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   Table of Contents - Current issue
Coverpage
January-June 2021
Volume 19 | Issue 1
Page Nos. 1-143

Online since Wednesday, March 31, 2021

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EDITORIAL  

Bridging the Gap Between Science and the Field p. 1
Wendy Ager, Camila Perera, Naser Morina, Mohammad Abo-Hilal
DOI:10.4103/INTV.INTV_9_21  
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ARTICLE Top

Capturing Intervention in Its Context: The Next Frontier in Disaster Response Evaluation and Scale-Up Planning p. 4
Michel Duckers
DOI:10.4103/INTV.INTV_49_20  
Disasters and humanitarian crises threaten the health and wellbeing of people across the world, especially in more vulnerable regions. Many efforts are made to ensure that public health interventions, including mental health and psychosocial support (MHPSS), are based on the best available evidence. Important progress has been made in effectiveness research in recent decades. However, our understanding of the value of MHPSS programmes for individuals and communities confronted with adversity still depends heavily on expert opinion and educated guess. This contribution proposes several steps to enhance our evaluation paradigm for the organised response to disasters. Obviously, we need to evaluate routinely, focusing beyond clinical outcomes, whilst applying a broader concept of the quality of mental health intervention. Moreover, disaster response evaluations need to be more attentive to capturing the intervention or disaster vulnerability context. This context includes risk and protective factors at different levels. The context might vary along the timeline of a particular event, but it remains a product of a locally unique interplay between exposure, history and culture. On the one hand, capturing this context is a prerequisite to understand what constitutes a high-quality post-disaster response. On the other, it is a key component for a viable scale-up of promising interventions.
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FIELD REPORTS Top

COVID-19 and Refugees in Malaysia: An NGO Response p. 15
Sharuna Verghis, Xavier Pereira, Anesha Gnana Kumar, Ashley Koh, Asha Singh-Lim
DOI:10.4103/INTV.INTV_18_20  
COVID-19, a watershed moment in global health, has brought health inequalities into sharp focus exposing structural disadvantage and institutional discrimination experienced by disenfranchised populations. Focusing on urban refugees and asylum seekers in Malaysia who are deemed of irregular status under the law, this field report outlines the legal and policy responses of the government and the impact of COVID-19 on refugees. It also highlights the organisational response of an organisation working with refugees in the greater Kuala Lumpur area. As pandemics become a reality of our times, it is imperative that pandemic preparedness and mitigation strategies adopt inclusive and universal approaches that include migrant populations such as refugees and asylum seekers.
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The Comfort Dog Project of Northern Uganda: An Innovative Canine-Assisted Psychosocial Trauma Recovery Programme p. 21
Meg Daley Olmert
DOI:10.4103/INTV.INTV_16_20  
In 2012, BIG FIX Uganda, an American-based animal welfare organisation, began offering veterinary health services and animal welfare education in northern Uganda to improve the wellbeing of animals and their guardians. In 2014, the organisation expanded its inclusive health platform with the creation of the Comfort Dog Project − an animal-assisted psychosocial intervention for survivors of war trauma through the facilitation of human-dog companionship. This article focuses on how blending community trauma counselling with dog training and bonding instruction can improve the social and emotional skills of dog guardians while creating loving, stress-buffering relationships with their dogs. Fifty-nine guardians and their comfort dogs graduated this 20-week animal assisted trauma intervention between 2015 and 2020. Psychological assessments taken pre- and post-graduation, as well as annual follow-up testing over a 4-year-period, indicate that this therapeutic model can be effective at reducing the symptoms of posttraumatic stress disorder and improving the wellbeing of both the guardians and their comfort dogs.
