Human Development Research Foundation

Islamabad, Pakistan

Human Development Research Foundation

Islamabad, Pakistan

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Fuhr D.C.,London School of Hygiene and Tropical Medicine | Salisbury T.T.,London School of Hygiene and Tropical Medicine | Salisbury T.T.,King's College London | De Silva M.J.,London School of Hygiene and Tropical Medicine | And 4 more authors.
Social Psychiatry and Psychiatric Epidemiology | Year: 2014

Purpose: To evaluate the effectiveness of peer-delivered interventions in improving clinical and psychosocial outcomes among individuals with severe mental illness (SMI) or depression.Methods: Systematic review and meta-analysis of randomised controlled trials comparing a peer-delivered intervention to treatment as usual or treatment delivered by a health professional. Random effect meta-analyses were performed separately for SMI and depression interventions.Results: Fourteen studies (10 SMI studies, 4 depression studies), all from high-income countries, met the inclusion criteria. For SMI, evidence from three high-quality superiority trials showed small positive effects favouring peer-delivered interventions for quality of life (SMD 0.24, 95 % CI 0.08–0.40, p = 0.003, I2= 0 %, n = 639) and hope (SMD 0.24, 95 % CI 0.02–0.46, p = 0.03, I2 = 65 %, n = 967). Results of two SMI equivalence trials indicated that peers may be equivalent to health professionals in improving clinical symptoms (SMD −0.14, 95 % CI −0.57 to 0.29, p = 0.51, I2= 0 %, n = 84) and quality of life (SMD −0.11, 95 % CI −0.42 to 0.20, p = 0.56, I2= 0 %, n = 164). No effect of peer-delivered interventions for depression was observed on any outcome.Conclusions: The limited evidence base suggests that peers may have a small additional impact on patient’s outcomes, in comparison to standard psychiatric care in high-income settings. Future research should explore the use and applicability of peer-delivered interventions in resource poor settings where standard care is likely to be of lower quality and coverage. The positive findings of equivalence trials demand further research in this area to consolidate the relative value of peer-delivered vs. professional-delivered interventions. © 2014, Springer-Verlag Berlin Heidelberg.


Rahman A.,University of Liverpool | Haq Z.,Human Development Research Foundation | Sikander S.,Human Development Research Foundation | Ahmad I.,Human Development Research Foundation | And 2 more authors.
Maternal and Child Nutrition | Year: 2012

Despite being an important component of Pakistan's primary health care programme, the rates of exclusive breastfeeding at 6 months remain among the lowest in the world. Low levels of literacy in women and deeply held cultural beliefs and practices have been found to contribute to the ineffectiveness of routine counselling delivered universally by community health workers in Pakistan. We aimed to address this by incorporating techniques of cognitive-behavioural therapy (CBT) into the routine counselling process. We conducted qualitative studies of stakeholders' opinions (mothers, community health workers, their trainers and programme managers) and used this data to develop a psycho-educational approach that combined education with techniques of CBT that could be integrated into the health workers' routine work. The workers were trained to use this approach and feedback was obtained after implementation. The new intervention was successfully integrated into the community health worker programme and found to be culturally acceptable, feasible and useful. Incorporating techniques of CBT into routine counselling may be useful to promote health behaviours in traditional societies with low literacy rates. © 2011 Blackwell Publishing Ltd.


Sikander S.,Human Development Research Foundation | Maselko J.,Duke University | Zafar S.,Human Development Research Foundation | Haq Z.,Human Development Research Foundation | And 4 more authors.
Pediatrics | Year: 2015

OBJECTIVE: To test the effectiveness of cognitive-behavioral counseling on the rate and duration of exclusive breastfeeding (EBF) during the first 6 months of an infant's life compared with routine counseling. METHODS: A single blind cluster-randomized controlled trial was undertaken in 40 Union Councils of a rural district in the northwest province of Pakistan between May 2009 and April 2010. By simple unmatched randomization, 20 Union Councils were each allocated to intervention and control arms. Two hundred twenty-four third trimester pregnant women in the intervention and 228 third trimester pregnant women in the control arm were enrolled and followed-up biweekly until 6 months postpartum. Analyses were by intention to treat. Mothers in the intervention group received 7 sessions of cognitive-behavioral counseling from antenatal to 6 months postpartum, whereas the control group received an equal number of routine sessions. Proportion of mothers exclusively breastfeeding at 6 months postpartum and duration of EBF through these 6 months was assessed. RESULTS: At 6 months postpartum, 59.6% of mothers in the intervention arm and 28.6% in the control arm were exclusively breastfeeding. This translates into a 60% reduced risk of stopping exclusively breastfeeding during the first 6 months (adjusted hazard ratio, 0.40 [95% confidence interval: 0.27-0.60], P < .001). Mothers in the intervention group were half as likely to use prelacteal feeds with their infants (adjusted relative risk, 0.51 [95% confidence interval: 0.34-0.78]). CONCLUSIONS: Compared with routine counseling, cognitive-behavioral counseling significantly prolonged the duration of EBF, doubling the rates of EBF at 6 months postpartum. Copyright © 2015 by the American Academy of Pediatrics


