Innovation summary

Common mental health problems are vastly under-addressed in areas affected by adversity, with the vast majority of people in need not able to access appropriate care. Reaching people in distress through delivering evidence-based psychological interventions in resource-limited areas is a possible solution. The goal of the Problem Management Plus (PM+) project is to design and demonstrate global feasibility of an evidence-based, low intensity intervention for common mental disorders and to engage strategic action in mental health care provision of this kind. This process involves systematic translation and cultural adaptation of the PM+ manual, training para-professionals and supporting them in delivering the intervention, through regular supervision.

PM+, in individual and group format, is an innovative psychological intervention which provides clients with skills to improve their management of practical problems (e.g., unemployment, interpersonal conflict etc.) and associated common mental health problems, via the provision of four strategies: problem solving counselling plus stress management, behavioral activation and strengthening social support. 

Impact summary

  • Pilot and definitive randomized controlled trials, through which evaluation indicators are investigated
  • At this stage, a key indicator of coverage is the number of clients served
  • The key outcome indicator is reduction in symptoms of common mental disorders as measured by improvement on the Hospital Anxiety & Depression Scale (Pakistan sites) and General Health Questionnaire (Kenya site) 

 

“I had lost hope even in terms of my business because it had failed and I did not think it could be revived. But when the community health worker taught me the skills, I realized I could solve my own problems and my attitude towards life changed.”

 

- Study participant in Kenya

 

“Participants benefited a lot from this programme. For example, patients have reported reduction in their domestic disputes; they have noticed change in themselves in terms of anger and stress.”

 

- Lady Health Worker, Peshawar, Pakistan

This innovation is funded by Grand Challenges Canada and others (please see Funders section).

Innovation details

WHO in consultation with partners has developed PM+, an innovative intervention that is brief, designed for use by non-specialist health workers, transdiagnostic and specifically developed to help adversity-affected people. Typically, PM+ is 5 sessions long and can be delivered to a group or to an individual client. Non-specialist health workers deliver the intervention having completed short intensive training and importantly, under close supervision. This is likely to result in reduced or no need for specialist involvement for many people with mild-moderate mental health problems. A strength of PM+ is its transdiagnostic approach. PM+ is designed to reduce distress for clients irrespective of formal diagnosis, reducing the need for specialist diagnostic processes and increasing the potential coverage of the intervention to anyone facing mental health problems after adversity. These clients may include people living in adversity, such as living in impoverished or violent neighborhoods or in camps for displaced persons. The intervention is not designed to be used with clients at imminent risk of suicide or those with severe mental disorder, such as psychosis.

PM+ draws upon well-known and evidence-based strategies: problem solving counselling combined with selected behavioral techniques. In combining these strategies, this program aims to address both psychological problems (for example, stress, fear, feelings of helplessness) and, where possible, underlying practical problems (for example, livelihood problems, conflict in the family and so on).

The intervention is fully manualized, including manuals for training purposes and for para-professionals to deliver the intervention in individual and group format. It also includes the assessment tools (pre-, during and post-intervention) and client worksheets (for the individual version) and pictures (for the group version). All manuals and tools are systematically translated to each local language and sensitively adapted to the cultural setting with inputs from a range of stakeholders. 

Key drivers

PM+ design

  • The simple design of PM+ ensures flexibility and low resource intensity
  • Fully manualized in a simple and user-friendly manner, PM+ has been designed for use by non-specialists with any level of education from high school up.
  • With up to two weeks training, it is possible for health workers to deliver PM+ with supervisory support from trained supervisors.
  • It can be translated and flexibly adapted to a range of cultures.

Fostering partnerships and high quality local project coordination

  • Research and health care partnerships are an essential part of implementation and testing. Rather than coordinating the research and implementation of PM+ from WHO headquarters, responsibility is sustainably placed with local teams from the start of research and implementation projects to build on local capacity.

Challenges

  • The intervention was originally developed to be trained in 4 weeks but availability of community health workers was less than 2 weeks in both Kenya and Pakistan
  • Existing protocols for cultural adaptation of psychological interventions are valuable but still leave too much room for non-systematic (adhoc) cultural adaptation.
  • The individual manual relied on some degree of literacy of clients through use of worksheets. This was unrealistic and so the group version does not use worksheets or require literacy. It relies on pictorial aides.
  • While the manual underwent rigorous translation and back-translation into local languages, many clients receiving the intervention speak various dialects. These dialects are largely oral and therefore the manual cannot be easily translated into these dialects. 

Continuation

PM+ has been designed originally for individual clients, and then adapted to group settings. One of the key principles of PM+ is that it is flexible to different settings and that it is likely scalable, so the possibility of scale-up to larger populations is envisaged. 

Partners

Funders

Conceptualization

Kenya testing (pilot and definitive RCT) 

Pakistan testing

Key partners delivering the innovation

Kenya

Nairobi City County and Ministry of Health in partnership with

Pakistan

KP government health services in partnership with

Nepal

Evaluation methods

Pilot and Definitive randomized controlled trials (RCT) have been or are being conducted. Exact outcomes vary by trial but all trials include a measure of common mental disorders, a measure of functioning and the PSYCHLOPS (Psychological Outcome Profiles questionnaire). The trials of the individual version of PM+  were conducted at PHC clinics in peri-urban areas of Nairobi, Kenya, and Peshawar, Pakistan. The trial of Group PM+ in Swat and Nepal are ongoing cluster RCTs. The intervention is delivered in the community in health workers homes or other appropriate community venues.

Cost of implementation

Data analysis to estimate the definitive cost-effectiveness of the intervention in Peshawar is underway.

Impact details

So far, PM+ has been used with more than 400 people with elevated levels of stress indicative of common mental disorders in Pakistan and Kenya.

Process evaluation interviews with clients, intervention providers, local decision makers and project staff showed that perceptions of the intervention were positive and that it had impacted positively on their lives, particularly for the facilitators. 

Results from the trials of PM+ (individual version) in Pakistan and Kenya are very encouraging. The results from the definitive trial Peshawar, Pakistan have now been published in the Journal of the American Medical association (JAMA; Rahman et al, 2016). In Peshawar, after 3 months, the intervention group showed lower levels of anxiety and depression than the control group. There were also significant differences in scores of posttraumatic stress, functional impairment, and problems for which the person sought help, with the intervention showing more positive results than enhanced care as usual. Effect sizes for most outcomes were between 0.5 and 1.0. Post hoc analysis showed that at baseline, about 90% % of participants in the intervention group and in the control group met criteria for depression. At 3 months, the rates were close to 30% and 60%, respectively. Initial severity did not affect results.  The study shows that PM+ may be a practical approach for helping adults with disabling psychological distress in conflict-affected areas. Please see the link to the article in the additional resources section.

Research

Tools

Multimedia

Associates

Mark van Ommeren WHO advisor on public mental health
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Country

Kenya, Pakistan, Nepal

Affiliated organizations

World Health Organization

Gallery

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