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ARTICLES Top

A System Innovation Perspective on the Potential for Scaling Up New Psychological Interventions for Refugees p. 26
Aniek Woodward, Marjolein A Dieleman, Egbert Sondorp, Bayard Roberts, Daniela C Fuhr, Peter Ventevogel, Marit Sijbrandij, Jacqueline E.W Broerse, On behalf of the STRENGTHS consortium
DOI:10.4103/INTV.INTV_29_20  
In recent years, a range of brief protocolised psychological interventions like Problem Management Plus have been developed. Such “scalable psychological interventions” are meant to be delivered by nonspecialists which can greatly increase access to psychological therapies for people affected by adversity, including forced displacement. However, embedding new interventions into mainstream practices is challenging. Novel interventions can remain in the research phase for a long time or stop altogether, which minimises their intended impact and reach. In this conceptual paper we propose a “system innovation perspective” on scaling up new psychological interventions for refugees and argue that existing mental health systems often need to change to integrate new interventions in a sustainable way. We present a conceptual framework, which includes ideas on cycles of deepening (learning by doing), broadening (repeating and linking), and scaling up (embedding) and the multilevel and constellation perspective. This framework has been operationalised in our scalability research as part of the STRENGTHS study in which we increase our understanding of the opportunities for scaling up four new psychological interventions in eight countries hosting Syrian refugees, including in Europe (Germany, Netherlands, Sweden and Switzerland) and the Middle East (Egypt, Jordan, Turkey and Lebanon). Key implications for practice
  • Researchers and practitioners involved in implementing and evaluating scalable psychological interventions such as Problem Management Plus should consider the inclusion of scalability assessments to increase understanding about the potential for integrating such innovations into mainstream services.
  • A system innovation perspective views scaling up as the integration of an innovation into mainstream practices and suggests that mental health systems commonly need to change in order to effectively adopt new interventions, allowing them to reach their desired impact at scale and in a sustainable way.
  • An improved understanding of the scalability of novel psychological interventions, including the potential (systemic) barriers and facilitators for scaling up, will provide essential knowledge for those involved in decision-making, implementation and evaluation of the further scale up of such interventions.
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Building Mental Health and Psychosocial Support Capacity During a Pandemic: The Process of Adapting Problem Management Plus for Remote Training and Implementation During COVID-19 in New York City, Europe and East Africa p. 37
Kelly A McBride, Sarah Harrison, Sudeshna Mahata, Kendall Pfeffer, Francesca Cardamone, Teresa Ngigi, Brandon A Kohrt, Gloria A Pedersen, Claire Greene, Darryll Viljoen, Orso Muneghina, Adam D Brown
DOI:10.4103/INTV.INTV_30_20  
On March 11, 2020, COVID-19 was declared a pandemic by the World Health Organization. In response to the sudden rise in COVID-19-related mental health and psychosocial impacts, we embarked on a digital training (e-learning) and remote delivery adaptation for Problem Management Plus Training for Helpers (Remote PM+ Training) based in New York City, four European countries and six African countries. This paper provides an overview of the two Remote PM+ Trainings, including key adaptations and lessons learned across the contexts. Trainings were approximately 75 hours in duration, with a mix of group and individual work, in diverse contexts. Overall, remotely delivered PM+ training and intervention appear appropriate. There were a number of critical lessons learned that contributed to the efficacy of the trainings, such as technological support, digital literacy, preparation and flexibility among the trainers and the trainees. There is also a need for cultural and contextual adaptation towards the delivery of remote training and implementation of PM+. However, the outcomes from these two trainings indicate that PM+ may be adapted for remote (online) training and, if supported with additional studies, could build workforce capacity in contexts in which there is limited in-person access to mental health and psychosocial support services and staff.
