%)	Control (n = 40) N. (%)	P-value (Chi-square test)
Acute respiratory infections	No	(92.5)37	(60)24	0.001
Acute respiratory infections	Yes	(7.5)3	(40)16	0.001
Diarrhea	No	(90)36	(47.5)19	0.001
Diarrhea	Yes	(10)4	(52.5)21	0.001
Exclusive breastfeeding until 6 months of age	Yes	(85)34	(27.5)11	0.001
Exclusive breastfeeding until 6 months of age	No	(15)6	(72.5)29	0.001

This study aimed to investigate the impact of WHO's THP on infant outcomes up to the age of 6 months. Data showed that the implementation of the THP program in depressed pregnant mothers and its continuation until 6 months after delivery, can have a positive effect on the infant's physical growth and birth weight, and improving the mother's mental health can improve the child's growth. According to Le Roux's study (2014), in the intervention group mothers who received home visits, the weight for height and weight for age were higher in the infants compared to the controls ⁽³²⁾, which is consistent with the findings of the present study. This result is also consistent with Mohd Shukri's study (2019) in which the infants of mothers in the intervention group had higher weight and body mass index (BMI) at 12–14 weeks and from the beginning to the end of the study ⁽³³⁾ Maselko's 2015 study compared the weight of the children in the intervention group mothers (pregnant women with depression who received THP) to the reference group mothers (who were not depressed and did not receive any intervention). Primary physical outcomes such as weight for age showed no difference between the infants in the two groups ⁽³⁴⁾, which is not consistent with the present study; in the cited study, however, the reference group included mothers who were not depressed, and they were compared with depressed mothers who had received the intervention.

Moreover, Tol's 2020 systematic review showed that the infants of depressed pregnant women who received the home visit intervention had no difference in weight at 6 months compared to the control group ⁽³⁵⁾, which is not consistent with the present study. According to this study, although all the included studies were clinical trials, some of them had not described their randomization sequence and some others had not described their allocation concealment very well, which is similar to the study by Rotheram (2010), in which the intervention continued up to 36 months of age ⁽³⁶⁾; this finding suggests that the decrease in height and head circumference manifests itself with the child's growth in later stages.

the findings of this study showed that this program, in addition to improving the physical development of the infant, can improve and promote the developmental growth of the child. It also reduces infancy infectious diseases and increases exclusive breastfeeding rates. According to the study by Kim (2021) ⁽³⁷⁾ and Baumgartner (2021) ⁽³⁸⁾, the mean score of the ASQ item improved at 6 months in the intervention group receiving CBT compared to the control group, which is in line with the present findings. In Ammerman's 2015 study, no difference in the infants' ASQ score was observed after birth between the CBT intervention group that had received the intervention at home and the control group that had received standard home visits ⁽³⁹⁾. The reason for this disparity could be that their study started two to ten months post-partum, when the mothers had missed the opportunity to receive this intervention during pregnancy to mentally prepare for raising their child. Moreover, in this study, randomization was based on ethnicity, home visits (in the standard visit group) and the allocation of the therapists (in the home CBT group).

According to Rahman's 2012 findings, CBT improves exclusive breastfeeding ⁽⁴⁰⁾. Moreover, in Sikander's study (2015), exclusive breastfeeding was markedly higher in women in the CBT intervention group than in the control group ⁽⁴¹⁾, which is consistent with the present findings. In Rahman's study (2008), although exclusive breastfeeding was not significantly different in the two groups, yet it had increased in the intervention group ⁽¹¹⁾. The findings of this study are also consistent with those of Le Roux's study (2014) ⁽³²⁾. Langer's 2005 study, which measured the effect of psychological support during labor and delivery on breastfeeding, also reported similar results (42).

According to the findings of this study, diarrhea was less frequent in the infants of the intervention group than in those of the control group. According to Rahman's (2008) study, a bout of diarrhea within the two weeks preceding the 12-month assessment was less likely in the children of the intervention group compared to the controls ⁽¹¹⁾. Furthermore, according to Le Roux's 2014 study, in the children of the intervention group mothers who received home visits, the rate of diarrhea up to 18 months was lower than in the children of the control mothers ⁽³²⁾.

Evidently, psychotherapy is effective in treating depression in patients in primary care, and its effects are comparable to those of antidepressants in the short term, and it may even be more effective in the long term ⁽⁴³⁾. By reviewing the mental health challenges of the prenatal period, it can be concluded that there is a need to expand public psychotherapy services and invest more in mental health services before pregnancy in order to reduce the complications and mortality of mothers and children ⁽⁴⁴⁾. To achieve this goal, by implementing the THP program with the help of non-specialist forces and at a low cost, according to WHO protocols, a great contribution can be made in improving the mental health of depressed pregnant mothers.

