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Tracking Maternal Depression and Child Growth

This idea proposes to incorporate depression and developmental screenings into the already existing National Program on Immunization (NPI) in Nigeria. The specific objectives would be to recognize postpartum depression (PPD) among mothers attending immunization clinics early enough and also to assess infant growth and recognize any delay or deviation from the expected developmental milestones in relation to World Health Organization (WHO) recommendations. This would encourage early interventions both for the mothers and the infants by treating the depression in the mothers, if present and providing nutritional and other health related advice to the mothers to improve the growth and milestones developments of their children.

Photo of Muideen Bakare
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Research consistently suggests that maternal post-partum depression (PDD) may lead to impaired maternal–infant interactions and negative perceptions of normal infant behavior. There is evidence from developed countries that a compromised mother–infant relationship adversely affects the child's cognitive, social, behavioral and emotional development. Infants of mothers with PPD are more likely to be abused and neglected and diagnosed with failure to thrive and hospitalized for poor health.

In a developing country like Nigeria, there are many factors that may be working against the optimal development of children. Such factors included poverty, diseases, inadequate housing and overcrowding among others. With the additional factor of maternal PPD, child underdevelopment may worsen. The achievement of the Millennium
Development Goals to improve maternal health, reduce child mortality, promote gender equality, empower women, achieve universal primary education and eradicate extreme poverty and hunger cannot be achieved unless there is a specific focus on maternal and child mental health. Therefore, addressing maternal PPD through early detection and interventions may improve optimal development of children in low resource countries like Nigeria. National Program on Immunization (NPI) would provide the best forum for early screening of mothers for PPD and interventions in Nigeria. NPI would also serve a useful avenue of screening for developmental concerns in Nigerian infants and children.

The project will introduce screening for maternal postpartum depression (PPD) and deviation in normal child development into already existing NPI at PHC level in selected Local Government Areas (LGAs) of Lagos State, Nigeria. The interventions at this level will include educating parents about PPD and Normal Developmental Milestones, counseling and support for the family by establishment of Family Support Groups where parents can share their apprehension and concerns before referral to tertiary care center for further evaluation and specific interventions as required by identified mothers and children.

The mothers would be screened for post-partum depression and their children growth trajectory would be assessed during every visits to the NPI Clinic until the children achieved the age of 12 months (1 year) [Updated 12/21/14].

For those mothers screened positive for post-partum depression at any point during their visits to NPI Clinic, baseline assessment and interventions would be provided, the mothers and children would then be followed up every three (3) months for further evaluation to see if positive results are being achieved both for the mothers and children and possible review of intervention plans, if necessary. The interventions for identified mothers would include a combination of pharmacotherapy and psychotherapy. The interventions for the children would include offering of nutritional and other health related advice based on clinical evaluation of each child [Updated 12/21/14].

Our team at Childhood Neuropsychiatric Disorders Initiatives comprises of multidisciplinary professionals like Psychiatrists, Pediatricians, Psychologists, Social Workers among others to provide multidisciplinary interventions. The project would collaborate with Federal Neuropsychiatric Hosital, Yaba, Lagos State, Nigeria, where mothers that need indepth assessment and possible in-patient interventions would be referred and followed up. This project will also collaborate with University Center for Excellence in Developmental Disabilities (UCEDD) and the Leadership Education in Neurodevelopmental and Related Disabilities (LEND) Programme in Boston. Childhood Neuropsychiatric Disorders Initiatives presently has an ongoing collaboration with these Institutions [Updated 12/11/14].

This project, if funded will launch into the already existing support being enjoyed by an existing project taking place in two Local Government Areas (LGAs) of Lagos State, Nigeria, concerned with screening for Neurodevelomental disorders among children under the age of 3 years attending immuniation clinics, the project is presently being funded by Grand Challenges Canada.

It is believed that this project would succeed because the idea behind the project has been piloted successfully in some Immunization clinics in South-Eastern Nigeria. During the initial pilot of the idea, limitations regarding the follow-up and interventions for the mothers and children because of lack of funding were identified as follows: "the design was cross-sectional and hence the growth parameters of the infants studied were measured only once. There was no follow up of the cases to monitor the growth trend of the infants over time and to see whether resolution of maternal PPD over time would reverse the negative association observed in the growth parameters of the infants. This is an area where future wider implementation of this idea needs attention". [Updated 12/26/14].

If funded, this idea would address these limitations over one year period to detect the benefit of early identification and interventions for the possibility of future scale-up and policy formulation to promote the implementation of the idea nationwide in Nigeria. [Updated 12/26/14].
 
 
 
 
 
 
 
 

Who will benefit from this idea and where are they located?

The primary target population for this project will be the mothers and children attending Immunization Schedules under NPI at PHC levels in Lagos State. Lagos State is the second most populous State in Nigeria after Kano out the 36 States and FCT in Nigeria.

How could you test this idea in a quick and low-cost way right now?