Zafar S.,Human Development Research Foundation | Sikander S.,Human Development Research Foundation | Haq Z.,Human Development Research Foundation | Hill Z.,University College London | And 5 more authors.
Annals of the New York Academy of Sciences | Year: 2014

Maternal psychosocial well-being (MPW) is a wide-ranging concept that encompasses the psychological (e.g., mental health, distress, anxiety, depression, coping, problem solving) and social (e.g., family and community support, empowerment, culture) aspects of motherhood. Evidence-based MPW interventions that can be integrated into large-scale maternal and child health programs have not been developed. Building on several years of research in Pakistan, we developed and integrated a cognitive behavioral therapy-based MPW intervention (the five-pillars approach) into a child nutrition and development program. Following formative research with community health workers (CHWs; n = 40) and families (n = 37), CHWs were trained in (1) empathic listening, (2) family engagement, (3) guided discovery using pictures, (4) behavioral activation, and (5) problem solving. A qualitative feasibility study in one area demonstrated that CHWs were able to apply these skills effectively to their work, and the approach was found to be useful by CHWs, mothers, and their families. The success of the approach can be attributed to (1) mothers being the central focus of the intervention, (2) using local CHWs whom the mothers trust, (3) simplified training and regular supervision, and (4) an approach that facilitates, not adds, to the CHWs' work. © 2014 New York Academy of Sciences.


Chowdhary N.,Sangath | Chowdhary N.,London School of Hygiene and Tropical Medicine | Sikander S.,Human Development Research Foundation | Atif N.,Human Development Research Foundation | And 6 more authors.
Best Practice and Research: Clinical Obstetrics and Gynaecology | Year: 2014

Psychological interventions delivered by non-specialist health workers are effective for the treatment of perinatal depression in low- and middle-income countries. In this systematic review, we describe the content and delivery of such interventions. Nine studies were identified. The interventions shared a number of key features, such as delivery provided within the context of routine maternal and child health care beginning in the antenatal period and extending postnatally; focus of the intervention beyond the mother to include the child and involving other family members; and attention to social problems and a focus on empowerment of women. All the interventions were adapted for contextual and cultural relevance; for example, in domains of language, metaphors and content. Although the competence and quality of non-specialist health workers delivered interventions was expected to be achieved through structured training and ongoing supervision, empirical evaluations of these were scarce. Scalability of these interventions also remains a challenge and needs further attention. © 2013 Elsevier Ltd. All rights reserved.


Fuhr D.C.,London School of Hygiene and Tropical Medicine | Calvert C.,London School of Hygiene and Tropical Medicine | Ronsmans C.,London School of Hygiene and Tropical Medicine | Chandra P.S.,National Institute of Mental Health and Neuro Sciences | And 4 more authors.
The Lancet Psychiatry | Year: 2014

Although suicide is one of the leading causes of deaths in young women in low-income and middle-income countries, the contribution of suicide and injuries to pregnancy-related mortality remains unknown. Methods: We did a systematic review to identify studies reporting the proportion of pregnancy-related deaths attributable to suicide or injuries, or both, in low-income and middle-income countries. We used a random-effects meta-analysis to calculate the pooled prevalence of pregnancy-related deaths attributable to suicide, stratified by WHO region. To account for the possible misclassification of suicide deaths as injuries, we calculated the pooled prevalence of deaths attributable to injuries, and undertook a sensitivity analysis reclassifying the leading methods of suicides among women in low-income and middle-income countries (burns, poisoning, falling, or drowning) as suicide. Findings: We identified 36 studies from 21 countries. The pooled total prevalence across the regions was 1·00% for suicide (95% CI 0·54-1·57) and 5·06% for injuries (3·72-6·58). Reclassifying the leading suicide methods from injuries to suicide increased the pooled prevalence of pregnancy-related deaths attributed to suicide to 1·68% (1·09-2·37). Americas (3·03%, 1·20-5·49), the eastern Mediterranean region (3·55%, 0·37-9·37), and the southeast Asia region (2·19%, 1·04-3·68) had the highest prevalence for suicide, with the western Pacific (1·16%, 0·00-4·67) and Africa (0·65%, 0·45-0·88) regions having the lowest. Interpretation: The available data suggest a modest contribution of injuries and suicide to pregnancy-related mortality in low-income and middle-income countries with wide regional variations. However, this study might have underestimated suicide deaths because of the absence of recognition and inclusion of these causes in eligible studies. We recommend that injury-related and other co-incidental causes of death are included in the WHO definition of maternal mortality to promote measurement and effective intervention for reduction of maternal mortality in low-income and middle-income countries. Funding: National Institute of Mental Health. © 2014 Elsevier Ltd.


