Wearable digital sensors to identify risks of postpartum depression and personalize psychological treatment for adolescent mothers: Protocol for a mixed methods exploratory study in rural Nepal

Background: There is a high prevalence of untreated postpartum depression among adolescent mothers with the greatest gap in services in low- and middle-income countries. Recent studies have demonstrated the potential of nonspecialists to provide mental health services for postpartum depression in these low-resource settings. However, there is inconsistency in short-term and long-term benefits from the interventions. Passive sensing data generated from wearable digital devices can be used to more accurately distinguish which mothers will benefit from psychological services. In addition, wearable digital sensors can be used to passively collect data to personalize care for mothers. Therefore, wearable passive sensing technology has the potential to improve outcomes from psychological treatments for postpartum depression. Objective: This study will explore the use of wearable digital sensors for two objectives: First, we will pilot test using wearable sensors to generate passive sensing data that distinguish adolescent mothers with depression from those without depression. Second, we will explore how nonspecialists can integrate data from passive sensing technologies to better personalize psychological treatment. Methods: This study will be conducted in rural Nepal with participatory involvement of adolescent mothers and health care stakeholders through a community advisory board. The first study objective will be addressed by comparing behavioral patterns of adolescent mothers without depression (n=20) and with depression (n=20). The behavioral patterns will be generated by wearable digital devices collecting data in 4 domains: (1) the physical activity of mothers using accelerometer data on mobile phones, (2) the geographic range and routine of mothers using GPS (Global Positioning System) data collected from mobile phones, (3) the time and routine of adolescent mothers with their infants using proximity data collected from Bluetooth beacons, and (4) the verbal stimulation and auditory environment for mothers and infants using episodic audio recordings on mobile phones. For the second objective, the same 4 domains of data will be collected and shared with nonspecialists who are delivering an evidence-based behavioral activation intervention to the depressed adolescent mothers. Over 5 weeks of the intervention, we will document how passive sensing data are used by nonspecialists to personalize the intervention. In addition, qualitative data on feasibility and acceptability of passive data collection will be collected for both objectives. Results: To date, a community advisory board comprising young women and health workers engaged with adolescent mothers has been established. The study is open for recruitment, and data collection is anticipated to be completed in November 2019. Conclusions: Integration of passive sensing data in public health and clinical programs for mothers at risk of perinatal mental health problems has the potential to more accurately identify who will benefit from services and increase the effectiveness by personalizing psychological interventions. Nepal is one of the poorest countries in South Asia with an economy that relies heavily on remittance from migrant laborers, development aid from high-income countries, and tourism. Nepal has a population of approximately 26.4 million, with 69.1 years life expectancy at birth. The United Nations ranks Nepal 145th out of the world’s 188 countries on the Human Development Index, indicating that Nepal has lower life expectancy, education level, and per capita income when compared with other countries [29]. This study will be conducted in Chitwan, a southern district bordering India. The total population of Chitwan is 579,984 (300,897 females) with about 132,462 households [30,31]. Chitwan has a slightly better health and development indicators than the national average. The infant mortality rate is 30.1 per 1000, lower than the national average of 40.5 per 1000. The under-five mortality rates for Chitwan is 38.6 per 1000 (national average is 52.9). Chitwan also has a higher literacy rate than the national average—78.9% in Chitwan compared with the national average of 67% [32]. The estimated age-standardized suicide rate in Nepal is the eighth highest in the world, with the female suicide rate ranking the third highest [33]. Suicide is a leading cause of deaths among reproductive-aged women in Nepal [34-36], with the highest rates of suicide among women younger than 25 years of age [37]. In Nepal, young mothers are burdened with persistent gender inequity and disproportionate expectations often placed on them following marriage [38-40]. Patrilocal tradition typically requires women to leave their maternal home and assume a relatively low social position in their husbands’ households. This can be socially isolating and accompanied by increased exposure to violence [40]. During periods of menstruation, childbirth, and early marriage, some families practice restrictions on women, limiting their geographic movements, physical and social interactions, and religious practices [41]. Social and psychological benefits for women, including upward social mobility, increased fulfillment and life satisfaction, and