We investigate the possibility of improving access to interventions among mothers screened positive for post-partum depression (PPD) at National Programme on Immunization (NPI) clinics randomly selected from Lagos and Enugu States in south-western and south-eastern Nigeria respectively. The principle of human centred design was employed by engaging the mothers screened positive for PPD to be part of the decision making regarding their further assessment and intervention services. The study brought intervention services to primary healthcare centre at the NPI clinics. Improvement in willingness to seek interventions was observed among the mothers screened positive for PPD in this study when compared to our observation in a previous report, where mothers diagnosed with PPD were referred and requested to visit a mental health facility closer to their NPI clinics for further assessment and interventions (95.2% versus 33.7%). Interventional services for the mothers diagnosed with PPD also impact positively on the growth parameters of their infants on follow-up. Principle of human centred design improved access to intervention services among the mothers and infants studied. NPI clinics at primary healthcare level would provide appropriate forum for early screening of mothers for PPD and interventions in low-resource setting like Nigeria. There would be improvement in maternal and child health coverage if the Nigerian Government can adapt human centred design principles employed in this study nationwide.

An earlier report described the attempt made at introducing depression and developmental screenings into the primary healthcare level of the National Programme on Immunization (NPI) in South-Eastern Nigeria^[1]. This report also documented association between maternal postpartum depression and growth parameters of weight and length among the infants of mothers studied. Mothers diagnosed with postpartum depression during the study were referred to Federal Neuropsychiatric Hospital, Enugu, Nigeria (a Mental Health Facility) for further assessment and interventional follow-up.

However, out of a total of 101 mothers diagnosed with depression in the study and referred for further assessment and interventional follow-up, only 34 (33.7%) eventually reported for further evaluation and interventional follow-up. The rest were lost to follow-up after the screening process^[1].

In response to the poor access to interventions by these mothers with post-partum depression as reflected by the above finding, probably due to stigma associated with visiting mental health facility in this environment, a study was set up using the principle of human centred design.

The study that was conducted in 2 phases of Piloting and Prototyping has the overall objective of improving access of mothers screened positive for postpartum depression to interventions and by that resolve their symptoms of depression, improve growth outcome in their infants and promote mother-child bonding.

The objective of the study was to improve access of mothers screened positive for postpartum depression to interventions and by that resolve their symptoms of depression, improve growth outcome in their infants and promote mother-child bonding.

First phase (Piloting phase)

The piloting phase engaged the women and made them to actively participate in decision making regarding their further assessment and subsequent follow-up treatment (Appendix 1) and asked the following questions:

1. How do we get more mothers to consent to intervention services?

2. How do we communicate screening outcome to mothers in a way not to confer a feeling of being stigmatized?

3. Where would the women screened positive for PPD prefer for further assessment and possible follow-up for interventions?

Two hundred and seventeen (217) women were screened for post-partum depression in the piloting phase of the study.

1. 57 (26.3%) of the 217 mothers screened had a cut-off point of 7 and above on EPDS and therefore screened positive for PPD and were administered the Appointment Booking Form (Appendix 1).

2. Majority of the women screened positive for PPD, 47 (82.5%) of 57 opted for further assessment and possible follow-up treatment at NPI clinics as against the option of Home visit intervention.

3. Many of the women, 54 (94.7%) of 57 opted for option of group therapy if they are going to be involved in further interventional follow-up.

Second phase (Prototyping phase)

The outcome in piloting phase of the study provided the template for full launch into second phase of the study, where further assessment and interventional follow-up focused largely on NPI clinics, following the baseline screening with EPDS. The location of the study was further extended to Enugu State in South-Eastern Nigeria during this phase.

In addition to the women screened at piloting phase, a total of 3,686 women were screened at the selected NPI clinics, 958 (26%) had a score of 7 and above on EPDS and were involved in further follow-up assessment. On further follow-up assessment using both clinical judgment and depressive module of MINI, 674 women (18%) met diagnostic criteria for post-partum depression.

The age range of the mothers with diagnosis of postpartum depression was between 22 and 35 years, with a mean age of 29.0 ± 3.8 years. The age range of their infants was between 0.5 and 3.5 months, with a mean age of 2.55 ± 0.91 months. The sex distribution of the infants were 405 females (60.1%) and 269 males (39.9%). The mean EPDS score at baseline was 11.2 ± 5.5.

Interpretation of Results

Maternal Postpartum depression (PPD) was diagnosed in the mothers screened, when their infants were average age of about three months (3 Months) {Table 1}. Growth parameters in the infants deteriorated over the following 3 months at initiation of interventions for the mothers’ depressive symptoms, when the infants were at about average age of six months (6 Months) {Table 2}. Following further interventions, the growth parameters of the infants had peaked over the subsequent 6 months, when the average age of the children was about nine months (9 Months) and the peak had been sustained {Table 3}. The fourth follow-up impact assessment, nine months after the baseline showed closer correlations with the standard WHO growth charts, the average age of the children at this stage was about twelve months (12 Months) {Table 4}.