Strengths

The current study has strong points, including the use of health liaisons in health centers that are acceptable among households and have low costs for psychological intervention. This study was performed in a virtual way that the mothers did not have to leave the house and go to the counseling place and time and money were saved. Also, this method of intervention was acceptable from the mothers' point of view, and they cooperated quite well.

Limitations

Due to the COVID-19 pandemic, it was not possible to administer this intervention face-to-face, and the spouses were only partially involved in the intervention, and it was not possible to have another family member present alongside the mother during the intervention. Future interventions should be administered face-to-face with mothers and with more involvement of the father to examine the data and the cost-effectiveness, and also more participants should be enrolled.

Also, the error of newborn anthropometric measurements in different final hospitals could not be controlled, because the mothers delivered in different hospitals at unknown times, and it was not possible for the researcher to measure the anthropometric indices of the newborns personally, and we had to rely on the information on the newborns' health cards recorded by medical staff of the hospitals to obtain these data.

One other limitation of this study which could not be controlled, is that mothers who were illiterate or did not have access to a smartphone were not included in the study.

In general, the results show that psychological interventions in depressed pregnant women can lead to improved mental health of the mother and thus help to improve the subsequent outcomes of the infant, including his physical and developmental growth, and as a result, can increase the health of the family and ultimately the whole society. By reviewing the results of the present study and related studies, it can be concluded that CBT is the preferred treatment for depression during and after pregnancy. Given the significant advances in the provision of mental health services in Iran, and the integration of this program into primary health services due to the high prevalence of mental disorders across the country, there is a need to improve the access to these services, especially in some small towns and villages. The government is responsible for creating a healthy society and welfare for its people and the accomplishment of these goals requires more attention to the subject of mental health services. Since mothers and children are among the most vulnerable groups of a society and constitute a high percentage of the population, investing in their mental health can be beneficial.

PPD(Post Partum Depression)

THP (Thinking Healthy Program)

WHO (World Health Organization)

CBT (cognitive behavioral therapy)

ASQ (Stages Questionnaire )

EPDS (The Edinburgh Postnatal Depression Scale(

BDI-II (Beck’s Depression Inventory-II(

ENACT (The ENhancing Assessment of Common Therapeutic Factors (

LMICs (low- and middle-income countries(

mhGAP (mental health Gap Action Programme(

MoHME (Ministry of Health and Medical Education(

Ethics approval and consent to participant

The study protocol was approved by the Ethics Committee of Tarbiat Modares university (code: IR.MODARES.REC.1399.108(. All procedures were in accordance with the ethical standards of the Regional Research Committee and with the Declaration of Helsinki 1964 and its later amendments. After explaining the study's purposes, informed written consent and verbal assent were obtained from all participants. They were informed that their participation was voluntary, confidential and anonymous, and that they had the right to withdraw from the research at any time.

Data availability statement

Data is provided within the manuscript or supplementary information files. Any other information or data, if needed, can be requested through the email of the corresponding author, then it will be sent.

Consent for publication

Not applicable.

Availability of data and material

The data sets used and analyzed for the current study are available upon reasonable request of the corresponding authors

Competing Interests

The authors declare no conflicts of interest.

Funding

None.

Authors' contributions

All authors contributed to the concept and design of the study. M.B performed the literature search. L.MB performed the statistical analysis. M.B, Sh.JS and A.M wrote the first draft of this manuscript. M.EN conducted the CBT training and supervised the implementation of the intervention by researchers and health liaisons. F.A. Participated in the localization of the program. All authors contributed to the revision of the article and read and approved the submitted manuscript.

Acknowledgments

This study was carried out with the kind collaboration of the participants. We would also like to appreciate the staff of the Tarbiat Modares University and the participating health care centers for their valuable contributions.

