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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

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

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.