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Table of Contents
FIELD REPORT
Year : 2021  |  Volume : 19  |  Issue : 1  |  Page : 91-100

Problem Management Plus Adapted for Group Use to Improve Mental Health in a War-Affected Population in the Central African Republic


1 Clinical Psychologist, Mental Health and Care Practices Advisor, Action Contre la Faim, Paris, France
2 Psychologist, Mental Health and Care Practices Programme Manager, Action Contre la Faim, Central African Republic
3 Psychologist, Senior Advisor Mental Health and Care Practices Sector, Action Contre la Faim, Paris, France

Date of Submission30-Aug-2020
Date of Decision24-Jan-2021
Date of Acceptance18-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Elisabetta Dozio
Clinical Psychologist, Mental Health and Care Practices Advisor, Action Contre la Faim, 14/16 Boulevard Douaumont, 75017 Paris
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INTV.INTV_36_20

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  Abstract 


A large number of the population in the Central African Republic has been exposed to potentially traumatic events as a result of the last conflict, which has led to the breakdown of social ties. In response to this situation, the nongovernmental organisation, Action contre la Faim, proposed a multisectoral project aimed at helping internally displaced persons to find an income-generating activity and offer psychosocial support through the adaptation of the Problem Management Plus protocol. A total of 946 IDPs in the country’s capital participated in the group intervention led by a team of paraprofessionals. Data collected from 111 participants showed that after 5 weeks of intervention, there was a significant reduction in posttraumatic symptoms and functional impairment. These results were confirmed during the postintervention evaluation 4 weeks later. In addition, participants declared that they had observed effects in their ability to live together in the community and in regaining a certain level of social cohesion. This experience gives encouraging results with regard to the feasibility and replicability of the adapted group protocol, taking into account specific cultural and contextual adaptations.

Keywords: Central African Republic, Problem Management Plus, posttraumatic stress disorder, social cohesion, war-affected population


How to cite this article:
Dozio E, Dill AS, Bizouerne C. Problem Management Plus Adapted for Group Use to Improve Mental Health in a War-Affected Population in the Central African Republic. Intervention 2021;19:91-100

How to cite this URL:
Dozio E, Dill AS, Bizouerne C. Problem Management Plus Adapted for Group Use to Improve Mental Health in a War-Affected Population in the Central African Republic. Intervention [serial online] 2021 [cited 2021 Apr 18];19:91-100. Available from: https://www.interventionjournal.org/text.asp?2021/19/1/91/312721




  Background Top


The Central African Republic (CAR) is a chronically threatened state whose situation has worsened year by year for more than 40 years. Since gaining independence in 1960, the CAR has experienced a succession of political and military crises which have acted as a major brake on its socioeconomic development (Isaacs-Martin, 2016; Knoope & Buchanan-Clarke, 2017). In December 2012, the country entered a new phase of instability because of a conflict which for years exposed the population to serious and massive abuses and violations of human rights, including rapes, acts of vandalism, scenes of looting, assassinations (Lallau, 2015). People seeking to understand the scope and scale of violence in the CAR over the past 2 years have cited a variety of social grievances centring on the political manipulation of religion, belonging and access to opportunities. Without denying that these factors have played a role, this field report argues that the violence must be understood in the context of social practices of violence that long predate the war, especially in light of the diffuse and noncentralised mode of organisation through which the ongoing war has played out.

The article focuses on the prevalence of popular punishment and vengeance, which have long histories as elements of statecraft in the CAR and have become even more widespread amid the generalised insecurity and anomie that have set in over the past few decades. It presents evidence of the workings of popular punishment from the intrafamily level to that of the crowd and “quartier” in both rural and urban locations. Though people have important reservations about popular punishment, they also see vengeance as an important tool for enforcing a circumscribed mode of empathy and a minimum set of standards for social behaviour. These experiences in the CAR suggest that those wishing to understand how wartime mobilisation happens must consider not just fighters’ grievances but also people’s conceptions of the practical and symbolic efficacy of vengeance and popular punishment as elements of politics and the management of threats (Lallau, 2015; Lombard & Batianga-Kinzi, 2015).