Guo S, Kaminga AC, Xiong J. Depression and coping styles of college students in china during COVID-19 pandemic: a systemic review and meta-analysis. Frontiers in Public Health. 2021;9:613321.
Stewart DE, Vigod SN. Postpartum Depression: Pathophysiology, Treatment, and Emerging Therapeutics. Annual review of medicine. 2019;70:183-96.
Fisher J, Mello MCd, Patel V, Rahman A, Tran T, Holton S, et al. 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. 2012;90:139-49.
F M, S T-N, K E, R D. Prevalence and Factors Affecting Pregnancy Depression: A Systematic Review Journal of Clinical Nursing and Midwifery. 2021;9:832-9.
Atif N, Lovell K, Rahman A, editors. Maternal mental health: The missing “m” in the global maternal and child health agenda. Seminars in perinatology; 2015: Elsevier.
Disorder PS. What is Cognitive Behavioral Therapy? 2017 [Available from: https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.
Branquinho M, de la Fe Rodriguez-Munoz M, Maia BR, Marques M, Matos M, Osma J, et al. Effectiveness of psychological interventions in the treatment of perinatal depression: A systematic review of systematic reviews and meta-analyses. Journal of Affective Disorders. 2021;291:294-306.
Singla DR, Kohrt BA, Murray LK, Anand A, Chorpita BF, Patel V. Psychological treatments for the world: lessons from low-and middle-income countries. Annual review of clinical psychology. 2017;13:149-81.
Ali R, Samira D. Systematic review of the effectiveness of health education interventions in promoting knowledge, attitude, and practice of Iranian health volunteers. Journal of Preventive Medicine. 2021;8(3):28-38.
Rahman A, Waqas A, Nisar A, Nazir H, Sikander S, Atif N. Improving access to psychosocial interventions for perinatal depression in low-and middle-income countries: lessons from the field. International Review of Psychiatry. 2021;33(1-2):198-201.
Rahman A, Malik A, Sikander S, Roberts C, Creed F. 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. 2008;372(9642):902-9.
Rahman A. Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan–a multi-method study. Archives of women's mental health. 2007;10:211-9.
Nisar A, Yin J, Yiping N, Lanting H, Zhang J, Wang D, et al. Making therapies culturally relevant: translation, cultural adaptation and field-testing of the Thinking Healthy Programme for perinatal depression in China. BMC pregnancy and childbirth. 2020;20(1):1-10.
south tehran health center [Internet]. 2023.
Vice Chancellor of Tehran University Health [Internet]. 2023.
Description of the duties of the urban health center [Internet]. 2021.
Vand MA, Kazemnejad A, Garshasbi I. Effects of an exercise program during pregnancy on the Edinburgh depression score in pregnant women. Bimonthly scientific-research journal of Shahid University. 2017;26(3):1-6.
Ghisvandi RHZFMAGGPTTSFE. Validity and reliability Beck Depression Inventory-II among the Iranian elderly Population. Sabzevar University of Medical Sciences. 2014;21(1):189-98.
Atif N, Nisar A, Bibi A, Khan S, Zulfiqar S, Ahmad I, et al. Scaling-up psychological interventions in resource-poor settings: training and supervising peer volunteers to deliver the ‘Thinking Healthy Programme’for perinatal depression in rural Pakistan. Global Mental Health. 2019;6.
Organization. WH. Thinking healthy: a manual for psychosocial management of perinatal depression Wgf-tv, 2015 (No. WHO/MSD/MER/15.1). World Health Organization. 2015.
Kohrt BA, Ramaiya MK, Rai S, Bhardwaj A, Jordans MJD. Development of a scoring system for non-specialist ratings of clinical competence in global mental health: a qualitative process evaluation of the Enhancing Assessment of Common Therapeutic Factors (ENACT) scale. Global mental health (Cambridge, England). 2015;2.
F.Hosaynisazi , A.Poorreza , M.Hosayni , D.Shojaee Depression during pregnancy. Journal of Gorgan University of Medical Sciences. 2005;7(1):60-5.
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. The British journal of psychiatry. 1987;150(6):782-6.
Montazeri A, Torkan B, Omidvari S. The Edinburgh Postnatal Depression Scale (EPDS): translation and validation study of the Iranian version. BMC psychiatry. 2007;7(1):11.
Stefan-Dabson K, Mohammadkhani P, Massah-Choulabi O. Psychometrics characteristic of Beck Depression Inventory-II in patients with magor depressive disorder. Archives of Rehabilitation. 2007;8:82-0.
Hamidi R, Fekrizadeh Z, Azadbakht M, Garmaroudi G, Tanjani PT, Fathizadeh S, et al. Validity and reliability Beck Depression Inventory-II among the Iranian elderly Population. Sabzevar University of Medical Sciences. 2011;22(1):189-98.
Kohrt BA, Mutamba BB, Luitel NP, Gwaikolo W, Onyango Mangen P, Nakku J, et al. How competent are non-specialists trained to integrate mental health services in primary care? Global health perspectives from Uganda, Liberia, and Nepal. International Review of Psychiatry. 2018;30(6):182-98.