generativity, are typically contingent upon becoming a mother and, more specifically, giving birth to a son [42,43]. Given the cultural milieu, it is possible that passive sensing technology may help to identify behavioral opportunities to mitigate the risk factors, such as social isolation, associated with adolescent motherhood. In Nepal, mental health services are restricted to a few government hospitals located in big cities and private hospitals. In Chitwan, mental health services include inpatient and outpatient services available in the district hospital and medical colleges. With 2 psychiatrists and a psychiatric ward in the district public hospital, the district has more capacity compared with most areas in Nepal. Over the past 8 years, Chitwan has been the Nepal implementation district for the Program for Improving Mental Health Care (PRIME), which has contributed to an increase in availability of mental health services. On the basis of PRIME studies, 12-month prevalence of suicidal ideation is 3.5% and attempts are 0.7% in community settings and 11.2% for ideation and 1.2% for attempts among patients presenting to primary care [44]. Moreover, in primary care settings, 11.2% of attendees were found to have depression, but only 1.8% had sought mental health services in primary care [45]. A psychological treatment for postpartum depression was adapted for use in Chitwan through the PRIME activities (additional details are provided in the Intervention section). Regarding the use and availability of mobile digital technologies, there has been a drastic increase in mobile penetration in the last decade. There are currently 2 leading telecommunication companies in Nepal, along with a few smaller mobile service providers. The nationwide mobile penetration in 2018 was 134% [46]; this number of mobile service plans per person is greater than 1 because many individuals have 2 or more plans with different service providers due to differences in coverage networks. The psychological intervention used in this study is the Healthy Activity Program (HAP) [45]. Although other low-intensity psychological interventions (eg, the Thinking Healthy Program) [6] have been developed for use in South Asia to treat postpartum depression, HAP has shown strong benefit with general depression treatment in India [47] and has added benefit for depression when combined with primary care treatment in Nepal [48]. In addition, HAP has similar psychological elements to the Thinking Healthy Program, with behavioral activation being a major component [47]. Behavioral activation is a type of psychological treatment developed out of cognitive therapy, grounded in learning theory; it has 2 primary components: the use of avoided activities as a guide for activity scheduling and the functional analysis of cognitive processes that involve avoidance [49]. Simplified versions, such as most variants used by nonspecialist providers in LMIC, emphasize the activity scheduling more than the functional analysis. Through PRIME in Nepal, HAP has been adapted for perinatal depression, and there are numerous government health workers trained in HAP for perinatal depression in Chitwan, Nepal. The HAP intervention that is currently being implemented in Nepal has been divided into 3 phases delivered over 5 sessions (see Textbox 1). Although HAP includes both behavioral activation and problem-solving therapy techniques, the behavioral activation element is the component in which passive sensing data are integrated for this study. Phase I: Assessment and psychoeducation Session 1: Initial assessments for psychosocial well-being and self-care Session 2: Psychoeducation based on HAP and self-care Phase II: Behavioral activation and problem solving Sessions 3 and 4: Behavioral activation and problem solving Phase III: Relapse prevention and wrap up Session 5: Relapse prevention and wrap up These sessions have been designed based on HAP as delivered by nonspecialists in LMIC settings [50]. Broadly, each HAP phase has the following content: In this phase, the psychosocial counselor engages with the participant and establishes an effective counseling relationship. It also involves describing HAP to the patients and eliciting participant’s commitment to continue and complete the counseling sessions. In this phase, the counselor assesses behavioral activation targets and encourages positive behaviors. The counselor, along with the participant, identifies the barriers to activation and ways to overcome these barriers. This phase also involves helping patients solve or cope with life problems. In this phase, the counselor reviews the progress in the last few weeks and discusses with the patient ways to strengthen the gains to prevent relapse. At present, 20 health facilities in Chitwan have adapted HAP for the treatment of maternal depression. In these settings, HAP is delivered by auxiliary nurse midwives who are part of the formal paid health infrastructure in Nepal. Auxiliary nurse midwives receive 18 months of training after a high school degree that is focused on midwifery, reproductive health including family planning, and community health. For HAP, auxiliary nurse midwives receive 5 days of training on basic psychosocial skills. Those displaying the strongest competency (as evaluated through observed structured role plays) [51] and those with good knowledge and attitudes then participate in 5 