5 Pillars Approach to Maternal Psychosocial Well-Being | MHIN (2024)

Poor maternal psychosocial well-being, a public health priority, has been associated with many long-term negative effects on infant physical and cognitive development including pre-term birth, low birth-weight¹and under-nutrition.²The 5 Pillars (5P) approach is a cognitive behavior therapy-based innovation, designed to be integrated into existing maternal and child health programs. It aims to reduce distress in women living in socioeconomically deprived settings and to improve health and development outcomes in their children.

The 5P approach consists of training lady health workers to deliver the following capacity-building components to mothers and their families:

• Empathic listening
• Family engagement
• Guided discovery using pictures
• Behavioral activation
• Problem-solving in day-to-day work

• 120 community health workers have been trained in one rural area

"We were accustomed to the 'telling'instead of listening to women, but after this training we have learned to first listen to the problems of a mother and family and then offer advice."

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- Lady Health Worker

The 5P approach is an integrated intervention for large-scale maternal and child health programs. Its key feature is that it can be integrated into the main intervention instead of serving as a stand-alone element, facilitating the existing work of community health workers instead of adding to it.

The 5P approach was developed after several years of research in Pakistan, using the principles of cognitive behavioral therapy. It involves five components, which are implemented by trained lady health workers during cognitive behavioral therapy sessions at homes with mothers. The lady health worker training consists of:

• Five-day program: 1.5 days of training, with skills practice for the remaining days
• Emphasized hands-on practice with role-play
• Short video clips portraying each component
• Observation and discussion of good and bad practices
• Tool-kit containing training manual, trainers with step-wise instructions for every visit, counselling cue cards, pictorial counselling cards for sessions, and a health calendar for the families

The 5P approach is integrated into monthly sessions delivered at home to the mother and family. In practice the approach works as follows:

Empathic listening

Each session begins with an open-ended conversation, allowing the woman to talk freely. The lady health worker uses active listening skills to convey empathy and makes a list of problems the woman faced in performing the desired behaviors that may have been suggested in a prior visit.

Family engagement

The initial home visits emphasize family participation, encouraging active participation for the duration of the program. Strategies to engage key household decision-markers are emphasized.

Guided discovery

Pictures conveying health messages related to play, stimulation or nutrition of the child are conveyed as the lady health worker discusses both undesired and desired behaviors. She is trained not to impose her views, but rather to allow the mother and the family to consider each viewpoint and come to their own conclusions.

Behavioral activation

Once the message is received and accepted, the activities related to it are made manageable so the participants feel as though they have mastered it. Lady health workers are trained to recognize how each nutrition or play-related task can be broken down and monitored with the help of family members.

Problem solving

The lady health worker discusses the problems the woman faced in carrying out the tasks suggest in the previous sessions(s). She discusses possible solutions through supervision or a family discussion.

The 5P approach is a long-term investment to increase program value, assisting with strengthening weak health systems. It is expected that mothers will become more empowered, informed and psychologically functional and in turn will be more receptive to the program.

• Stakeholder engagement

• Ensuring quality in training and ongoing supervision

• Health Services Academy(Pakistan)
• Human Development Research Foundation (HDRF)(Pakistan)
• Institute of Child Health(UK)
• London School of Hygiene and Tropical Medicine(UK)
• The University of Liverpool(UK)

Funder

• Wellcome Trust(UK)

Pilot feasibility study followed a cluster-randomized control design.

The5Papproach is currently part of theSPRING randomized control trialin Pakistan and India, with feasibility, effectiveness and cost-effectiveness as planned components.

The pilot feasibility study showed that lady health workers were able to apply the 5P approach effectively to their work. The approach was found to be useful by the community health workers, their supervisors, the mothers and their families.3

Evaluation of the lady health workers training (53 observations of 13 workers) showed changes in:

Family support

• 63% involved key family members in the discussions
• 57% encouraged family members to support mother and infant

Empathic listening

• 98% greeted the mother
• 92% showed she was listening by nodding, eye contact, etc.

Guided Discovery

• 86% showed the picture and asked the family what it was about
• 76% explained the picture and discussed positive behavior

Behavioral Activation

• 58% used positive words and gestures when the mother said something right
• 56% counselled in steps rather than only giving advice

Problem Solving

• 52% asked about problems the family may have had in practicing the advice
• 70% discussed ways of overcoming the problems

1. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010 Oct;67(10):1012-24. doi: 10.1001/archgenpsychiatry.2010.111. PMID: 20921117; PMCID: PMC3025772.
2. Surkan PJ, Kennedy CE, Hurley KM, Black MM. Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis. Bull World Health Organ. 2011 Aug 1;89(8):608-15. doi: 10.2471/BLT.11.088187. Epub 2011 May 26. Erratum in: Bull World Health Organ. 2011 Sep 1;89(9):631. PMID: 21836759; PMCID: PMC3150769.
3. Zafar S, Sikander S, Haq Z, Hill Z, Lingam R, Skordis-Worrall J, Hafeez A, Kirkwood B, Rahman A. Integrating maternal psychosocial well-being into a child-development intervention: the five-pillars approach. Ann N Y Acad Sci. 2014 Jan;1308:107-117. doi: 10.1111/nyas.12339. PMID: 24571213.