With each follow-up impact assessment, few of the mothers were being lost to follow up, which may necessitate the need for remote interface for the purpose of assessment and interventions in future study design.

From the foregoing, a total of 95.2% of the mothers diagnosed with post-partum depression in this study accessed interventions until the fourth and last impact assessment follow-up period, when the average age of their infants was about 12 months. This result is an improvement over the observation made in our previous report, where only 33.7% of the women diagnosed with post-partum depression showed up for further assessment and interventions following referral to a mental health facility^[1].

Main Findings

The present study showed an improvement in the percentage of women willing to seek intervention, if the intervention is taking to primary care level at immunization clinics, as against referral to mental healthcare facility, where the mothers may have perceived stigma visiting.

More women were likely to consent to treatment and intervention if they are engaged and made to be part of the decision making in their own treatment. Follow-up assessment and interventions for the mothers showed a positive impact on the growth parameters of the infants over time.

Immunization clinics and intervention for maternal PPD

Immunization clinics at the primary healthcare centers had been earlier noted to constitute major clinical source of convergence for mothers and their infants and might provide a good forum for screening for depression in the mothers and developmental concerns in the children^[1][2] and may also provide a right forum for providing interventions^[1][2]. It is along this assumption that the idea behind the present study was tested.

Human centred design and interventional follow-up

Human centred design is defined as a creative approach to interactive systems development that aims to make systems usable and useful by focusing on the users, designing around their needs and requirements at all stages, and by applying human factors/ergonomics, usability knowledge, and techniques. This approach enhances effectiveness and efficiency, improves human well-being, user satisfaction, accessibility and sustainability; and counteracts possible adverse effects of use on human health, safety and performance^[3][4].

The principle of human centred design was employed in the piloting and prototyping phase of this study by engaging the women and making them to actively participate in determining the course of their own interventions and treatment. This principle probably went a long way in promoting the willingness of the women to seek interventions, which also in turn served the ultimate benefit of promoting the growth and development of their infants as reflected by the findings of this study.

Maternal PPD and infant growth

Previous studies^{[1][5][6][7][8][9][10][11][12][13]}had documented association between maternal depressive symptoms and child stunting. Observation in this study showed that the interventional follow-up of the mothers produced improvement in growth parameters of their infants followed up in this study.

Addressing maternal PPD through early detection and interventions would improve optimal development of infants in low resource countries like Nigeria. Principle of human centred design improved access to intervention services among the mothers and infants studied. NPI clinics would provide appropriate forum for early screening of mothers for PPD and interventions in low-resource setting like Nigeria. We are of the opinion that there would be improvement in maternal and child health care coverage if the Nigerian Government can adapt human centred design principles employed in this study nationwide.

Location

The locations of the study were four randomly selected NPI Clinics in two randomly selected Local Government Areas in Lagos State, South-Western Nigeria and Enugu State, South-Eastern Nigeria respectively. The first phase of the study which is the Piloting phase was restricted to Lagos State only. The second phase of the study, prototyping the observations made in the Piloting phase was carried out both in Lagos and Enugu States in Nigeria and involved interventional follow-up of the mothers screened positive for post-partum depression (PPD) and their infants over a nine month period.

The Federal Government of Nigeria in 1999 introduced the National Programme on immunization (NPI) to replace the existing Expanded Programme on Immunization that was initiated in 1979. The NPI was established with a key focus to provide support to the implementation of the state and local government area immunization programs^[2]. NPI clinics serve as media for interacting with both mother and child in Nigeria.

Participants

Participants were mothers bringing their infants for routine immunization schedules in the selected immunization clinics for the study. The inclusion criteria are given informed consent to participate in the study and the infant age within three and half (3.5) months and below, this was to afford the planned follow-up of the mothers and their infants over the following 9 month period. While the exclusion criteria are mothers who did not give informed consent; mothers with previous history of mental illness; mothers with multiple births, for example, mothers of twins and triplets, because the infants are likely to have a low birth weight and preterm infants who are also likely to have low birth weight.

Ethical Consideration

Informed consent was obtained from the participants after explaining the objectives of the study to them both in the Piloting and Prototyping phases of the study. The ethical approval for the study was obtained from the Institutional Review Board (IRB) of Federal Neuropsychiatric Hospital, Yaba, Lagos State, Nigeria.

Materials

Sociodemographic questionnaire

Sociodemographic questionnaire was used to elicit mothers' and infants' information such as age, marital status, religion, educational level, occupation, parity, number of children, mode of delivery, as well as child-related questions like age, birth weight, feeding method and history of any physical illnesses and any previous history of mental illness. The measured weight, length and Head Circumference (HC) of each infant as well as the equivalents (in relation to WHO recommendations) were recorded in this questionnaire.

