Phiona Naserian Koyiet is a Senior Technical Advisor in Mental Health and Psychosocial Support (MHPSS). She provides technical input for MHPSS programs in fragile and crisis contexts and leads MHPSS program strategies for World Vision International.
Link between Poor Maternal Mental Health and Newborn Health
Communities need to address maternal and child health by implementing comprehensive interventions that emphasize improving maternal mental health. About 10 percent of pregnant women and 13 percent of women who have just given birth worldwide experience a mental disorder, primarily depression. Many women with mental disorders are left undiagnosed or untreated and without access to care. This is of particular concern as maternal mental health is linked to newborn health. In low-resource settings, maternal depression is directly linked to preterm birth and low birthweight, higher rates of diarrheal diseases, early cessation of breastfeeding, infant undernutrition within the first year of life, higher rates of stunting, and lower rates of completion of recommended immunizations.
Unfortunately, when mothers are experiencing depression, many are blamed and considered irresponsible when their newborn’s health suffers. This perpetuates stigma around mental health concerns and further emphasizes the need for communities to provide mental health resources for mothers.
Building Community Capacity to Improve Mental Health
Maternal mental health disorders are treatable. Health workers are striving to build community capacity to scale up mental health care and are providing awareness and sensitization to reduce stigma in the community and to garner support for maternal and child health programs. Combining maternal and child health programs to provide support for positive parenting and psychosocial support for caregivers can have long-term benefits on children’s health and development as well as on maternal mental health outcomes.
When mothers have access to mental health resources, such as therapy, children experience better health outcomes, including improved cognitive development, increased vaccination coverage, and fewer diarrheal episodes.
World Vision acknowledges that it is critical to consider mental health in addressing poverty and improving the holistic well-being of communities in fragile contexts, and has contributed to many global guidelines so the organization’s field experience and lessons learned can help improve community interventions’ scalability and effectiveness in caring for mothers’ mental health. World Vision has also actively recruited faith leaders to be advocates and leaders in MHPSS programs as they have presence within and access to communities.
The inclusion of faith leaders in MHPSS programs can maximize the community impact through community responsiveness to faith identities. Additionally, their inclusion contributes to the sustainability of programs at the grassroots level and builds the legitimacy of the program in the eyes of the community. Faith leaders can facilitate dialogue around stigma and access to care and reinforce inclusive social values and best practices.
Two Key Interventions: PM+ and IPT-G
In collaboration with the World Health Organization (WHO) and others, World Vision has tested two psychological interventions, Problem Management Plus (PM+) and Group Interpersonal Therapy (IPT-G). The first, PM+, is a brief simple evidence-based intervention of five sessions delivered face to face in 90-minute sessions that focus on:
Get going, keep doing (managing emotions)
Strengthening social support
Staying well and looking forward
PM+ aims to build the clients’ capacities to self-manage practical problems (e.g. unemployment, interpersonal conflict) and common mental health concerns (e.g. depression, anxiety, stress, grief). PM+ was specifically designed to be delivered by non-specialized mental health workers, such as trained and supervised community health workers.
Studies in Kenya and Pakistan Reveal Efficacy of PM+
World Vision conducted two notable studies of PM+ trial interventions in Kenya and Pakistan. In Kenya, the implementation of trial interventions (published in this journal article) was among women with a history of gender-based violence, while the trial intervention in Peshawar, Pakistan, (study published here) participants were routine patients from three primary care centers. In both studies PM+ was effective in reducing symptoms of depression, anxiety, and post-traumatic stress disorder, and improving functioning and maternal health outcomes.
World Vision implemented another study in Kenya where an adapted group version of PM+ contributed to significant reductions in men’s impaired functioning, psychological distress, alcohol use, and violence against or from women. These outcomes were sustained (and in many cases further improved) three months after the program. The success of PM+ trials has led to PM+ programming in many countries, including the Democratic Republic of the Congo, Uganda, Nicaragua, Iraq, Syria, and Turkey.