- By carrying out a cross sectional survey of the ideas which has already been prototyped in a previous study (http://www.sciencedirect.com/science/article/pii/S0163834313002521). - By carrying out pre and post test knowledge assessment of the mothers about postpartum depression and normal developmental milestones in their children. - By quickly assessing the cross sectional association between postpartum depression and failure to thrive in the children at the immunization clinics which has also been prototyped in a previous study (http://www.sciencedirect.com/science/article/pii/S0163834313002521).

What kind of help would you need to make your idea real?

Feedback from the OpenIDEO community on how the ideas can be further improved.

Is this an idea that you or your organization would like to take forward?

  • Yes. I am ready and interested in testing this idea and making it real in my community.
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Team (4)

David's profile
David Citrin

Role added on team:

"David, I will kindly like to add you to m team, your comments are quite insightful. Many thanks. Muideen"

Muideen's profile
Bettina's profile
Bettina Fliegel

Role added on team:

"Hi Bettina, I would love to add you to our team because of the interest you have shown in our proposed project. We believe you can give us further insights. Thank you!"

Scott's profile
Scott Sloan

Role added on team:

"I would like to add you to our team and would be glad to collaborate with you. Thanks for being in touch!"

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Attachments (4)

Article.pdf

Related piloted idea in a cross-sectional survey done in South-Eastern Nigeria.

Milestones.pdf

Developmental Milestone Visual by CDC

User Experience Map.pdf

User Experience Map

55 comments

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Spam
Photo of Monica Wirawan
Team

Hi Muideen! Congratulations! Such a brilliant idea which would be implementable to the real field! I hope it would help most of the women there! Keep give us update about the implementation progress!

Spam
Photo of Muideen Bakare
Team

Many thanks Monica! We will be posting updates as the Project progresses.

Spam
Photo of Bettina Fliegel
Team

Exciting news Muideen! Congratulations to you and your team in Nigeria! What a cool way to get a grant!
I look forward to hearing updates on the programming! Where are you in the process now?
All the best,
Bettina

Spam
Photo of Muideen Bakare
Team

Many thanks Bettina. In the coming weeks, we would be putting formal Application for Ethical Clearance and Permission from the Lagos State Primary Health Care Board in Nigeria. Thank you once again for your critical comments that helped shape the Idea.
Best Wishes,

Muideen

Spam
Photo of Karime Perchy
Team

Congratulations! this is such a wonderful idea! All my respect, thru this project you are helping so many women in your community.

Spam
Photo of Muideen Bakare
Team

Many thanks Karime

Spam
Photo of Julian Marembo
Team

Hello Dr. Muideen! This is a great project! Please update us on any new developments so far.

Spam
Photo of Muideen Bakare
Team

Hello Julian. Thank you! We are presently discussing with the Lagos State Primary Healthcare Board in Nigeria, a body that oversee the Primary Health Care Clinics that we are going to collaborate with in implementing the screening and interventions.

Spam
Photo of Bettina Fliegel
Team

Hi all!
Great to hear there is movement on the project Muideen. Are these discussions formalities regarding getting official permission to move forward on the project, or are there discussions on how to implement which include conversations amongst various stakeholders - nurses, doctors, mental health workers, patient representatives, physical therapists, speech therapists etc? Both?
What time frame are you looking at for getting the project running?

Spam
Photo of Muideen Bakare
Team

Hello Bettina,
The ongoing discussions centered on getting official permission from the Primary Health Care Board, application process for Ethical Clearance, as well as stakeholders meeting. Tentatively, we are looking at a starting date of first or second week of May, 2015. A lot also depends on getting funds to support the project. We are hopeful.

Spam
Photo of Bettina Fliegel
Team

Hi Muideen. Congratulations on being selected as a winning idea!

Spam
Photo of Muideen Bakare
Team

Thank you Bettina!

Spam
Photo of Adam Reterski
Team

Not many people realise how great this issue is and how many women how to face depression. Reading this post brought back memory of my sister who suffered from post birth depression, the help she received was not sufficient even though our country is perceived as developed.Again, many thanks for posting this idea. Brilliant!

Spam
Photo of Muideen Bakare
Team

Many thanks Adam for your supportive comment!

Spam
Photo of Kağan Rüstem
Team

Great idea Muideen. How do you plan to try and counteract any adverse effects on children who's mothers we're diagnosed at an early stage who may have already suffered adversely?

It's great that you have though of looking at the mental health of mother and child rather that just the practicalities of healthy living which can so often become the sole focus of help ideas in poverty stricken regions.

Spam
Photo of Muideen Bakare
Team

Many thanks Kagan. The usual picture is neglect of child care by the depressed mothers, which can lead to failure to thrive. Once interventions are put in place, the mothers would start improving and pay better attention to their child care, including nutrition and bonding.

Thanks once again for your kind comment.

Spam
Photo of Dean James
Team

Good idea as it looks at addressing an issue that is often ignored, your idea is original and should be highly successful.

Spam
Photo of Muideen Bakare
Team

Many thanks Dean!

Spam
Photo of Ana Paula Menezes
Team

Great idea! You have chosen a problem that is neglected in many areas and it is extremely important to work around it. Many women never even get diagnosed for post partum depression, and they really need the assistance in order guarantee their children will thrive.
Would you also help women who are diagnosed negative?
Good luck!

