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Born to Bond: Psychosocial wellbeing for mothers and babies [Updated 6 January 2015]

Born to Bond is intended to develop materials and research impacts of an approach that includes elements of maternal mental health and infant play to contribute to the physical, neurological and psychosocial wellbeing of infants, and reduce postnatal depression. It addresses the problem of supporting maternal mental health and optimal infant development that is commonly lacking in low resource settings by taking a multi-sectoral approach to maternal and newborn health. Community Health Workers in West Bank will be trained in an Enhanced Timed and Targeted Counselling program that will integrate support for physical health, maternal mental health, creative play and infant stimulation to optimise the holistic wellbeing of mothers and babies.

Photo of Andrew Binns

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Depression is the third leading contributor to the global disease burden and the leading cause of disability, affecting more than 121 million people. Mothers living in low and middle income countries (LAMIC) are at higher risk of maternal depression. Conflict in the West Bank, combined with poverty and high rates of unemployment adds to the burden of mental illness. When mothers are depressed during pregnancy, stress hormones are raised in their bodies and brains, which has physical effects on both the pregnant women and her unborn child. Following birth, mothers with depressive symptoms are often less engaged with their children and reduce their responsiveness to meeting their children’s needs. Such infants tend to become apathetic or irritable and less able to gain their mother’s attention in positive ways, risking a cycle that can lead to child neglect and underachievement for the infant in all areas of their development. For example, mothers with depressive symptoms can be intrusive, forceful or withdrawn in their interactions with their infants. They sometimes struggle to bond with their infants resulting in children developing insecure attachments, potential social difficulties, and behavioral problems leading to long term mental health issues, including their own risk for depression later in life. [updated 6 Jan. 2015]
 
In 2011, World Vision Jerusalem, West Bank, Gaza (WV JWG) implemented a maternal child health home-visitor project titled “Towards Nourished Infants” using a timed and targeted counselling (ttC) model. Evaluation of this project showed a 23% increase in Palestinian mothers applying improved childcare practices (improved hygiene, feeding and immunisation practices), increased awareness of child rearing needs and an unintended benefit of improving mother to mother-in-law and sister-in-law relationships. Mothers reported that the home-visitor model was culturally sensitive, personalised and they felt comfortable discussing their needs with Community Health Workers (CHWs) who delivered the ttC program. This was further affirmed in recent key informant interviews that reiterated the home visitor approach was helpful for mothers of newborns [updated 6 Jan. 2015].  Despite the successes of ttC, the evaluation also indicated that greater awareness of psychosocial needs for mothers and their infants was needed in order to reduce symptoms of postnatal depression and to maximise the psychosocial development and potential of infants. This was additionally confirmed in the recent qualitative study [updated 6 Jan. 2015] with mothers reporting a desire to know more about holistic development needs of their infants and CHWs stating their need for being able to provide stronger support to mothers who needed to play and engage more with their infants.  This also supports recent research findings that have demonstrated multiple benefits of maternal mental health and infant stimulation activities for optimal child development. Thus, a systematic model of combining physical, mental and psychosocial support for both mother and infant is needed for future scale-up of interventions. 
 
Based on the success of ttC in West Bank, and known benefits of maternal psychosocial wellbeing and infant stimulation/play this project will take a multi-sectoral approach by developing an Enhanced ttC (EttC) model.  EttC will comprise physical development and health messages for mother and child (based on stand-alone ttC), as well as the 5-pillars approach to reduce symptoms of depression amongst mothers.  The 5-pillars approach, known as the Thinking Healthy Program, includes empathic listening, family engagement, guided discovery with pictures, behavioural activation and problem solving.  This will be combined with parent-infant stimulation initiatives using Learning Through Play (LTP) and regular child development indicators based on the Nipissing District Development Screen (NDDS). 
 