Since the second half of 2016, the dynamic of returns to Bangui, the capital, which began in November 2015, have intensified. Several factors such as the gradual closure of internally displaced persons (IDPs) sites in the city, increased coverage and the type of humanitarian assistance to returnees and the decrease in security incidents in neighbourhoods accompanied this dynamic. Despite the closure of IDP sites in the first half of 2020, more than 100,000 people were still displaced in Bangui (CMP, 2020). More recently, the violence and insecurity surrounding the general election of December 27, 2020 has forced over 30,000 people to flee into neighbouring Cameroon, Chad, the Democratic Republic of the Congo and the Republic of the Congo. Tens of thousands more have been displaced inside the country (UNCHR, 2021).

These repeated sociopolitical crises as well as poverty lead to psychological and behavioural changes in exposed populations that have a negative impact on their social relations and which handicap adults and children in their adaptation to daily life. Displaced persons face obstacles such as the destruction of their homes during the crisis, a lack of financial means to support the resettlement process (reconstruction of the house, purchase of food, etc.) and the fear that existing tensions do not degenerate into violence again. Persistent insecurity in many areas of the country continues to hamper the ability of the population to rebuild and reconcile.

Action contre la Faim

Since 2013, the nongovernmental organisation (NGO), Action contre la Faim (ACF), has been carrying out psychological and psychosocial support projects for adults and children in distress following the conflicts in the CAR (Dozio et al., 2016, (2019]). These projects have shown that risks to mental health within the population (such as depression, risk of decompensation, suicidal tendencies) remain very prevalent in different parts of the country. About 60% of the population of Bangui and its outskirts show symptoms of trauma and require appropriate and immediate psychosocial monitoring (ACF, 2019; Vandendyck, 2017).

Unfortunately, in the CAR the repetition of sociopolitical shocks has severely affected the state’s capacity to provide quality mental health services. The presence of qualified and trained mental health personnel is almost nonexistent (World Health Organization [WHO], 2018a). At the University of Bangui, a course in psychology was reintroduced in 2015, but the capacities of specialised personnel remain too limited given the scale of the needs. In light of the absence of nonspecialist resources in the country, training is needed to implement psychological support projects to develop a team of paraprofessionals (psychosocial workers) supervised by a psychologist.

To meet the needs of the population of Bangui and support the displaced in the process of integration in the original neighbourhoods of the capital, a consortium of NGOs proposed a programme to support and perpetuate the dynamics of return to Bangui through adapted and strengthened social, economic and protection mechanisms. To achieve this result, the project planned to accompany IDPs in income-generating activities (IGAs), and to give them the financial and material capacity to start living again in the original neighbourhoods abandoned during the conflict.

As part of this project, ACF developed a mental health intervention strategy to strengthen the psychosocial resilience of communities. This strategy was implemented as psychosocial support to those people in distress who were involved in the income-generating activities planned in the project in order to strengthen the long-term results of the intervention. The goal was to give people the confidence and self-esteem they needed to project into the future. For this, ACF opted to use the Problem Management Plus (PM+) intervention (WHO, 2018b) which had been developed to support distressed adults in communities who are exposed to adversity that may cause depression, anxiety and stress.

Adapting Programme Management Plus for Group Use

The CAR conflict has weakened the ability of people to live together and trust each other. A group approach appeared necessary to work on collective dynamics: knowing how to listen to each other, trusting each other, leaning on each other to form very fragile social links. In addition, ACF has a policy to implement brief group clinical interventions as a public health strategy to cover more needs with limited resources. For this reason the PM + approach was adapted for use in groups. A specific manual for Group Problem Management Plus (Group PM+) was only released in August 2020 (WHO, 2020) and as this manual was not available when the project was implemented in Bangui, the ACF team adapted the individual version of PM+. This involved modifying the structure of the sessions to make them suitable for groups, but respecting the content provided in the original version. We subsequently implemented PM+ adapted for group use1 to meet identified needs. This field report discusses some of the adaptation procedures and difficulties faced, in particular about challenges in cultural aspects, and presents the findings and client outcomes of this programme.


  Methods Top


Participants

The PM+ adapted for group use intervention was made available to people in the returnee neighbourhoods of the 3rd arrondissement of Bangui and in the Boeing locality in the commune of Bimbo. These groups were identified as being particularly vulnerable and in need of support for the implementation of economic relaunch activities. In particular, the population of PK5 (Point Kilometre 5) was exposed to atrocities during the 2013 attacks, with houses burnt and destroyed and a large part of the population forced to flee.

PK5 is the Muslim district of Bangui. Since the crisis of 2013, the security situation in the district has been unstable and the population has been the victim of violent clashes on several occasions, such as in April 2018 (OCHA, 2018) and December 2019 (Conseil de Sécurité UN, 2020). In order to encourage the dynamics of return of displaced persons, the PK5 district represented a priority area in terms of strengthening social cohesion, with very significant needs in terms of support for economic and psychological development.

