BackgroundGender-based violence (GBV) represents a major cause of psychological morbidity worldwide, and particularly in low- and middle-income countries (LMICs). Although there are effective treatments for common mental disorders associated with GBV, they typically require lengthy treatment programs that may limit scaling up in LMICs. The aim of this study was to test the effectiveness of a new 5-session behavioural treatment called Problem Management Plus (PM+) that lay community workers can be taught to deliver.Methods and findingsIn this single-blind, parallel, randomised controlled trial, adult women who had experienced GBV were identified through community screening for psychological distress and impaired functioning in Nairobi, Kenya. Participants were randomly allocated in a 1:1 ratio either to PM+ delivered in the community by lay community health workers provided with 8 days of training or to facility-based enhanced usual care (EUC) provided by community nurses. Participants were aware of treatment allocation, but research assessors were blinded. The primary outcome was psychological distress as measured by the total score on the 12-item General Health Questionnaire (GHQ-12) assessed at 3 months after treatment. Secondary outcomes were impaired functioning (measured by the WHO Disability Adjustment Schedule [WHODAS]), symptoms of posttraumatic stress (measured by the Posttraumatic Stress Disorder Checklist [PCL]), personally identified problems (measured by Psychological Outcome Profiles [PSYCHLOPS]), stressful life events (measured by the Life Events Checklist [LEC]), and health service utilisation. Between 15 April 2015 and 20 August 2015, 1,393 women were screened for eligibility on the basis of psychological distress and impaired functioning. Of these, 518 women (37%) screened positive, of whom 421 (81%) were women who had experienced GBV. Of these 421 women, 209 were assigned to PM+ and 212 to EUC. Follow-up assessments were completed on 16 January 2016. The primary analysis was intention to treat and included 53 women in PM+ (25%) and 49 women in EUC (23%) lost to follow-up. The difference between PM+ and EUC in the change from baseline to 3 months on the GHQ-12 was 3.33 (95% CI 1.86–4.79, P = 0.001) in favour of PM+. In terms of secondary outcomes, for WHODAS the difference between PM+ and EUC in the change from baseline to 3-month follow-up was 1.96 (95% CI 0.21–3.71, P = 0.03), for PCL it was 3.95 (95% CI 0.06–7.83, P = 0.05), and for PSYCHLOPS it was 2.15 (95% CI 0.98–3.32, P = 0.001), all in favour of PM+. These estimated differences correspond to moderate effect sizes in favour of PM+ for GHQ-12 score (0.57, 95% CI 0.32–0.83) and PSYCHLOPS (0.67, 95% CI 0.31–1.03), and small effect sizes for WHODAS (0.26, 95% CI 0.02–0.50) and PCL (0.21, 95% CI 0.00–0.41). Twelve adverse events were reported, all of which were suicidal risks detected during screening. No adverse events were attributable to the interventions or the trial. Limitations of the study include no long-term follow-up, reliance on se...

Background:Problem Management Plus (PM+) is a brief multicomponent intervention incorporating behavioral strategies delivered by lay health workers. The effectiveness of PM+ has been evaluated in randomized controlled trials in Kenya and Pakistan. When developing interventions for large-scale implementation it is considered essential to evaluate their feasibility and acceptability in addition to their efficacy. This paper discusses a qualitative evaluation of PM+ for women affected by adversity in Kenya.Methods:Qualitative interviews were conducted with 27 key informants from peri-urban Nairobi, Kenya, where PM+ was tested. Interview participants included six women who completed PM+, six community health volunteers (CHVs) who delivered the intervention, seven people with local decision making power, and eight project staff involved in the PM+ trial.Results:Key informants generally noted positive experiences with PM+. Participants and CHVs reported the positive impact PM+ had made on their lives. Nonetheless, potential structural and psychological barriers to scale up were identified. The sustainability of CHVs as unsalaried, volunteer providers was mentioned by most interviewees as the main barrier to scaling up the intervention.Conclusions:The findings across diverse stakeholders show that PM+ is largely acceptable in this Kenyan setting. The results indicated that when further implemented, PM+ could be of great value to people in communities exposed to adversities such as interpersonal violence and chronic poverty. Barriers to large-scale implementation were identified, of which the sustainability of the non-specialist health workforce was the most important one.

Introduction:Kenya has some of the highest rates of gender-based violence (GBV) in the world, particularly intimate partner violence. World Vision completed a rapid ethnographic assessment to explore common problems faced by men and local perspectives about the links between men, mental health, alcohol use and GBV.Methods:Data from community free-listing surveys (n = 52), four focus group discussions and two key informant interviews formed the basis for thematic analysis and findings.Results:Lack of jobs, ‘idleness’ and finances were viewed as top priority concerns facing men; however, alcohol and substance use were equally prioritised. Family problems, crime and general psychosocial issues (e.g., high stress, low self-esteem) were also reported. Men withdrawing socially, changing behaviour and increasing alcohol consumption were described as signs that men were experiencing mental health challenges. The community observed alcohol use as the biggest cause of GBV, believing men resorted to drinking because of having ‘too much time’, marital conflict, psychosocial issues and access to alcohol. The findings theorise that a circular link between unemployment, alcohol and crime is likely contributing to familial, psychosocial and gender concerns, and that men's mental health support may assist to re-direct a trajectory for individuals at risk of perpetrating GBV.Conclusions:Data confirmed that GBV is a major concern in these Kenya communities and has direct links with alcohol use, which is subsequently linked to mental health and psychosocial problems. Attempting to disrupt progression to the perpetration of violence by men, via mental health care interventions, warrants further research.

