1
|
Malik A, Waqas A, Atif N, Perin J, Zaidi A, Sharif M, Rahman A, Surkan PJ. Multiple mediation analysis of a task-shared psychosocial intervention for perinatal anxiety: Exploratory findings from a randomized controlled trial in Pakistan. J Affect Disord 2024; 364:41-47. [PMID: 39137833 DOI: 10.1016/j.jad.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 07/16/2024] [Accepted: 08/09/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND The "Healthy Mother Healthy Baby" (HMHB) study is a phase three, single-blind randomized clinical trial conducted at Holy Family Hospital (HFH) in association with Rawalpindi Medical University (RMU). We aimed to examine the mediators of a specialized psychosocial approach based on Cognitive Behavioural Therapy principles, targeting pregnant women experiencing anxiety. The HMHB intervention was effective in treating perinatal anxiety symptoms and preventing future depressive episodes. METHODS The trial randomized participants into two arms: the HMHB intervention or Enhanced Usual Care (EUC), following World Health Organization guidelines. The HMHB intervention comprised strategies to strengthen social support networks, improving mother-baby bonding and strategies to deal with interpersonal conflicts, economic challenges, and societal gender preferences using cognitive and behavioural techniques and culturally resonant illustrations. Participants underwent rigorous data collection at three pivotal timepoints: baseline, third trimester, and 6-weeks postnatal. The primary outcome was anxiety symptom severity scores using the Hospital Anxiety and Depression Scale (HADS) at 6-weeks post-childbirth. Four potential mediators - social support, behavioural activation, perceived stress, and pregnancy experience - were assessed in the third trimester of pregnancy. RESULTS A total of 1200 participants were randomized to the HMHB and EUC arms. In the six-week follow-up time point, 379 participants remained in the EUC group, and 387 continued in the HMHB group. Post-intervention, HMHB participants displayed significant improvements in postnatal anxiety and depression scores. Mediation analyses revealed social support and pregnancy hassles as significant mediators of the intervention's effect on postnatal anxiety outcomes, while only social support emerged as a significant mediator for depression outcomes. CONCLUSION The HMHB intervention showed promising results in improving anxiety and depression scores among pregnant women. Significant mediation effects suggest the importance of targeting social support and managing pregnancy-related hassles for optimal intervention effectiveness.
Collapse
Affiliation(s)
- A Malik
- Department of Public Mental Health, Health Services Academy, Islamabad, Pakistan
| | - A Waqas
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom.
| | - N Atif
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - J Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - A Zaidi
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - M Sharif
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - A Rahman
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - P J Surkan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| |
Collapse
|
2
|
Nisar A, Xiang H, Perin J, Malik A, Zaidi A, Atif N, Rahman A, Surkan PJ. Impact of an intervention for perinatal anxiety on breastfeeding: findings from the Happy Mother-Healthy Baby randomized controlled trial in Pakistan. Int Breastfeed J 2024; 19:53. [PMID: 39095863 PMCID: PMC11295719 DOI: 10.1186/s13006-024-00655-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/29/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The study examined the effects of Happy Mother-Healthy Baby (HMHB), a cognitive-behavioural therapy (CBT) intervention on breastfeeding outcomes for Pakistani women with prenatal anxiety. METHODS Breastfeeding practices were evaluated in a randomized controlled trial between 2019 and 2022 in a public hospital in Pakistan. The intervention group was randomized to receive six HMHB sessions targeted towards prenatal anxiety (with breastfeeding discussed in the final session), while both groups also received enhanced usual care. Breastfeeding was defined in four categories: early breastfeeding, exclusive early breastfeeding, recent breastfeeding, and exclusive recent breastfeeding. Early breastfeeding referred to the first 24 h after birth and recent breastfeeding referred to the last 24 h before an assessment at six-weeks postpartum. Potential confounders included were mother's age, baseline depression and anxiety levels, stress, social support, if the first pregnancy (or not) and history of stillbirth or miscarriage as well as child's gestational age, gender. Both intent-to-treat and per-protocol analyses were examined. Stratified analyses were also used to compare intervention efficacy for those with mild vs severe anxiety. RESULTS Out of the 1307 eligible women invited to participate, 107 declined to participate and 480 were lost to follow-up, resulting in 720 women who completed the postpartum assessment. Both intervention and control arms were similar on demographic characteristics (e.g. sex, age, income, family structure). In the primary intent-to-treat analysis, there was a marginal impact of the intervention on early breastfeeding (OR 1.38, 95% CI: 0.99-1.92; 75.4% (N = 273) vs. 69.0% (N = 247)) and a non-significant association with other breastfeeding outcomes (OR1.42, 95% CI: 0.89-2.27; (47) 12.9% vs. (34) 9.5%, exclusive early breastfeeding; OR 1.48, 95% CI: 0.94-2.35; 90% (N = 327) vs. 86% (N = 309), recent breastfeeding; OR1.01, 95% CI: 0.76-1.35; 49% (N = 178) vs 49% (N = 175) exclusive recent breastfeeding). Among those who completed the intervention's six core sessions, the intervention increased the odds of early breastfeeding (OR1.69, 95% CI:1.12-2.54; 79% (N = 154) vs. 69% (N = 247)) and recent breastfeeding (OR 2.05, 95% CI:1.10-3.81; 93% (N = 181) vs. 86% (N = 309)). For women with mild anxiety at enrolment, the intervention increased the odds of recent breastfeeding (OR 2.41, 95% CI:1.17-5.00; 92% (N = 137) vs. 83% (N = 123). CONCLUSIONS The study highlights the potential of CBT-based interventions like HMHB to enhance breastfeeding among women with mild perinatal anxiety, contingent upon full participation in the intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT03880032.