Participants were the beneficiaries of the support in income-generating activities (IGAs) which were selected on the basis of socioeconomic criteria. The identification was carried out in coordination with the prefect, the sub-prefect, the mayor of the city, the neighbourhood chiefs and religious and community leaders. The inclusion criteria were therefore to be a person included in the IGAs. We excluded people with severe mental illness, risk of suicide or cognitive impairments.

Procedure

As indicated in [Figure 1], all adults (men and women) identified for IGAs participated in a psychoeducation session organised by the psychosocial workers. The psychoeducation focused on the symptoms most frequently observed in communities exposed to adversity, including acute stress, anxiety, depression, etc. After the psychoeducation session, the participants were invited for an interview with the psychosocial workers. In the interview, the psychosocial worker assessed people’s level of wellbeing, using the World Health Organization wellbeing index (WHO-5) and invited them to participate in groups based on PM+ on a weekly basis for 5 weeks. The groups consisted of a maximum of 10 people without gender or age separation. In other parts of the country, separation between men and women in the groups would have been necessary. ACF’s multiyear experience in psychosocial programmes in the country has shown that in Bangui mixed groups are not a difficulty, but rather promote interesting and enriching exchanges of experience.
Figure 1 Programme Flow and Procedure. Group PM+, Group Problem Management Plus; IGAs, income-generating activities; WHO-5, World Health Organization scale 5 wellbeing index.

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Priority was given to participants with a low level of wellbeing (WHO-5 ≤ 13). All participants scoring above 13 were included in the groups and they participated in the second round of care. There was no cut-off point to prevent participation. Participation was on a voluntary basis, following the psychoeducation session which presented the PM+ interventions.

At the beginning of the first session, each participant did some pretests to better understand their psychological difficulties. At the end of the fifth and last session, participants completed the posttest to measure improvement in wellbeing and reduction in distress.

One month after the intervention, the psychosocial workers administered the tests to a sample of participants for a postintervention assessment, They also took part in a discussion about their impressions of the sessions and possible effects in their daily lives in order to capture the qualitative outcomes of the intervention.

Measures

Quantitative Outcomes. The quantitative outcomes of the PM+ adapted for group use intervention were measured using several tools at different timeframes (see [Table 1]).
Table 1 Assessment Tools and Timeline

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The WHO-5 (Staehr, 1998; Topp et al., 2015) was used to measure the overall wellbeing of a person. Each answer to the questions has a corresponding score. The closer the final score of all the responses accumulated to 25, the greater the wellbeing. If the score is less than 13, depression may be present in the person. People with a score of 13 or less were included in the groups as a priority. Changes in wellbeing were also measured during the endline and postintervention.

The following measures were used at baseline, endline and postintervention assessment:
  1. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers et al., 2013) assesses the severity of posttraumatic stress reactions. The total symptom severity score can be obtained by summing the scores for each of the 20 items (range: 0–80). Although further research is needed, a cut-off score between 31 and 33 is indicative of probable posttraumatic stress disorder (PTSD).
  2. The World Health Organization Disability Assessment Schedule (WHODAS 2.0, 12-item version; Ustün et al., 2010; WHO, 2010) assesses functional disability that people are facing across six domains (cognition, mobility, self-care, getting along, life activities and participation) over the previous 30 days. Difficulties are scored on a five-point scale (none, mild, moderate, severe or extreme).
  3. The Psychological Outcome Profiles (PSYCHLOPS; Ashworth et al., 2004) assesses problems identified by the persons concerned. PSYCHLOPS is a measure consisting of four questions. Responses are scored on a six-point scale with a maximum score of 20.


In addition to these three assessment periods, PSYCHLOPS were used at each session to monitor the weekly progress of the participants.

Qualitative Outcomes. At the end of the project and at the postintervention assessment (1 month after the end of the PM+ adapted for group use), participants could express their level of satisfaction about the service received and the benefit perceived (if any).