Leichner A, Akhtar A, a Bhaird CN, Wener R, Perera SM, Weissbecker I. Mental health integration in primary health services after the earthquake in Nepal: a mixed-methods program evaluation. Global Mental Health. 2021;8:e10.
Jordans M, Coetzee A, Steen H, Koppenol-Gonzalez G, Galayini H, Diab S, et al. Assessment of service provider competency for child and adolescent psychological treatments and psychosocial services in global mental health: evaluation of feasibility and reliability of the WeACT tool in Gaza, Palestine. Global Mental Health. 2021;8:e7.
Mwenge MM, Figge CJ, Metz K, Kane JC, Kohrt BA, Pedersen GA, et al. Improving inter-rater reliability of the enhancing assessment of common therapeutic factors (ENACT) measure through training of raters. Journal of Public Health in Africa. 2022;13(3).
Squires J, Bricker D, Potter L. Revision of a parent-completed developmental screening tool: Ages and Stages Questionnaires. Journal of pediatric psychology. 1997;22(3):313-28.
Le Roux IM, Rotheram-Borus MJ, Stein J, Tomlinson M. The impact of paraprofessional home visitors on infants’ growth and health at 18 months. Vulnerable children and youth studies. 2014;9(4):291-304.
Mohd Shukri NH, Wells J, Eaton S, Mukhtar F, Petelin A, Jenko-Pražnikar Z, et al. Randomized controlled trial investigating the effects of a breastfeeding relaxation intervention on maternal psychological state, breast milk outcomes, and infant behavior and growth. The American Journal of Clinical Nutrition. 2019;110(1):121-30.
Maselko J, Sikander S, Bhalotra S, Bangash O, Ganga N, Mukherjee S, et al. Effect of an early perinatal depression intervention on long-term child development outcomes: follow-up of the Thinking Healthy Programme randomised controlled trial. The Lancet Psychiatry. 2015;2(7):609-17.
Tol WA, Greene MC, Lasater ME, Le Roch K, Bizouerne C, Purgato M, et al. Impact of maternal mental health interventions on child-related outcomes in low- and middle-income countries: a systematic review and meta-analysis. Epidemiol Psychiatr Sci. 2020;29:e174.
Rotheram-Fuller EJ, Tomlinson M, Scheffler A, Weichle TW, Hayati Rezvan P, Comulada WS, et al. Maternal patterns of antenatal and postnatal depressed mood and the impact on child health at 3-years postpartum. Journal of consulting and clinical psychology. 2018;86(3):218.
Kim ET, Opiyo T, Acayo PS, Lillie M, Gallis J, Zhou Y, et al. Effect of a lay counselor delivered integrated maternal mental health and early childhood development group-based intervention in Siaya County, Kenya: A quasi-experimental longitudinal study. Journal of affective disorders. 2021;292:284-94.
Baumgartner JN, Ali M, Gallis JA, Lillie M, Owusu R, Abubakr-Bibilazu S, et al. Effect of a lay counselor-delivered integrated maternal mental health and early childhood development group-based intervention in Northern Ghana: a cluster-randomized controlled trial. Global Mental Health. 2021;8.
Ammerman RT, Altaye M, Putnam FW, Teeters AR, Zou Y, Van Ginkel JB. Depression improvement and parenting in low-income mothers in home visiting. Archives of Women's Mental Health. 2015;18(3):555-63.
Rahman A, Haq Z, Sikander S, Ahmad I, Ahmad M, Hafeez A. Using cognitive‐behavioural techniques to improve exclusive breastfeeding in a low‐literacy disadvantaged population. Maternal & child nutrition. 2012;8(1):57-71.
Sikander S, Maselko J, Zafar S, Haq Z, Ahmad I, Ahmad M, et al. Cognitive-behavioral counseling for exclusive breastfeeding in rural pediatrics: a cluster RCT. Pediatrics. 2015;135(2):e424-31.
Langer A, Campero L, Garcia C, Reynoso S. Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial. BJOG: an international journal of obstetrics & gynaecology. 1998;105(10):1056-63.
Cuijpers P, Quero S, Dowrick C, Arroll B. Psychological Treatment of Depression in Primary Care: Recent Developments. Current psychiatry reports. 2019;21(12):129.
Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313-27.

No competing interests reported.

Download PDF

Editor assigned by journal
13 Mar, 2024
Editor invited by journal
03 Feb, 2024
Submission checks completed at journal
03 Feb, 2024
First submitted to journal
26 Jan, 2024

You are reading this latest preprint version

Implementing WHO Thinking Healthy Program in A Population of Iranian Pregnant Women with Depression and its Impact on Infant Outcomes

Status:

Version 1

Abstract

Background

Method

Result

Conclusion

Figures

Key Message

Background

Methods

Study procedure and participants

Health Liaisons

Intervention

Sampling, randomization, and blinding

Follow-up

Sample size

Results

Discussion

Strengths

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1