days of HAP training. After training, the auxiliary nurse midwives receive in-person supervision from a psychosocial counselor who has completed a 6-month training specialized for Nepal [52]. HAP supervision from psychosocial counselors (and psychiatrists when necessary) occurs approximately biweekly with additional phone and in-person support as needed. The psychosocial counselor supervisors also provide HAP services in areas without trained midwives. For this study, we will include depressed adolescent mothers who are receiving HAP from either an auxiliary nurse midwife or a psychosocial counselor (collectively referred to as providers in this protocol). To guide our study, we developed a simple conceptual model (see Table 1) demonstrating how the passive sensing data domains may distinguish differences between depressed and nondepressed adolescent mothers (objective 1) and how domains could be integrated into a brief behavioral activation psychological intervention (objective 2). Conceptual domains related to depression that can be monitored through passive sensing data collection. aGPS: Global Positioning System. The Android operating system provides access to several sensors that enable the monitoring of motion. For this study, we used the accelerometer and gyroscope sensors along with the Activity Recognition API, which is built on top of these sensors. The Activity Recognition API automatically detects activities such as walking, riding in a vehicle, and standing. It does this by passing these sensor data into a machine learning model. These data will be interpreted along with GPS data to estimate the frequency, quantity, and type of activity undertaken. We hypothesize that depressed mothers will have less physical activity and less consistent routine of physical activity compared with nondepressed mothers. Self-reported physical limitations are correlated with postpartum depression severity [53]. Prospective studies of women during pregnancy and the postpartum period using self-report measures of daily rhythms demonstrated that women with disrupted sleep and daily rhythms had worsening of depressive symptoms [54]. In the same study, women with histories of mood disorder were more likely to report disrupted rhythms. Wrist actigraphy measurements among postpartum women also showed an association between disrupted routines and poor mental health outcomes; postpartum women with dysrhythmic fatigue patterns reported more stress and less vigor compared with the women where fatigue patterns followed consistent daily cycles [55]. Moreover, clinical insomnia is associated with less regularity in daily physical activity [56]. Therefore, for our first objective, we will explore if women without depression have more stable activity routines compared with women with postpartum depression. For our second objective, we will explore how providers use the activity data to identify and monitor mood-enhancing physical activity. We hypothesize that depressed mothers in the intervention will increase their physical activity and the routinization of their physical activity over the course of the intervention. This would be expected because 1 element of behavioral activation included in HAP is the scheduling of behaviors that have mood-enhancing qualities. This domain will use GPS data collected from a mobile phone. In a study of pregnant mothers, the daily radius of travel was associated with depression symptoms, with greater depression levels associated with more restricted radii of travel [57]. The same study also found that an increase in depressive symptoms predicted smaller radii of travel in subsequent days. For objective 1, we hypothesize that mothers with depression will have more restricted GPS range of movement compared with nondepressed mothers, that is, they will be more isolated and show less movement outside the home. For objective 2, we will explore how providers delivering HAP use the GPS data to identify targets for increased social engagement and physical activity, as well as monitor engagement in mood-enhancing locations identified by the depressed mothers. We hypothesize that depressed mothers in the intervention will show increased GPS geographic range over the course of the intervention. This information will be generated by a Bluetooth beacon (RadBeacon Dot; Radius Networks, Inc) [58] attached to the child’s clothing. Every 15 min, the phone will scan for the presence of the beacon and determine the distance between the devices (proxies for the individuals) using received signal strength indication (RSSI). If the beacon is not detected, the mother and child are assumed to be apart. These data will be used to determine the total amount of time a mother and child spend together each day and the routine of their time together. As mentioned above, routinization of daily behaviors is associated with more positive mood, less fatigue, and lower risk of maternal depression [54,55]. Therefore, in addition to physical routine, we will also capture the daily interaction routine between mothers and infants. We hypothesize that the nondepressed mothers in the study are likely to have more consistent routines over the 2-week period compared with depressed mothers. We also hypothesize that depressed mothers will have less time apart from their child (eg, have no break from child care responsibilities). Self-reported lack of social support for child care