At the end of the five PM+ sessions, in addition to a test participants were asked to evaluate the programme through two multiple-choice questions that are systematically used in ACF’s psychosocial projects (see [Table 2]). Then, 1 month later, during the postevaluation phase, after the psychometric test, participants were able to express their opinions about participating in PM+ in a focus group led by an investigator from ACF’s MEAL (Monitoring, Evaluation, Accountability and Learning) team. The questions asked are shown in [Table 2]. The answers were recorded during the focus group using a note-taking survey and then quantified by frequency of response.
Table 2 Endline and Postintervention Questionnaires

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Consent

Participants were informed about the programme, the objectives and modality of participation. They were also informed about the use of their data and the possibility of sharing for publication purposes. They were given an informed consent form which includes the right to withdraw at any moment. Participants provided a signed consent form to ACF prior to having data collected.

Data Management and Analysis

Data were collected confidentially in pen-and-paper format and then entered in Epi Info for Windows software, developed by the Centers for Disease Control and Prevention (CDC; CDC, 2016). Statistical analyses were carried out using the Statistical Package for the Social Sciences (SPSS) version 21 (IBM Corp, 2012).

Composition and Training of the Team

The team consisted of a clinical psychologist and 11 psychosocial workers. The profile of psychosocial workers was quite heterogeneous in terms of the number and type of studies. A minority had a bachelor’s degree (2 years) in psychology. The others had between 1 and 4 years of university studies in the fields of social sciences (sociology, education, social services and community development), communication and law. Some did not have a university education, but had professional experience in community services. The whole team had previously worked in ACF psychosocial programmes and had been trained by expatriate psychologists on psychological trauma. For the programme presented here, psychosocial workers received a 2-week initial training and continuous supervision by the expert psychologist. Practice analysis sessions were organised every week. This constant training and support enabled the team to adopt the PM+ protocol comfortably.

Programme Management Plus Adaptation for Group Use

PM+ was adapted from its individual version for group use. Each group consisted of a maximum of 10 participants. The intervention was organised in five sessions of approximately 2 hours each. Each group was facilitated by two psychosocial workers to manage the group and individual needs and to offer the best support possible to the participants.

The content of the sessions followed the sequence and structure of the individual version. However, in each session it was necessary to combine moments of group activity and explanation with moments of individual work. For example, administering the PSYCHLOPS in each session and defining and highlighting progress on one’s own personal problem management project needed an individual focus. Although this necessitated individual work, it was still possible to plan for sharing of experience and solutions with the other members of the group. The strategy for each session was presented and worked on in groups, and then taken up and adapted individually for each beneficiary. The psychosocial workers were trained in group facilitation techniques in order to solicit participation, encouraging the flow of speech without forcing the beneficiaries to speak and enabling the group members benefit from the shared experience.

In practice, this means that throughout the sessions the steps for problem management strategy are first developed in the group, based on an example chosen collectively by the participants. In a brainstorming session, the participants list problems and then choose one that is representative for all. The psychosocial workers then facilitate the group in formulating a more precise definition of the problem, and in reflection and the choice of effective strategies, leaving everyone the opportunity to contribute their point of view, to reflect back on the stories of others, etc. Several options are left open as there will not be one way to deal with a problem, but the input from each person helps to see different facets of the problem and different possibilities of strategies to deal with the difficulties. The action plan is also initially worked on in groups based on the example chosen collectively. In the individual work of each session, the participants can draw on the group experience and choose their own issues to be addressed and their action plan. Progress on individual projects is also shared in groups at the beginning of each session for those who wish to do so.


  Results Top


Quantitative Results

A total of 1354 participants attended the psychoeducation sessions. Among them, 946 were enrolled in the PM+ adapted for group use intervention. About 408 participants in the psychoeducation did not wish to take part in the psychosocial intervention. This was due in particular to difficulties in travelling to other provinces in the country. The volatile context and the complex working and security conditions make it difficult to fulfil all the evaluation phases scheduled by the monitoring procedures. [Table 3] gives details of the data collected and shows that unfortunately we missed the baseline data for two measures (WHODAS and PCL-5).
Table 3 Data Available for the Three Assessment Phases (Baseline, Endline and Postintervention)

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In addition to this, the postevaluation was not foreseen in the initial project, but given the interest in understanding the longer term effects of the protocol, part of the team were recruited again to carry out a postevaluation. Due to time and budget constraints, it was not possible to reach all participants and we chose to focus primarily on those for whom we had all the baseline and endline measurements. Data from baseline, endline and postintervention are complete for only 111 participants. The profile of the participants is presented in [Table 4]. The profile of the 111 participants with complete data shows similar characteristics to the group of 946 participants in the programme.
Table 4 Demographic Characteristics of People Enrolled in Group PM+

