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Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial
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Background The treatment of perinatal depression is a public-health priority because of its high prevalence and association with disability and poor infant development. We integrated a cognitive behaviour therapy-based intervention into the routine work of community-based primary health workers in rural Pakistan and assessed the effect of this intervention on maternal depression and infant outcomes.Methods We randomly assigned 40 Union Council clusters in rural Rawalpindi, Pakistan, in equal numbers to intervention or control. Married women (aged 16-45 years) in their third trimester of pregnancy with perinatal depression were eligible to participate. In the intervention group, primary health workers were trained to deliver the psychological intervention, whereas in the control group untrained health workers made an equal number of visits to the depressed mothers. The primary outcomes were infant weight and height at 6 months and 12 months, and secondary outcome was maternal depression. The interviewers were unaware of what group the participants were assigned to. Analysis was by intention to treat. The study is registered as ISRCTN65316374.Findings The number of clusters per group was 20, with 463 mothers in the intervention group and 440 in the control group. At 6 months, 97 (23%) of 418 and 211 (53%) of 400 mothers in the intervention and control groups, respectively, met the criteria for major depression (adjusted odds ratio (OR) 0.22, 95% CI 0.14 to 0.36, p<0.0001). These effects were sustained at 12 months (111/412 [27%] vs 226/386 [59%], adjusted OR 0.23, 95% CI 0.15 to 0.36, p<0.0001). The differences in weight-for-age and height-for-age Z scores for infants in the two groups were not significant at 6 months (-0.83 vs -0.86, p=0.7 and -2.03 vs -2.16, p=0.3, respectively) or 12 months (-0.64 vs -0.8, p=0.3 and -1.10 vs -1.36, p=0.07, respectively).Interpretation This psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in resource-poor settings.
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“It has been successfully adapted for use by CHWs to address mental health concerns in perinatal populations in rural Pakistan 23,24 , showing the effective use of CHWs to deliver such interventions in a Muslim population 23,28 .”
From Addressing Behavioral Health Disparities for Somali Immigrants Through Group Cognitive Behavioral Therapy Led by Community Health Workers (2017) · cites this paper as [24]
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“The Thinking Healthy Program is a culturally adapted intervention involving psychosocial treatment delivered by lady health workers that has previously demonstrated effectiveness at successfully treating perinatal depression in Pakistan.26”
From Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally (2019) · cites this paper as [26]
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“The use of CBT in face-to-face or computerized settings, individually or in groups, has been well established 21,22 , and when delivered by community health workers (CHWs) offers great potential to increase access to psychological support in resource-poor settings 23,24 .”
From Addressing Behavioral Health Disparities for Somali Immigrants Through Group Cognitive Behavioral Therapy Led by Community Health Workers (2017) · cites this paper as [24]
In the citing paper
“emerging evidence indicates that it is possible to reduce complexity without deleterious consequences (e.g., Rahman, Malik, Sikander, Roberts, & Creed, 2008).”
From User‐centered design for psychosocial intervention development and implementation. (2016) · cites this paper as Rahman, Malik, Sikander, Roberts, & Creed, 2008
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“but maternal depression has been shown to affect child health47 and growth.48”
From Effect of psychosocial interventions on social functioning in depression and schizophrenia: meta-analysis (2013) · cites this paper as [47]
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“Task-sharing is a strategy that can expand the availability of mental health providers by shifting delivery of psychological treatments from specialist providers to non-specialist community health workers (Chibanda et al., 2016; Patel et al., 2011; Rahman et al., 2008; Raviola et al., 2019).”
From Acceptability and feasibility of digital technology for training community health workers to deliver brief psychological treatment for depression in rural India (2019) · cites this paper as Rahman et al., 2008
In the citing paper
“In Pakistan, a cognitive behaviour therapy (CBT) based Thinking Healthy Programme (THP) was delivered via lady health workers (LHWs)—PHC employee working in the community on mother and child health agendas—and produced significant results favouring the treatment arm [20].”
From Barefoot therapists: barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan: a qualitative study (2016) · cites this paper as [20]
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Metadata
- Authors
- Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F.
- Affiliations
- Human Development Research Foundation (PK)
- University of Manchester (GB)
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2008-09
- Volume
- 372
- Issue
- 9642
- Pages
- 902-909
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC2603063
- OpenAlex
- W2128974992
- Cited by
- 993
- References
- 33
- Citations by year
- 2026: 45 · 2025: 48 · 2024: 43 · 2023: 65 · 2022: 83 · 2021: 73 · 2020: 60 · 2019: 68 · 2018: 66 · 2017: 56 · 2016: 48 · 2015: 75 · 2014: 64 · 2013: 64 · 2012: 37
- FWCI
- 31.99
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Licence
- Locations
- The Lancet (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- Funders
- Wellcome Trust
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and Neonatal Healthcare
- Keywords
- perinatal depression, maternal depression, cognitive behavioral therapy, community health workers, primary health workers, psychological intervention, infant growth, rural Pakistan, Rawalpindi, third trimester, intervention sustainability, maternal mental health services
- MeSH terms
- Adolescent, Adult, Birth Weight, Community Health Workers, Depressive Disorder, Female, Humans, Infant, Newborn, Male, Maternal Age, Middle Aged, Pakistan, Pregnancy, Pregnancy Complications, Pregnancy Trimester, Third, Social Class, Social Support, Cognitive Behavioral Therapy, Prevalence, Cluster Analysis, Outcome Assessment, Health Care
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