The Thinking Healthy Program (THP)

The theoretical basis for this research project, i.e., the development of an evidence- based, feasible and acceptable intervention for maternal psychosocial wellbeing, originated from the Thinking Healthy Programme (THP), developed for the management of maternal depression, in a low-income rural setting in Rawalpindi, Pakistan (11). The THP is based on principles of cognitive behavioural therapy (CBT), which is the most widely researched and evidence-based form of talking therapy (101). THP adapted the techniques of CBT so that these could be used by CHWs working with women suffering from perinatal depression in rural Pakistan. Briefly, the intervention consisted of 16 home delivered individual sessions—four weekly sessions in the last month of pregnancy, three fortnightly sessions in the first postnatal month, and nine monthly sessions there- after.

THP was a targeted intervention for women suffering from perinatal depression. The author’s aim in this project was to adapt the THP so it could be delivered as a universal intervention to all women living in conditions of psychosocial adversity. The aims and objectives of this project are further elaborated in the next chapter, but some of the strategies used in the Thinking Healthy Programme are described in further detail below.

5.3.1. Cognitive Behavioural Therapy

CBT is one of the fastest developing fields in psychotherapy (102). The therapy, delivered by trained mental health specialists helps people recognize and gently challenge the thoughts and emotions that lead to the unhelpful behaviour patterns that characterize depression.The word ‘Cognitive’refers to thoughts and‘behaviour’ refers to actions that take place as a reaction to the thoughts. This talking therapy aids clients in altering the unhealthy or unhelpful thinking patterns and as a result brings about a change in unhelpful or undesirable patterns of behaviour. CBT has proved to be very effective in breaking this unhealthy cycle especially in people who have lack of confidence, depression, and difficulty with relationships. The cognitive approach of the therapy focuses on altering the ways of thinking into more helpful or adaptive patterns. In the case of mothers, this can help change their perceptions, beliefs, fears and opinions about themselves, significant others, and their parenting abilities. The behavioural aspect of CBT helps the mother in taking actions that have desirable results. The clients in CBT are given “homework” or assignments to speed up the progress. Imagery is a powerful tool that is utilized in CBT. The client recalls an image and then is encouraged to modify the image by thinking positively. Further details of the Thinking Healthy Programme can be found in the THP Training Manual available at

http://hdrfoundation.org/docs/training/THINKING%20HEALTHY%20PROGRAM ME%20FULL%20MANUAL.pdf.

5.3.2. Adaptation of Cognitive Behaviour Therapy in Thinking Healthy Program

The main adaptations to the CBT approach included the following;

 A child focused approach to address maternal depression because of the stigma attached to mental health issues

 Illustrations that were culturally appropriate were used as imagery that helped mothers easily form their own mental images. Active involvement of the whole family to support the mother

The three areas of THP include the mother’s personal health, mother infant relationship and relationship with others for social support. The THP cognitive behaviour therapy techniques include training LHWs to use active listening skills while communicating with mothers so that they can learn about the unhealthy or unhelpful thinking patterns and then guiding mothers to gently consider alternative healthy or more helpful patterns of thinking. Collaboration with the family is considered an important component to gain their support. To practice new behaviours between sessions, “homework” and activities are suggested to the mothers to practice in between the sessions and putting what has been learned into practice. These were applied to health workers’ routine practice.

The strength of the THP intervention lies in its simplicity and applicability in the community settings through community health workers. It is also an evidence-based intervention, tested through one of the largest cluster randomized trials of a psychological intervention in low-income settings (11) . The target population in the trial was representative of rural population and hence the intervention can be generalized to other rural settings. The intervention, control and the outcomes were explicitly described and standard tools were used for measurement. The randomization was adequate and both intervention and control groups were treated in the same way, by providing routine care to the control. The cluster-randomized trial revealed that the intervention more than halved the rates of depression in prenatally depressed women compared with those receiving enhanced routine care.

Moreover the intervention had some other affects that are important in the context of early child development. These included higher immunization rates, less episodes of diarrhoea, parents spending more time playing with their infants and higher contraceptive use than those in the control group.

In summary, of all the interventions reviewed, the Thinking Healthy Programme was based on the therapy with the strongest evidence-base, achieved the best effect size, and had been delivered in real-life settings, largely integrated into a community- based health system in a low-income setting. For these reasons, the intervention was selected for adaptation from a targeted intervention for depressed mothers to a universal intervention for all mothers.

5.4. The case for integrating interventions for maternal psychosocial wellbeing into maternal and child health platforms

We have seen from subsequent sections that maternal mental health, specifically maternal depression, is a significant public health problem, which is associated with negative outcomes for women, their children and families. Maternal psychosocial wellbeing, maternal depression and child outcomes are inextricably linked through multiple pathways, some of which have been captured in Figure 7. It would therefore make sense to have interventions that are integrated so that these can have a synergistic effect, and benefit not just maternal and child health programmes but also mental health programmes. The case for integration is gaining considerable momentum in recent years (1). Some of the advantages have been discussed before. These include; integrated MCH and mental health approach prevents working in ‘silos’(103), integrated approach being more attractive to community, MCH platforms is suited to taking into account the psychosocial wellbeing across the life course and MCH programmes becoming more effective as a result of integrating mental health care. Conversely, there are benefits for mental health programmes – we have seen from this chapter that effective treatments exist for maternal depression, but few patients have access to such treatments. In many low-and middle-income countries, the ratio of specialist to population is 1:0.5 million and in some, as low as 1:4 million. Even in high income countries only 2 in 10 adults and an even less children, with common mental health problems receive care from a mental health specialist in any given year. As MCH programmes are population and community-based, these are more likely to provide equitable care, especially to rural and difficult-to-access communities.

The challenges of integrated interventions include workload, communication, coordination, common language and measurement (104). These are not insurmountable, and it is likely that the benefits will outweigh the costs. In spite of these benefits, there are no interventions for maternal psychosocial wellbeing that can be integrated into maternal and child health platforms at scale. The research is an attempt to develop and pilot such an intervention.