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ARTICLE
Year : 2022 | Volume
: 20
| Issue : 2 | Page : 139-150
Highlighting Complementary Benefits of Problem Management Plus (PM+) and Doing What Matters in Times of Stress (DWM) Interventions Delivered Alongside Broader Community MHPSS Programming in Zummar, Ninewa Governorate of Iraq
Protus Musotsi1, Phiona Koyiet2, Neenib Bihnan Khoshaba3, Aveen Hussein Ali3, Fahad Elias3, Muhammad Waduallah Abdulmaleek3, Ken Simiyu1, Eva Rosenkranz4
1 Sentum Scientific Solutions, Silver Spring, Maryland, USA
2 World Vision International, Nairobi, Kenya
3 World Vision International, Iraq
4 World Vision Deutschland e.V., Friedrichsdorf, Germany
Correspondence Address:
MPH Protus Musotsi
Sentum Scientific Solutions, HQ, 1626 Oakview Dr, Suite 101, Silver Spring, Maryland 20903
USA
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/intv.intv_7_22
Internally displaced persons (IDPs), refugees, returnees and host communities in conflict settings experience high rates of mental health problems associated with prolonged and repeated exposure to multiple exposure to distress, as is the case in Iraq. We sought to highlight the outcomes and complementarity of Problem Management Plus (PM+) and Doing What Matters in Times of Stress (DWM) in addressing the mental health and psychosocial support needs of IDPs, returnees and host community teens and adults in Zummar, Iraq. A total of 290 adults were included in the PM+ intervention, while DWM included 648 adults and 282 teens. DWM was delivered to adults with accessibility barriers to receiving PM+ and to all teens in the study due to security reasons and COVID-19 restrictions. The Patient Health Questionnaire (PHQ-9) and World Health Organization Disability Assessment Schedule (WHODAS 2.0) were used to measure psychological distress and functioning in adults, respectively. The Revised Children Anxiety and Depression Scale (RCADS) was also used to measure symptoms of depression and anxiety in teens pre and postintervention. Personally identified problems were measured using the Psychological Outcome Profiles (PSYCHLOPS) for adults and teens. Psychological and emotional challenges were the main problem faced by both teens and adults at baseline. For PM+ and DWM interventions in adults, the mean difference in PSYCHLOPS, WHODAS and PHQ-9 scores between preintervention and postintervention assessment were significant (P < 0.001). For DWM teens, the paired mean difference for pre and postintervention RCADS and PSYCHLOPS teens was 55.9 (SD = 8.0) and 4.8 (SD = 2.40), respectively (P < 0.001, Cohen’s d > 2). There was a significant reduction in the number of days off work and increased ability to carry out usual activities after both interventions. The study findings highlight the applicability of PM+ and DWM in conflict settings of Iraq when there are barriers to applying one.
Keywords: Doing What Matters in Times of Stress, Iraq, MHPSS, Problem Management Plus
Problem Management Plus (PM+) and Doing What Matters in Times of Stress (DWM) interventions demonstrated positive results in addressing the mental health and psychosocial support needs of internally displaced persons, returnees and host community teens and adults in Iraq.DWM intervention can be delivered to vulnerable populations exposed to distress when there are barriers to delivering PM+ which is a face-to-face intervention.There is a need for long-term, follow-up of PM+ and DWM intervention beneficiaries to determine if the observed effect is sustained over time. Introduction A high prevalence of mental health disorders has been reported in conflict-affected settings globally, with the prevalence being as high as 22.1% at any given time for common mental disorders (depression, anxiety and posttraumatic stress disorder [PTSD]; Charlson et al., 2019). A meta-analysis of studies among adult asylum seekers and refugees reported the prevalence of PTSD, depression, anxiety disorder and psychosis to be 31.5%, 31.5%, 11.0% and 1.5%, respectively (Blackmore et al., 2020a). Another meta-analysis reported the pooled prevalence of major depressive disorder, PTSD, bipolar disorder and psychosis among this group to be 32%, 31%, 5% and 1%, respectively. The prevalence of major depressive disorder among low- and middle-income countries (47%) was higher than that in high-income countries (28%; Patanè et al., 2022).
The high prevalence of mental disorders in such settings might be due to repeated and multiple exposures to adversity such as violence and destructions of war, which are prolonged (Alpak et al., 2015). In addition, such populations face multiple stressors even in the settings they seek refuge (Nickerson et al., 2011). Such post-migration or displacement-related stressors include social isolation due to the loss of social networks, lack of access to basic needs, loss of possessions, unemployment, challenges in navigating the new areas of settlement, discrimination and other stressful conditions associated with material and social conditions of everyday life (Miller & Rasmussen, 2017).