Spam
Photo of Muideen Bakare
Team

Thank you Ana. Mothers that are screened negative would only benefit from the preliminary information that would be provided to all mothers about Postpartum Depression, Child Developmental Milestones and Nutrition prior to the commencement of screening. However, they would also benefit from follow-up screening each time they bring their children for immunization schedule, up to the age of 12 Months.

Thank you once again!

Spam
Photo of Irene Blas
Team

Original area to work in! Great job!

Spam
Photo of Muideen Bakare
Team

Many thanks Irene!

Spam
Photo of Ayman Hanafi
Team

Great stuff Muideen and what a great difference the success of this service would make for mothers and their children. PPD must be such a debilitating disease. How can mothers in such a condition be in a fit state to care for their children?Hoping you will have a great success with this project, Good luck!

Spam
Photo of Muideen Bakare
Team

Thank you Ayman.

Spam
Photo of Laura Schwecherl
Team

This is a fascinating idea!

For the interventions, will depression and PPD be treated by group therapy, individual sessions, medication, etc? Who is conducting these interventions?

Also, after the 3 months, what qualifies as 'success' when meeting with the patient? Do you foresee any challenges measure mental health outcomes since it's not as 'visible' as physical health ailments?

Spam
Photo of Muideen Bakare
Team

Thank you Laura.

As I earlier highlighted, pharmacotherapy (Antidepressant Medications) and psychotherapy would constitute the interventions. The psychotherapy component would be eclectic in approach. Psychiatrists, Psychologists and other multidisciplinary professionals would provide the interventions. After every 3 months, improved score on Edinburgh Postnatal Depression Scale (http://en.wikipedia.org/wiki/Edinburgh_Postnatal_Depression_Scale) and inter-rater clinical judgement using Clinical Global Impression (http://en.wikipedia.org/wiki/Clinical_Global_Impression) would qualify for success. You can also read our earlier pilot of the idea (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/pdf), without the follow up component.

Kindly let me know if you need further clarification.

Spam
Photo of Chioma Ume
Team

Muideen, I'd love to get a better sense of what you mean by eclectic. Is a multidisciplinary approach to treatment unique, or have you observed it being effective in other settings? Thank you for sharing your paper. I read the abstract and see that it concludes this intervention might be appropriate to continue. Do you currently have support (i.e. funding or implementation assistance) to continue the screenings, or is that what you are hoping to receive from Amplify?

Spam
Photo of Muideen Bakare
Team

Thank you Chioma for your comment.

Eclectic approach in the practice of Psychotherapy simply means different modalities of Psychotherapy techniques would be employed. For instance, a mother with depression could be treated using cognitive behavior therapy, family therapy, group therapy or individual centered therapy. In situation where a mixture of these approaches is employed is referred to as "Eclectic Approach". Multidisciplinary approach simply means that individuals of different disciplines are involved in management of clients with mental health problem. Multidisciplinary approach to management is the hallmark of management in the field of mental health because the causes or etiologies are often multidimensional - Biological causes, Psychological causes and Social causes.

For instance, in mothers with depression, there are documented neurotransmitter abnormalities which would be controlled by medication. Psychological dimension to depression etiology may be concern about self-worth, for which self esteem of the mother needs to be restored through psychological treatment (psychotherapy) as earlier highlighted above.

There may be social components to etiology of depression in mothers - issues like marital conflicts, rejection and stigma of being a single unmarried mother as prominent in some African culture. All these may require interventions from Social Workers through house-hold visits and organizing family meetings.

So, the hallmark and most effective form of interventions in mental health problems, irrespective of the diagnosis is multidisciplinary approach.

We are looking at the possibility of getting funding from Amplify to continue the screening and follow up these mothers and children to evaluate the benefit of early interventions with the ultimate aim of scaling up and recommending this method as part of Primary Healthcare Policy in Nigeria and maybe other sub-Saharan African countries.

Kindly let me know if you need further clarification.

Spam
Photo of Chioma Ume
Team

Hi Muideen, thanks so much for the comprehensive answer! I appreciate that you have done a lot of research and study around the method you are pursuing. As you've begun the screenings, have you also solicited feedback from the mothers that you are serving? Have you learned anything that has modified your approach?

Spam
Photo of Muideen Bakare
Team

Thank you Chioma. What we have learned so far as feedback from the mothers is the need for them to understand clearly the objectives behind the screening. This has intensified our pre-screening education and information to the mothers as I earlier highlighted in my previous responses. For example, the educational information needs to be provided to the mothers in different media they can identify with. This includes telling stories to paint scenario around the project objectives, didactic lectures, songs, pictorial, video and print media. To get information across to the general public about the idea, the use of radio, television and social media platforms have been found helpful with our ongoing project being supported by Grand Challenges Canada (http://cndinitiatives.com/sponsor.html). We hope to apply same media, if this proposal gets funded.

Another helpful approach is that of providing rewards to the mothers for participating in the screening. These rewards include children toys, feeding cups and spoons given to the mothers.

Spam
Photo of Chioma Ume
Team

Thanks Muideen, and Happy New Year!

