Primary Health Care Based Group Interpersonal Therapy (Ipt-g), for Depressed Postpartum Adolescents Living With HIV in Nairobi: an Implementation Science Study.
Abstract
Introduction: Postpartum depression may occur among some mothers after childbirth. Adolescent
pregnancy can lead the expectant girl to drop out of school, receive poor obstetric care and family
support. Adolescent mothers are prone to severe postpartum depression as compared to older
women. Early sexual initiation increases the risk of unintended pregnancies and potentially
increases HIV exposure. Interpersonal therapy (IPT) is an evidence –based intervention focusing
on interpersonal relationship problems. IPT acknowledges that life changes elicits mood changes
which could lead to interpersonal distress. IPT has four components of problem areas: role
transition, loss and grief, role conflict and loneliness/social isolation. IPT seeks to enhance
emotional processing, reduce interpersonal distress, improve interpersonal skills building and
enhance social support. WHO recommends Group interpersonal Therapy (IPT-G) as an evidencebased
intervention for use in primary health care settings. We assessed the acceptability and
feasibility of community health workers (CHWs) delivering IPT-G among depressed postpartum
adolescents (PPAs) living with HIV.
Study Objectives
Broad Objective
The overall objective is to assess whether trained community health workers can deliver group
interpersonal therapy to depressed postpartum adolescents living with HIV within primary health
care settings.
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Specific Objectives
a) Primary Objectives
Among adolescents with postpartum depression and living with HIV in routine clinical settings.
In this study, all outcomes are assessed postpartum at baseline 6–12 weeks, 20 weeks, 28 weeks,
and at 36 weeks;
Objective 1: Evaluate whether IPT-G administered to depressed PPAs living with HIV by primary
health care workers compared to treatment as usual (receiving routine PMTCT clinic services),
alters depression as assessed by Edinburgh Postnatal Depression scale score 16 weeks after
initiation of intervention (EPDS cut-off ≥10 indicative of depression).
Objective 2: Evaluate whether IPT-G administered to depressed PPAs living with HIV by primary
health care workers compared to treatment as usual (receiving routine PMTCT clinic services),
alters the HIV-related stigma levels as measured by HIV/AIDS Stigma Instrument.
Objective 3: Evaluate whether IPT-G administered to depressed PPAs living with HIV by primary
health care workers compared to treatment as usual (receiving routine PMTCT clinic services),
alters the levels of social functioning in the participants as measured by World Health Organization
Disability Assessment Schedule 2.0.
b) Secondary Objectives
Among adolescents with postpartum depression and living with HIV in routine clinical settings.
In this study, all outcomes are assessed postpartum at baseline 6–12 weeks, 20 weeks, 28 weeks,
and at 36 weeks;
Objective 1: Assess traumatic experiences associated with adolescent pregnancy among depressed
PPAs living with HIV using the Impact Event Scale and ascertain its association with depression.
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Objective 2: Determine if the IPT-G administered to depressed PPAs living with HIV by primary
health care workers compared to treatment as usual (receiving routine PMTCT clinic services),
alters levels of adherence to HAART using viral load tests and The CASE adherence index
Objective 3: Evaluate the influence of IPT-G training of primary health care workers on their
competency in mental health care (knowledge of postpartum depression, HIV related stigma and
interpersonal skills)
Objective 4: Determine the influence of the IPT-G administered to depressed PPAs living with
HIV by primary health care workers compared to treatment as usual (receiving routine PMTCT
clinic services), on child health and developmental profile, such as weight and HIV status using
Malawi Developmental Assessment Tool (MDAT).
Objective 5: Evaluate the perception, experiences, and competency of primary health care workers,
health center management, and participants on IPT-G; fidelity, feasibility, acceptability and
sustainability.
Method
Study design, participants and setting
This is an implementation research adapted from Proctor et al. (2009) conceptual framework. IPTG
has shown to be efficacious in reducing depression. In our implementation research, we
conducted a pilot feasibility study to evaluate task sharing using CHWs to deliver IPT-G among
depressed PPAs living with HIV in primary health care context.
The study was conducted among depressed postpartum adolescents living with HIV who were
attending the prevention of mother-to-child HIV transmission (PMTCT) clinics in two primary
care health centers. Twenty-four PPAs aged 15–24 years, 6–12 weeks postpartum and living with
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HIV were eligible for participation. Our study is a two-arm intervention implementation study with
12 participants for intervention group and 12 participants for control group. Eight trained CHWs
delivered IPT-G under continuous support supervision by a clinical supervisor to ensure protocol
was maintained. Intervention group received 8 sessions of IPT-G which was conducted a session
per week and thereafter the delayed IPT-G was administered to waitlist group for a similar period.
After all had completed IPT-G, follow-up for the intervention group and waitlist group was done for
8 weeks to assess if the benefits of the IPT-G could be sustained over time by evaluating patient
outcomes.