With the many stressors in the premigration and resettlement areas, refugee children and adolescents have also been found to have a high prevalence of mental health disorders. A recent meta-analysis among children and adolescent refugees and asylum seekers reported the prevalence of PTSD, depression, anxiety disorder and attention-deficit/hyperactivity disorder to be 22.7%, 13.8%, 15.8% and 8.6%, respectively (Blackmore et al., 2020b). Even more worrying are the mental health impacts on more vulnerable children affected by the conflict and its associated consequences, such as breakdown of social and family structures (Ehntholt & Yule, 2006), loss of provisions and disruption of normal developmental pathways (Punamäki, 2002).
Besides, COVID-19 has magnified the mental health crisis among the already vulnerable populations, especially those in humanitarian settings and children and adolescents, due to loss of livelihoods among primary caregivers and increased weakening of the existing social structures (Seidi et al., 2020). Such is the case in Iraq, where the country has been affected for the last three decades by long-lasting conflict, instability and economic collapse. In 2005, mental health disorders were projected to be the fourth leading cause of morbidity among people aged >5 years in Iraq (WHO, 2006).
The World Health Organization (WHO) developed interventions for reducing psychological distress in people affected by adversity in remote settings, including Problem Management Plus (PM+; Dawson et al., 2015) and Self Help Plus (SH+; Epping-Jordan et al., 2016). PM+ is a name that reflects the aims of the approach: to help people improve their management of practical (e.g. unemployment and interpersonal conflict) and common mental health problems (e.g. depression, anxiety, stress, or grief). The “plus” refers to the evidence-based cognitive behavioural strategies used in the intervention. These include managing stress and problems, getting going and keeping doing (known as behavioural activation) and strengthening social support. Additional strategies include psychoeducation and motivational interviewing to encourage clients to engage with PM+ and in relapse prevention. It can be delivered in groups or individually by trained and supervised nonspecialists, such as community health volunteers. PM+ for individuals has been formally tested in violence-affected communities in Kenya and Pakistan and was shown to reduce depression and anxiety and improve functioning (Bryant et al., 2017; Khan et al., 2019).
Doing What Matters in Times of Stress (DWM; WHO, 2020) is a core part of the WHO’s SH+ intervention (Epping-Jordan et al., 2016), a five-session stress management course that uses prerecorded audio complemented with an illustrated self-help book adapted for the target cultural group for large groups of up to 30 people. DWM is a brief, illustrated self-help book accompanied by brief prerecorded audio exercises with five sections covering psychoeducation on stress and the core strategies from the SH+ course, which are based on acceptance and commitment therapy. It was designed to support learning during SH+ but can be used as a standalone intervention with or without support from a trained helper. The stress management guide includes five sections, each focusing on a specific skill: Section 1: grounding — bringing attention back to the present moment when caught up in distressing emotions. Section 2: unhooking — noticing difficult thoughts and feelings, naming difficult thoughts and feelings and refocusing on what you are doing. Section 3: acting on your values — identifying personal values and taking small or big actions to live in line with these values. Section 4: being kind — enhancing and encouraging kindness towards oneself and others. Section 5: making room — learning to tolerate stress while acting consistently with values (WHO, 2020).
Unlike PM+, DWM can be delivered as unguided self-help and is less costly and time-consuming. The effectiveness of the more extensive SH+ course in reducing emotional distress and improving functionality was demonstrated in a large randomised controlled trial (RCT) among South Sudanese female refugees in Uganda (Tol et al., 2020). It has also been shown to prevent mental health disorders among Syrian refugees in Turkey (Acarturk et al., 2022a) and asylum seekers and refugees in Western Europe (Purgato et al., 2021). While, to the best of our knowledge, the efficacy of DWM as a standalone intervention has not been tested, self-help psychological interventions for depression are recommended by WHO (Dua et al., 2016). While PM+ has been shown to be effective in reducing mental health stress in settings facing a paucity of specialised mental health practitioners, the applicability and complementarity of the two interventions have not been evaluated when delivered in the same setting.
The project team implemented a multilayered programme that included PM+ and DWM to provide mental health and psychosocial support (MHPSS) to address the mental health needs of adults and teens in the Ninewa Governorate, Zummar subdistrict, Iraq. This paper presents the outcomes of the DWM and PM+ interventions in addressing the MHPSS needs of internally displaced persons (IDPs), returnees and host community teens and adults in the conflict-affected setting of Zummar, Iraq, and highlights the potential complementarity of the two interventions.