Spam
Photo of Muideen Bakare
Team

Happy New Year Chioma!

Spam
Photo of Chioma Ume
Team

Thank you!

Spam
Photo of Chioma Ume
Team

Hello Muideen and Team! We've been having early childhood experts take a look at the ideas in Refinement and we want to share some of their feedback with you: Bundling PPD screening to routine child immunizations is very innovative and we're very inspired by your work. How will you make the case that NIP staff have the capacity to conduct these screenings, and that the NIP system is adequate to provide referrals and other follow-up after the screenings? Also, would child development issues would be noted elsewhere, such as in other child health screenings? If PPD is the issue that is really getting missed, why not just focus on that especially given the capacity concerns about NIP bundling additional services? Or if both PPD and child developmental deficits are being ignored in a serious way, why are these two services critical ones to address together? It's also important that the materials and family support groups are engaging which requires deep audience insight. It would be interesting to think about where else the materials you develop could be distributed and by who. Could they be shared with social or religious social networks and with schools, for example?

Spam
Photo of Muideen Bakare
Team

Hi Chioma,

Thank you for the feedback. Various questions raised have been addressed as follows:

- How will you make the case that NIP staff have the capacity to conduct these screenings, and that the NIP system is adequate to provide referrals and other follow-up after the screenings?

Response – The NPI staffs would be trained on the use of the two screening instruments prior to the commencement of the project. The two instruments (EPDS and Depressive Episode Module of MINI) are simple instruments and easy to administered. EPDS (http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf) is a self administered Questionnaire for clients that are literate and can read. For those who cannot read, the content of the instrument would be read to them to answer. EPDS has been translated and validated in two (2) major Nigerian languages (Yoruba and Igbo), Yoruba is the native language of the State where this study would be taking place. The Depressive Episode Module of MINI would be administered to the mothers by the Primary healthcare workers following their training.

The screening process had already been piloted as documented in our previous Article published by General Hospital Psychiatry (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/pdf). A pdf copy of the Article is also uploaded among the materials included with this idea on the IDEO website. We would launch on the present integrated service delivery model, with 2 supervisory nurses monitoring the process of screening and referral in the NPI Clinics, where the project would be taking place.

- Also, would child development issues would be noted elsewhere, such as in other child health screenings? If PPD is the issue that is really getting missed, why not just focus on that especially given the capacity concerns about NIP bundling additional services? Or if both PPD and child developmental deficits are being ignored in a serious way, why are these two services critical ones to address together?

Response – The essence of the screening is to provide longitudinal follow up to evaluate the influence of interventions on mothers’ response and whether these interventions and response have positive influence on child development.

For example, women with postpartum depression often neglect breast feeding, so they cannot be treated in isolation of their children. Part of the treatment is to encourage breastfeeding for appropriate child development on one hand and to promote mother-child bonding on the other hand.

In our article published by the General Hospital Psychiatry (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/pdf), we documented limitation following the cross-sectional screenings, which I copied below:

“The main limitation of this study is that the design is cross-sectional and hence the growth parameters of the infants studied were measured only once. There was no follow up of the cases to monitor the growth trend of the infants over time and to see whether resolution of maternal PPD over time would reverse the negative association observed in the growth parameters of the infants. This is an area where future wider implementation of this idea needs attention. It is necessary to incorporate intervention services for the mothers and their infants within the NPI and do prognostic follow up of the mothers and their infants.”

The objective of this present idea is to address and fill the gaps documented in the above limitation of the initial pilot. For a proper understanding of our present idea, a detail reading of our previous article is recommended (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/pdf).

The evidence, which we hope to gather, that the interventions work and bring positive changes to the mothers and children would justify a scale-up of the idea and future recommendation of the idea to Governments in Nigeria and other sub-Saharan African Countries for the purpose of inclusion in their Primary Healthcare Policies. This justify why these two services are critical ones to address together.

Spam
Photo of Bettina Fliegel
Team

Hi Muideen.
What services are currently available at the immunization clinics? Are infants brought there simply to receive the vaccines or are they also weighed and measured there? Are they examined at any time during infancy by a physician or advanced practice nurse? Are these immunization clinics run by nurses? Are infants ever screened for developmental milestones in the health system in Nigeria, or is the project you have running, with support by the Grand Challenge Canada, where you are evaluating infants and toddlers for developmental problems something completely new in health care for young children in Nigeria?
It would help to understand what the current practice is in primary health care for children in Nigeria to get a fuller picture of how your project fits into the big picture.
Perhaps a flow chart illustrating how a mother/infant receives services now and how they will receive services in your program can highlight the new services and illustrate how they might affect outcomes over time? What are the current outcomes over time?

Also - in the photo of the clinic it appears to be a large room, many moms/babies and two women (?nurses) at a central table. Is this the location where the infants are vaccinated or is this a registration desk? Will the depression screenings be done in a private space?

Spam
Photo of Muideen Bakare
Team

Hi Bettina,

The current practice in our immunization clinic is that the mothers brings the children to immunization clinics to get vaccinated, most often times without any developmental screening being done. Sometimes only the weight are measured and other aspects of developmental milestones are not assessed as we presently do with Grand Challenges Canada supported project. Assessing overall milestones developments is a new innovation we introduced.