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Cultural Adaptation of a Low-Intensity Group Psychological Intervention for Syrian Refugees p. 48
Aemal Akhtar, Michelle H Engels, Ahmad Bawaneh, Martha Bird, Richard Bryant, Pim Cuijpers, Pernille Hansen, Hadeel Al-Hayek, Zeynep Ilkkursun, Gulsah Kurt, Marit Sijbrandij, James Underhill, Ceren Acarturk, and On behalf of the STRENGTHS Consortium
DOI:10.4103/INTV.INTV_38_20  
Given the increasing use of low-intensity psychological interventions in humanitarian mental health and psychosocial support work, more attention is needed to strengthen the intersection between evidence-based interventions and cultural contextualisation. Undertaking the process of cultural adaptation ensures the appropriateness and acceptability of psychological interventions in these contexts. We present the process and results of conducting a cultural adaptation for the Group Problem Management Plus (GroupPM+) intervention, for Syrian refugees across two contexts; Jordan in camp settings and Turkey in urban settings. The first step of the adaptation was to conduct a rapid qualitative assessment following the Design, Implementation, Monitoring and Evaluation model proceeded by cognitive interviews and a workshop designed to apply changes according to the Bernal framework. Based on the results, a total of 82 changes were proposed across the intervention manual, training, supervision and implementation protocols. Changes ranged from minor amendments to terminology to broader changes to how metaphors, stories and illustrations are presented during the intervention. Additionally, two substantial adaptations were suggested: (1) the addition of a session designed to enhance family engagement, and (2) the development of a male case study. Changes were incorporated prior to the implementation of the GroupPM+ intervention in Jordan and Turkey.
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Adapting Problem Management Plus for Implementation: Lessons Learned from Public Sector Settings Across Rwanda, Peru, Mexico and Malawi p. 58
Sarah F Coleman, Hildegarde Mukasakindi, Alexandra L Rose, Jerome T Galea, Beatha Nyirandagijimana, Janvier Hakizimana, Robert Bienvenue, Priya Kundu, Eugenie Uwimana, Anathalie Uwamwezi, Carmen Contreras, Fátima G Rodriguez-Cuevas, Jimena Maza, Todd Ruderman, Emilia Connolly, Mark Chalamanda, Waste Kayira, Kingsley Kazoole, Ksakrad K Kelly, Jesse H Wilson, Amruta A Houde, Elizabeth B Magill, Giuseppe J Raviola, Stephanie L Smith
DOI:10.4103/INTV.INTV_41_20  
Problem Management Plus (PM+) is a low-intensity psychological intervention developed by the World Health Organization that can be delivered by nonspecialists to address common mental health conditions in people affected by adversity. Emerging evidence demonstrates the efficacy of PM+ across a range of settings. However, the published literature rarely documents the adaptation processes for psychological interventions to context or culture, including curriculum or implementation adaptations. Practical guidance for adapting PM+ to context while maintaining fidelity to core psychological elements is essential for mental health implementers to enable replication and scale. This paper describes the process of contextually adapting PM+ for implementation in Rwanda, Peru, Mexico and Malawi undertaken by the international nongovernmental organisation Partners In Health. To our knowledge, this initiative is among the first to adapt PM+ for routine delivery across multiple public sector primary care and community settings in partnership with Ministries of Health. Lessons learned contribute to a broader understanding of effective processes for adapting low-intensity psychological interventions to real-world contexts. Key implications for practice
  • PM+ can be contextualised based on cultural and implementation considerations while maintaining core psychological elements across different settings.
  • The adaptation of PM+ for local health systems and articulation of practical guidance on implementation for routine care is essential.
  • Partnerships across implementing sites are fundamental for iterative PM+ adaptation and provide opportunities for sharing lessons learned.