Materials and MethodsSetting
Iraq is a country that has been affected by unending conflict, instability, and economic collapse and faces one of the worst humanitarian crises globally. The Iraq Mental Health Survey of 2007 found anxiety disorder (13.8%) and anxiety (7.2%) to be prevalent among Iraqi adults (Alhasnawi et al., 2009). The Iraqi health system has limited mental health services, mainly facility-based and dependent on scarce psychiatrists and mental health professionals (WHO & Ministry of Health Iraq, 2006). Another challenge is that even the few available trained mental health professionals have little formal training in the mental health of children and adolescents (Al-Obaidi et al., 2010).
The project, “Responding to the Critical Mental Health and Psychosocial Support (MHPSS) and Protection Needs of the Crisis Affected Population in Zummar”, was implemented in the Zummar subdistrict of Ninewa Governorate, Iraq. It was operationalised in an integrated wellbeing centre parallel to the primary health care centre. Ninewa is one of the regions that witnessed direct conflict with the Islamic State of Iraq, and the situation remains dire (OCHA, 2021). The vast population of the area and a nearly 1.7 million returnee population make it an area with urgent humanitarian needs (OCHA, 2021). With a lack of basic needs, the returnees and IDPs in the region face multiple stressors, and many suffer from mental health disorders.
Target Population
Over 13 months, the project team worked in the subdistrict of Zummar in Ninewa Governorate to contribute towards MHPSS and child protection programming for IDPs, returnees and host communities. For this project, IDPs were Iraqis displaced from their original place of residence within Iraq who were out of camp. Returnees were Iraqis who had sought refuge in other parts of Iraq but were now back in their former areas of residence, while host community members were none displaced Iraq community members who received or hosted the IDPs and returnees in the study setting. The project targeted approximately 140,000 vulnerable out-of-camp IDPs, returnees and host community members. There were 20,000 direct project beneficiaries (those who benefited or were personally engaged in the project) and 120,000 indirect beneficiaries (those not directly involved in the project but received information or were indirectly impacted by the project).
Study Population
For the PM+ intervention, IDPs, returnees and host community adults with emotional distress, according to Patient Health Questionnaire-9 (PHQ-9; score of 3–15; Kroenke et al., 2001) and/or functional impairment (World Health Organization Disability Assessment Schedule, WHODAS 2.0; score of ≥17; Üstün et al., 2010; WHO, 2010), formed the study population.
Those adults who met the inclusion criteria for PM+ but were in hard-to-reach areas, therefore, could not be accessed physically due to reasons such as COVID-19 restrictions and personal reasons such as work, family and care work reasons were enrolled in DWM. Moreover, because of the challenges in access, security reasons and COVID-19 restrictions, all teens between 15 and 17 years (including 15 and 17 years) who met the inclusion criteria were enrolled on the DWM intervention, which was also deemed age-appropriate for teens compared to PM+.
Eligibility Criteria
For PM+ and DWM adults, screening excluded those participants who:
were <18 years,scored <17 (≤16) on WHODAS,scored <3 (≤2) on PHQ-9,had plans to end their lives within two weeks of the preassessment hence imminent suicide ideation,had a severe mental health disorder as indicated by PHQ-9 score >15 andthose judged by the trained assessor to have a neurological or severe mental disorder, substance use disorder or cognitive impairment.Disorders Exclusion Criteria
Community members seeking PM+ and DWM were assessed based on a four-scale observation yes/no assessment of impairments due to severe mental, neurological or substance use disorders. A three-scale self-reporting suicide assessment scale was administered. Those with suicide plans or severe mental health disorders were referred and facilitated for further clinical management at existing public mental health facilities receiving support from the project and at the integrated community wellbeing centre operationalised by the project, which had two full-time clinical psychologists, one part-time psychiatric nurse and one part-time psychiatric doctor all trained in the Mental Health GAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies.
For DWM, teens below 14 years, and those who scored above 70 on the Revised Children Anxiety and Depression Scale (RCADS; Chorpita et al., 2000), were excluded.
Ethical Considerations
Approval for the project was sought from the Iraqi Ministry of Health and the Directory of Health in the Ninewa region, and an awareness-raising project was done in the study area. Detailed information regarding the project and the different surveys were explained to each participant in Arabic. Verbal consent was sought from each assessed participant before the assessment was administered. For teens below 18 years, consent was sought from their parents/guardians, and assent was sought from them. During project implementation, local norms and cultures were respected, and ethical principles of autonomy, justice, beneficence and nonmaleficence were adhered to.