activities is correlated with risk and severity of postpartum depression [53,59,60]. High levels of instrumental social support are associated with lower postpartum depression symptom severity [61]. Among low-income Latina women in the United States, lack of partner engagement was associated with greater childcare responsibilities and greater risk of maternal depression [62]. A study in Kenya found that providing social support and addressing caregiver burden were especially important for pregnant adolescents [63]. With regard to the mothers in the psychological treatment, we will explore if providers use the daily proximity data to identify opportunities for mood-enhancing activities. We also hypothesize that mothers will show increasing routinization of their schedule with the child over the course of the intervention. Using episodic audio recording on a mobile phone, 30 seconds of audio will be recorded every 15 min on the mobile phone provided to the mother. We hypothesize that depressed mothers are more likely to have prolonged periods without verbal communication compared with nondepressed mothers (ie, depressed mothers will have greater silence throughout the day). Audio recordings with human speech will be used as proxy for social interaction. Social isolation is associated with postpartum depression [64]. Loss of social group membership is a risk factor for postpartum depression [65], and this loss of social group is of particular risk for adolescent mothers. In addition, limited verbal engagement between mothers and infants is a manifestation of postnatal depression and predicts poor development for children [66,67]. For objective 2, we hypothesize that depressed mothers in the psychological intervention will show increasing exposure to verbal communication over the course of the intervention. Changes in loneliness and perceived social support are associated with the course of postpartum depression [68]. Women with perinatal depression in therapy showed reduction in depression associated with greater interaction with their infants [69]. For the project, we are using 2 devices—a mobile phone (Samsung J2 Ace) and a passive Bluetooth beacon (RadBeacon Dot) paired with the phone to serve as a proximity sensor. The Samsung J2 Ace phone is a cost-effective mobile phone (US $114) that is popular in the study setting. Commonly-used low-end mobile phones in Nepal cost US $70-US $120, and therefore the device selected the study was only modestly more expensive than commonly-used devices. Most individuals in the area already own a mobile phone or have a close family member with a mobile phone. Hence, there is minimum risk of stigmatization because of the mobile phone use in the study. We selected the Samsung J2 Ace phone because it is widely available for purchase within Nepal and it was the cheapest option that could effectively run all the features and apps required for the study. The participants will be provided with the phone for the duration of the study. They will return the phone after the data collection. This information is clearly stated in the consent form. The mobile phone will be used to collect 4 types of data—proximity, episodic audio, activity, and location. To collect these data, we will install our custom-built Electronic Behavior Monitoring app (EBM version 2.0). The EBM app is designed to passively collect data for 30 seconds every 15 min between 4 am and 9 pm. First, the EBM app scans for the presence of advertising packets from the assigned Bluetooth beacon. For episodic audio recording, the microphone in the phone will be used to record 30-second audio clips saved in an MP3 format. The audio data will be collected directly on the mobile phone and uploaded in our cloud-based storage. The processing service that uses machine learning model then converts the audio into a categorical variable with a confidence score; therefore, the research staff and counselors never hear the audio. We produced a video to explain this process to participants, which was published in a previous paper [70]. Moreover, the participants can request for audio files to be deleted before uploading. Participants can also turn off their phone anytime. We will make the participants aware of these options. We have piloted the approach with participants collecting the audio and deleting it in South Africa [71]. Finally, GPS on the mobile phone will collect the mother’s position, and the Activity Recognition API used to record the predicted activity being undertaken at the time of recording. A folder, NAMASTE, is created automatically once the EBM app is downloaded on the mobile phone. All data are recorded within the folder. The proximity sensor (Figure 2) is fitted to the child’s clothing, and the mother is asked to carry the mobile phone to measure the distance between the mother and child. Our assumption is that the beacon is always on the child, and the mobile phone is with the mother. The EBM app will scan for beacons and record proximity information every 15 min, which will give an indication of how often the mother and the child are physically close. In addition, the RSSI gives an approximation of the distance between mother and child. The RadBeacon transmission power was set to show the child as in proximity if the distance between phone and beacon was less than 7 m [72]. This distance is affected by the presence of walls, furniture, and other