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The sample with complete data attended more sessions, as we decided to extract data only for participants with the complete set of assessment. Among this sample, 96.4% participated in all the sessions and in the postintervention evaluation. Among the total participants of the PM+ adapted for group use intervention (n = 946), a majority (73%) attended all 5 sessions and only 6% attending less than 3 sessions ([Table 5]).
Table 5 PM+, Sessions Attended

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The paired t test conducted on the sample of 111 participants ([Table 6]) showed a statistically significant reduction of the PTSD symptoms (t = 19.96, P < 0.001) as a significant reduction of functional impairment (t = 17.43, P < 0.001) between baseline and endline scores. A significant difference was also observed in the improvement of wellbeing (t = −28.99, P < 0.001) and in the reduction of problems identified PSYCHLOPS (t = 26.28, P < 0.001). These results were confirmed at the postintervention evaluation after 4 weeks. The high values of PCL-5 at baseline indicate a widespread presence of PTSD symptoms among the population involved in programme. After participating in the endline assessment, two participants (1.8%) still had >33 score (i.e. PTSD syndrome) and at the time of the postassessment, there were eight participants (7.2%). This shows that, despite the significant improvement, distress remains high for some people.
Table 6 Paired Samples t Test (Baseline vs Endline and Baseline vs Postintervention assessment) for Psychological Outcomes (n = 111)

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Qualitative Results

At the end of the PM+ protocol, participants were invited to express their perception of the project. They could choose from a list of items. The choice could be multiple. About 831 people filled in this questionnaire during the endline assessment. 645 (77%) participants stated that they had learned new knowledge. 658 (79%) were able to share their experiences. For 376 (45%), the sessions allowed them to relax. 279 (33%) participants said that they were able to get out of physical and psychological isolation and in particular for 528 (63%), the session was an opportunity to meet people. Finally, for 171 (20%) people, the group was a calm and safe space, which encouraged friendly listening. In the interviews conducted during the postevaluation (1 month after the end of the group treatment), the participants were able to spontaneously express their perception of the effects of the PM+ adapted for group use. Some of quotes are shown in [Table 7].
Table 7 Perceived Utility of PM+ Adapted for Group Use

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Challenges in the Cultural, Local Adaptation of PM+

The implementation of the PM+ adapted for group use has presented some challenges, particularly related to the need to adapt some contents and tools to the specific cultural context.

Two aspects presented certain obstacles. Firstly, at the beginning of the protocol about understanding adversity, the word “adversity” has no corresponding translation in Sangho (the language spoken in the CAR). In addition to this, as in most conflict and postconflict contexts, adversity is an integral part of people’s lives. It was therefore very complicated for the team to work around this concept. The notion of adversity being omnipresent, the participants in the sessions did not immediately understand the reflection that is required around adversity and they sometimes reproached the teams for not taking into account their real daily primary problems which were hunger or lack of water.

The second obstacle concerned the fact that the approach is based on a Western conception of time and linked to the setting up of an action plan. This was the most difficult element to understand, adapt and implement. The use of an action plan requires a clear representation of time. It asks participants to represent themselves in a space-time for 7 days and this is not always possible for those who live day by day, with limited representation of the future. It also depends on a person’s ability to write and only 20% of the participants were used to holding a pencil in their hand. For those who can write, it is difficult to fill in the sheet because there is no light after nightfall. The paper with the action plan was often difficult to keep till the end of the protocol because of the very precarious living conditions as well as the perception of the usefulness of the tool, which was sometimes lost, stolen or used to make a fire.

These obstacles were overcome and worked on by the team. Constant, regular supervision enabled the psychosocial workers to deal with difficulties encountered with participants and with the frustration of the team, especially during the initial experiences of the first PM+ groups.


  Discussion Top


This psychosocial programme was developed with the aim of helping displaced people in Bangui and its periphery to reduce symptoms of stress and anxiety so that they were able to start an income-generating activity and keep it going over time. The objective was to encourage the return to their original neighbourhoods and to rebuild a dynamic of cohabitation and collaboration between neighbours. We opted for a group approach centred on problem-solving that could be carried out by paraprofessionals. To do this, we adapted the PM+ protocol developed by the WHO, which had already proved its effectiveness in communities exposed to adversity in low- and middle-income countries (Bryant et al., 2017; Rahman et al., 2016).