Sampling and Sample Size
Purposive sampling was used with all IDPs, returnees and host community teens (14–17 years) and adults (18 years and above) found to have psychological distress on screening during outreaches and who consented or assented to participate in the intervention being included. A sample of 290 adults was included in the PM+ intervention, while DWM included 648 adults and 282 teens.
Intervention
Community mobilisers in this intervention were lay counsellors who received 3 weeks of training. Four days were used for training on psychological first aid (PFA), which was enhanced with basic psychosocial support skills (including understanding the spectrum of psychosocial support needs and strategies for addressing them, problem-solving approaches, impacts of stigmatisation and how to recognise when individuals may need specialised services, such as for more severe forms of mental disorder). After PFA training, the lay counsellors received PM+ training for 8 days, which included training in the classroom and the field. The classroom-based training included information on common mental health conditions such as anxiety, stress and depression, PM+ strategies and their rationale, basic helping skills, role-play and demonstration of the delivery of the critical PM+ strategies and the basic helping skills. The training included practising these skills and strategies through role-plays and with practice clients and regular supervision when putting PM+ into practice with clients.
DWM training took 5 days. The main features of this training were to make sure participants understood all the techniques in the DWM manual. Additionally, it included understanding the purpose of the three appointments, the inclusion and exclusion criteria for adults and adolescents and assessment protocol for adults and adolescents. Before the end of each day of classroom training, role-play was used to practically demonstrate the content taught. In addition, the lay counsellors received positive parenting training for 2 days. All this training aimed to ensure effective delivery of psychosocial support among the communities and raise awareness of referral pathways.
The training was delivered by the organisation’s Senior Technical Advisor for MHPSS, experienced in all PM+ strategies, with the help of the organisation’s in-country trained MHPSS specialist. Following classroom training, the lay counsellors underwent supervised in-field practice sessions, offering five sessions of PM+ to three clients with less severe presentations (e.g. not with severe depression) and under close supervision that included fidelity checks upon client consent. The organisation’s in-country MHPSS specialist did this, and weekly supervision was facilitated by the organisation’s Senior Technical Advisor for MHPSS and country MHPSS Specialist. This was aimed at strengthening the lay counsellors’ skills and understanding of PM+ and helping boost their confidence in the intervention delivery and to ensure they conceptualised the content and were competent and experienced in all of the strategies included in PM+ (i.e. problem-solving therapy, stress management, behavioural activation and strengthening social supports) and also self-care.
Staff working in the community wellbeing centre, namely the psychiatric doctor, nurses and psychologists, also received training in mhGAP-HIG: Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies. The organisation established mobile MHPSS services, which included four teams comprised of one social worker (four in total) and six community mobilisers (24 total), who reached out to the community at the household level, community centres, disseminating information, education and communication (IEC) materials about the project, psychoeducation materials, conducting follow-up visits with beneficiaries and referring those in need of other MHPSS services.
Before recruiting participants, mental health and intervention awareness sessions were conducted in the community and at local health facilities, including the integrated community wellbeing centre. An assessment of the local MHPSS needs and preferred interventions was also done to inform the interventions. However, the results of this assessment are not presented in this paper.
After the awareness sessions, the participants went voluntarily to the integrated community wellbeing centre and the tents set up by the mobile clinics for screening. After providing verbal consent, they were screened for eligibility, and those found eligible were given appointments for the first intervention session. Before the intervention, eligible participants were asked who else needed to know of their participation and if they would like to be assisted in informing them. Most female participants reported their husbands, with two reporting their mothers-in-law. For those who needed assistance informing their husbands, a male supervisor accompanied the female lay counsellor during the engagement visit to inform the husbands. Those whose husbands refused to give consent were left out of the intervention.
During the intervention delivery, the lay counsellors received weekly clinical supervision from trained professional psychologists who were Trainer of Trainers in PM+, DWM and PFA. The supervisors (psychologists) received biweekly supervision from the organisation’s Global Senior Technical MHPSS Advisor.
If participants required further assistance or encountered a problem between meetings, the lay counsellor provided the necessary information on where they could get further help if the required services were not being offered by the project. Those who required support for services offered by the project were referred accordingly. None of the included participants required another MHPSS intervention apart from the one they were enrolled in.
PM+ Intervention
Those meeting the criteria for individual PM+ intervention were introduced to it, and those who consented verbally were enrolled. Trained lay counsellors conducted the screening by administering the WHODAS, Psychological Outcome Profiles (PSYCHLOPS) and PHQ-9 questionnaires. The Project Coordinator and Monitoring and Evaluation team supervised the assessment process. The intervention started no later than two weeks after the assessment. The PM+ intervention was offered per the WHO PM+ Arabic field generic guidance (WHO, 2016). Five follow-up assessments were done at each intervention session visit, at an interval of 7 days after the preintervention.