The IPT-G Approach to Address Depression
The second intervention World Vision tested, IPT-G, specifically addresses depression. IPT-G complements the mental health Gap Action Programme Intervention Guide from WHO. The eight IPT-G sessions usually include six to ten members with each session lasting 90 minutes to two hours. IPT-G is founded on the idea that there is a connection between a person’s mood and their interpersonal relationships. Interpersonal difficulties can often trigger periods of depression.
IPT-G recognizes four categories of interpersonal difficulties associated with the onset and persistence of depression as problem areas: grief, disputes, life changes, and loneliness or social isolation. Not everyone who struggles with these interpersonal difficulties will develop depression. However, years of studies on the impact of life events on health show that these problem areas significantly increase a person’s chances of developing depression.
Thus, the IPT-G sessions focus on:
the links between a person’s depression and current problems that influence relationships
finding new ways to deal with those problems
The implementation of IPT-G has resulted in improved school attendance for children, improved productivity and sanitation in communities, reduced conflict in families, and greater cohesion among community members.
Equipping Communities for PM+ and IPT-G
In order to implement IPT-G or PM+, facilitators and helpers need at least 80 hours (10 full days) of training. The training provides participants with information about common mental health problems (i.e. depression, anxiety, stress), the rationale for the IPT-G and PM+ strategies and guidance for how to deliver them. Participants learn basic helping skills and practice these skills and strategies through role-plays and with practice clients. When facilitators put PM+ and IPT-G into practice with real clients, they do so under the regular supervision of trained supervisors.
Adopting these practices within the community helps shift the focus of health from medical care to social determinants of health. Working with faith leaders and proper community mobilization of therapeutic programs can aid communities as they seek services, reduce stigma associated with mental health, and increase care for those that need interventions.
Communities may face challenges with limited integration and prioritization of MHPSS or from the lack of paid, trained community health workers to implement mental health strategies. However, real scale up and sustained systemic change is feasible as governments and other organizations provide consistent funding and support initiatives to improve mental health that integrate MHPSS into regular programming.
Watch the Webinar
Phiona Koyiet provided additional insight into addressing maternal and child health by answering the questions below.
Question: My organization operates in pastoralist communities where young girls at the age of 10 to 12 get married. Can this act of early marriage cause mental health issues and if so, what are the strategies or mechanisms to bridge the gap or deal with those issues?
Response: Early marriage or any sort of abuse for any child basically puts significant risks of mental health to both the child who is getting married and her future children. There are various interventions that can be used to address the issue depending on whether you are already working with a child you’ve rescued from early marriage or whether you are supporting a child who is in a current marriage.
Of course the first thing you need to do is rescue the child from marriage because that is abuse and a violation of her rights. Have the child’s basic and psychological needs met. This would mean you may want to link the child to help or a targeted intervention as you restore the rest of the relationship with parents and with family. Psychological first aid training is indeed necessary for all frontline works. Psychological first aid with a focus on children is a humane, supportive response to someone who is suffering, experiencing distress, and needing support.
Providing physical and emotional comfort by modeling calmness enables a constructive format through active listening that allows survivors to voice their concerns and needs. It also helps to connect survivors to practical assistance through referral networks and information on positive coping strategies. World Vision is piloting a faith-based universal intervention delivered in children’s natural environments in their homestead by faith leaders within their communities “walking with children enduring hardship”, as well as equipping community-based faith agents to provide psychosocial Support to children and their families.
The intervention has two phases, the first phase includes building relationship and trust with children in their natural settings called “Entering the World of Children” done through children-selected, structured and guided play and stories. The second phase involves the process of healing from distress which builds on the foundation of relationship and trust from phase one and uses children-selected and guided play, stories to address distress.
Question: Have you, or could you, train pastors to identify cases of depression or other mental problems, and refer them, or help address these issues in collaboration with health professionals?