The pilot of EttC and subsequent research hypothesises posits that Enhanced ttC will reduce Edinburgh Postnatal Depression Scale (EPDS) scores in the intervention arm versus control, after 1-year of intervention in West Bank (occupied Palestinian territories - oPt).  Secondarily, it is expected that (1) fewer children will report ‘no-responses’ on the NDDS after 12 months of EttC; (2) the physical health of children in the intervention arm will be greater than the control (e.g. growth monitoring, supplement intakes, breastfeeding and complementary practices, proper management during illness); (3) improved social emotional outcomes in infants will be observed; and (4) improvements in Early Childhood Development Knowledge, Attitudes and Practices (based on the ECD-KAP measure) will be demonstrated.

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

The immediate and direct benefits will be 400 Palestinian mothers living in West Bank (oPt) of any age in their third trimester of pregnancy. The project will implement a Cluster Randomised Control Trial [updated 6. Jan 2015] where half of the mothers will benefit from stand-alone ttC while the other half will benefit from the EttC intervention. For both groups, a further 400 Palestinian infants will benefit from the program. The project will train approximately 40 data collectors for the research as well as approximately 20 community health workers in the EttC training program. Various other people will benefit from the program indirectly, including fathers, sister and mother-in-laws, and siblings of the infants benefiting from ttC/EttC. All participants will be from West Bank (oPt) villages that surround Bethlehem, Hebron, Nablus & Ramallah. [Updated 6 Jan. 2015]

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

In a one-month testing opportunity for this idea, the first three things to hone in on would be: • Development of the EttC package – combining the stand-alone ttC manual and program with the aspects of the thinking healthy program (using the 5-pillars approach), learning through play and developmental screener checks. Based on learnings from the key informant interview study into this concept, development of the EttC package will also need to examine ways for strengthening the engagement of fathers and extended family members in the program, possible ways of utilising technology as an alternative support system and materials that may be helpful for continued education of mothers about child development (e.g. family ‘hand-outs’/brochures). This process will require the dedicated work of one individual for at least one month and most likely, design-workshops with West Bank women, CHWs and partners to finalise the EttC package. [Updated 6. Jan 2015]

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

This project will be dependent upon various partnerships, including, but not limited to the following groups: • Palestinian Ministry of Health so that the approach is monitored for future scalability in West Bank and potentially Gaza. • Al Quds University for local assistance on translations and testing of research measurement instruments. Data collectors may also be recruited from the university and their support in data analyses and reporting of findings will be critical. This local university will also be used to support ethics approval for the research and ensure compliance with ethics protocols. • Human Development Research Foundation (HDRF) in Pakistan, working in partnership with the University of Liverpool, have been global leaders in establishing a low cost, low resource Cognitive Behavioural Treatment, using the 5-pillars approach, for women experiencing post natal depression. HDRF and University of Liverpool will be substantial technical partners in the development of the EttC program and piloting of its implementation; • Learning Through Play (LTP) partners will support the integration of play initiatives for parents as part of the EttC model to be developed. This will be in collaboration also with staff from the Nippising District Development Screener (NDDS) association, so that measures relevant to the psychosocial wellbeing of infants can be monitored throughout the project and implementation of EttC model. • West Bank women and CHWs to contribute to the overall design of the EttC package, and particularly, to help strengthen elements of the proposed EttC package to ensure greater inclusion of fathers and extended family members; [updated 6 Jan 2015] • Possible information technology support to explore ways that modern technology and social media may be able to augment the program for ease of delivering key messages, providing social support to families and supporting the efficient work of CHWs; [updated 6 Jan 2015] • Support from a local artist to ensure readability of the EttC materais and the design and development of educational materials for families. [updated 6 Jan 2015]

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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Attachments (5)

Born to bond story board user experience map.pdf

Born to bond - story board user experience map

Born to Bond Refinement QandAs.pdf

Born to bond - refinement QandAs

Key Informant Interviews summary report.pdf

Born to bond - Key informant interviews summary report

Born to Bond Refinement Process Notes.pdf

Born to bond - Refinement process notes

Born to bond title brainstorm notes.pdf

Born to bond - title brainstorm notes

27 comments

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Photo of Jessica Burg
Team

Hi Andrew,

Thank you so much for this contribution. I think we sometimes get so caught up in the health of the child (with very good reasons), but often the mother is left to her own devices. The postnatal period is such a difficult time for many mothers, but they support they need is so difficult to access.