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Health care should be informed by the physical, socioeconomic, mental, and emotional well-being of the person, and account for social circumstances and culture. Patient-generated outcome measures can contribute positively to mental health research in culturally diverse populations. In this study, we analysed qualitative responses to the Psychological Outcome Profiles (PSYCHLOPS) Questionnaire—a patient-generated outcome measure based on open-ended questions, and compared the qualitative responses gathered to conventional, nomothetic measures used alongside the PSYCHLOPS in two studies. Data were collected as part of outcome research on a psychological intervention in Pakistan ( N = 346) and Kenya ( N = 521). Two researchers coded the qualitative responses to the PSYCHLOPS and identified overarching themes. We compared the overarching themes identified to the items in the conventional, nomothetic outcome measures to investigate conceptual equivalence. Using the PSYCHLOPS, the most frequently reported problems in Kenya were financial constraints, poor health, and unemployment. In Pakistan, the most frequent problems were poor health and emotional problems. Most of the person-generated problem concepts were covered also in nomothetic measures that were part of the same study. However, there was no item equivalence in the nomothetic measures for the most frequent PSYCHLOPS problem cited in both countries. Response bias and measurement bias may not be excluded. More research on the use of PSYCHLOPS alongside conventional outcome measures is needed to further explore the extent to which it may bring added value. Use of a PSYCHLOPS semistructured interview schedule and efforts to minimise response biases should be considered.

Background: To address shortages of mental health specialists in low-and middleincome countries, task-shifting approaches have been employed to train nonspecialists to deliver evidence-based scalable psychosocial interventions. Problem Management Plus (PM+) is a brief transdiagnostic nontrauma focused intervention for people affected by adversity. This study reports on the capacity of PM+ to address specific symptoms of posttraumatic stress disorder (PTSD). Methods: Individual patient data from three randomised controlled trials were combined and analysed to observe the impacts of PM+ (n = 738) or enhanced treatment as usual (ETAU) (n = 742) interventions on specific PTSD symptoms at posttreatment and 3-month follow-up. The PTSD-Checklist for DSM-5 (PCL-5) was used to index PTSD symptoms, and presence of each symptom was defined as moderate severity (score ≥ 2 on individual items).Results: The average PCL-5 score at baseline was 26.1 (SD: 16.8) with 463 (31.3%) scoring above 33, indicative of a diagnosis of PTSD. Following intervention, 12.5% and 5.8% of participants retained a score greater than 33 at postassessment and follow-up, respectively. There was greater symptom reduction for PM+ than for ETAU for most symptoms. Hyperarousal symptoms were the most common residual symptoms after PM+, with more than 30% of participants reporting persistent sleep disturbance, concentration difficulties, and anger. Conclusion:PM+ led to greater reduction in symptoms relating to re-experiencing and avoidance. The evidence indicates that strategies focusing on hyperarousal symptoms including sleep, concentration, and anger difficulties, could be strengthened in this brief intervention.

This paper proposes a framework for Comprehensive, Collaborative Community-based Care (C4) for accessible mental health services in low-resource settings. Because mental health conditions have many causes, this framework includes social, public health, wellness and clinical services. It accommodates integration of stand-alone mental health programs with health and non-health community-based services. It addresses gaps in previous models, including lack of community-based psychotherapeutic and social services, difficulty in addressing comorbidity of mental and physical conditions, and how workers interact with respect to referral and coordination of care. The framework is based on taskshifting of services to non-specialized workers. 6While advocating for increased mental health funding, it is essential to make optimal use of existing resources. The WHO developed and launched mhGAP in 2008 to strengthen and scale up care of mental, neurologic and substance use conditions by healthcare workers, especially in LMICs (World Health Organization, 2008). The mhGAP initiative provides multiple resources (World Health Organization, 2015a; World Health Organization, 2016b; World Health Organization, 2018f; World Health Organization, 2019) that build upon previous global mental health programming to bring mental health interventions by non-specialists to scale. WHO in collaboration with the broader global mental health field endorsed and refined complementary evidence-based, low-intensity and scalable psychological interventions for use by lay counselors (World Health Organization, 2015b; World Health Organization, 2016a; World Health Organization, 2016b; World Health Organization, 2020a; World Health Organization, 2020b). WHO also recently released a self-help guide (World Health Organization, 2021b). WHO, the United Nations Children's Fund (UNICEF), the United Nations High Commissioner for Refugees (UNHCR) and the United Nations Population Fund (UNFPA) have developed the Minimum Service Package (MSP) for Mental Health and Psychosocial Support in Humanitarian Settings consisting of key activities, methods and tools focusing on Health, Education and Protection programming and based on explicit MHPSS service standards (World Health Organization et al., 2021c). Altogether, these resources cover provision of care in routine services as well as support in emergencies. Preparedness (or disaster risk reduction), response and building back better can work together to strengthen systems in the longterm, and together, these resources provide a robust set of practical tools to begin to guide front-line providers in delivering mental health care and services in low-resource settings, and represent a significant advance for the field (World Health Organization, 2022; World Health Organization, 2013c; Inter-Agency Standing Committee, 2021). This paper describes a Framework for the Delivery of Comprehensive, Collaborative Community-based Care (C4) around which these and other mental health resources and approaches can be organiz...

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