ASHA Bangladesh--An Integrated Intervention to Address Depression in Low Income Rural Women

Abstract A leading cause of global disability, depression is widespread among women in low and middle income countries (LMIC). Poverty plays a major role in depression via multiple pathways, while depression worsens poverty, compromising economic productivity. Efforts to increase access to depression treatment in LMIC have been hampered by low treatment uptake/engagement and weak treatment effects. Recently, researchers and policy makers have pointed to the importance of poverty alleviation in the fight against the global depression pandemic. We propose to implement an integrated poverty alleviation/depression treatment intervention for low income women in rural Bangladesh, designed to break the toxic cycle of poverty and depression. A capacity building component will build skills and support career development in qualitative implementation research for young scientists and establish a year-long research fellowship for graduate students at the University of Dhaka. Our project builds on an established partnership between the University of Massachusetts Chan Medical School and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). in Dhaka. Following our successful pilot study, we will implement a cluster randomized trial of an integrated intervention, recruiting 660 low income women with depression from 44 villages. Villages will be randomized into one of two treatment arms: 1) evidence based depression treatment, using an adaptation of WHO’s Group Based Problem Management Plus (PM+); 2) an integrated intervention consisting of PM+ and an asset/skill transfer poverty alleviation program. Participants will be followed for 24 months. We hypothesize improved depression outcomes at 6 months and other timepoints in the combined arm, compared to depression treatment alone. A detailed, mixed methods process evaluation, designed to generate new hypotheses regarding program and contextual factors influencing outcomes, will include qualitative interviews with program participants and staff, conducted by ASHA fellows. The proposed project will generate findings with significant implications for policy makers. To date, the work of depression researchers and economic development groups has included little collaboration. Programs that seek to reduce depression do not address the devastating impact of poverty; while similarly poverty alleviation programs do not address the role of mental health in economic productivity. Results of this study, if promising, will generate evidence to guide collaborations among development agencies, researchers, policymakers, and treatment providers. Our team’s dissemination efforts will bring government agencies, international and national health and economic development NGOS to consider the potential for a new generation of collaborative, integrated intervention approaches.