Yes, the National Program for Immunization (NPI) is run by only Nurses and some Community Healthcare Workers (CHWs). As obtained presently,there is no provision screening mothers for postpartum depression. It is a new innovation we are bringing into the picture.

Yes, the clinic is a large room where the mothers are educated and given information collectively and that is where the vaccination and the PPD screening is also done. The PPD screening only involves the mothers answering about 15 item questions that can be completed in about 10 mins. Any mother that need further counseling following the screening are seen in a separate room.

What are the current outcomes over time? I will suggest you read our previously published article on prototyping this idea (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/pdf) to get a better understanding of what our projections are in the presently proposed longitudinal follow up .

Thank you.

Spam
Photo of Bettina Fliegel
Team

Hi. Yes I know PPD screening will be a new intervention. It was not clear what if any developmental assessments or growth assessments are done as a general practice. Thanks for clarifying.
Will interventions be available in local communities? Will they be provided by the public health system?
Good luck with your work.

Spam
Photo of Muideen Bakare
Team

Thank you Bettina.

Yes, the interventions are available locally.

Spam
Photo of Bettina Fliegel
Team

Great that the interventions are available locally. That will definitely benefit families!

Spam
Photo of OpenIDEO
Team

Congratulations on making the Zero to Five Refinement list, Muideen! We really like how your idea focuses on the impact of a mothers mental health on her ability to foster the development of children from 0 to 5. It’s great that you plan to build on an existing initiative – do you plan on this being a direct addition to the program supported by Grand Challenges Canada? Will the screenings be held at the same facilities? How do you plan to get mothers interested in this program? Do you anticipate stigma around mental health issues to play a role in how receptive people are to this idea? Is it an organization or hospital administration that will carry this idea out and facilitate the mothers groups? If it requires additional work from these groups, do you anticipate it being challenging to secure their support? We’d love to get a clearer sense of how a mother might participate in this program. Please create a a User Experience Map http://ideo.pn/0to5-map and check out tips for Refinement http://ideo.pn/0to5-tips-refine here.

Spam
Photo of Chioma Ume
Team

You were also selected for early feedback on your idea. IDEO designers in New York and Shanghai took a look at your idea and have shared their feedback.

Here are some things that you may wish to consider as you refine your idea:

CONSIDER YOUR STAKEHOLDERS

-Who are all the stakeholders and what will motivate / engage them to get behind this initiative? Think through the following:

-Who will say yes to adding this element to the existing program (i.e. policy maker, administrator…etc.)?
- Who will fund the additional costs of the program?
- Who will implement the program (i.e. nurse, doctors, staff members…etc.)?
- Who will participate in the program (i.e. mothers, husband, her family members…etc.)?

-What are some potential areas of resistance to incorporating the program? How might you address those challenges?
For example:
Adding this extra element will give nurse additional work…they already have to deal with too many patients, why would they want to do this?
Might there be any reason for the husband to not want his wife to do this?


CONSIDER YOUR AUDIENCE
- In addition to the timing of your interventions, think about the range of interactions and delivery of materials. What different forms or format can your information be presented? It doesn’t just have to be a piece of paper.

- As part of the screening process can you start to model what a positive mother/baby behavior is? Are there materials or takeaways that can help build a bond between a mother and newborn like a toy or game? Are there ways to incorporate other family members, like a children’s book that entertains and educates?

QUALITY CONTROL

- How might you ensure quality of the added PPD screening?
- Is there a training element to ensure the nurse/staff can pick up right cues and sensitive in how to deal with a potentially depressed patient?
- Is there an administrative element to actively manage and ensure implementation is done and done correctly?

PROTOTYPING

Some suggestions for prototyping this idea:

- Service Design / Actual Screening Method: how to design an innovative, most culturally relevant, easy / fun to execute screening method

- Must be easy to implement for the staff/nurses. Consider the hectic environment the screening will be implemented and the mindset (possibly annoyed, rushed) of the staff/nurse

- Must be engaging enough for an illiterate, and potentially depressed mother to want to go through
- Might you consider a “reward” element for everyone involved in the screening?

- Service Design / Feedback Loop: the “so what” after the screening is done. How will you effectively link resources to help mothers who actually have PPD?

COMMUNICATION DESIGN

- How will you launch / educate all stakeholders about PPD and importance of it so there is buy-in?

- The explanation of your the idea is very academic – if it’s communicated to people in such a way, will it be likely to gather support?
- Try and help people understand why this will be helpful and what is in it for them

- Often, we only think about the moment when these events occur, in this case postpartum, but if we think about the larger user journey, you maybe able to get your message into the right hands at a more receptacle moment.

- In addition to the timing of your interventions, think about the range of interactions and delivery of materials. What different forms or format can your information be presented? It doesn’t just have to be a piece of paper.


