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. xviii 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. xix 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 xx 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. xxi 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 xxii 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 xxiii 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