Collapse
Affiliation(s)
- Anum Nisar
- Institute of Population Health, University of Liverpool, Liverpool, UK
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - Haoxue Xiang
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jamie Perin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Abid Malik
- Health Services Academy, Islamabad, Pakistan
| | - Ahmed Zaidi
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - Najia Atif
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - Atif Rahman
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Pamela J Surkan
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
| |
Collapse
|
3
|
Siebach KF, Perin J, Malik A, Atif N, Zaidi A, Rahman A, Surkan PJ. Results of a cognitive behavior therapy-based intervention for antenatal anxiety on birth outcomes in Pakistan: a randomized control trial. Sci Rep 2024; 14:13806. [PMID: 38877077 PMCID: PMC11178914 DOI: 10.1038/s41598-024-64119-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 06/05/2024] [Indexed: 06/16/2024] Open
Abstract
Antenatal anxiety is among the risk factors for adverse birth outcomes, which are common in Pakistan. Between 2019 and 2022, we conducted a randomized controlled trial to evaluate the effects of the Happy Mother-Healthy Baby program, designed to reduce anxiety during pregnancy through use of Cognitive Behavior Therapy, on birth outcomes with 796 women in Rwalpindi, Pakistan. We performed intent-to-treat analysis and per protocol analyses. Intention-to-treat analyses showed no difference in the odds of low birthweight (LBW) (Adj. OR = 0.82, 95% CI 0.55-1.28 p = 0.37), preterm birth (PTB) (Adj. OR = 1.20 95% CI 0.83-1.71, p = 0.33) or small-for-gestational age (SGA) birth, (Adj. OR = 0.76, 95% CI 0.56-1.09, p = 0.16). Among completers who received ≥ 5 intervention sessions, the odds of LBW and SGA were 39% and 32% lower (Adj. OR = 0.61, 95% CI 0.43-0.87, p < 0.01; Adj. OR = 0.68, 95% CI 0.53-0.89, p < 0.01). The significant LBW and SGA results among the intervention completers suggest that the program may be effective when a sufficient dose is received. However, confirmation of these findings is needed due to the fact that randomization is not maintained in completer analyses.Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03880032, 19/03/2019.
Collapse
Affiliation(s)
- Kirsten F Siebach
- Department of International Health, Johns Hopkins School of Public Health, 615 N. Wolfe Street, Room E5523, Baltimore, MD, 21205, USA
| | - Jamie Perin
- Department of International Health, Johns Hopkins School of Public Health, 615 N. Wolfe Street, Room E5523, Baltimore, MD, 21205, USA
| | - Abid Malik
- Health Services Academy, Chak Shahzad, Islamabad, Pakistan
| | - Najia Atif
- Human Development Research Foundation, Rwalpindi, Pakistan
| | - Ahmed Zaidi
- Human Development Research Foundation, Rwalpindi, Pakistan
| | - Atif Rahman
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Pamela J Surkan
- Department of International Health, Johns Hopkins School of Public Health, 615 N. Wolfe Street, Room E5523, Baltimore, MD, 21205, USA.
