Addressing alcohol misuse and mental health comorbidities in humanitarian settings
To address alcohol misuse and mental health comorbidities among conflict-affected populations in Ukraine and Uganda.
Problem Management Plus And Alcohol (PM+A) is a brief transdiagnostic intervention addressing alcohol misuse and mental health comorbidities among conflict-affected populations.
Conflict-affected populations are vulnerable to psychosocial distress and are at risk of considerably higher levels of mental disorders than non-conflict-affected populations1, including alcohol misuse2. This is a direct consequence of exposure to violent and traumatic events, and ongoing daily stressors in their new areas of settlement such as impoverishment, unemployment, poor living conditions, social isolation and discrimination.
However, alcohol misuse among forcibly-displaced populations is a neglected problem, with no evidence-based interventions to tackle this problem among conflict-affected populations3.
The overall aim of CHANGE is to address alcohol misuse and associated adversities among conflict-affected populations in Uganda and Ukraine through a brief, transdiagnostic, and scalable psychological intervention.
The intervention will build upon Problem Management Plus (PM+), an evidence-based psychological intervention developed by WHO designed for people with psychological distress exposed to adversity4. CHANGE will complement PM+ by adding an additional psychological component addressing alcohol misuse.
- The primary indicator of outcome will be the percentage of days abstinent (PDA) in the past 14 days at the 3 months outcome assessment.
- The secondary indicators of outcome will include measures of psychological distress, depression, anxiety, PTSD, functional disability, and perpetration of intimate partner violence
“By introducing a component addressing alcohol misuse to PM+, we hope to address alcohol misuse and associated adversities among conflict-affected populations. We are keen to develop an intervention which can be integrated into existing mental health and psychosocial support programmes. Our partners bring in-depth expertise about the local population, and it is very exciting for us to be able to compare outcomes and processes between our two study sites which are so very different to each other. This will inform the future development, application and scalability of PM+A with other conflict-affected populations.”
- Daniela Fuhr, LSHTM
PM+ is a brief (5 sessions), transdiagnostic, scalable intervention that can be delivered by trained non-specialists and targets mild and moderate symptoms of depression, anxiety, and PTSD4. However, PM+ currently does not cover alcohol misuse despite high rates of alcohol use disorder reported in a variety of conflict-affected settings5,6.
The aim of CHANGE is to complement PM+ with components addressing alcohol misuse, and to develop a new transdiagnostic intervention addressing alcohol misuse and other mental health co-morbidities. The PM+A intervention will be made freely available.
Effectiveness and cost-effectiveness of PM+A will be tested through two randomised controlled trials. The trials will be complemented by a longitudinal qualitative study which will investigate implementation mechanisms, and by a separate work package which will inform scaling up.
PM+A has not yet been implemented. However, a number of key drivers are likely to contribute to its possible success in implementation:
- The development of PM+A will take a participatory approach with key stakeholders and conflict-affected populations involved in the development, implementation and scaling up of the intervention.
- An extensive process will be in place in order to adapt PM+A to local circumstances and to examine the feasibility, acceptability, perceived effectiveness, and preliminary impact of PM+.
Testing of different types of evidence
- CHANGE will examine the implementation of PM+ from a number of perspectives by testing its effectiveness, cost-effectiveness, its potential for scaling up as well as analysing its implementation process through and in-depth longitudinal qualitative study.
An entire work package within the CHANGE project will be devoted to assessing the potential for scaling up of PM+A in Uganda and Ukraine. We define scaling up according to the WHO/ExpandNet definition of scaling-up as ‘deliberate efforts to increase the impact of successfully tested pilot, demonstration or experimental projects to benefit more people and to foster policy and programme development on a lasting basis”.
To help make PM+A widely available, we will investigate how PM+A can be scaled-up through the health system (both government and humanitarian) and also integrated within other humanitarian sectors. This will strengthen the potential range of delivery mechanisms for PM+A and support multi-sectoral aid delivery which is strongly promoted in the humanitarian sector.
