Table 1 Elements of the Positive Health Programme (PHP)

Theoretical basis

Based on principles of cognitive behavioural therapy (CBT)

Based on the previously mentioned findings and the literature review of empirical culturally based therapies for depression, cognitive behavioural therapy (CBT) was taken as the most suited approach that could be adapted for use with British Pakistani women. The ‘here and now’ problem solving CBT approach was felt to meet the requirements reported above and in the qualitative interviews.

Delivery

Minimally trained clinical staff, health research facilitators, mental health graduates such as assistant psychologists, IAPT psychological wellbeing practitioners. Intervention is simple enough to be delivered by anyone trained in mental health.

Rahman (2007) devised the following requirements for delivery:

1. Participant = family level

• Should focus on overall maternal health rather than maternal depression

• Should focus on the identified maintaining factors for depression

• Should be active and empowering

• Should be skill based

2. Delivery and facilitation level

• Should be culturally sensitive

• Should be simple and pragmatic

• Should avoid stigmatisation

3. Health system level

• Should be evidence-based

• Should move away from ‘medical model’ to a ‘Psychosociospiritual’ model

• Should be community based

• Should be culturally adapted

• Should be cost effective

Structure of the intervention

12 sessions, each session approximately 60–90 min

Group CBT based manual with step-by-step instructions for conducting each session. Activity workbooks and hand-outs for mothers

Structure of the group

Group welcoming and connecting, introduction to the session topic, group discussion, engaging in skill based activities, planning individual goals, and homework setting session

On-going training and supervision by clinical staff including a senior CBT therapist and a senior psychiatrist

Areas covered in the sessions/manual

• Identifying the pressures and expectations of being a British Pakistani woman

• Understanding and managing self-esteem

• “Keeping up with the Joneses” “Chaudhry’s”

• Exercise, looking good and ways of building motivation

• Religion and spirituality

• Relaxation: “Taking time out”

• Culturally sensitive assertiveness and confidence building

• Breaking Social isolation and building social networks

• Practising CBT and assessing change

The ABC model of CBT was used to demonstrate the relationship between thoughts, feelings and behaviour in each session. Specific interventions included psycho-education, behavioural activation, problem solving, relaxation, and managing negative thoughts.