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FIELD REPORTS Top

Task-Sharing Psychosocial Support with Refugees and Asylum Seekers: Reflections and Recommendations for Practice from the PROSPER Study p. 67
Anna Chiumento, Leah Billows, Annette Mackinnon, Rachel McCluskey, Ross G White, Naila Khan, Atif Rahman, Grahame Smith, Christopher Dowrick
DOI:10.4103/INTV.INTV_17_20  
To address the unmet need for accessible mental health services for refugees and asylum seekers in high-income countries, the PROSPER study is testing implementation of the World Health Organization Problem Management Plus (PM+) intervention. Incorporating task-sharing strategies, the intervention is delivered by Peer Lay Therapists with lived experience of seeking asylum or migration. The PM+ training adopts a cascade apprenticeship model, where Master Trainers train and supervise Wellbeing Mentors; who subsequently train and supervise the Peer Lay Therapists. We describe application of this training and supervision approach in PROSPER, drawing on Master Trainer and Wellbeing Mentor perspectives. We then reflect on our experiences, highlighting logistical challenges when working with refugee and asylum-seeking Peer Lay Therapists, the strategies to promote their ongoing engagement and the opportunities for team and personal growth. A core learning point has been the role of straddling the intervention and research components of the PROSPER study. Based on our experiences, we make recommendations for others adopting a task-sharing approach by training refugees and asylum seekers as Peer Lay Therapists in high-income countries, so that this might inform service programming and/or associated research activity.
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Living Six Hours Away from Mental Health Specialists: Enabling Access to Psychosocial Mental Health Services Through the Implementation of Problem Management Plus Delivered by Community Health Workers in Rural Chiapas, Mexico p. 75
Fatima G Rodriguez-Cuevas, Erika S Valtierra-Gutiérrez, Juana L Roblero-Castro, Carolina Guzmán-Roblero
DOI:10.4103/INTV.INTV_28_20  
Living with a mental health condition in rural Chiapas, the southernmost state of Mexico, where adversity, poverty and health in accessibility prevail, make it challenging to reach for mental health services since they are mostly centralised in urban settings, understaffed and underfunded. The Mexican sister organisation of the international non-profit, Partners In Health, has served in marginalised communities in collaboration with the Mexican Ministry of Health and has provided mental health services since 2014. In 2019, community mental health workers began delivering individual Problem Management Plus (PM+) sessions to people with mental health conditions through home visits. This field report aims to share implementation practice findings through the voice of four implementers, two of whom currently deliver PM+, and through two brief case reports. Results show PM+ has had a positive impact on patients’ symptoms and community health workers’ attitudes toward mental health and themselves. However, incompletion of sessions, appropriateness and acceptability of the intervention are issues that implementers still need to tailor to the context. Despite having made adaptations, complex problems such as intimate partner violence, stress due to structural adversity and grief related to the emerging COVID-19 pandemic represent challenges that the intervention needs to address to meet the needs of underserved areas.
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After the Randomised Controlled Trial: Implementing Problem Management Plus Through Humanitarian Agencies: Three Case Studies from Ethiopia, Syria and Honduras p. 84
Ashley Nemiro, Edith Van’t Hof, Sendrine Constant
DOI:10.4103/INTV.INTV_34_20  
Problem Management Plus (PM+) is an evidence-based intervention developed for adults impaired by distress in communities exposed to adversity. After being tested and released by the World Health Organization, a capacity building project was launched to increase the uptake of the intervention within humanitarian settings. Humanitarian organisations were trained and supported through supervision to implement individual PM+. After the two master trainings were completed, case studies were conducted in Ethiopia, Syria and Honduras to describe the uptake of the intervention by organisations following the training. When the case studies were drafted in July 2019, 34 master trainers had gone on to train and supervise 305 PM+ providers throughout the globe. The case studies show that individual PM+ is both relevant and appropriate for use in various humanitarian settings. Through these case studies, we gathered meaningful examples of the different ways that PM+ can be implemented in various settings with non-specialised providers. Having a robust supervision system (remote or face-to-face) in place is essential, along with practising the intervention before it was fully delivered. Additionally, dedicated staff or volunteers, adequate time to conduct the initial training and contextualisation and a system to ensure quality were also paramount to ensure successful implementation.
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Problem Management Plus Adapted for Group Use to Improve Mental Health in a War-Affected Population in the Central African Republic p. 91
Elisabetta Dozio, Ann Sophie Dill, Cécile Bizouerne
DOI:10.4103/INTV.INTV_36_20  
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.