I'm curious how you will be involving fathers or other family members in this program, so that the mothers are able to focus on being mentally well?

Thank you again for this valuable addition to the discussion. If we want our children to thrive, we really do need to make sure that the caregivers are healthy as well.

Jessica

Photo of Alison Schafer
Team

Thanks for your encouragement Jessica. Currently, the program is formally targetted for mothers and their babies, however, the inclusion of fathers and other extended family members is informally encouraged - so we don't specifically exclude them, but the program is yet to identify ways to be more deliberate in their inclusion. Our brief concept study showed us, that like you say here, there appears to be a need to more deliberately include fathers and other family members in the process; and indeed, this is something we wish to examine further during design phases. In particular, we need to explore options for greater inclusion of fathers and extended family members during the design and development process when the final EttC manuals/materials are created. We would welcome any suggestions you or others might have in how we might better achieve this outcome. Alison

Photo of OpenIDEO
Team

Congratulations on making it to the Zero to Five Challenge Refinement list, Andrew! We are intrigued by the fact that your idea integrates mother mental health and play for children and are interested in learning more. Particularly, we are interested to know what engagement with women and families would look like as part of this program. For example, would the support be delivered one-on-one? In groups? It would be helpful if you filled out a User Experience Map to help us understand how this intervention could play out http://ideo.pn/0to5-map. We see that you have outlined a pilot as a way to test your idea, but wonder whether there are less intensive ways to initially test some of the assumptions behind it. For example, would women identified as having mental health issues readily present themselves for such an intervention? What role do you anticipate stigma around mental health issues playing? Another thing we’d like to understand better is the scope of this project. Are you affiliated with World Vision Australia? Are you seeking support for all or part of this project? How long do you anticipate this project running for? If it was successful, what would happen next? Is there another organization that would take it on? Check out tips for Refinement http://ideo.pn/0to5-tips-refine.

Photo of Andrew Binns
Team

We are so excited to be shortlisted! Thanks for your enquiry. The support would be delivered one-to-one. The Community Health Workers (CHWs) would be visiting women and their infants in their homes, which is a model the original ttC program proved to be highly beneficial and we believe, will mitigate the stimga associated with mental health care. Home visits by CHWs will not be obvious within the community as a mental health care support function, so privacy of mothers will be maintained throughout their support. The pilot study would be an essential precursor to the full research, because it will ensure we are able to reach the mothers and their infants in their homes. Inclusion to the program would be via outreach approaches using existing community networks (e.g. locla health facilities) rather than trying to attract women to 'come to' receive the service and support. So the pilot will help us determine the viability of this approach and whether we will be able to access the necessary numbers for the rollout. But having said this, we're interested in whether others have suggestions about less intensive ways to test some of our assumptions and I will seek more advice on this and keep you posted!

On other questions. Yes, we are affiliated with WV Australia but part of the wider WV partnership that includes WV International technical support experts (such as me - who is based out of WV Australia) and our colleagues in WV West Bank. We would be seeking support for the whole project initially.

We anticipate the project would run for approximately 3 years in total. One year for set up and pilot, 18 months for research (because we need to follow women from third trimester of pregnancy through to infants tuning 1-year old) and the remaining 6 months for analyses and findings. If it was successful, we would be updating all of WV International's ttC approaches and packaging this EttC approach for other iNGOs and community based organisations to implement. The potential scale-up is substantial.

I have reviewed your suggestions on the User Experience Map. Myself and my colleagues in West Bank are working through this process now. We're looking forward to sharing that with you all in the next 10 days.