The CHANGE project is divided in different packages and each of them will address different questions in relation to PM+A using different methods.
- Intervention development: Strategies and techniques from evidence-based alcohol misuse therapies will be identified through a global literature review, ToC workshops, community-based qualitative research in Ukraine and Uganda, mock sessions, and a treatment development workshop..
- Adaptation of PM+A: This work package will adapt the intervention to local circumstances and examine the feasibility, acceptability, perceived effectiveness and preliminary impact of PM+A by conducting a before/after treatment cohort study, translating, adapting, and validating selected outcomes assessment tools in Ukraine and Uganda, and by conducting two pilot RCTs in Ukraine and Uganda.
- Effectiveness and cost-effectiveness of PM+: To evaluate the effectiveness and cost-effectiveness of PM+A two RCTs will be conducted in Ukraine and Uganda.
- Process evaluation of PM+: The process of implementation of PM+A will be assessed using process evaluation techniques such as semi-structured interviews, ethnographic observation, and an implementation process evaluation toolkit.
- Potential for scaling up PM+: We will examine the potential for scalability of PM+A through document and policy reviews, by using data from previous work packages to characterize opportunities and barriers for scaling-up PM+A, through ToCs, and by conducting semi-structured interviews with key stakeholders in Ukraine and Uganda.
Cost of implementation
One work package of the CHANGE project will be specifically devoted to the assessment of the cost and the cost-effectiveness of PM+A through the following objectives:
- Assess the incremental cost per DALY averted and cost per QALY of PM+A compared to EUC from a societal perspective over a life-time horizon.
- Gather primary data on provider and client economic costs.
- Estimate DALY’s averted by converting AUDIT, a measure of alcohol use disorder, and mental health outcomes measured in the RCT using standard disability weights.
- Estimate cost per QALY gained by employing the EQ-5D-5L questionnaire; the EQ-5D is an established tool for calculating QALYs (based on validated utility weights).
- Explore the impact of the intervention on non-health effects and capabilities (using the Oxford CAPabilities questionnaire - Mental Health/OxCap-MH). OxCap-MH is an outcome measurement developed to capture non-health effects and welfare inequalities of mental health interventions.
The CHANGE project is expected to have a number of impacts which include:
- The first trans-diagnostic evidence-based intervention targeting alcohol misuse among conflict-affected populations which can be delivered in the community or primary health care settings, and which will be made freely available.
- Guidelines for treating alcohol misuse in conflict-affected populations (based on the PM+A manual developed in the study) which will inform the WHO mhGAP-HIG intervention guide and can be used by humanitarian actors.
- Improved understanding of the mechanisms influencing the delivery and take-up of a low intensity MHPSS/alcohol misuse intervention in two complex environments.
- Increased knowledge of how PM+A can be scaled up and integrated within the health system and other humanitarian sector activities.
- Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford W, Saxena S. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. Lancet 2019
- Lo J, Patel P, Shultz JM, Ezard N, Roberts B. A Systematic Review on Harmful Alcohol Use Among Civilian Populations Affected by Armed Conflict in Low- and Middle-Income Countries. Substance use & misuse. 2017;52(11):1494-510.
- Greene MC, Ventevogel P, Kane JC. Substance use services for refugees. Bull World Health Organ. 2019;97(4):246-a
- WHO. Problem Management Plus (PM+). Individual psychological help for adults impaired by distress in communities exposed to adversity. Geneva: WHO; 2016.
- Roberts B, Felix Ocaka K, Browne J, Oyok T, Sondorp E. Alcohol disorder amongst forcibly displaced persons in northern Uganda. Addict Behav. 2011;36(8):870-3.
- Ramachandran A, Makhashvili N, Javakhishvili J, Karachevskyy A, Kharchenko N, Shpiker M, et al. Alcohol use among conflict-affected persons in Ukraine: risk factors, coping and access to mental health services. European journal of public health. 2019.
- Kaner EF, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N, et al. Effectiveness of brief alcohol interventions in primary care populations. The Cochrane database of systematic reviews. 2018;2:Cd004148.