After the Randomised Controlled Trial: Implementing Problem Management Plus Through Humanitarian Agencies: Three Case Studies from Ethiopia, Syria and Honduras

Ashley Nemiro; Edith Van’t Hof; Sendrine Constant

doi:10.4103/INTV.INTV_34_20

FAMILY PRACTICE

Year : 2021 | Volume : 19 | Issue : 1 | Page : 84-90

After the Randomised Controlled Trial: Implementing Problem Management Plus Through Humanitarian Agencies: Three Case Studies from Ethiopia, Syria and Honduras

Ashley Nemiro¹, Edith Van’t Hof², Sendrine Constant¹
¹ Terre Des Hommes, Chemin du Pré-Picot 31223 Eaux-Vives, Switzerland
² World Health Organization, Avenue Appia 20, 1202 Genève, Switzerland

Date of Submission	30-Sep-2020
Date of Decision	07-Jan-2021
Date of Acceptance	30-Jan-2021
Date of Web Publication	31-Mar-2021

Correspondence Address:
Ashley Nemiro
Terre Des Hommes, Rosenørns Alle 12, 1634 Copenhagen
Switzerland

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INTV.INTV_34_20

Abstract

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.

Keywords: Ethiopia, Honduras, lay helpers, Problem Management Plus (PM+), psychological intervention, Syria

How to cite this article:
Nemiro A, Hof EV, Constant S. After the Randomised Controlled Trial: Implementing Problem Management Plus Through Humanitarian Agencies: Three Case Studies from Ethiopia, Syria and Honduras. Intervention 2021;19:84-90

How to cite this URL:
Nemiro A, Hof EV, Constant S. After the Randomised Controlled Trial: Implementing Problem Management Plus Through Humanitarian Agencies: Three Case Studies from Ethiopia, Syria and Honduras. Intervention [serial online] 2021 [cited 2023 Jun 7];19:84-90. Available from: http://www.interventionjournal.org//text.asp?2021/19/1/84/312719

Introduction

During and after emergencies and humanitarian crises, there are large numbers of people who are impaired for prolonged periods by distress. Grief and acute stress are usually transient psychological reactions to adversity and loss, but extreme stressors may also trigger prolonged states of anxiety and depression (Charlson et al., 2019; Thornicroft et al., 2017). These chronic problems undermine the functioning of individuals and their communities, which can be essential for their survival and is vital for socioeconomic recovery. In these periods of crisis, the health systems tend to be overwhelmed and are unable to meet the demand for essential services, and often the existing supportive care systems in the communities have also been damaged (Ventevogel et al., 2015).

The World Health Organization (WHO) developed a psychological intervention called Problem Management Plus (PM+) for adults impaired by distress in communities exposed to adversity (Dawson et al., 2015; WHO, 2010). Individual PM+ was found effective in two randomised controlled trials in Kenya and Pakistan (Bryant et al., 2017; Rahman et al., 2016). A group version of PM+, called Group PM+, was developed to allow for greater reach and acceptability (WHO, 2020) and was found to be effective in a study in Pakistan (Rahman et al., 2019). PM+ is a scalable, manualised, evidence-based intervention that can be used by both the health and social sector to reduce distress and improve functioning. It has proven to be effective in diminishing depression and anxiety and improving people’s functioning and self-selected, culturally relevant outcomes. Some of its very distinct and innovative features include:

a transdiagnostic intervention, addressing a range of client identified emotions (e.g. depression, anxiety, traumatic stress, general stress) and practical problems;
designed for low-resource settings;
intended for people in communities affected by any adversity (e.g. violence, disasters), not just focusing on a single kind of adversity and
it is empowering as it teaches adult participants to self-manage their distress for sustainable, long-term solutions.

In individual PM+, clients are seen on an individual, face‐to‐face basis for 5 weekly sessions with a lay helper. The length of the sessions is 90 minutes, to allow adequate time for explanation of a strategy and application to client‐identified problems. Independent practice of strategies between sessions is encouraged and reviewed in subsequent sessions, thus enhancing learning through repetition.

After release of the individual PM+ manual, Terre des Hommes and the World Health Organizationlaunched a capacity-building project. The aim of the project was not only to train humanitarian organisations in implementing PM+, but also to provide support beyond the training during the implementation phase. The support was provided through continuous group and individual supervision, a community of practice hosted on MHPSS.net and webinars on implementation, adaptation and sharing models across contexts.