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A Field Report on the Pilot Implementation of Problem Management Plus with Lay Providers in an Eritrean Refugee Setting in Ethiopia p. 101
Frezgi Gebrekristos, Liyam Eloul, Shannon Golden
DOI:10.4103/INTV.INTV_39_20  
We conducted a pilot to train paraprofessional helpers to deliver Problem Management Plus (PM+) in refugee camps with Eritrean refugees in Ethiopia. This field report presents reflections from trainers, supervisors and participants. We offer lessons learned from material translation and adaptation, including strategies for training on PM+ with low-literacy populations. The training covered foundational helping skills and the PM+ intervention. We share lessons from the training process, highlighting the importance of role plays and considerations for trainee selection. We discuss the importance of supervision for this intervention, particularly in contexts where paraprofessionals have experienced violence and displacement. We present challenges encountered, as well as adaptations for a low-resource, camp-based context. Overall we found it was possible to train nonspecialist helpers in PM+ within 2 weeks; however, intensive supervision was required for the first course of clients. We found PM+ to be useful, but our field experience suggests that PM+ may be more appropriately applied with the local population facing adversity, as we found it did not meet some of the primary needs, constraints and symptom severity encountered in the refugee camp context. Further field experience and research is needed to understand in which contexts PM+ is suitable for widespread roll-out.
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Development of a Tool to Assess Competencies of Problem Management Plus Facilitators Using Observed Standardised Role Plays: The EQUIP Competency Rating Scale for Problem Management Plus p. 107
Gloria A Pedersen, Frezgi Gebrekristos, Liyam Eloul, Shannon Golden, Mahmoud Hemmo, Aemal Akhtar, Alison Schafer, Brandon A Kohrt
DOI:10.4103/INTV.INTV_40_20  
Problem Management Plus (PM+) is used to address mental health needs in humanitarian emergencies, including in response to COVID-19. Because PM+ is designed for non-specialist facilitators, one challenge is ensuring that trainees have the necessary competencies to effectively deliver the intervention and not cause unintended harm. Traditional approaches to evaluating knowledge of an intervention, such as written tests, may not capture the ability to demonstrate PM+ skills. As part of the World Health Organization Ensuring Quality in Psychological Support (EQUIP) initiative, we developed a structured competency rating tool to be used with observed standardised role plays. The role plays were designed to elicit demonstration of the key mechanisms of action for PM+. These role plays can be objectively rated by trainers, supervisors or other evaluators to determine facilitators’ competency levels in PM+. These competency assessments can highlight what skills require additional attention during training and supervision, thus supporting facilitators to fill gaps in competencies. The integration of role plays in training and supervision also allows organisations to establish quality control metrics for competency standards to deliver PM+. We describe lessons learned from piloting the PM+ competency role plays with the Center for Victims of Torture programme with Eritrean refugees in Ethiopia.
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PERSONAL REFLECTIONS Top

Personal Reflections on Problem Management Plus: Written by Syrian Helpers at Stichting Nieuw Thuis, Rotterdam, The Netherlands p. 118
Mazen Basil, Muzkin Youssef, Lima Al-Khatib, Annas Shebrek, Sarah Akili, Maral Zakrian
DOI:10.4103/INTV.INTV_32_20  
This article aims to describe how the psychological intervention, Problem Management Plus (PM+), impacted the lives of the helpers who delivered this training to their Syrian peers. It tells how they became involved in the project, what they thought worked well, and what challenges they encountered when carrying out PM+. It ends with five brief personal reflections on what it meant to them to be a PM+ helper. Five Syrian men and women working at Stichting Nieuw Thuis in Rotterdam who were trained on how to use PM+ and received supervision from professional trainers contributed to the article. According to the helpers, PM+ was a helpful way of supporting Syrian people living in the Netherlands. Furthermore, it was agreed that learning about PM+ strategies and being part of this programme had a highly positive effect on the helpers’ own lives.