EPDS^[3]

The EPDS is a 10 item self-report questionnaire (developed at health centers in Livingstone and Edinburgh) in which women were asked to rate how they had felt in the previous 7 days. Each question has 4 possible responses that are scored 0 to 3 (for a total score range of 0 to 30). In Nigeria, the EPDS has been translated into 3 local languages and validated in 2 of these languages^[4][5][6]. It has been translated and validated in south-western and south-eastern Nigeria. For the purpose of this study, a cut-off point of 7 and above was considered as being screened positive for PPD, this was in contrast with our initial study where we chose a cut-off point of 9 and above, that gave a sensitivity of about 74% for EPDS^[1]. A cut-off point of 7 and above was chosen in this study to improve the sensitivity of EPDS and include more women for further assessment and possible interventional follow-up. Screening positive on EPDS does not imply diagnosis of depression. It rather signifies the need for further assessment and evaluation towards definitive diagnosis and interventions.

Appointment Booking Form (Appendix 1)

This was used during the piloting phase of the study to communicate the outcome of the screening to mothers screened positive for PPD and to enable the mothers to select preferred option of location for further follow-up assessment and interventions to be conducted either at the NPI clinic or through Home visit. A copy of this form is included in Appendix 1.

WHO Standard growth charts^[7]

Growth charts are visible displays of a child's physical growth and development. WHO standard growth charts have two reference curves for both sexes in relation to weight for age, length for age and Head Circumference (HC) for age. Normal variations are assumed to include 2 standard deviations above and below the mean, that is, 3rd and 97th percentile. Recordings below the 3rd percentile would be said to be an indication of delayed growth. For this study, the weight for age, length for age and HC for age charts for both sexes were used. For the purpose of this study, weight for age, length for age and HC for age at 50th percentile on the growth charts were used as reference points of comparison to the parameters that were obtained from the infants studied.

MINI^[8]

The M.I.N.I. is designed as a brief structured interview for the Major Axis I psychiatric disorders in Diagnostic and Statistical Manual of Mental Disorders, 4th Edition and ICD-10. Validation and reliability studies have been done comparing the M.I.N.I. to the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised and the CIDI, a structured interview developed by the WHO for lay interviewers based on ICD-10 criteria. The results of these studies show that the M.I.N.I. has acceptable validity and reliability. Its advantage over other diagnostic instruments is its brevity and that it can be administered in a much shorter period of time. It is divided into different diagnostic modules and for this study; major depressive episode module was used. At the beginning of the diagnostic module for major depression, screening questions corresponding to the main criteria of depression are presented. At the end, diagnostic boxes permit the clinician to indicate whether diagnostic criteria for depression were met or not.

Procedure

The study took place between September, 2015 and February, 2017. The screenings were preceded by educational talk on post-partum depression by trained primary healthcare workers at the immunization clinics. The procedure adopted for the screening was essentially similar to what was done in our earlier report^[1], with minor change that included administration of Appointment Booking Form during the piloting phase of the study.

The mothers were screened for depression using the EPDS and the infants of the mothers had their anthropometric measurements (weight, lengths and Head Circumference) taken as follows:

For weight measurement, infants were weighed in nude using a calibrated beam scale (Mechanical Baby Scale manufactured by Zhejiang Conqueror Weighing Apparatus Co. Ltd). The infants were placed at the center of the tray without being held, and the scale was read at eye level. The weights were recorded to the nearest 10 g. For the length measurement, the infants' lengths were measured using a calibrated length board (Seca 416 Mechanical Infantometer), which had a fixed headpiece and a moveable foot piece perpendicular to the surface of the board. The infants were placed in a recumbent (lying down) position on the board after their shoes and hair pieces have been removed. An assistant (nurse) held the child still with legs straightened, and the moveable foot piece was adjusted in order to record the lengths. The lengths were recorded to the nearest 0.1 cm. For the HC measurement, flexible non-stretchable tapes (manufactured by The Perfect Measuring Tape Company) were used to measure the HCs of the infants. The tapes were securely wrapped around the widest possible circumference of the infants' head, which is over the most prominent part of the occiput and just above the supraorbital ridges. Measurements were recorded to the nearest 0.1 cm. The results of these anthropometric measurements obtained from the infants were compared to the WHO growth charts recommendation using 50th percentiles as reference point of comparison to identify whether there were growth deviations from the WHO recommendations^[7].

The mothers who scored 7 and above on EPDS were administered Appointment Booking Form during the piloting phase of the study to determine where they would prefer to continue further assessment and possible interventional follow-up.

Interventions provided for those with diagnosis of postpartum depression included prescription of medications, where deemed necessary, individual therapy that involved counseling and group therapy where women shared their experiences and concerns about their symptoms and challenges they were facing.

Data Analysis

Data analysis was carried out using the Statistical Package for Social Sciences, version 16 for Windows.

This study is supported in part by UK Aids, Open Ideo & Ideo.Org in a project titled, “Tracking Maternal Depression and Child Growth” - Grant Number: CNDI-CH0204-NIG-15.

The authors declare no conflicts of interest.

Informed consent was obtained from the participants after explaining the objectives of the study to them both in the Piloting and Prototyping phases of the study. The ethical approval for the study was obtained from the Institutional Review Board (IRB) of Federal Neuropsychiatric Hospital, Yaba, Lagos State, Nigeria.

No fraudulence is committed in performing these experiments or during processing of the data. We understand that in the case of fraudulence, the study can be retracted by ScienceMatters.