The intervention was delivered over five weeks, with each weekly session lasting 90 minutes. During the session, PM+ strategies were delivered: stress management (“Managing Stress”), problem-solving (“Managing Problems”), behavioural activation (“Get Going Keep Doing”), strengthening social supports (“Strengthening Social Supports”) and relapse prevention (“Staying Well and Looking Forward”). Each strategy was built on session after session. The PM+ intervention sessions were delivered per the WHO PM+ protocol (WHO, 2016).
The PM+ intervention sessions were delivered at the location of the participant’s choice, including home, integrated community wellbeing centre, clinic or place of work. The intervention was delivered by a lay counsellor of the same gender as the participants for cultural appropriateness.
During the first sessions, the lay counsellor introduced themselves to the participant and shared information regarding the intervention and how the confidentiality of the participant’s information would be maintained. A detailed explanation of what the intervention entails and what it helps address was given. Besides, information on how the PM+ intervention would be delivered and how long it would take was also shared. During each visit during the intervention, a PSYCHLOPS assessment was done.
DWM Intervention
The DWM intervention is a brief stress management guide designed to be read over one month. It is practical so that users can practise skills regularly on their own, illustrated with accompanying audio files to support regular practice.
DWM was provided as guided self-help following the published WHO manual designed for these purposes (WHO, 2020). After eligibility assessment and verbal consenting, the participants in DWM were given their manual and audio in Arabic, delivered to their homes by the community mobilisers (lay counsellors) of the same gender as the participant. The community mobiliser met the participants in three meetings: An introductory appointment: This covered an introduction to the stress management guide, discussion of interest, assessment and planning. These sessions took up to 1 hour. One-week follow-up: This covered the use of the stress management guide and support with overcoming barriers or problems with use and clarifying concepts. This took between 20 and 50 minutes. One-month follow-up: This covered the use of the stress management guide, supported overcoming barriers or problems with use, planning for continued future use and completing follow-up assessment and goodbye or referral. This also took approximately 1 hour.
Data Collection Tools and Process
Data Collection Tools
Participants referred for MHPSS PM+ and DWM intervention were assessed for mental health distress using WHODAS 2.0 (Üstün et al., 2010), PSYCHLOPS (Ashworth et al., 2004) and PHQ-9 (Kroenke et al., 2001). Their demographic information and risk of suicide were also assessed. The assessment was conducted face-to-face. The WHODAS is an instrument used for the generic assessment of disability and health (WHO, 2010), applicable across cultures and health states. It assesses the difficulties of individuals because of their health conditions covering the six functioning domains of self-care, mobility, getting along, cognition, participation and life activities, with scoring covering 30 days before the assessment on a five-point Likert scale. The 12-point version was used in this project.
PSYCHLOPS is used to assess the mental health outcome progress of the person receiving the psychotherapeutic intervention. It comprises four questions covering three domains; problems, functioning and wellbeing, with participants asked to state the problem. It is scored on a six-point scale. The maximum score on PSYCHLOPS is 20, while the minimum score is 0. The PSYCHLOPS was administered at both baseline during screening, every intervention visit and at the intervention’s end. The PSYCHLOPS version administered in preintervention has four questions with one additional question during the session. It has five questions and one additional one during postintervention, making it six questions. In the preintervention version, participants are asked to think of their problem, select two that trouble them most and tell how much the problem has affected them for the last week using a six-point Likert scale. There is also a functioning question scored on a Likert scale. For the during and postintervention versions, participants were asked about the problem they previously reported in preintervention and rated how much it had affected them during the last week. The version administered at the end of the intervention and during follow-up included a question evaluating self-rated outcomes (Ashworth et al., 2004). It is a validated tool for use in a primary healthcare setting (Czachowski et al., 2011; HéÐinsson et al., 2013). For the teens referred to DWM, the RCADS (Chorpita et al., 2000) was used to assess mental distress in addition to the PSYCHLOPS teens.
On the other hand, the PHQ-9 is a nine-item instrument used to assess the presence and severity of depression with questions covering events two weeks prior to the assessment date. Its total score ranges from 0–27 (Kroenke et al., 2001).
Data Collection Process
A team of 11 lay counsellors collected the data with assistance from the project Monitoring, Evaluation, Accountability and Learning (MEAL) team. The data were collected face-to-face on android tablets using the SMAP system (https://www.smap.com.au/). The trained lay counsellors collected the data during preassessment, each intervention visit and at the end of the intervention. The period between pre and postassessment was 5–7 weeks.
