Thinking Healthy is a WHO-endorsed, evidence-based program that supports non-specialist service providers referred to as “peers” to deliver mental health interventions to support mothers experiencing perinatal depression from pregnancy through one year postpartum. The app helps peers implement key ingredients of the program with expected quality, provides training and supervision modules, and supports data collection to monitor progress. The efficacy of the app is currently being evaluated in rural Pakistan.
Active since 2021
Developer Human Development Research Foundation, Pakistan and University of Liverpool, UK
- Technology utilized
Pregnancy – 6 months postnatal
- Target audience
ECD Focus areas
- Responsive caregiving Parents/caregiver’s ability to observe, understand, and respond to children’s cues appropriately.
- Caregiver well-being and mental health Support for caregivers own emotional, social, and mental well-being by supporting development of required skills to identify, manage, and cope with stressors and providing counseling support.
- Health and nutrition Support for children’s physical and emotional health and access to diverse nutrient rich food. This also includes maternal health and nutrition including during pregnancy.
How it works
The Thinking Healthy program uses techniques based on cognitive behavioral therapy (CBT), which aims to modify negative thought patterns to address emotional and behavioral challenges, to help mothers develop problem solving skills and improve their mental health.
The program, delivered by peers or non-specialist workers with support of the app, includes 8 30-60 minute sessions that focus on three areas of mothers’ well-being: their physical and mental health, connection with her baby, and relationship with significant others.Read more
To maintain the integrity of the session content, key therapeutic messages are delivered through the app in short segments by ‘avatar therapists’ or animated characters through contextually-appropriate illustrations and voiceover videos, while the peer provides empathy and support. The peer pauses between segments to facilitate a discussion on the relevance of the message on the mother’s own life and offers encouragement.
The app also has brief animated videos that depict stories from the lives of women from the community who experienced depression and how they overcame it. Peers also help mothers set a goal related to their health (e.g., diet, relaxation exercises) and can track its progress on the app through a ‘progress tree’ that flowers when a goal is achieved. In case the mother has not been able to make progress towards the goal, the peer helps develop a solution to address it by utilizing a pre-populated list of challenges and solutions located in the app.
Validated screening and evaluation tools for maternal depression have been integrated into the app to help peers identify women experiencing depression and track improvement in their symptoms over time. Peers also have access to referral guidelines through the app to support mothers who do not show improvement or are at a risk of self harm or interpersonal violence.
The app can also be used by peer trainers to conduct group trainings and supervision sessions for the peers. The training modules feature ‘avatar trainers’ who deliver the core messages that focus on the use of technology, developing counseling skills, and dealing with challenging situations. Peer trainers pause after each message to facilitate practice through role plays. The app also has modules on supervision and provides access to peers’ attendance, session duration, and progress made by their clients. During monthly supervision meetings, peer trainers can access this data to discuss challenges, brainstorm solutions, and if needed, revise training content.
In the future, there will also be a mobile app for mothers so they can refer back to session content on demand. Further, on completion of the ongoing evaluation, the program will be translated to English and content will be tweaked to be context-agnostic so it can be used in other settings.
User engagement strategies
- Gamification Using common gaming design elements (e.g., points, badges, trophies, leaderboard).
- Goal setting Allowing users to choose their goals for a particular theme, usually from a list of pre-populated goals.
- User progress tracking Tracking user’s progression across tool features (e.g., number of activities completed, progress towards goals).
- Providing referrals to service providers Directing users towards more specialized support (e.g., mental health professionals, child services) to address needs.
- Supporting program implementation Supporting frontline workers (e.g., CHVs, home visitors) and supervisors conduct and monitor sessions, and collect relevant data.
- Training program implementers Providing pre-service, in-service, or refresher training modules to frontline workers and supervisors.
Reach and relevance
Variable50 peers and 500 women with perinatal depression are currently part of the trial.
- Country of origin
The tool is currently being evaluated in Pakistan.
To identify women from the community who could serve as a peer, the Thinking Healthy team worked closely with the Lady Health Worker Program, a program instituted by Pakistan’s Ministry of Health to build a network of community health workers. Identified women were then interviewed and recruited. For the first session, lady health workers accompanied the peers to mothers’ homes to facilitate an introduction.
Technology and access
The Thinking Healthy app is currently available for use on tablets and smartphones. Once downloaded, the app can be used completely offline and all the data inputted by peers (e.g., session duration, progress of mother) is stored in the tablet. When the peer has internet access, they can upload all the data to the central server.
The Thinking Healthy app has in-built features to monitor the fidelity and impact of the program. The Patient Health Questionnaire (PHQ-4), a validated 4-item tool to detect depressive and anxiety symptoms, is integrated into the app, and used at baseline and then every 3 months to track mothers’ improvement. In addition, the app supports monitoring by tracking session duration, peers’ attendance, and progress towards mothers’ goals. A randomized control trial evaluating the app is currently underway.
The program is funded by National Institute of Health Research, UK. The tool is developed through the partnership between the University of Liverpool, UK and the Human Development Research Foundation, Pakistan. The developers of the tool are also keen to partner with interested teams to test and validate the tool in countries outside Pakistan.