INSPIRATION

Read this story of how GE made the MRI experience more enjoyable for children and their families : http://newsroom.gehealthcare.com/from-terrifying-to-terrific-creative-journey-of-the-adventure-series/

Spam
Photo of Muideen Bakare
Team

Thank you for your comment. The questions are addressed as follows:

- Do you plan on this being a direct addition to the program supported by Grand Challenges Canada (GCC)?

Yes, it is an addition but not necessarily a direct addition because the project design is somewhat different. While children that would be involved in this project are going to be new born babies below the age of three (3) months and would be followed up every 3 months until they achieved the age of 12 months or 1 year, if they show symptoms of failure to thrive on baseline screening and/or their mothers are screened positive for postpartum depression, the children in Grand Challenges Canada supported project undergo screening every six (6) months for the sole purpose of early detection of Childhood Neurodevelopmental Disorders before the age of 3 years. So, children above one (1) year and below the age of three (3) years are still involved in Grand Challenges Canada supported project and the mothers do not undergo any form of screening to detect depression. By definition, post-partum depression onset of symptoms usually occurs within few weeks of childbirth and the symptoms may develop or persist up to one year post-delivery period. Hence, the need to follow up the mothers and the children until the children achieved twelve months or one year of age.

- Will the screening be held at the same facilities?
Yes, the screenings would be held at the same facilities as the GCC supported project, at the Immunization Clinics of the two (2) randomly selected Local Government Areas (LGAs) of Oshodi and Mushin in Lagos State, Nigeria.

- How do you plan to get mothers interested in this program?
The best way is education, educating the mothers about the nature of depression, the direct and indirect effects on their children growth and the reason why screenings need to be done. This is usually through health talk prior to commencement of immunization clinic for the day. We employed the same method of education in our initial pilot of this idea in Enugu, South-Eastern Nigeria (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/abstract) and we got well over 90% consent of the mothers approached to participate in the screenings.

- Do you anticipate stigma around mental health issues to play a role in how receptive people are to this idea?

Yes, our team anticipates this and the way we had gone around this problem in our previous pilot was to explain to the mothers that the process of child birth and child rearing are shades of joy and stress as African culture portrays it. The joy brings about happiness, while the stress may bring anxiety and depression. Hence, the need for mothers to pay attention to their physical and psychological health. The explanation made the idea of screening to be more receptive to the mothers in our previous cross-sectional survey (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/pdf). Moreover, the symptoms of depression among Africans do not carry high level of stigma as other mental health problems like psychotic disorders and depressed African women tend to present more with somatic symptoms.
- Is it an organization or hospital administration that will carry this idea out and facilitate the mothers group?
It is the organization in collaboration with the hospital administration that will carry this idea out and facilitate the mothers group. There is presently such an ongoing collaboration in the Grand Challenges Canada supported project. We hope also to use the same template of collaboration in this project, where the organization leads the way and the hospital administration collaborates.

- If it requires additional work from these groups, do you anticipate it challenging to secure their support?
The screenings may constitute additional work for primary health care nurses at the immunization clinics. The program plans to motivate the primary health care nurses by providing them with stipends to take up the additional responsibilities. We also hope to hire two full time supervisory nurses that would participate and supervise screening activities in each of the two selected LGAs in Lagos State. The mothers would be motivated to participate in the project by provision of toys for their children. We believe these measures would help in securing support of the primary healthcare nurses and the mothers who are stakeholders.

- User Experience Map
A User Experience Map has been uploaded. The screening phase would follow the methodology stated in our previously published paper with minimal or slight modifications (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/pdf). The additional steps that would be taken as reflected in the ‘User Experience Map’ would be to address the limitations of follow-up on child development and resolution of depressive symptoms in the mothers over a period of time, which could not be achieved in the previously piloted idea.

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CONSIDER YOUR STAKEHOLDERS

- Who are the Stakeholders?
- Who will say yes to adding this element to the existing program?
Response – Lagos State Government Primary Health Care Board at first instance and ultimately Nigeria Federal Ministry of Health, if the idea is bought into as a National policy.

- Who will fund the additional costs of the program?
Response – Allowances for Professionals like Psychiatrists, Pediatricians, Psychologists, Nutritionists, Social Workers, Tertiary Healthcare Nurses among others that would provide multidisciplinary assessment and interventions, would be leveraged by the collaborating Tertiary Institution, Federal Neropsychiatric Hospital, Yaba, Lagos .

- Who will implement the program?
Response – Primary healthcare nurses working at the Immunization Clinics, two full time supervisory nurses to be hired for the purpose of the project. Other multidisciplinary professionals like Psychiatrists, Pediatrician, Psychologists, Social Workers, Nutritionists, among others.
- Who will participate in the program?
Response – Mothers and their children at the screening phase. Mothers, children and their families at the phases of interventions and follow-up.

- What are some potential areas of resistance to incorporating the program? How might you address those challenges?
Response – Extra work for the nurses: they would be paid some stipends to motivate them to take the extra responsibilities. Two full time supervisory nurses would be hired to help with and supervise the screenings for the period of the project. Refusal to participate or give consent by the mothers: Adequate information and education for the mothers, husbands and other members of the family on the importance of screenings and benefit of interventions for both the mothers and children. These measures are expected to reduce the resistance of the mothers to the idea.