The first master training took place in Cairo, Egypt in March 2018, and the second master training was held in Istanbul, Turkey in May 2019. Participating organisations were asked to select someone to be trained as PM+ trainer and implementer. The master training courses consisted of prereading, an introduction webinar and 8 full training days on how to train and implement individual PM+. At the time of writing this report, the 34 master trainers trained within the project have trained and supervised 305 PM+ providers throughout the globe.

As part of the evaluation phase of the project, three case studies were conducted with three different humanitarian organisations between April 2019 and July 2019. The main aim was to evaluate the relevance and appropriateness of scaling PM+ in humanitarian settings. Utilising in-depth, semi-structured qualitative interviews to identify barriers and facilitating factors, the project consultant conducted both individual and group interviews with PM+ master trainers/supervisors who were trained in Cairo, country level supervisors, PM+ helpers and PM+ clients.

This field report describes the three field studies conducted in Ethiopia, Syria and Honduras. The interviews were conducted in-person by the project consultant in Ethiopia and remotely in Syria and Honduras. All qualitative interviews were recorded, transcribed and coded with consent from the respondent. When necessary, translation services were utilised. The semi-structured interview guide was developed in collaboration with the project consultant and the project leads from Terre des Hommes and the World Health Organization. The guide addressed topics relevant to PM+ providers (acceptability, adoption, treatment fidelity and competence), clients (acceptability and satisfaction) and fidelity of implementation (consistency between what it is in the manual and what was done) as well as the extent of adaptation of the manual to local context. Due to the interviews being conducted remotely in Syria and Honduras, client-related data was only gathered in Ethiopia.

Integrating PM+ into Existing Mental Health and Psychosocial Support Propgrammes in Ethiopia

To serve Eritrean refugees living in camps in Ethiopia, PM+ is used as an intervention to support clients that are experiencing extreme distress due to poor living conditions, grief, loss of loved ones, stress, isolation and extreme poverty. The implementing organisation is delivering PM+ through their healing centres for clients alongside their signature therapeutic groups. PM+ was adopted by the organisation to serve individuals who were not ready to attend group-based sessions, did not meet the criteria for group sessions or needed continued support following the culmination of the group sessions.

The trainer who attended the master training in Cairo conducted a 7-day PM+ helper training, using the PM+ training manual, for national mental health workers and refugee psychosocial counsellors. Before PM+ providers were seeing the clients, the PM+ supervisor conducted biweekly supervision sessions for 4 months using role plays, observation and discussion. One person acted as the client, one role played the PM+ provider and the third person observed the session using the WHO competency assessment developed to accompany the training manual. The generic PM+ manual was adapted and translated into Tigrinya with support from both national and refugee staff to ensure the PM+ manual and handouts were in the provider’s and client’s language and that local idioms of distress were used instead of terms that were not contextualised or culturally relevant.

Nine implementing staff (national mental health workers and refugee psychosocial counsellors) and two clients were interviewed about their experience delivering and receiving PM+. The results from those interviews were positive, with one female PM+ helper reporting, “I believe that PM+ is a valuable intervention and I’m seeing a lot of progress in my client who is attending the PM+ sessions,” and “it is very interesting for those who are living in the camp as refugees because most of the refugees living in the camp have low mood, are isolated, sleep all day, cry a lot and don’t do activities, and that is why PM+ is important to support them to manage their problems and bring them out of their low mood”. She continued, “when clients start practising the techniques they are taught (in PM+), it will help them to break the low mood cycle and get out to engage in activities by solving their problems by themselves and using the calendar which helps them to engage in activities to make them feel grounded and encouraged when they complete a task on the calendar”. In using the manual, she reported, “the PM+ sessions are step-by-step and clear and help clients to learn tools and build strategies”. The only barrier she reported was the length of the sessions (90 minutes) and how challenging it is to stick to the exact time given for each step in the manual. A psychosocial counsellor providing PM+ reported that as clients share their stories and their troubles through PM+, it helps them to manage their problems; he also mentioned that the PM+ intervention is easier to follow and use because it is manualised.

