Effectiveness of a brief behavioural intervention on psychological distress among women with a history of gender-based violence in urban Kenya: A randomised clinical trial

Abstract

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...

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“…One of these, called Problem Management Plus (PM+), was designed for use in communities affected by adversity (Dawson et al, 2015). PM+ is available as an individual version (Individual PM+) evaluated in Pakistan (Rahman et al, 2016) and Kenya (Bryant et al, 2017) and as a group version (Group PM+) under evaluation in Swat, Pakistan (Chiumento et al, 2017; Khan et al, 2017). …”

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“…PM+ is multiproblem (designed to address depression, anxiety, stress or grief among adults, as well as client-identified practical problems, such as interpersonal conflict and financial problems), but does not appear to be modular, in that it has set elements delivered in a linear order for all clients. To date, there have been two pilot PM+ studies Rahman et al, 2016) and one large trial in Kenya (Bryant et al, 2017). It intentionally focuses on elements perceived by the developers to be lower in complexity and to require less theoretical background.…”

“…Much in line with the public health approach discussed in this article, PM+ was designed to be a low-intensity intervention to be delivered via task-sharing. In the large RCT in Kenya (N = 421), PM+ was compared to enhanced treatment-as-usual for a gender-based violence-affected sample (Bryant et al, 2017). PM+ integrates evidence-based problem-solving and behavioral treatment techniques into four core strategies: (a) Managing stress (simple stress management strategies such as deep breathing), (b) Managing problems (teaching basic problem-solving skills to address practical problems), (c) Get going, keep doing (BA strategies to increase positive reinforcement from the environment to improve mood and functioning), and (d) Strengthening social support (increasing the individual's capacity to re-engage in their community and elicit support from other individuals and agencies; Dawson et al, 2015).…”

“…PM+ integrates evidence-based problem-solving and behavioral treatment techniques into four core strategies: (a) Managing stress (simple stress management strategies such as deep breathing), (b) Managing problems (teaching basic problem-solving skills to address practical problems), (c) Get going, keep doing (BA strategies to increase positive reinforcement from the environment to improve mood and functioning), and (d) Strengthening social support (increasing the individual's capacity to re-engage in their community and elicit support from other individuals and agencies; Dawson et al, 2015). To date, there have been two pilot PM+ studies Rahman et al, 2016) and one large trial in Kenya (Bryant et al, 2017). In the large RCT in Kenya (N = 421), PM+ was compared to enhanced treatment-as-usual for a gender-based violence-affected sample (Bryant et al, 2017).…”

“…To date, there have been two pilot PM+ studies Rahman et al, 2016) and one large trial in Kenya (Bryant et al, 2017). In the large RCT in Kenya (N = 421), PM+ was compared to enhanced treatment-as-usual for a gender-based violence-affected sample (Bryant et al, 2017). Results showed moderate effects for psychological distress (d = 0.57) and for idiographic outcomes (i.e., participants' top two identified problems; d = 0.67), and small effects for functioning (d = 0.26) and PTSD (d = 0.21).…”