| |
Collapse
|
4
|
Atiq M, Nazir H, Rahman A, Malik A, Atif N, Surkan PJ. Exploring preference for delivery methods for a psychosocial intervention for prenatal anxiety: A qualitative study from a tertiary care hospital in Pakistan. Glob Ment Health (Camb) 2024; 11:e66. [PMID: 38827335 PMCID: PMC11140489 DOI: 10.1017/gmh.2024.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 04/03/2024] [Accepted: 04/29/2024] [Indexed: 06/04/2024] Open
Abstract
Objective This qualitative study explores therapists' and participants' preferences for delivery methods (face-to-face and phone sessions) of a cognitive behavioral therapy-based psychosocial intervention for prenatal anxiety delivered in a tertiary care hospital. Setting The research was conducted in a randomized controlled trial in Pakistan, where a shift from face-to-face to phone-based therapy occurred during the coronavirus disease-2019 (COVID-19) pandemic. Participants Twenty in-depth interviews and a focus group discussion were conducted with participants and therapists, respectively. Transcripts were analyzed using thematic analysis. Results Participants generally preferred face-to-face sessions for rapport building, communication, and comprehension. However, barriers like venue accessibility, childcare, and lack of family support hindered engagement. Telephone sessions were favored for easy scheduling and the comfort of receiving the session at home, but there were challenges associated with phone use, distractions at home, and family members' limited mental health awareness. A mix of face-to-face and telephone sessions was preferred, with rapport from in-person sessions carrying over to telephone interactions. Conclusion This study underscores the need for adaptable intervention delivery strategies that consider cultural norms, logistical challenges, and individual family dynamics. By combining the benefits of both delivery methods, mental health interventions can be optimized to effectively address prenatal anxiety and promote well-being in resource-constrained settings like Pakistan.
Collapse
Affiliation(s)
- Maria Atiq
- Human Development Research Foundation, Gujar Khan, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Gujar Khan, Pakistan
| | - Atif Rahman
- Human Development Research Foundation, Gujar Khan, Pakistan
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Abid Malik
- Human Development Research Foundation, Gujar Khan, Pakistan
- Public Mental Health Department, Health Services Academy, Islamabad, Pakistan
| | - Najia Atif
- Human Development Research Foundation, Gujar Khan, Pakistan
| | - Pamela J. Surkan
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
5
|
Surkan PJ, Malik A, Perin J, Atif N, Rowther A, Zaidi A, Rahman A. Anxiety-focused cognitive behavioral therapy delivered by non-specialists to prevent postnatal depression: a randomized, phase 3 trial. Nat Med 2024; 30:675-682. [PMID: 38365951 PMCID: PMC11060845 DOI: 10.1038/s41591-024-02809-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/09/2024] [Indexed: 02/18/2024]
Abstract
Anxiety experienced by women during pregnancy is highly prevalent, especially in resource-poor settings and strongly predicts postnatal common mental disorders (CMDs), anxiety and depression. We evaluated the effectiveness of an anxiety-focused early prenatal intervention on preventing postnatal CMDs. This study was a phase 3, two-arm, single-blind, randomized controlled trial conducted in Pakistan with women who were ≤22 weeks pregnant and had at least mild anxiety without clinical depression. Participants were randomized to the Happy Mother-Healthy Baby program, based on cognitive behavioral therapy, consisting of six one-on-one intervention sessions in pregnancy delivered by non-specialist providers, or to enhanced care alone. The primary outcome was major depression, generalized anxiety disorder or both at 6 weeks after delivery. Overall, 755 women completed postnatal assessments (380 (50.3%), intervention arm; 375 (49.7%) enhanced-care arm). The primary outcomes were met. Examined jointly, we found 81% reduced odds of having either a major depressive episode (MDE) or moderate-to-severe anxiety for women randomized to the intervention (adjusted odds ratio (aOR) = 0.19, 95% CI 0.14-0.28). Overall, 12% of women in the intervention group developed MDE at 6 weeks postpartum, versus 41% in the control group. We found reductions of 81% and 74% in the odds of postnatal MDE (aOR = 0.19, 95% CI 0.13-0.28) and of moderate-to-severe anxiety (aOR = 0.26, 95% CI 0.17-0.40), respectively. The Happy Mother-Healthy Baby program early prenatal intervention focusing on anxiety symptoms reduced postpartum CMDs. ClinicalTrials.gov identifier NCT03880032 .
Collapse
Affiliation(s)
- Pamela J Surkan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Abid Malik
- Human Development Research Foundation, Near Government Rural Health Centre Mandra, Rawalpindi, Pakistan
- Department of Public Mental Health, Health Services Academy, Islamabad, Pakistan
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Najia Atif
- Human Development Research Foundation, Near Government Rural Health Centre Mandra, Rawalpindi, Pakistan
| | - Armaan Rowther
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Psychiatry, Los Angeles County Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Ahmed Zaidi
- Human Development Research Foundation, Near Government Rural Health Centre Mandra, Rawalpindi, Pakistan
| | - Atif Rahman
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|