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Problem Management Plus When You Can’t See Their Eyes: COVID-19 Induced Telephone Counselling p. 121
Shomoa Sabry, Nancy Baron, Fatuma Galgalo
DOI:10.4103/INTV.INTV_35_20  
The COVID-19 pandemic turned our world upside down. This included an immediate need to transition our Problem Management Plus (PM+) counselling from our counselling centre offices to the telephone. In this personal reflection, we explain how our counsellors made this transition and are able to offer a modification of PM+ by telephone even without seeing the eyes of those they were trying to counsel.
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Personal Reflections on Group Problem Management Plus in Nepal: The Importance of Cultural Adaptation and Supervision p. 125
Renasha Ghimire, Pragya Shrestha
DOI:10.4103/INTV.INTV_37_20  
Two clinical supervisors supported the implementation of Group Problem Management Plus (PM+) in feasibility, acceptability and effectiveness trials in Nepal. In this personal reflection, they share lessons learned and experiences on the importance of cultural adaptation and supervision in implementing an intervention delivered by lay community workers. They outline how they made these adaptations and what they learned from doing trials in a new setting such as Nepal. Interventions such as PM+ are simple and effective in any community and work even better in communities affected with adversities. The personal reflection discusses best practices for training, the challenges faced, and the impact that the project had on the clinical supervisors and the Group PM+ facilitators.
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Bringing Problem Management Plus to Ukraine: Reflections on the Past and Ways Forward p. 131
Anna E Goloktionova, Monica Mukerjee
DOI:10.4103/INTV.INTV_42_20  
This personal reflection describes the experience of two mental health programme coordinators who have supported the implementation of Problem Management Plus in conflict-affected Eastern Ukraine. Their reflection highlights the successes of the methodology and the challenges in ensuring the ownership and support for the national scale-up.
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Addressing Mental Health and Psychosocial Needs in Displacement: How a Stateless Person from Syria Became a Refugee and Community Helper in Iraq p. 136
Hivine Ali, Kawa Ari
DOI:10.4103/INTV.INTV_46_20  
This personal reflection contains two stories that got intertwined due to the involvement of both authors with Problem Management Plus (PM+). One of the authors −Kawa Ari − is a stateless young man from Syria who was displaced in 2012 to the Kurdistan region of Iraq. He works as a mental health and psychosocial support community worker in the refugee camp where he lives. He was trained in PM+ and describes how this has helped him and his family and enables him to support others in a more effective way. The second author − Hivine Ali − trained Kawa Ari in PM+. The article is based on an interview with Kawa concerning his personal and professional story. It also includes Hivine’s reflections concerning the key role of forcibly displaced persons in providing support to other community members, drawing on her field experience of PM+ and her close collaboration with MHPSS community workers in Iraq. It describes how interventions like PM+ also have a positive impact on the personal development and resilience of the refugees who are trained as providers. This is an important contribution to their community mental health and psychosocial wellbeing and should be recognised as such. The story of Kawa and many other refugees also prompts reflections on Hivine’s own background, coming from a family that experienced displacement.
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COMMENTARY Top

Problem Management Plus and Alcohol (PM+A): A New Intervention to Address Alcohol Misuse and Psychological Distress Among Conflict-Affected Populations p. 141
Daniela C Fuhr, Sergey Bogdanov, Wietse A Tol, Abhijit Nadkarni, Bayard Roberts
DOI:10.4103/INTV.INTV_27_20  
Problem Management+ (PM+) is a transdiagnostic intervention and addresses symptoms across multiple common mental disorders. It does not yet include strategies to reduce alcohol misuse which is a considerable problem among conflict-affected men, and part of the co-morbidity spectrum. In this commentary, we describe the need to address symptoms of common mental disorders and alcohol misuse among conflict-affected populations. We introduce the CHANGE project (Alcohol use in humanitarian settings: A programme of work to address alcohol use and associated adversities among conflict-affected populations in Uganda and Ukraine) which tries to fill the evidence gap in intervention research, and seeks to complement PM+ with components addressing alcohol misuse. The principal output of the CHANGE project will be a new intervention manual called PM+A which will be made available in an open access format.
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