Efficacy of Dietary Intervention and Psychosocial Management for Depression Care Among Perinatal Women in Urban Low-income Nairobi Kenya

Abstract

Depression is the most common mental health problem affecting women during pregnancy and after childbirth. Simultaneously, nutritional deficiencies are common in pregnancy, and after child birth. Poor nutrition has been associated with an increased risk for depression and makes it a good target for early intervention. Furthermore, the World health organization recommended cognitive behavioral therapy as the first line intervention for depression care. Therefore, the main objective of this study, was to examine the efficacy of dietary intervention and psychosocial management (Thinking healthy - Cognitive Behavioral Therapy) for depression care among pregnant women in urban low-income Nairobi, Kenya. This study consisted of two designs. A cross-sectional design was used to collect baseline data to understand the situational context on the association between exposure variables, and outcome. All pregnant women who came for the antenatal checkup, and met the inclusion criteria were screened for depression using Edinburg depression scale (EPDS), and other baseline data collected, these included the socio-demographic characteristics, assessment of nutrition status, by Mid-Upper Arm Circumference and Body Mass Index indicators, 24-hour recall assessment for dietary intake. Brain Food Essentials assessed using a brain food checklist, nutritional knowledge, attitude, and practice assessed using knowledge test tool. A longitudinal cohort design was used for the intervention study. The cohort involved depressed pregnant women, who screened positive for depression on the Edinburg depression scale. After baseline assessments, enrolled in the intervention were pregnant women who were 18 years and older and were in the second/third trimester with a specific depression score (EPDS cut-off ≥10) a score indicating moderate depression levels and higher. The intervention study comprised two arms. The intervention group were depressed pregnant women who received the combined dietary intervention, and psychosocial management (Thinking healthy - Cognitive Behavioral Therapy). The comparison group consisted of depressed pregnant women, who received usual enhanced care which was general nutrition education/ counselling, health talks, and reading materials. The sample size estimation for longitudinal designs was used to calculated sample size for two-time points with attrition by Diggle et al., formula. Approximately100 subjects were required, 50 subjects for each group, considering attrition, 120 participants were required for the study. At baseline, a consecutive sampling was used to obtain the required sample size, all pregnant women who came for the antenatal checkup, and met the inclusion criteria were screened for depression. A total of 262 pregnant women were screened to obtain the required sample, all women who had EPDS of ≥10, were asked to participate in the longitudinal study. Both groups were followed prospectively from second /third trimester pregnant to fourth months postpartum for the study period (March to November 2019). Descriptive statistics summarized the percentages, means, and standard deviation. An EPDS score of >13 pointed the presence of clinical depression. Outcome measures were assessed by (EPDS score) as a continuous variable and categorical defined by score ranges and compared between clinically depressed and non-depressed women. Inferential statistics were used to draw an association between independent and outcome variables. An odds ratio with a 95% confidence interval (CI) was used to test the associations. Variables with p < 0.05 were considered significant. For the intervention study, a comparison between the two groups was performed to assess the degree of comparability. The primary outcome was depression remission, the recovery from clinical xx

depression, and depressive symptoms. Secondary outcomes were the women’s Body Mass Index change and the newborn’s outcome. A comparison for outcome measures was made at various time points (at baseline, at three months after baseline, and at 14 weeks postpartum). ANOVA was used for groups’ comparisons and specific follow-ups. Multiple generalized regressions were performed to understand the effect of variation due to groups and due to follow-up time. Results at baseline revealed that out of the 262 pregnant women screened, 33.6% were found to have clinical depression. Pregnant women in the second trimester were three times more likely to experience depression [OR 3.37; (95% C.I 1.60 - 7.10); p <0.001]. The lower-income level <10,000 Kes per month was statistically significantly associated with maternal depression [OR 0.39; (95%; C.I 0.23 – 0.66); p<0.001]. Thematic analysis of qualitative data indicated that poverty, lack of social support, domestic violence, and unfriendly health care services were major contributors to perinatal depression. Poor nutrition status by Mid Upper Arm circumference indicator was statistically significantly associated with depression [OR 0.27; (95% 0.11-0.63); p< 0.001]. Poor intake of brain food essentials was statistically significantly associated with depression p= 0.002. Poor nutrition status by Mid Upper Arm Circumference < 23 cm was statistically associated with low intake of brain food essentials [OR 2.631 (95% 1.15-6.00); p= 0.018]. Low education level was statistically significantly associated with poor nutritional knowledge P <0.001. For the intervention study, 85 pregnant women completed the study and their data analyzed, 43 women from the intervention group and 42 from the comparison group. Results revealed a clinically significant depression remission from baseline as indicated by EPDS mean scores 16.8±3.4 and endpoint assessment 4.4±2.2 in the intervention group. In the comparison group depression remission from 15.4±3 to 4.4±2.6. Multiple generalized regressions reveal that, the follow-up time with the intervention was statistically significantly associated with depression remission p = 0.000 in both groups. Pearson's correlation revealed a strong positive correlation in weight gain among pregnant women from baseline to second point assessments to endpoint assessment p=0.00. There was positive neonatal weight gain from birth to fourteen weeks postpartum p=0.00 in both groups. Brain food items were evaluated, and after the intervention, there was an improvement adherence to brain foods essential items p=0.00, and improved nutrition attitude and practice. The study findings led to the conclusion that both interventions were beneficial for perinatal women to recover from their depression. But combined dietary intervention and Thinking Healthy- Cognitive-behavioral Therapy was more efficacious in improving depression, nutrition and neonatal outcome than usual care enhanced alone. The cognitive-behavioral therapy was an instrumental to women to get over their depression, better manage stress, and take up nutrition intervention positively. The study recommends integrating nutrition-enhanced mental health counseling for depressed women. Moreover, findings led to recommendation to the Ministry of Health to include screening of depression as part of routine antenatal care to identify women needing mental health intervention and intensive dietary monitoring.