Public Disclosure Authorized Figure 1: Action Against Hunger (AAH) - PDF document

Public Disclosure Authorized Feasibility study to identify and treat post-partum depression : Understanding clinical presentation, use of Patient Health Questionnaire 9 (PHQ-9) and suitability of thinking healthy intervention Project implemented from 18 th March to 30 th July 2019 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Figure 1: Action Against Hunger (AAH) staff providing on-the-job training to a nurse and supervisor on filling the patient register and use of the PHQ-9 screening tool, Sar-e-Naw Comprehensive Health Centre (CHC), May 2019 1

This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies of the World Bank and its Board of Executive Directors. 2

Final Report Period covered by the report: From the 18 th of March to the 31 st of July 2019 3

Acronyms AAH: Action Against Hunger BHC: Basic Health Center CHC: Comprehensive Health Center EPDS: Edinburgh Postnatal Depression Scale HF: Health Facility IMAM: Integrated Management of Acute Malnutrition Infant and Young Child Feeding IYCF: MCHP GP: Mental Health and Care Practices, Gender and Protection MEAL: Monitoring, Evaluation, Accountability and Learning OHPM: Organization for Health Promotion and Management PHQ-9: Patient Health Questionnaire-9 PMHO: Provincial Mental Health Officer PNO: Provincial Nutrition Officer PPHD: Provincial Public Health Directorate PPD: Post-Partum Depression WB: World Bank WHO: Work Health Organization 4

1. Introduction Between the 18 th of March and the 31 st of July 2019, Action Against Hunger (AAH) implemented a feasibility study to determine if health facilities in Afghanistan would be able to diagnose and treat Post- Partum Depression (PPD) using the Patient Health Questionnaire 9 (PHQ-9) as a screener to diagnose and the World Health Organization (WHO) Thinking Healthy Intervention protocol to treat PPD. The study was implemented in two health facilities in Parwan Province, one being a Basic Health Center (BHC) and one being a Comprehensive Health Centre (CHC). In order to determine the feasibility of the implementation of PPD related diagnosis and treatment, the study measured the following five specific objectives: 1. To train nurses in two primary health care districts in Afghanistan to screen women attending perinatal health services for depression; 2. Assess the extent to which nurses understand and are able to effectively implement the screening tool; 3. Based on the numbers of women screening positive, to calibrate the cut off scores to determine who received treatment; 4. To assess whether trained nurses can provide safe and appropriate treatment; 5. To assess the acceptability of the intervention to women receiving the intervention and to assess the extent to which targeted women take up the intervention and return for sessions. 2. Results of Feasibility Study In order to monitor and evaluate the objectives of this feasibility study, AAH created several tool, the results of which are compiled in this section. These tools are: Activity Progress Reports, patient register and patient file, PPD protocol, database, individual interviews with health facility staff and with a representative sample of the beneficiaries. Annexes can be found at the end of this report and attached. Objective 1: To train nurses in two primary health care districts in Afghanistan to screen women attending perinatal health services for depression 1.1. Results Two trainings took place in two primary health care centers in Parwan province, one in Gul-Bahar BHC and one in Sar-e-House CHC. AAH’s master trainers trained HFs staff and Provincial Public Health Directorate (PPHD) staff on both Integrated Management of Acute Malnutrition (IMAM) and Infant and Young Child Feeding (IYCF), and on PPD protocol: - A six-day training on IMAM and IYCF was conducted on the 28 th of March and between the 30 th of March and the 4 nd of April 2019; - A four-day training on the Thinking Healthy protocol was conducted between the 6 th and the 10 th of April 2019 Both trainings took place in the training hall of the Organization for Health Promotion and Management (OHPM)’s. The training was provided to ten participants, composed of: 5

- Six HF staff including: two doctors, two midwives, one nurse and one psychosocial counsellor; - Two AAH staff in charge of supervising the study implementation; and - Two members of the PPHD: one Provincial Nutrition Officer (PNO) and one Provincial Mental Health Officer (PMHO). Among the ten attendees, six were women and four were men. The training results are below and the reports can be also found in the annexes 1 and 2. The pre- and post-tests conducted during the IMAM/IYCF trainings show an improvement of all the attendees’ s cores. The average score of the pre-test for the IMAM and IYCF training was 48.9%. Following the training sessions, the average score of participants was 88.7%. At the end of the IMAM/IYCF trainings, nine of the ten participants scored 85% or above, showing that participants had a very good comprehension of the topics presented during the project. Pre and Post-Test Scores of IMAM Trainees 150 98 93 93 93 92 88 86 85 85 74 76 69 100 65 51 48 42 38 34 33 33 50 0 Doctor CHC Midwife Nurse CHC PSS Doctor BHC Midwife DoPH DoPH AAH AAH CHC Counselor BHC Doctor Doctor Supervisor Supervisor CHC Pre-Test Post-test Figure 1: Pre and Post-test scores of the Nutrition Training The pre- and post-tests conducted during the PPD training show an improvement of all the attendees’ scores. The average score of the pre-test was 37.9%. Following the training sessions, the average score of participants was 88.1%. At the end of the PPD training, six of the eight participants scored 100%, showing that participants had a very good comprehension of the intervention protocol. All the HF staff responsible for directly implementing the project (counselors and midwives) scored 100%. Pre and Post-Test Evaluation Scores 150 100 100 100 100 100 100 100 55 55 55 50 50 44 30 50 15 15 15 0 Doctor CHC Midwife CHC Nurse CHC PSS Doctor BHC Midwife BHC AAH AAH Counselor Supervisor Supervisor CHC Pre-Test Post-Test 6

Figure 2: Pre and Post-test scores of the PPD Training During the interviews to the HF staff at the end of the project, all staff mentioned they were satisfied with trainings received at the start of the project on Nutrition screening and treatment, PPD and the Thinking Healthy Intervention Protocol. However, staff suggested that future trainings last longer. When asked if they would have benefited from refresher trainings, all HF staff said that it would be beneficial for them to receive additional trainings. They clarified that they would have liked to receive additional trainings on PPD, as the subject material was quite new for them. In addition, AAH supervisors provided near daily support to HF staff with on the job trainings and support throughout the duration of the project. Supervisors were present throughout the working day and monitored the implementation of activities by HF staff, providing support when needed. When asked to the HF staff during the interviews if they had received weekly on the job training from AAH, all staff confirmed that they had received additional support and information throughout the duration of the project. They also mentioned that the coordination between AAH and HF staff was good and that AAH did not interfere in the health facilities other activities. Thinking Healthy Certification, Parwan Province, 9th of April 2019 1.2. General Recommendations for Future Implementation In order to ensure that HF staff are well trained in future implementations of the project, AAH proposes the following recommendations: 7