Atif N.,Human Development Research Foundation | Lovell K.,University of Manchester | Rahman A.,University of Liverpool
Seminars in Perinatology | Year: 2015

While the physical health of women and children is emphasized, the mental aspects of their health are often ignored by maternal and child health programs, especially in low- and middle-income countries. We review the evidence of the magnitude, impact, and interventions for common maternal mental health problems with a focus on depression, the condition with the greatest public health impact. The mean prevalence of maternal depression ranges between 15.6% in the prenatal and 19.8% in the postnatal period. It is associated with preterm birth, low birth weight, and poor infant growth and cognitive development. There is emerging evidence for the effectiveness of interventions, especially those that can be delivered by non-specialists, including community health workers, in low-income settings. Strategies for integrating maternal mental health in the maternal and child health agenda are suggested. © 2015 Elsevier Inc.


Rahman A.,University of Liverpool | Sikander S.,Human Development Research Foundation | Malik A.,Human Development Research Foundation | Malik A.,University of Sheffield | And 3 more authors.
British Journal of Psychiatry | Year: 2012

Background: Poverty may moderate the effect of treatment of depression in low-income countries. Aims: To assess poverty and lack of empowerment as moderators of a cognitive-behavioural therapy (CBT)-based intervention for perinatal depression in rural Pakistan. Method: Using secondary analysis of data from a randomised controlled trial (trial registration: ISRCTN65316374) we identified predictors of depression at 1-year follow-up and moderators of the intervention (n = 791). Results: Predictors of follow-up depression included household debt, the participant not being empowered to manage household finance and the interaction terms for these variables with the trial arm. Effect sizes for women with and without household debt were 0.80 and 0.55 respectively. The effect size for women in debt and not empowered financially was 0.94 compared with 0.50 for women with neither of these factors. Conclusions: Our findings demonstrate the importance of household debt and lack of financial empowerment of women as important maintaining factors of depression in low-income countries and our locally developed intervention tackled these problems successfully.


Hamdani S.U.,Human Development Research Foundation | Atif N.,Human Development Research Foundation | Tariq M.,Human Development Research Foundation | Minhas F.A.,Institute of Psychiatry | And 3 more authors.
International Journal of Mental Health Systems | Year: 2014

Background: There are at least 50 million children with an intellectual or developmental disorder in South Asia. The vast majority of these children have no access to any service and there are no resources to develop such services. We aimed to explore a model of care-delivery for such children, whereby volunteer family members of affected individuals could be organized and trained to form an active, empowered group within the community that, a) using a task-sharing approach, are trained by specialists to provide evidence-based interventions to their children; b) support each other, with the more experienced FaNs i.e. family networks, providing peer-supervision and training to new family members who join the group; and c) works to reduce the stigma associated with the condition. Methods: We used qualitative methods to explore carers' perspectives about such a care-delivery model. Results: The key findings of this research are that there is a huge gap between the needs of the carers and available services. Carers would welcome a volunteer-led service, and some community members would have time to volunteer. Raising community awareness in a culturally sensitive manner prior to launching such a service and linking it to the community health workers programme would increase the likelihood of success. Gender-matching would be important. It would be possible to form family networks around the more motivated volunteers, with support from local non-governmental organizations. The carers were receptive to the use of technology to assist the work of the volunteers as well as for networking. Conclusions: We conclude that family volunteers delivering evidence-based packages of care after appropriate training is a feasible system that can help reduce the treatment gap for childhood intellectual and developmental disorders in under-served populations. © 2014 Hamdani et al.; licensee BioMed Central Ltd.


Hamdani S.U.,Human Development Research Foundation | Minhas F.A.,Institute of Psychiatry | Iqbal Z.,Human Development Research Foundation | Rahman A.,Human Development Research Foundation | Rahman A.,University of Liverpool
Pediatrics | Year: 2015

As in many low-income countries, the treatment gap for developmental disorders in rural Pakistan is near 100%. We integrated social, technological, and business innovations to develop and pilot a potentially sustainable service for children with developmental disorders in 1 rural area. Families with developmental disorders were identified through a mobile phonëCbased interactive voice response system, and organized into ¡°Family Networks.¡± ¡°Champion¡± family volunteers were trained in evidence-based interventions. An Avatar-assisted Cascade Training and information system was developed to assist with training, implementation, monitoring, and supervision. In a population of ∼30 000, we successfully established 1 self-sustaining Family Network consisting of 10 trained champion family volunteers working under supervision of specialists, providing intervention to 70 families of children with developmental disorders. Each champion was responsible for training and providing ongoing support to 5 to 7 families from his or her village, and the families supported each other in management of their children. A pre-post evaluation of the program indicated that there was significant improvement in disability and socioemotional difficulties in the child, reduction in stigmatizing experiences, and greater family empowerment to seek services and community resources for the child. There was no change in caregivers' wellbeing. To replicate this service more widely, a social franchise model has been developed whereby the integrated intervention will be ¡°boxed¡± up and passed on to others to replicate with appropriate support. Such integrated social, technological, and business innovations have the potential to be applied to other areas of health in low-income countries. © 2015 by the American Academy of Pediatrics.

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