Effect of Community Based Depression Management and Child Development
Condition: Maternal Depressive Symptom and Child Development
MeSH terms: Depression
Study type: Interventional

Summary: 
      Investments in Early childhood Development (ECD) programs produce higher economic return
      through maximizing human potential. In developing countries over 200 million children do not
      reach their developmental potential. Early nutritional support and psycho social stimulation
      are essential for optimum development of children. Mothers are usually the key providers of
      childcare.

      Depression is reported as a leading cause of disease burden for women and maternal mental
      health is identified as one of the major predictors of child development.

      In Bangladesh, almost 60% children are at risk of poor development due to high prevalence of
      Low Birth Weight (22%), under nutrition (41%), poverty, and sub-optimal stimulation. About
      one third of Bangladeshi mothers suffer from depression. Early stimulation interventions in
      Bangladesh have showed moderate improvements to children's development. This indicates that
      there are still some gaps in the pathway to delivery. So, it is crucially important to
      address maternal mental health along with any Early Childhood Development intervention at
      community level to get bigger impact.

      In Bangladesh mothers with sub clinical depressive symptoms often do not seek treatment due
      to the stigma attached to it. Depressed mothers who do not receive treatment often fail to
      provide sufficient stimulation and care for their children and in turn compromise benefits of
      early stimulation programs. Rahman and colleagues (2008) tested an innovative model of
      community-based depression management using Cognitive Behavioral Therapy in Pakistan and
      reported improvement in maternal depression 6 months postpartum.

      The study plans to combine the above treatment of depression with an evidenced-based Early
      Childhood Development program to achieve maximum benefits on reducing maternal depressive
      symptoms as well as improving children's overall development.
    

Detailed description: 
      Present study proposes to conduct the study in rural areas covered by community clinic (CC)
      services and will use their community based staff to deliver the intervention. Each Community
      Clinic is established at grass root level providing one stop service center for Primary
      Health Care for approx. 6000 population. There are over 12000 Community Clinics operating in
      Bangladesh. We chose this population as almost 75% of people live in rural areas and they
      will form a representative sample for scaling in future. There will be 2 groups in the study
      i) Intervention group (Cognitive Behavioral Therapy + play stimulation) and ii) control group
      (with none)..

      Previous studies reported moderate benefit with both home and center based psycho social
      stimulation program in Bangladesh. However in most parts we found low self esteem among the
      mothers that required quite effort to bring them into the task. So it is assumed that the
      proposed community based Cognitive Behavioral Therapy model (Rahman et al 2008) for
      management of depressive symptoms, will be a unique sustainable approach to get maximize
      effect psycho social stimulation intervention. The study aimed to deliver the intervention
      using government health infrastructure. The study will evaluate the workload of existing 2
      staff -Health Assistant (HA) and Family Welfare Assistant (FWA) at each Community Clinic who
      regularly go for home visits and will train them for intervention. The study may need to
      train one additional person from the same community to assist Health Assistant or Family
      Welfare Assistant in delivering the intervention. The overall success of the project will be
      able to come up with a model that can be used by other Community Clinics to take it to scale.

      After selection of study sites under 30 Community Clinics, randomization will be done. The
      study will do several small group discussions with mothers living in those communities to
      know about their lifestyle, local terminologies of depressive symptoms, view about depressive
      symptoms, child rearing practices and coping strategies. Then Health Assistants and Family
      Welfare Assistants of 15 intervention Community Clinics will be identified and will receive
      training in batches. In next step, after taking consent, screening will be conducted in the
      community among mothers of 9-12 months old children by trained psychologists. Considering the
      Community Clinics as a center, data collectors will start screening from center to periphery
      in the community until we get 10 mothers with depressive symptoms. Mothers, who will fulfill
      the study enrollment criteria, will be offered to join the study and will be invited to the
      test center for baseline assessment (of mother-child dyad). We will set up temporary test
      centers in villages under each Community Clinic, using a space in Community Clinics (provided
      there is available space) or rooms in schools or convenient rented rooms in residence of
      local people. Two teams of testers and interviewers will be rotated from one Community Clinic
      to another after completing screening and baseline psychological assessments in areas under
      that Community Clinic which on average would take 2-3 days. It is expected that the baseline
      assessment will be covered by 2 months. Soon after baseline assessment in one Community
      Clinic, intervention in villages under that Community Clinic will be started by the trained
      Health Assistant/Family Welfare Assistant assigned to that Community Clinic. In the middle of
      the study, the study will conduct in-depth interview on two mothers under each Community
      Clinic to know about mothers' perception and comments about the intervention for further
      modification of the program. The study will also conduct small group discussions with the
      Health Assistant and Family Welfare Assistant about the intervention during monthly meetings
      with them- to know their views about the program. After 12 months intervention, final
      assessment will be done following the same procedure"
    

Intervention name(s): Cognitive behavioral therapy: Alter of negative thinking, positive thinking and social support and psychosocial stimulation: play stimulation and parenting
Intervention type(s): Behavioral
Intervention description(s): A:Cognitive Behavioral Therapy specifically focused on "changing thinking style toward positive" and not associated with any medication. CBT found to be effective in managing or treating not only depression, also a variety of other conditions-e.g. mood, personality, stress, eating habit, tic etc.
B: Psycho social stimulation will follow a set of culturally appropriate, semi-structured, child's age appropriate curriculum.
Other intervention name(s): CBT & PS
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Depression; Child Development; Stimulation; CBT; Bangladesh