Cheers,
Alison

Photo of Meena Kadri
Team

Great to hear. Be sure to summarise your responses to the OpenIDEO questions and any other discussion here by the end of the Refinement phase. As mentioned in our Refinement Tips post, the way to do this will be to fill out the Word doc found on the challenge brief, then export as a PDF and upload it to your concept here.

Photo of Meena Kadri
Team

Could also be good for you to create an OpenIDEO profile for yourself Alison (so you don't have to post as Andrew :^) Then Andrew can also add you to the team for this idea via the Manage Team button.

Photo of Alison Schafer
Team

Thanks Meena - I've done that now. Will chat with Andrew so he and I are on the same team.

Photo of Meena Kadri
Team

Great – and we'd also love it if your team might find some time to look over other ideas in Refinement and chime in with questions, feedback and suggestions. OpenIDEO is a space to collaboratively develop ideas so we hope you'll join in with input for others with your valuable experiences and perspectives.

Photo of Meena Kadri
Team

Friendly reminder that our Refinement phase closes tomorrow. We hope you'll be uploading your responses to the OpenIDEO questions above. More instructions can be found here: http://ideo.pn/0to5-tips-refine

Photo of Chioma Ume
Team

Hello Andrew and Team! We've been having early childhood experts take a look at the ideas in Refinement and we'd like to share some of their feedback: Thank you for addressing the issues of maternal mental health in difficult contexts and linking this actively to children and their broader development as well as the overall happiness of the mother and her family. The focus on parents and play are welcomed and, if this works, it could potentially be translated to many different settings. You also do a great job of identifying clear next steps. Areas that you could explore in more detail are how to make sure the package is cross-sectoral to include nutrition, hand washing and breastfeeding etc, as well as psychosocial support. To think about who else can deliver it in addition to health workers, how you'd bring the service to people who might not easily access healthcare and who else the service applies to, such as fathers. You could anchor your plans more explicitly around insights from people and their social networks. Open and maintain the conversation with end users to learn and adapt.

Photo of Alison Schafer
Team

Hi Choma. Thanks for your comments and from your experts panel. There are many questions and ideas here, so I will do my best to address them each in turn.

We agree that this material could be translated and adapted to many different settings. It is for this reason that we wish to firmly establish the approach as an evidence-based one so that future scale up has greater potential. I’d like comment that the standard Timed and Targeted Counselling (ttC) program, which currently exists and was researched with successful impacts in West Bank (under the project titled “Towards Nourished Infants”) already includes aspects of nutrition (initially support for exclusive breastfeeding and later, gradual introduction of nutritious solid foods), hygiene, vaccinations and other key messages related to the physical health of the mother and infant. These elements will remain, but the additional ‘enhanced’ elements will include the psychosocial support for maternal mental health and infant play and stimulation. The project intends for Enhanced ttC (EttC) to indeed be a multi-sectoral approach.

The original intent and research initiative will target Community Health Workers (CHWs) as the delivery agents of the program. However, this is intended to be indicative of any lay persons being able to receive training and provide these services in other settings. In essence, the research needs first and foremost to establish the evidence base for delivery by lay personnel. Ideally, the home-visitor model is critical to the people available to provide the EttC program to women and their families as this will help to alleviate healthcare support, notably mental health care support, which is in short supply in many settings.

Inclusion of fathers and other extended family members was a need that emerged strongly in our refinement research and key informant interviews. Currently, this aspect of the program requires greater attention; but we believe the project design process, particularly the development of the EttC materials will provide opportunity to ensure we address this need. Similarly, this process will also allow us to explore options for ‘anchoring’ social support plans for mothers and their infants, potentially using social media which was another finding key informant interviews suggested. Indeed, having local mothers and CHWs part of the design process, including development to the materials will help ensure local insights are maintained.

Thanks again and we look forward to further inputs from you and the team.
Ali

Photo of Chioma Ume
Team

Thanks for the comprehensive response, Ali!