CONSIDER YOUR AUDIENCE

- What different forms or format can your information be presented?
Response – In addition to papers like flyers, pamphlets, health education materials to the mothers attending immunization clinics can be provided in form of song and choruses which the mothers can easily identify with. Other methods are pictorial and video media. This project would employ some of these additional formats.

- Modeling what a positive mother/baby behavior is to improve bonding?
Response – This would include mother-baby play and emphasis on exclusive breast feeding to encourage frequent mother-baby eyes contacts, which helps to promote bonding. Suggestions are welcome from the community on further ideas that can promote positive mother/baby behavior.

QUALITY CONTROL

- The screenings would be done by the primary healthcare nurses at the immunization clinics and two full time supervisory nurses that would be hired for the period of the project. They would be trained on use of screening instruments and child growth charts. The procedure and methods of screening would follow documentation in our previous report (http://www.ghpjournal.com/article/S0163-8343%2813%2900252-1/pdf).

- Is there a training element?
Response – Yes, there would be training for primary healthcare nurses prior to commencement of the screening process.

- Is there an administrative element to actively manage and ensure implementation is done and done correctly?
Response – Yes, first is the administrative hierarchy of Childhood Neuropsychiatric Disorders Initiatives and other two Institutions that would collaborate in the implementation process (Lagos State Primary Health Care Board and Federal Neuropsychiatric Hospital, Yaba, Lagos). In addition, a Project Coordinator would be hired to see to day to day coordination and implementation of the project. Both progress and challenges regarding the implementation would be documented and reviewed.

PROTOTYPING

Suggestions highlighted under this section have been noted and would be put into consideration during implementation.

- Might you consider a “reward” element for everyone involved in the screening?
Response – Yes, “reward” element would be considered as indicated in my previous comments.

- Service Design/ Feedback Loop: the ‘so what’ after the screening is done: How will you effectively link resources to help mothers who actually have PPD?
Response – The service design would be Integrated Service Delivery Model that would link immunization clinics in primary care setting to multidisciplinary professionals at the tertiary care of Federal Neuropsychiatric Hospital, Yaba, Lagos. The mothers with PPD would undergo assessment and interventions that would be a combination of pharmacotherapy and psychotherapy and they would be followed up every three months or as deemed necessary based on clinical assessment until their children achieved the age of one year and above. [Continuation in the next post……..]

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COMMUNICATION DESIGN

- How will you launch/educate all stakeholders about PPD and importance of it so there is buy-in?

Response – Radio, Television, Print and Social Media would be used to give information to the larger audience and stakeholders about PPD and the potential negative effects on mother-baby relationship and eventual child development. Copies of Final Report on the outcome of this project would be sent to Lagos State Primary Health Care Board, Nigeria Federal Ministry of Health, UNICEF Nigeria among other relevant agencies. This would be aimed at encouraging scaling of this idea by both the States and Federal Government in Nigeria. The ultimate objective is for the idea behind this program to become a National policy that will be implemented Nationwide if found beneficial.

Format of information dissemination would be tailored to the specific audience need for the purpose of easy comprehension and understanding of potential benefits the program proposes to offer.

INSPIRATION

The GE experience has shown that not only the idea behind a project is important, but also the approach to implementation matters a lot.

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Thank you Bettina for your comment

The mothers and infants are going to be screened each time they access Immunization Clinics based on the immunization schedules as follows:

- Birth (0 to 1 week) - BCG (Tuberculosis)
- 6 Weeks – First dose of OP V & DPT
- 10 Weeks – Second dose of OPV & DPT
- 14 to 16 Weeks – Third dose of OPV & DPT
- 24 Weeks (6 Months) – Extra Appointment to be booked for this period.
- 36 to 52 Weeks (9 to 12 Months) – Measles and Yellow Fever Vaccines

However, mothers that are screened positive for postpartum depression and their children would enter Intervention phase at any of the above points. They would be followed up and evaluated every three (3) Months to assess the impact of the interventions both on the mother and child.

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Hi Muideen and team.
By chance there is a very interesting and pertinent opinion piece in the NYTimes from 12/4/14 on depression in patients in the developing world and innovative work that is being done to provide care. The piece begins by highlighting the huge need for mental health care that has arisen secondary to the Ebola epidemic and the limited resources available.

I linked the article below.
Are you familiar with any of the initiatives highlighted in which lay people are trained and are then rendering care in local communities? Studies done on these initiatives show good results.
Here is a clip from the article which focuses on a project in South Asia. This project targeted pregnant women and mothers who had recently given birth. They were screened for Post Partum Depression and if found to have signs/symptoms were enrolled into the program.
"More recently, similar work has gone on in South Asia. In rural Rawalpindi, Pakistan, the Thinking Healthy Program taught basic cognitive behavioral therapy for only two days to female community health workers with a high school education. The trainees, called Lady Health Workers, then integrated the therapy into their regular visits with pregnant women and new mothers. (Studies often focus on women, especially new mothers, because they suffer depression more than men and their mental health is crucial to their children’s development. It allows health workers to paint the program — truthfully — as a way to help the baby, which is more socially acceptable than treating depression in the mother.) Six months later, only 3 percent of those treated were still depressed. The largest study was in Goa, India, where local people with no health background were given an eight-week course in interpersonal psychotherapy and worked with physicians to treat patients with mental health disorders. This, too, was very successful."

http://opinionator.blogs.nytimes.com/2014/12/04/a-depression-fighting-strategy-that-could-go-viral/?action=click&contentCollection=N.Y.%20%2F%20Region&module=MostEmailed&version=Full®ion=Marginalia&src=me&pgtype=article&_r=0

What is the care plan and who will provide it in your proposal? Will mothers receive care in their local areas?
I am excited to learn more and would love to hear your thoughts on the highlights from the NY Times piece.