obstacles between the mother and child. RadBeacon Dot (Radius Networks Inc.). Use of the RadBeacon Dot was approved by the Nepal Health Research Council for the purpose of this study. RadBeacon Dot also has United States Federal Communications Commission (FCC) certification, a body that oversees the permissible exposure level for all devices with radio frequency. In the United States, the Food and Drug Administration (FDA) relies on FCC for inputs on medical devices [73]. FDA considers devices such as activity trackers as general wellness devices because these devices have “(1) an intended use that relates to maintaining or encouraging a general state of health or a healthy activity or (2) an intended use that relates the role of healthy lifestyle with helping to reduce the risk or impact of certain chronic diseases or conditions and where it is well understood and accepted that healthy lifestyle choices may play an important role in health outcomes for the disease or condition” [74]. Moreover, in our study, RadBeacon is not a medical device used for treatment or for the transmission of health information (eg., temperature, pulse, respiration) from the infant. It is only used to track proximity between mother and infant during daytime hours. Regarding the safety of exposure for infants, the FCC limit for radiation from devices is 1600 mW/kg [75], which equates to approximately 800 mW for a 5 kg infant. The RadBeacon Dot specifications are +4 to −20 dBm, which equates to 2.5 to 0.1 mW. These ranges are comparable to an infant in a house with a standard wireless network and Bluetooth devices. We conducted preliminary studies on the collection of passive sensing data in rural Nepal [70]. We developed videos demonstrating the use of passive sensing data collection in households in Nepal. The videos featured devices for continuous video recording, continuous audio recording, episodic audio recording, as well as wearable cameras placed on the children, Bluetooth beacons placed on the children, and environmental sensors in the home. The videos were shown to female community health volunteers and mothers with young children to assess their perspectives on how passive data collection impacted confidentiality, safety of their children, social acceptability in the family and community, and level of interference on daily activities. In addition, we asked community health volunteers and mothers to identify which types of passive data collection devices they considered most likely to have utility for improving child development and maternal-child interactions. In rural Nepal, the use of passive Bluetooth beacons placed on the children to monitor when the child was in proximity to the caregiver scored well on these criteria, especially confidentiality and social acceptability. Episodic audio recording had similar perceived utility and social acceptability, but caregivers wanted to assure that confidentiality could be maintained. Regarding safety and low risk of interference in daily life, the episodic audio recording scored better than the proximity beacon. A total of 3 devices (proximity beacon, episodic audio recording, and a child’s wearable camera) were then piloted with mothers and children aged 2 to 5 years. On the basis of the results of that pilot study (unpublished data), we selected the proximity beacon and episodic audio recording as appropriate for mothers and their infants aged younger than 1 year in this study. The Sensing Technologies for Maternal Depression Treatment in Low Resource Settings (StandStrong) Platform will be an Android App that the providers can use to access the passive sensing data about participants in HAP. Through this platform, the counselor can review the data collected by the EBM app and provide personalized HAP sessions to the mothers. Additional functionality will be direct text messaging between the mother and the providers, summary of HAP sessions, awards and goals for mothers (contingent to behavioral activation), and psychoeducational materials. We designed the StandStrong app to compliment HAP. This was not a new intervention that we developed, as HAP was already developed for the treatment of depression in South Asia. However, there was not an app to monitor passive sensing data for incorporation into HAP; this was the purpose of developing the StandStrong App. Moreover, we designed the StandStrong app specifically with the conditions of low-resource settings in mind. The app has low data usage, can be used in older versions of Android, and is translatable into various languages. To the best of our knowledge, this is the first app to bring together this specific package of passive data collection and intervention support in the same platform. The app has the following 3 main screens (demonstrated in Multimedia Appendix 1): The StandStrong app. From left to right: Homepage, People, Awards, and Direct messaging. Award categories. aDaily routine was established by looking at the hourly pattern of time spent together with the child and alone. If the pattern was similar across 2 or more days, the award was triggered. Similar was defined as the same state (together or alone) appearing 1 hour before, at the same time, or 1 hour later. Educational messages, designed to facilitate discussion between providers and mothers, are available within the StandStrong app. Providers can show the messages displayed in the StandStrong app