Response: So how we train in World Vision is we only train in the space where there is comprehensive programming because we do not want to clinically diagnose people and do nothing. Our approach is to build the capacity of the pastor such as with psychological first aid. It gives them ideas on how to serve in a humane way. If somebody is overwhelmed by crying, can you pray for the person and do something else as well? How do you manage someone who is extremely distressed at the moment? What is the ethical way for you to do that and of course how do you effectively refer? The biggest challenge with referral is there is no referral in most settings. You refer someone, but they don’t get help. So we go further to ensure an enhanced referral mechanism.
Rather than teaching or training faith leaders to just diagnose people, we train them on a targeted intervention or therapy like PM+ or IPT-G. If somebody is diagnosed or if you’ve run a patient health questionnaire and their depressing symptoms are high, maybe include them in problem management session and take them through or include them in an interpersonal therapy for a group session. That would be more helpful because they are not just referring people to anywhere. It is possible to train the leaders to not just diagnose but to manage the condition.
Question: Can you give a few examples of how WV adapts PM+ to be responsive to local culture and religion in contextualizing this work to the many different contexts in which it is being implemented? i.e. how different does/should PM+ look in Syria vs. Uganda for example? Is there adaptation for context/culture/religion in the other tools like IPT or the gender-based violence work?
Response: The first thing we do normally is adaptations to local context to address a number of issues, including the following: correct and understandable translation into the local language; inclusion of local expressions and metaphors. The way we implement the PM+ in different contexts is totally different just because we respect the cultures and values that people hold in different countries. You will not find us adapting the same way or even the training the same way. The training guides are adapted depending on the context which is done jointly by our World Vision staff in-country and also representatives from the community.
Question: Why is plus added to PM? What are the strategies of PM that are different from PM+ that make the latter more effective?
Response: Problem Management Plus (PM+) is a title that reflects the aims of the approach: to help people improve their management of practical (e.g. unemployment, interpersonal conflict) and common mental health problems (e.g. depression, anxiety, stress or grief). The “plus” refers to the evidence-based cognitive behavioral strategies that are added to problem-solving counselling to create PM+. These include approaches for managing stress, managing problems, to get going and keep doing (known as behavioral activation) and strengthening social supports.
Additional strategies include psychoeducation, motivational interviewing to encourage clients to engage with PM+ as well as relapse prevention. PM+ is called a ‘transdiagnostic approach’ because it can be used to treat different symptoms and mental health problems and can be used without a full diagnosis. This also allows PM+ to be delivered by nonprofessional mental health workers, such as Community Health Volunteers. PM+ is an individual five-week intervention delivered face-to-face over five times with 90 minutes each.
Question: Is World Vision engaging in advocacy on this issue? If so, to whom is WV advocating? What are your advocacy asks?
Response: Naturally, World Vision strongly advocates for meeting the physical, familial and environmental needs of people, however it is now well established that the mental health and psychosocial support (MHPSS) of adults and children affected by crisis and poverty is an important consideration for their holistic well-being and World Vision’s work.
One of the key advocacy messages is the importance of ensuring psychosocial care takes an integrated and multi-sectoral approach. Stand-alone services, particularly in some cultural settings, can generate stigma and fragment already splintered care systems. Well integrated MHPSS programs need to build on existing capacities, uphold cultural norms, reach more people and are more likely to be sustained once humanitarian or NGO engagement ceases.
WHO released the PM+ Manual as an intervention guide to reduce psychological distress.
WHO released the ITP-G Manual as an intervention guide for addressing depression.
World Vision video of a Ugandan program addressing a gap in mental health care by utilizing the IPT framework.
About the Author: MPH Candidate 2021, Cassady Mecate is currently studying Community Health at Baylor University. She plans on pursuing a career in advocacy and policy development to build resilient health systems that can better combat the spread of infectious disease.