Decker, Ellie

School of Public Health - International Health



Uganda-Maternal Mental Health Uganda

Perinatal depression is a problem effecting approximately one in five women in post-conflict Uganda. These rates of depression are high due to a multitude of risk factors including unwanted or unplanned pregnancies, experiencing domestic violence, chronic sickness, poverty and relationship difficulties. It is not only important to address the problem of perinatal depression for the sake of the mother, but recent research has also shown a link between the mental health of a mother and the health and development of her offspring. Maternal depression is a known risk factor for a range of child-related outcomes, including preterm birth and low birth weight; suboptimal breastfeeding and immunization rates; being underweight or stunted; higher rates of diarrhea and febrile illness; and negative impacts on child development.

To address the high burden of perinatal depression in post-conflict Uganda, the Peter C. Alderman Foundation (PCAF), in collaboration with the government of Uganda and the department of Mental Health at JHSPH, has developed an innovative stepped-care model that attempts to integrate mental health screening and services into the existing maternal and child health care system. This stepped-care model starts with screening at antenatal care visits and utilizes community health care workers to deliver psycho-education, an evidence-based low-intensity intervention that has been shown effective in reducing depression symptoms in up to 75% of women. Then, only women who do not improve with psycho-education are referred to PCAF staff for group interpersonal therapy. This method of task-shifting attempts to provide services in a sustainable and effective way while reducing the burden on scarce and overworked primary health care workers and mental health specialists.

Following completed formative research, this care model has been rolled out in two districts of post-conflict Uganda: Soroti District in eastern Uganda and Kitgum District in northern Uganda. Both regions were chosen because they were targeted during the 20-year conflict with the Lord's Resistance Army (LRA). This enduring and tragic conflict is still strongly exerting its negative impacts on the community 10 years after the cessation of hostilities. PCAF is now interested in expanding this program to South Sudanese refugees living in northern Uganda.

PI Mentor: Wietse Tol

Upon arriving in Kampala our driver took us, Leah and I, to our AirBnB, which it turns out was in the middle of a slum. Leah was another GHEFP student working with the same organization as me in Uganda. We learned this upon arrival when our new coworker called, concerned about the area. Right away I learned our coworkers cared, they wanted to help. I also learned that help, much like planning and so many other things throughout my time in Uganda could come at the almost last possible minute. Despite the last-minute thing, from my first day on I knew someone had my back in Uganda. This was true in Kampala, when doing field work in the north, and in my social life, too. This knowledge, along with a culture focused on relationships before productivity brought a tangible reduction in stress which lasted most of my time in country.

While in Uganda I worked with the Peter C. Alderman Foundation. The program was in the process of transitioning to the Peter C. Alderman Program (PCAP) for Global Mental Health. Observing this transition was an opportunity to witness firsthand the choices organizations face when moving from grassroots level to large, multi-country NGOs. Loss of or changes in power were subtle. The shift in focus seemed to be moving, slowly, from programs to funders. In an already fast-paced and work heavy environment business development has become a larger priority. Staff was asked to choose focus areas from a predetermined list of seven. The list was created with input from the Country Director and HealthRight International partners. This focus may improve outcomes, it also changes the way the organization is familiar with working moving from a solely mental health focus to mother and child health, early childhood development, and sexual and reproductive health. With increased focus on outcomes and indicators, sometimes comes a decreased focus on the humans. Not intentionally of course, more through wanting to reach new goals and expand impact. And the changes were not all bad, maybe over time most will be positive. But as the changes happened, I often wondered who would get the credit in the end, if things worked out well. Would it be the country teams or the headquarters leadership? Would it be both?

These questions brought me to more fundamental questions about who should be providing interventions and running organizations in Uganda. What is my role in improving mental health? Keeping these questions in mind brought me continuously to funding, programmatic and strategic planning roles. National and refugee staff provided all mental health care through the PCAP model. I saw my biggest impact when I could assist with funding opportunities, helping to explain language and information US donors would be wanting to find. Similarly, when writing funding reports, I used an outsider’s perspective to help the team think more about how to organize and explain information. These experiences and job search reflections with the project PI brought me to considering programmatic roles as I look for next steps in my global health career.

In thinking further about next careers steps, with an interest in global mental health, I have also thought more about interventions to prevent mental health disorders. This line of thinking has brought further considerations of the underlaying causes of mental health disorders, such as poverty and trauma. Seeing the effects of poverty and trauma on mental health first hand remains difficult to describe. These experiences emphasized the level at which interventions need to start to prevent mental health disorders. This expanded my initial ideas of mental interventions and changed my idea of how I can work to address this problem. I still want to work in global mental health, however, I am now thinking more broadly about the work. Through this new perspective social protection and peace building work are of strong interest. As a whole this experience fundamentally changed by personal and professional outlook. I am endlessly grateful for the experience, the perspective I gained and the people who joined my life story.

Team Photo


Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

August 2019



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