and discuss them with the mothers. The educational messages cover a range of topics such as general depression, perinatal depression, self-care, and sleep regulation. These messages are included in the app with the purpose of psychoeducation for mothers and their family members. It allows participants to learn on their own, as well as discuss these topics in HAP sessions with the counselor. The provider can send direct messages to the participants through this feature. Providers use this feature in the app to type out a message, which is then sent to the mother and received on her phone through the Viber app. The participant can respond directly through Viber, and the counselor will receive the message on the StandStrong app (Figure 3). The EBM app captures GPS, activity, and proximity data into text files, which are then loaded into the MySQL database through Scheduler. The captured audio .mp3 files need to be processed through Tensorflow, which predicts the social interaction. Thus, produced predictions are loaded into database through Scheduler. The counselor requires the StandStrong counselor app in offline mode while visiting the participant at home where internet is not available. The app gets synchronized to new data when available in the server through REST API. Using Viber API, the counselor and the participants can post or send messages to each other. Figure 4 shows the StandStrong architecture. The StandStrong architecture. DAO: Data Access Object; EBM: Electronic Behavior Monitoring; GPS: Global Positioning System; API: Application Programming Interface. The study will be divided into 3 overlapping components (see Figure 5): a qualitative formative component; an observational, passive data collection component; and a care monitoring component. Adolescent mothers (aged 15-25 years) with infants (<12 months) will be recruited for the study. This pilot study will be conducted among participants who will be visiting health facilities in Chitwan, Nepal. Conceptual map of the study. In the formative phase, the community advisory board will be established to identify the feasibility and acceptability of using sensing technology among adolescent and young mothers in the community. In addition, community advisory board members will assist in understanding the cultural context, particularly, the experiences of adolescent mothers in the community and the use of mobile technology among young mothers. The community advisory board will include auxiliary nurse midwives and female community health volunteers currently working in the 7 health facilities. They were included on the basis of the following criteria: Throughout the project, we will also recruit adolescent mothers to join the community advisory board after they have completed the study procedures. The community advisory board meetings, facilitated by the research staff, will be held at regular intervals throughout the study period to understand perceived challenges for adolescent mothers and the potential for using technology to improve mental health outcomes. In addition, we will elicit feedback throughout the iterative development of the StandStrong app. Focus group discussion data will be collected during the first community advisory board meeting, along with field notes and meeting minutes from each of consecutive meetings. These data will be used alongside the other data in components 2 and 3 to assess the overall feasibility and appropriateness of the platform and study. Following the formative phase, we will collect passive sensing data from both depressed mothers (n=20) and nondepressed mothers (n=20) to assess the differences in passive data between these groups. We will also determine the feasibility, acceptability, and utility of the data based on the feedback from the adolescent mothers and community advisory board members. For the observational passive sensing data phase, female research assistants will reach out to the adolescent mothers in postnatal clinics and immunization camps and then, on receiving consent, administer Patient Health Questionnaire (PHQ-9) for screening. Mothers between the age of 15 and 25 years with infants up to 12 months of age will be considered for recruitment. Research assistants will make home visits for the mothers who agree to participate. During the time, research assistants will discuss the technology and get family consent, which is considered integral in the cultural context. For adolescent mothers aged younger than 18 years, the parental permission form will also be signed at this time. Women with a PHQ-9 score higher than or equal to 10 will be recruited as depressed mothers and those below 7 or equal as nondepressed mothers. We will collect passive sensing data from both depressed and nondepressed mothers for 2 weeks. We will compare the data for these 2 groups. A series of mental health and other assessment measures will be used for monitoring mental health and triangulation with sensing data. All tools underwent a standardized process of transcultural translation and validation that our team has used extensively in Nepal [76-79]. This procedure involves producing a Nepali translation, followed by review with Nepali mental health experts. Tools are then evaluated through focus group discussions with Nepali beneficiary populations. A back translation is then reviewed by the study team to compare with the original tool. At each