The programme using the PM+ adapted for group use shows positive results for the intervention which was carried out with women and men affected by the CAR conflict. The results indicate a significant reduction in the symptoms of trauma (PCL-5) and functional impairment (WHODAS), as well as an improvement in general wellbeing (WHO-5). These results are comparable to those of the feasibility studies of the Group PM+ protocol (Rahman et al., 2019). Beyond the quantitative results, the participants’ accounts show a high level of adherence to the protocol (also supported by frequency data at the sessions, which remain high despite the security conditions of the postconflict context).

In line with the Group PM+ feasibility study in the earthquake-affected regions of Nepal (Sangraula et al., 2020), we also observed an improvement in somatic symptoms as well as benefits specific to the group dimension of the proposed care. The group dimension of the adapted protocol enabled the participants to find a form of therapeutic community, where concerns and problems could be tackled and solved by several persons, while starting from their own difficulties. The use of the PM+ protocol in a group setting offered a caring and reassuring space, allowing a process of individual and group resilience.

The beneficial impact of the individuals was diffused in the households through the sharing of techniques acquired during therapeutic sessions. In particular, the participants appreciated the relaxation exercises and integrated them into their daily lives by involving other family members, including children. However, these effects also spread beyond the family. The group allowed participants to confront each other in a safe space. Men and women, distrustful of each other after years of intracommunity conflict, were able to meet again, to listen to each other, to understand each other and to find common problem-solving strategies, by sharing experiences, doubts and know-how. In the spontaneous words of the participants, an unexpected effect of this empowerment, that of a strengthened social cohesion, was observed. This encouraging impact will have to be better evaluated during future use of this protocol in similar contexts and placed in relation with the future results of the Group PM+ experiences being evaluated in different countries (Chiumento et al., 2017; Uygun et al., 2020).

Another important element to highlight is the use of the protocol by the team. Training and regular supervision enabled the psychosocial workers to assimilate the PM+ adapted for group use approach. They were able to accompany the participants in their therapeutic and professional project. Supervision also took into account the possible frustrations due to difficulties in cultural adaptation. The results of this programme demonstrate the possibility of employing nonspecialists in mental health to carry out a psychological intervention with this protocol.

Limitations

Despite the very good results, the programme has some limitations. First of all, the group adaptation of the PM+ protocol was done based on the individual version. Some elements may have been revised to better adapt to groups, thanks to the recent publication of the WHO manual (WHO, 2020).

It is difficult to see a difference between group effect and PM+ protocol, as we did not have a control group/waiting list in this intervention. It will be interesting in the future to compare Group PM+ versus other protocols in groups, and/or Individual PM+ versus Group PM+ to assess which component is effective in trauma treatment and social cohesion.

In addition to this, since this programme was integrated with an IGA, it is very difficult to separate the effects of each intervention (economic and psychosocial) on the wellbeing of the participants. It is not possible to assess whether the results were based on the hope offered to the participants by the employment opportunities, the ability to live independently, etc. Monitoring and performance indicators that take into account the impact of the two activities offered to the beneficiaries could give a better understanding of the role of each in improving wellbeing.

The monitoring of the programme could also be improved to have more data on a larger sample. A postintervention measurement at 3 and 6 months could give a more reliable idea of the sustainability of the results obtained on the improvement of wellbeing and the sustainability of individual income-generating projects as well as community cohesion.


  Conclusion Top


The protocol used presented advantages in terms of the setting and mental containment through the structured organisation of the intervention. It has proved to be very relevant in getting the beneficiaries out of passivity and the inability to imagine themselves again in the future. Although not designed to treat people affected by trauma, we observed a significant reduction in posttraumatic symptoms following participation in the sessions. Group adaptation has proven to be effective and has had an effect on individual wellbeing, but it also strengthened collective resources by helping people to break out of their isolation and to rely on the abilities and support of neighbours. These elements proved important in a context that has been disrupted by intracommunity violence for the reconstruction of a new way of living together, which seems to be positive for renewed social cohesion. This experience gives encouraging results with regard to the feasibility and replicability of the group protocol, taking into account specific cultural and contextual adaptations.

Acknowledgements

Authors thank the team of psychosocial workers from Action contre la Faim in the Central African Republic, supervised by Ernest Last. Authors would like to thank Ninon Leduc (Field Coordinator in Bangui) who believed in the project and helped to make it happen.

Financial support and sponsorship

The project was financed by the European Union through the Bêkou Trust Fund in favour of the Central African Republic.

Conflicts of interest

There are no conflicts of interest.

1We use the phrase “PM+ adapted for group use” to differentiate our intervention from the later WHO version, “Group PM+”.









 
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    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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