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Hi Muideen. This is an exciting initiative. I am a US based pediatrician. I am curious about what interventions you have in place for mothers with PPD in your area in Nigeria. Are they treated with medication as well as counseling?
Regarding the developmental screening that you are planning - Are you developing a program for early intervention that will be community based for infants/toddlers identified with delays?
I am curious about Family Support Groups that you mention. You state that the families will be referred for counseling and support before having an assessment at a tertiary care center. Why refer before a specific diagnosis is made? Wouldn't this cause unnecessary anxiety in those cases that are not ultimately diagnosed with depression or a delay? During the research phase of this challenge I reached out to a colleague who is a developmental/behavioral pediatrician in NY. She works at a center which takes a team approach to diagnosis and treatment of developmental or behavioral problems in children. The children are referred for evaluation by MDs, teachers, and parents who self refer. She remarked that parents of children who are treated there find community with other parents and this is comforting to them. It becomes a place of socialization for them. There are also formal groups with counselors but parents find each other which is great.
Good luck moving this initiative forward!

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Hi Bettina,
Thank you for your comments. In response to your questions, this project would work collaboratively with Federal Neuropsychiatric Hospital in Lagos State, Nigeria where mothers with Postpartum depression (PDD) would be referred for treatment. Yes, the treatment is a combination of medication and counseling after detail clinical assessment. We do not intend to refer before making specific diagnosis. We stated that "The interventions at primary care level will include educating parents about PPD and Normal Developmental Milestones, counseling and support for the family by establishment of Family Support Groups where parents can share their apprehension and concerns before referral to tertiary care center for further evaluation and specific interventions as required by identified mothers and children". The interventions at primary care is essentially education of the parents and support groups to be led by a healthcare worker, where they can share their concerns about themselves and their children's development and advice given. This is like a form of Group Therapy, it rather helps to relieve apprehension and alleviate anxiety before referral to tertiary care where Individualized Family Specific Interventions (IFSI) would be provided based on specific diagnoses made, again after detail clinical assessment at tertiary care center. The objective of family support here is almost the same as highlighted by your pediatrician colleague in NY. We have an ongoing project being supported by Grand Challenges Canada, where we already instituted this template - http://www.grandchallenges.ca/grantee-stars/0323-04/ . It is our belief that this project, if funded will launch into the already created foundation.

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Thank you for the clarification. My understanding was that the moms and children were only screened in primary care and referred on for further evaluation and diagnosis of specific delays. Sorry for my misreading. This is the model we often use here. In primary care we observe children, screen by parental report, and examine. Close follow up is done if there is a concern detected with subsequent referrals made if needed. Further evaluation, diagnosis and recommended treatment plan is often done by a multidisciplinary team. Interestingly my colleague who works at a specialized evaluation and treatment center told me that parents in many instances report that this process is a great learning experience for them as it is hands on and comprehensive. Not all children referred are ultimately diagnosed as delayed and receive services. This insight really pointed to how great it would be to be able to provide comprehensive hands on sessions for all parents on child development of children at all different ages.
Best of luck moving forward on this project!

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Thank you Bettina.

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Thanks Muideen, for this post. Global mental health posts are very exciting to see, and I like your aim to integrate into existing government programs. Excited to see how this intervention develops further. Are government healthcare workers trained in mental healthcare services in Lagos State? I'm curious only because we are trying to improve mental healthcare services where we work in far western Nepal, as it seems to be one of the largest service delivery gaps in solving for our patients. As the GHP article you reference mentions, PPD was associated with lower developmental growth measures of children, which makes sense. Have there been any qualitative assessments done to determine maternal thinking around "what thriving looks like"? Maybe understanding what mothers fear/wish for their children would help customize the intervention?

Thanks again, look forward to following this thread.

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Many thanks David, mental health knowledge gap remains a major area of focus to achieve impact in community mental health. It is this idea that culminated in development of mhGAP. People from lower resource settings like us have to find a simple way of passing this knowledge. You are right, getting the idea of what mothers fear/wish for their children would help greatly in customizing the intervention. This would be looked at in more details. Thanks for sharing your thoughts. It is deeply appreciated!

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Many thanks for your suggestions. They are deeply appreciated!!

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Great thought starter, Muideen! With more than 3 weeks left in the ideas phase – we're looking forward to seeing this idea grow. Check out these tips on evolving it further: http://ideo.pn/oi-evolve