A mental health worker at the organisation stated that moving forward he would like to change the rating scales used to determine if the client meets the inclusion criteria. He suggested, “when rating functioning, it would be better to use pictorial representations of functioning versus using the WHODAS 2.0¹”. He continued to say, “when I first taught deep breathing to my client, she was confused and I explained to her that I was also confused when I first learned it, in the end she tried the exercise at home and came back and reported that deep breathing helped her”. Thus, another challenge was explaining deep breathing to clients, but this was resolved when he shared his personal difficulties. When he ran the Managing Problems session with a female client he reported, “she knew how to solve problems but had to be reminded that she had those skills”. He discussed two additional barriers to delivering PM+ in saying, “I hesitate to terminate the session after the fifth session is complete because some people might need six or seven sessions and it is difficult to determine if five sessions are enough for them”. He continued to state, “sometimes it is difficult to stick to the time allocated in the PM+ manual because each session is 90 minutes long”.

A 23-year-old woman who completed all five PM+ sessions said, “I would recommend PM+ to a friend because I would want them to learn the skills that I learned to be able to help them manage their stress”. She also reported that her PM+ helper taught her a skill that she can use when she is feeling stressed or worried, called deep breathing. She said, “these skills could help anyone who was feeling stressed, angry or aggressive because when you take a deep breath in, you feel relaxed”. She also reported that sharing her stressors with her PM+ helper supported her. Another older female client even said that before she received PM+, she did not speak or look at anyone in the camp. She felt ashamed that her husband left and could not bear facing the community. During session two, Managing Problems, her PM+ provider helped her come up with a plan to start saying hello to a few people on the street every day. Even though saying hello is a simple task, she reported that it was extremely powerful since she previously had had no contact with others.

Based on the results of the case study, PM+ was successfully integrated into an existing mental health and psychosocial support programme for Eritrean refugees and served as a therapeutic tool for individuals experiencing distress. Following a 7-day training and 4 months of practice before implementing PM+, both national mental health workers and refugee psychosocial counsellors began seeing clients. The prolonged training and practice period speaks to how important it is to ensure PM+ helpers are ready to deliver the intervention. Both PM+ helpers and clients receiving the intervention reported that PM+ includes important skills and tools to support people to manage stress and solve problems, especially the managing stress strategy (deep breathing) and using the managing problems strategy to develop simple plans using the PM+ activity calendar. PM+ helpers found the manualised approach to be easy to follow, providing step-by-step guidance.

Using Remote Supervision to Implement PM+ in Hard to Reach Areas with Psychosocial Workers in Syria

Through an initiative led by the World Health Organisation Mental Health and Psychosocial Support Technical Working Group, 26 Syrian and Turkish mental health practitioners from multiple humanitarian organisations were trained as PM+ trainers in November 2018 over the course of 9 days. Directly following the training, each trainee took on two practice cases and received remote group supervision for 3 months. A translator who was trained in PM+ supported the remote supervision calls in Arabic because the supervisor only spoke English. It was required that each trainer complete two practice cases before training nonspecialists on PM+.

Following the supervised practice cases, the 26 individuals went on to train and supervise 120 psychosocial workers (PSWs) living in northern Syria who have seen 219 clients to date. Nongovernmental organisations (NGOs) working inside Syria created the position of PSW to fill in the large gap in providing psychosocial support services. Furthermore, in July 2019, 70 additional PSWs were trained on PM+ and receive weekly supervision as they see practice cases. Each training was 9 days long, following the WHO PM+ training manual. The key to the programme’s success was a robust supervision system that included group supervision sessions, on-site observations and a refresher training.

Weekly group supervision sessions were conducted for 90 minutes with seven to eight PSWs per group. This weekly supervision lasted 4 months, followed by a refresher training based on the supervisor’s feedback of the skills and strategies needing to be reviewed. After the 4-month PM+ specific supervision provided by the project, most PSWs continued to receive supervision delivered by their respective NGOs. Various supervision techniques were used, with a specific focus on case presentations using a case reflection form that was completed before the supervision session and sent to the supervisor via WhatsApp. Role plays were also used to support PSWs with challenging cases. Each supervisor completed one observation session per PSW and completed the WHO competency assessment form to assist the PSW with skill development.

To support the eight field supervisors, a master supervisor conducted remote weekly supervision sessions for 120 minutes with four supervisors per group. In a similar manner to the supervision for PSWs, supervisors presented on their supervisees’ challenges and sought support from their peers. To ensure fidelity to the PM+ protocol, an external supervisor (based outside the region) met with the master supervisor weekly to discuss frequently asked questions and support any technical issues. Using a tiered model of supervision ensures that the PSWs have various levels of support from the outset.