Data Management and Analysis
The data were checked for completeness and accuracy by the field supervisors daily. It was entered and coded in Microsoft Excel, which was double-checked for accuracy. The data were imported into IBM Statistical Package for Social Sciences (SPSS) version 27.0 (IBM Corp., 2020) for analysis. For descriptive analysis, frequency and percentages were used for categorical variables, while for continuous variables such as scores, mean or median and their corresponding measures of dispersion standard deviation (SD) or interquartile range (IQR) were used. The mean was used for normally distributed continuous variables, while the median was used for continuous variables whose data were not normally distributed. Paired sample t-test was used to determine any significant differences in paired mean scores at baseline and postintervention. For PSYCHLOPS with measures at more than two sessions, repeated measure analysis of variance (ANOVA) was used to determine if there was a significant change in mean scores between baseline and postassessment and between baseline and each of the assessment session measures. A P < 0.05 was used as a cutoff to indicate statistical significance. Content analysis was used to analyse qualitative PSYCHLOPS data using QSR NVivo software version 12 (QSR International Pty Ltd., 2018) with the frequency with which a given problem was mentioned quantified. The results are presented in the form of tables, prose format and graphs.
ResultsMain Problems Reported by Adults and Teens Pre-DWM Intervention
Most adults reported psychological and emotional challenges as the main problem faced, including anxiety, stress, worry, depression, emotional distress, grief and fear. Other reported problems included financial and unemployment challenges, insecurity and life hardships such as lack of shelter and basic needs. A few reported health issues, including illness, accidents and the pandemic as the main problem pre-DWM intervention.
Similarly, among teens, emotional and psychological problems were the main cited problems preintervention. Of the emotional problems, anxiety, fear, pressures, worry, depression, nervousness and grief were the most frequently mentioned problems. Other main reported problems by teens included educational and study challenges, family and social problems, bullying and child abuse (see [Table 1]).
Table 1 Categorisation of the Main Problem with Weighted Percentage based on the Number of Times MentionedSome of the most occurring psychological and emotional issues mentioned as the main problem by adults and teens pre-DWM are shown in [Table 2].
Table 2 Breakdown of Emotional and Psychological Problems Cited by Adults and TeensSample citations reported by adults and teens are provided in [Table 3].
Table 3 Example Synopses of Responses to PSYCHLOPS Question Main Problem Domain from Adults and TeensPM+ and DWM Mental health Outcomes in Adults
The mean PSYCHLOPS, WHODAS and PHQ-9 scores pre- and postintervention are presented in [Table 4].
For PM+ intervention, there was a significant reduction in the mean PSYCHLOPS score between preassessment and postassessment (paired mean difference, MD = 12.4, SD = 2.2, P < 0.001). The MD for the WHODAS score was 17.8 (SD = 8.1), and the difference was statistically significant (P < 0.001). Similarly, a significant MD of 9.3 (2.7) was noted between preassessment and postassessment PHQ-9 scores, which was statistically significant (P < 0.001). The intervention had a large effect size, with Cohen’s d > 1 for PSYCHLOPS, WHODAS and PHQ-9. The mean reduction in the number of days unable to work or do usual activities was 9.3 (SD = 6.3), and the reduction was statistically significant (P < 0.001). There was also a statistically significant reduction in the mean number of days participants cut back on usual activities by 8.6 (SD = 6.5). The mean difference in the number of days difficulties presented between pre and post-PM+ intervention was 11.0 (SD = 6.3), and the difference was significant (P < 0.001). The effect of the intervention on functionality was very large (Cohen’s d > 1).
For DWM adults, the MDs for PSYCHLOPS, WHODAS and PHQ-9 scores were 10.2 (SD = 4.4), 16.7 (SD = 7.4) and 9.6 (SD = 3.1), respectively, and the difference was statistically significant (P < 0.001). There was also a statistically significant reduction in the number of days the difficulties persisted, and the individual was unable to work and cut back on usual activities (P < 0.001). The intervention’s effect size was large (Cohen’s d > 1; [Table 5]).
Table 5 Paired Sample T-test of Post and Pre-PM+ and DWM Assessment for AdultsThere were significant differences between the mean PM+ PSYCHLOPS scores at different sessions using an ANOVA with repeated measures with a Greenhouse–Geisser correction; F(1.171, 717.471) = 2547.270, P < 0.001. Post hoc tests using the Bonferroni correction showed that there were significant mean differences between PSYCHLOPS measures at all time points (P < 0.001), with the mean score reducing significantly at each assessment point from preassessment (First assessment, 1) to postassessment (last assessment,7; [Table 6]).