Implementation Outcomes
From the two study sites, we assessed using FGDs, key informant interviews (KIIs), audio
recordings and field notes the perception of the CHWs, PPAs and the health care providers towards
delivery of IPT-G within primary health care context.
a) Intervention outcomes where feasibility was assessed by looking at the CHWs’ level of
engagement and adherence to IPT-G protocol. In addition, we observed the session’s
attendance and retention rate as indicators of IPT-G acceptability. For fidelity, we
randomly selected 3 out of the 8 IPT-G recordings of the 8 sessions per study site to assess
their level of adherence to protocol and also Interpersonal Knowledge test was used to
evaluate the competency of the CHWs on IPT-G protocol as per the WHO, manual, 2016.
Interpersonal inventory was used to assess changes in attachments and social relationships
of the PPAs post-intervention
b) Service outcomes was assessed by inquiring their perception on the duration of 90 minutes
for each sessions for 8 weeks, linking activities in the sessions, peer group support and
perception on the nature of the intervention.
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c) Patient outcomes was assessed by inquiring on their level of satisfaction from IPT-G,
changes in social functioning, changes in mean scores for depression, HIV-related stigma
and reduction in total disability. Other mental outcomes such as traumatic experiences,
adherence to ART and child development were also assessed pre- and post-intervention
and thereafter changes in their mean scores over time were reported.
Assessment Instruments
Depression was assessed using the Edinburgh postnatal depression scale (EPDS) and those with
EPDS ≥10 participated in the intervention. The responses were 0,1,2,3 and possible scores on the
EPDS range from 0 to 30, with higher scores indicating clinically significant depression. EPDS is
a screening instrument and not diagnostic hence clinical judgement is of essence when dealing
with patients presenting with features of depression. HIV-related stigma was screened using
HIV/AIDS Stigma Instrument (HASI–P) and social functioning was rated using the World Health
Organization’s Disability Assessment Schedule 2.0 (WHODAS 2.0). Interpersonal inventory was
used to assess attachments and social relationships of PPAs; testing of ART adherence using viral
load and CASE Index; Impact Event Scale-Revised to assess traumatic experiences; Clinical
Outcomes for Routine and Evaluation Outcome Measure to assess response of clinical symptoms
to the intervention; Malawi Developmental Assessment tool to evaluate child development. FGDs
and In-depth interviews were used to assess experiences and perceptions of CHWs, PPAs and
health care providers towards delivery of IPT-G. Interpersonal Knowledge test was used to
evaluate the competency of the CHWs.
Data Management and Analysis
Descriptive statistics was be used to compare changes in depression, HIV-related stigma, and
social functioning between baseline and eight weeks and, between 16 weeks and 24 weeks. The
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changes were explored along with the differences between intervention and treatment as usual
groups reporting effect sizes (Cohen's d). Longitudinal continuous outcome variables across the
time points analysed using the Generalized Linear Model.
All the transcripts were read and re-read to ensure they were of good quality and captured
everything from the audio and the semi-structured interviews. For qualitative data, thematic
framework was derived from exploratory factor analysis. Once the thematic factors were identified
in the factor analysis, all interviews were thoroughly read through and relevant themes
documented. We aimed to identify aspects relevant to delivery process of IPT-G and, personal
perceptions and narratives on IPT-G. The qualitative analysis helped in generating contextual
account (feasibility, acceptability and fidelity) of IPT-G being delivered by CHWs among
depressed PPAs living with HIV
Results
Most of the participants: were aged 21-24 years 21(87.5 %), with a partner of 17 (70.8%), and
with a parity of fewer than 2 children 19 (79.2%). The study had a retention and follow-up rate
of 21(87.5%) out of the 24 of the PPAs. Among the 8 CHWs recruited to deliver IPT-G, one of
the CHV encountered sudden death outside the study area leaving 7(87.5%) who participated in
completion. This study highlights preliminary evidence that IPT-G being delivered by CHWs
clinically reduces postpartum depression (PPD) and decreases HIV-related stigma. The
intervention is feasible and acceptable as expressed by both CHWs and PPAs from their narrations
during the FGDs. Trained CHWs became competent to deliver IPT-G and PPAs living with HIV
showed positive changes in their lives as they could engage in open communication and socialize
within their communities. Key barrier to smooth training of CHWs on delivery of IPT-G were
other auxiliary assignments within the health center that affected their attention. Lack of
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remuneration for CHVs compels them to seek other income-generating activities hence affecting
their timely availability for IPT-G sessions.
We observed that, for every unit drop in the depressive score in the wait-list group, the intervention
group dropped by about 6 units with a notable significant difference for depressive scores
(p=0.017). However, a minimal improvement in adherence to ART was found vis-à-vis
intervention.
Conclusion
We uphold the observation that group interpersonal therapy delivered by community health
workers was feasible and acceptable, and depressed PPAs living with HIV can benefit from group
interpersonal therapy in reducing depression, minimizing HIV-related stigma and improving social
functioning within primary health care.
Ethics and Dissemination
The Kenyatta National Hospital-University of Nairobi approved this study of Nairobi Ethics and
Research Committee (Approval No. P97/02/2018).
Keywords: Postpartum depression, HIV-related stigma, Group Interpersonal Psychotherapy,
community health volunteers, community health assistant, prevention of mother-to-child
transmission, task sharing
Publisher
University of Nairobi
Subject
Adolescents Living With HIVRights
Attribution-NonCommercial-NoDerivs 3.0 United StatesUsage Rights
http://creativecommons.org/licenses/by-nc-nd/3.0/us/Collections
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