Photo of Muideen Bakare
Team

Hi Andrew,

Great idea here, especially the component addressing post-partum depression. Can you kindly give an insight into what are detail components of counseling method you hope to adopt. Research has shown that once there are established symptoms of post-partum depression, a multiphase BioPsychoSocial approach to management is recommended and counseling only might not achieve the aim of symptoms resolution. Kindly let me know your thoughts.

Photo of Alison Schafer
Team

Hi Muideen. Thanks for your thoughts and comments. The Thinking Healthy Program is the title of the counselling and psychosocial support approach intended to be used to support mothers’ mental health. This program has effectiveness evidence from research in Pakistan, but is yet to be tested in this type of integrated program. Thinking Healthy Program uses a 5-pillars approach where CHWs are trained to use strong empathic listening skills, and support family engagement, behavioural activation and problem solving through a series of pictorial guided discovery processes. The grounding theory of the program is based on cognitive behavioural therapy approaches to maternal psychosocial wellbeing, which have a strong evidence base globally, including in low-resource settings. Should some women not improve from a purely ‘talking therapy’ and supportive approach, they will still have CHW assistance to be referred for biological interventions if deemed necessary. The advantage of these stepped approaches is that the least intensive and costly approaches can be tested with clients first. I strongly appreciate that the best treatment options for depression, including post-partum depression, can be a hotly debated topic across the professions, but low-resource settings command for us to ensure we take the most culturally relevant, least stigmatizing and more socially supportive approaches as a first line of treatment given the likely challenges for individuals to be able to sustain any medium to long term medication-based interventions. I hope this goes some way to addressing your concerns. Ali

Photo of Muideen Bakare
Team

Thank you Alison,

The assertion, that those not responding to only the 'talk therapy' technique would be referred for pharmaco-therapy is comforting. The general guideline in management of postpartum depression is a mixture of medication therapy and psychotherapy. However, since the 'talk therapy' is being proposed just as a preliminary approach to management, the idea is great.

Best wishes in pursuing this idea.

Photo of Diini Omar
Team

This project is exhilarating inspiration as we know every country has experience a woman with maternal mental health whatever they are low income or not but mainly is due to stress and all over UK has programme that support and eventually revolve the problem. But those counties really benefit this project to reduce postnatal depression. This serious disease and if the women don’t get support can take over her life and end up in metal hospital which heart breaking to witness a family to go through this path. Well done Diini

Photo of Alison Schafer
Team

Thanks for your encouragement Diini. Indeed, mothers the world over need support and the stress of mothers in low-resource settings is indeed just as great, if not more so, than for mothers in high-resource settings like UK. Ali

Photo of Alison Schafer
Team

This challenge/idea has been submitted by Andrew Binns and me! Feel free to address questions to either one of us, though as the technical specialist, any more technical questions will be replied by me. Thanks. Ali

Photo of Uve Kindia
Team

Good concept. This is a slow figure that is slowly rising. Its better it be tackled sooner rather than later

Photo of Alison Schafer
Team

Thanks Uve. I'm very passionate about this topic. Depression, by 2030, is believed to become the world's highest burden of disease. Indeed, we have to start investing in this area of depression amongst mothers if we are to give any hope and prevention of mental illness amongst the children and youth of today - who by 2030, will be our young adults. Alison.

Photo of Bettina Fliegel
Team

Hi all. Interesting project! Congratulations on moving into refinement!
Has enhanced ttC been used before as a treatment modality for PPD in women? (apologies if this is already answered above...)
Is this a model that is specific to World Vision or is it a model that World Vision is adopting or adopting/adapting to local context?

I wonder what the differences would be for moms who received this intervention during the third trimester of pregnancy vs. moms who start it postnatally. Do you anticipate that it might be protective? that these moms may not develop PPD?

Do you anticipate any resistance from moms regarding enrolling in EnhancedttC vs. ttC alone? How will the diagnosis of PPD be made and who in the family will the diagnosis be shared with? as ttC is a model which involves the extended family do you anticipate that this may be an obstacle for Enhancedttc?