Similarly, with the DWM intervention, there was a statistically significant reduction in PSYCHLOPS scores at each session assessment to the postintervention (P < 0.001; [Table 6]).
The profile plot in [Figure 1] illustrates the change in PSYCHLOPS score for PM+ intervention with each subsequent session, indicating improved MHPSS wellbeing ([Figure 1]).
DWM Intervention Among Teens
There was a reduction in mean RCADS and PSYCHLOPS scores from 66.2 (SD = 1.5) and 13.9 (SD = 3.0) preintervention to 9.3 (SD = 7.9) and 4.4 (SD = 1.9) postintervention, respectively ([Table 7]).
The MD for RCADS between pre and post-DWM intervention for teens was 55.9 (SD = 8.0), which was statistically significant (P < 0.001). The MD for PSYCHLOPS pre and post-DWM assessment was 4.8 (SD = 2.40), which was also significant (P < 0.001), and the effect size was very large (>2; [Table 8]).
There were significant differences in PSYCHLOPS scores over the different sessions from preintervention to postintervention, with the scores reducing significantly from preassessment to postintervention. Repeated measure ANOVA with Greenhouse–Geisser correction showed that the mean PSYCHLOPS at the three different measurement points was statistically different (F(1.68, 467.8) = 1781.281, P < 0.001; [Table 9]).
Table 9 Pairwise Comparison of PSYCHLOPS Scores at the Different Sessions Discussion Global access to MHPSS among people in need of such services can be significantly improved by developing, deploying and evaluating scalable interventions. The SH+ from which DWM is derived and PM+ are such interventions that have gained prominence, especially in humanitarian settings where the populations are faced with adversities (Goloktionova & Mukerjee, 2021; Rahman et al., 2016; Riello et al., 2021). Such areas are mostly underdeveloped, with dysfunctional health systems and a wide range of barriers to accessing formal mental health care systems, such as the under-resourced health system (World Health Organization, 2017).
In our study, PM+ proved effective in addressing the mental health distress and daily problems among the underserved population of Zummar Iraq, in agreement with previous studies where it was effective in improving mental health outcomes (reduced symptoms of anxiety, depression and PTSD) and psychosocial functioning among conflict-affected and displaced individuals in Turkey (Acarturk et al., 2022b), Pakistan (Rahman et al., 2016; (2019)) and Kenya (Bryant et al., 2017).
Similarly, we found DWM to be effective in both adults and teens. This result is promising and suggests the need for research trials of DWM to see if it performs in a similar way to SH+, whose effectiveness has been demonstrated in reducing psychological distress and PTSD symptoms three months postintervention among refugees in Uganda (Tol et al., 2020). SH+ was also found effective in preventing the development of mental health disorders among Syrian refugees in Turkey (Acarturk et al., 2022a) and asylum seekers in five Western Europe countries (the United Kingdom, Italy, Austria, Germany and Finland; Purgato et al., 2021).
Nonspecialists can provide PM+ and DWM. In addition, although DWM can be self-guided, PM+ was delivered by helpers, ensuring access to otherwise unavailable support, hence increasing the capacity for self-help among communities, resulting in improved functioning, mental health and resilience development (World Health Organization, 2017). Both interventions resulted in significant reductions in psychological distress among the participants. It is hypothesised that the success of PM+ and DWM might be attributed to the established trust between the helper and client and the client’s connection with the support system and the training materials. It is unlikely that a positive impact will be observed without a positive relationship between the client and the counsellor (Goloktionova & Mukerjee, 2021).
Our project was among a few interventions where different interventions were utilised to cater to the circumstances limiting access to mental health and psychosocial interventions. It was also among the first interventions to utilise DWM among teenage groups and to show its potential use in such a population.
The study findings indicate that both DWM and PM+ are helpful interventions that can be implemented in the same settings simultaneously, with the possibility of the participants being enrolled in one depending on their circumstances without being disadvantaged in any way. DWM can be delivered to individuals in three brief meetings. The task-sharing approach fronted by DWM empowers the beneficiaries and the community members in general. It is worth noting that DWM could be rapidly rolled out among a large population of adults, leading to a significant improvement in functioning, wellbeing and reduction in psychological distress, as was the case in a randomised study among South Sudanese refugees (Tol et al., 2020). Besides, the two interventions can be rolled out rapidly, with the benefits extended to people in hard-to-reach areas. Structured identification of lay counsellors, training and competency assessment of the helper plays a key role in quality intervention delivery. Deliberate identification of lay counsellors through an interview process that met a basic competency criterion must have been crucial to the success of the project. In addition, after training, each lay counsellor needed to demonstrate a passion for helping people affected by adversity, have a good understanding of PM+ (i.e. based on the individual PM+ in classroom and field competency assessments), be comfortable using basic helping skills (e.g. nonjudgement, active listening and empathy), be open to new and original solutions and ideas raised by participants, have lots of energy to manage clients experiencing difficulties and have some basic facilitation skills. The aim is to improve the quality of PM+ intervention delivery, the competence of helpers and consistency in service delivery across the implementation.