stage, comprehensibility, acceptability, relevance, and completeness of tools are evaluated to determine cultural equivalence. This optimizes semantic, content, construct, and technical equivalence of the items. This assures that somatic complaints, terminology for suicide and self-harm, and idioms of distress are culturally relevant. We also include specific Nepali cultural concepts of distress, such as heart-mind problems and ethnopsychological models that are more culturally acceptable to discuss than stigmatized psychiatric terminology [80-83]. On the basis of the feedback from components 1 and 2, we will start the care monitoring phase (component 3) where we will provide the providers with the passive sensing data which will be incorporated during HAP sessions. With these data, the providers can provide tailored counseling sessions to the adolescent mothers with the risk of depression. We will develop the StandStrong app, which will be used to systematically visualize the passive sensing data. In the care monitoring phase, we will refer the depressed adolescent mothers recruited in the observational phase to HAP counseling sessions. We will provide the providers with a tablet with StandStrong app to access passive sensing data of the depressed mothers. The HAP providers can then provide tailored HAP sessions based on the case’s passive sensing data as visualized in the StandStrong app. In addition, we will conduct exploratory analyses on changes over time of the behaviors monitored by the passive sensing data. We will use the same recruitment criteria for component 3 as was used for depressed mothers in component 2. Participants from component 3 will also be analyzed as cases in Component 2 using the first two weeks of their passive data collection. Therefore, we anticipate that some of the 20 depressed women recruited for component 2 will also be included in component 3. All the quantitative data collection used in component 2 will also be used for component 3. In addition, because component 3 involves a therapeutic intervention (HAP), the BDI is also ideal to measure changes in symptom severity over the course of implementation. The BDI will be administered weekly for approximately 6 to 8 weeks. Similar to component 2, for component 3, key informant interviews will be conducted with each woman within the first 3 days of passive data sensing data collection and again at end line (after approximately 5 weeks). This key informant interview is particularly helpful for our team to optimize the passive sensing data and the StandStrong app for the culture and context of its users. The second key informant interview will be conducted on the use of technology and the integration of passive sensing data in StandStrong app. Interviews will elicit several domains about the feasibility, acceptability, barriers, and facilitators of using and understanding the passive sensing data used for the intervention. Informed consent will be documented from each participant. All qualitative interviews will be conducted in Nepali, transcribed verbatim (also in Nepali), and then translated into English, preserving culturally meaningful terms. Textual transcripts will be imported into qualitative data analysis software and systematically coded for the themes described above. Content analysis will be used to reduce, synthesize, and provide rich descriptions for StandStrong’s acceptability and feasibility, particularly to assess if, and how, the approach can be brought to a larger scale. We will systematically triangulate each passive data collection strategy with the appropriate qualitative and quantitative data (Table 3). The GPS and beacon proximity data will be triangulated with the daily diary elicitation. The Episodic Audio Recorder (EAR) output will be triangulated with the OMCI and HOME. Finally, the exit interview asks the mother to tell us if she thinks her data (seen in the StandStrong app) is accurate and asks her to interpret and describe her behaviors. An overview of the data collection methods and outcome measures. aGPS: Global Positioning System. bPassive data will not be collected. cPassive data will be collected. dN/A: not applicable. This project will be dealing with quantitative unstructured data produced passively by a range of sensors. These sensors include proximity, GPS location, and episodic audio recordings. Working and analyzing these data are complex, and many of the analytic methods are still experimental and evolving. There is however an agreed-upon analytic pipeline that will be used for all sensor data collected in this study (Figure 6). Analytic pipeline for sensor data. We aim to validate the sensing data using qualitative and quantitative data collected from the study tools. Our sensing data (activity, GPS, and proximity) will be validated using qualitative (Day in Life) and quantitative (HOME, OMCI, WHODAS, BDI, and PHQ) tools. Our team has included several other measures to benchmark the passive sensing data particularly because the novel technology has few markers of precision and sensitivity. Finally, we expect that mothers with fewer stimulating occurrences (described above with the EAR) and mothers with prolonged time with their infant (proximity) to have lower HOME and OMCI scores. The study has been granted ethical approval by the Nepal Health Research Council (327/2018) and George Washington University Institutional Review Board (#051845).