I am very curious about your comment that ttC had the unintended benefit to improve mother to mother in law and sister in law relationships. Do women go to live in their husbands home with his extended family after marriage?
What is your sense as to why this intervention improved these relationships? Was their any effect on the relationship with the mom and her mother? or was this not examined as her mother was not involved in the program?

Interesting stuff! Looking forward to learning more.

Photo of Andrew Binns
Team

Hi Bettina. Thanks for your interest. So many questions! Let me see if I can reply to each one:
*Enhanced ttC (EttC) has not yet been created (and therefore not yet tested). We have ttC and we have the other materials for supporting PPD (this being the thinking health program tested with effectiveness in Pakistan via one of our proposed partners), and we have the materials for Learning Through Play and the Nippising District Development Screeners (NDDS). The EttC will be created to combine these evidence-based resources and approaches into one program for delivery in a holistic way. So we are proposing a research project in order to test its impact. We know the components, individually applied, are evidence-based, but we don't yet know the extent of impacts if they are all combined into one program and delivery approach.
*ttC is a World Vision model, though many organisations use similar home-visitor approaches. West Bank has already adapted this for their local context. The Thinking Healthy Program, learning Through Play and NDDS approaches are all approaches used by WV-partners (not specific to WV) that will require some cultural adaptations. So we'll join together to create EttC and test its impact. The adaptations is another justification for taking a research approach.
*The pre-birth interventions are more about physical health and preparing the mother for what's to come post-birth. We don't hypothesise a protective element to the program, but certainly, this could be analysed as part of the data.
*ttC has shown wide acceptability in this culture, because it is a private home visitor approach. We therefore dont anticipate resistance to the other 'Enhanced' elements.
*PPD will not be formally diagnosed by the CHWs. They will simply have an indication of women who are high on the spectrum of symptoms (or low). If they are especially high, they will be reuqired to support a referral, which is where the full diagnoses will take place. The EPNDS would be used as a measure of maternal wellbeing than as a diagnostic tool.
*ttC has proven effective BECAUSE it can be both CHW to mother directly, but we also encourage other family members to participate - we're going to describe this in our story board, currently underway... watch this space! This is why ttC has shown improved relaitonships, because various members of the family are receiving the same information. This is especially important in the Palestinian context where women go to live with their husbands family, who can sometimes be highly critical. Usually, the mother's mother (maternal grandmother to the child) is not directly involved in the raising of the infant - at least not to the same extent as the in-laws. In previous ttC interventions, this wasn't measured because the maternal grandmother is rarely at the household during the CHW visits.

I hope this helps! Thanks again for your interest and feel free to post more questions. We're super excited about the prospects for this program, so I'm happy to share more about it and respond to questions.

Alison (MHPSS Technical Advisor - World Vision)

Photo of Bettina Fliegel
Team

Hi Allison. Thank you for the information and clarifications!

Photo of Andrew Binns
Team

Dear team. OpenIDEO has enquired about whether we might be able to find a way to test the assumptions of our research idea in a less intensive way than running an actual pilot. I'd love to hear more from others about any suggestions or ideas you might have on how we could do this? Thanks!

Photo of Guy Viner
Team

Interesting gobal share, Andrew. Do you have an existing network of organizations on the ground to facilitate this trial? Are you affiliated with an NGO there?

Photo of Guy Viner
Team

Here's a friendly tip: update your OpenIDEO profile so folks can dig who they're collaborating with. Think skills, experience, passions & wit! Looking forward to seeing more of you across conversations on this challenge...

Photo of Andrew Binns
Team

Hi Guy. Alison (from WV) responding on behalf of Andrew. Thanks for your comments. WV has a local office in West Bank, where we already have a trained and existing cohort of ttC community volunteers, all linked with the local Ministry of Health (MoH). So for the trial we would working through them rather than a CBO, but this is beneficial because the links with the MoH have huge potential for sustainability. We also have a partnership with the local Al Quds University, where we would utilise students for the data collection and seek their input and support to the data analyses.
Thanks too for the tip on the profile. I'll look into that now!
Ali