The in-class and practical in-field training sessions of lay counsellors might have played a key role in the quality delivery of the intervention per protocol, hence better intervention outcomes. Besides, the weekly clinical support supervision was essential in supporting the lay counsellors, ensuring the effective delivery of the intervention. The time provided within sessions allowed the participants to try it out before the next session. Practice at home/homework before the next session might have been essential in the intervention’s effectiveness.
However, due to the limitation of not having a control group, it is not possible to entirely link our study’s observed improvements to the DWM and PM+ intervention. Besides, the complementary application is threatened because it is hard to standardise the delivery of the intervention. While the intervention met some of the participants’ needs, the other problems faced by the participants are practical issues such as unemployment, loss of livelihood, family conflicts and separation, which are likely to be affecting their mental health situation and cannot be holistically addressed by the interventions alone, indicating the need for additional services and support such as livelihoods interventions to address these broader, social determinants. Similarly, individuals with severe symptoms had to be referred for special MHPSS offered by staff trained in the mhGAP-HIG (WHO, 2015): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies. Such cases are expected in humanitarian settings, as was the case in this study, hence the need to offer complementary professional services in addition to those offered by trained lay counsellors to cater for the needs of all. This also presents an ethical dilemma, as highlighted by Gebrekristos et al. (2021), especially in cases where professional mental health services are lacking. Managing those with severe mental health problems in such a situation remains a challenge and an ethical concern, especially in deciding whether to include them in the available lay providers’ interventions or leave them out.
LimitationsThe intervention evaluation did not have a control group, affecting the internal validity of the results. This is particularly important for DWM, which has not been tested in RCTs. Without a control group, it is difficult to attribute the observed high effectiveness to the intervention alone. While the PM+ and DWM interventions showed highly significant findings with large effect sizes, the effect of bias and confounding cannot be ruled out. However, with the large effect size, it is unlikely that the results would change significantly if the two were controlled for in totality. Considering the large effect size, the effectiveness of the intervention cannot be ignored. Further, PM+ has already been demonstrated to effectively address the MHPSS needs of populations in different settings, while guided self-help (e.g. DWM) has been shown to be effective and is supported by WHO guidelines (Dua et al., 2016).
However, the chances of information and social desirability bias cannot be ruled out. Considering the sensitive nature and stigma associated with mental health problems, it is likely that some participants would tend to hide some information despite being assured of confidentiality. Besides, having received services, some will not wish to give a bad rating.
Another challenge is that the PM+ and DWM protocols do not specify how such programmes utilising these interventions could be maintained to sustain the gains. With the short-term assessment of outcomes, it remains unclear if the observed effectiveness of DWM and PM+ can be sustained in the long term.
While PHQ-9 has been validated in different settings (Carroll et al., 2020), with indications of high reliability, it has not been validated in the Iraq population where the study was conducted.
ConclusionBased on the evidence gathered from the intervention, PM+ and DWM have the potential to be effective in humanitarian settings in addressing mental distress and managing problems among this population. Moreover, they can be tailored to local settings, hence are feasible and valuable interventions. The study findings also highlight the application of PM+ and DWM interventions in case of barriers to the application of one. Examples are challenges of accessibility, as is the case with most humanitarian settings and the current pandemic period where physical meetings are not feasible. DWM can be self-directed by the beneficiary with minimal physical interaction or guidance.
Through this project, we also gathered meaningful insight into the usefulness and applicability of DWM among teens, an area with less evidence. The results of DWM in teens form the basis for further evaluation of the same in controlled trials to inform its scale-up in the teenage population, among which less adaptable interventions exist.
Recommendations
There is a need to monitor if the observed beneficial effects of the two interventions persist in the long term. In addition, continuous mental health capacity building among local specialised and nonspecialised MHPSS providers is needed to help increase the population reach and impact. Future studies on DWM need to utilise the randomised control trial approach to offer strong evidence of its effectiveness.
Acknowledgements
The authors thank all community members who participated in the project, fieldworkers and lay counsellors who played a crucial role in the project implementation.
Financial support and sponsorship
The project was funded by Aktion Deutschland Hilft e.V. (ADH) and supported by World Vision Germany e.V.
Conflicts of interest
There are no conflicts of interest.
References
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