The master supervisor said, “my role was not only to support the supervisors with PM+ but also to make sure to focus on staff care since my staff are living and working in a war zone”. He reported that “PM+ is one of the first manualised and structured interventions used in the region” and “PSWs have reported that they feel as though they have more skills to use in their work because of PM+”. He also stated, “PM+ gave two things to this region. It gave PSWs a method to support people in the community using an evidence-based approach, and secondly there has also been a gap in structured supervision which has since changed due to the rollout of PM+”. He went on to say that he “appreciated the supervision forms that were used and sent by the supervisors before each session”. The supervision forms allowed him to read through the supervisors’ reports and reflection forms and familiarise himself with their caseload before the group supervision session started each week. He was initially sceptical about conducting group supervision remotely and still prefers supervision face-to-face. However, he is grateful that remote supervision is available and sees it as the only option in this case because northern Syria is often inaccessible.

Four PSWs in northern Syria delivering PM+ through protection and primary healthcare centres were interviewed together. Despite living in a war zone, they saw very positive results with PM+. One female PSW reported, “some of the barriers we face are that when clients are referred to us, they don’t always meet the inclusion criteria for PM+ and ask for different services such as money and economic support”. They stated that this was the only barrier they faced, and overall, they believe that PM+ is very accepted in the community because it covers “real-life situations for them”. A male PSW continued to say, “because it is a simple programme, it was accepted quickly and it supports people with common mental health concerns”. Furthermore, another female PSW added that, “the supervision sessions were beneficial because we were provided with real feedback”. This was the first time they engaged in consistent supervision because previously a culture of supervision did not exist; it has now been created for PSWs.

Over the course of 9 months, the supervisors and PSWs developed a frequently asked questions list with over 50 questions and relevant answers that were reviewed by the core supervision team. This working document will continue to support PM+ providers and programme staff for years to come. Furthermore, the Syria team adapted the generic PM+ manual by asking the PSWs to create drawings that were more appropriate for their settings. Please see the adaption of the Get Going Keep Doing Inactivity Cycle in [Figure 1].

Figure 1 The PM+ Inactivity Cycle Drawn by a Trainee in Syria During the PM+ Helper Training. An Example of Adaptations Made to Ensure the Manual is Culturally and Contextually Relevant to the Population

Click here to view

Similar to the case study conducted in Ethiopia, training and robust supervision was critical to ensuring the successful implementation and scale of PM+ in northern Syria. Most notable was that remote supervision was key to the success of PM+ and served as a catalyst for structured supervision systems to be built within implementing organisations. The various supervision tools included in the PM+ training manual were utilised and institutionalised as best practice. PM+ served as an evidence-based manualised approach for PSWs, a relatively new cadre of non-specialised mental health and psychosocial staff, to deliver psychological interventions to individuals. PSWs reported that PM+ was widely accepted in the community and they saw positive results from clients who were experiencing mental health concerns.

Implementing PM+ with a Volunteer Workforce in Honduras

A mixed training for PM+ helpers and future trainers was conducted in December 2018. Twelve community volunteers and five psychologists participated for 6 days with 2 additional days for future trainers. From January 2019-May 2019, each trainee received 10 hours of remote individual supervision for two practice cases. Starting in April 2019, supervisors started group supervision for community volunteers. In June 2019, the supervisors travelled to Honduras to conduct face-to-face supervision and a refresher training session.

As of July 2019, the 12 community volunteers have worked with 32 clients, 20 of which completed the PM+ sessions and 12 of which are still completing the sessions. Ten follow-up sessions have been conducted where the PM+ strategies are reviewed with clients 2 or 3 months after completion.

Three interviews were conducted with staff from this implementing organisation: one master supervisor, one supervisor and one community volunteer PM+ helper. When asked about the effectiveness of individual supervision, the master supervisor reported, “once group supervision started, it was more effective than individual supervision, and it took a while for the community volunteers to get comfortable with the supervisors”. She continued, “during the refresher training and face-to-face supervision, I could tell that they were more comfortable, which makes me think that more face-to-face contact is important”. She stated that in the beginning, “it was difficult to get the project (PM+) started because we couldn’t find resources and the settings in which we were working in already had projects. It was difficult to explain to the implementing partners why supervision was so essential and that the training couldn’t be conducted without supervision”. She also noted, “we had to involve various partners, which made it difficult to convince everyone of the importance of PM+”. Now that the first PM+ training has been conducted with partners and community volunteers, she added, “in the future we want to train community volunteers first on basic mental health or work with volunteers who have some experience identifying people with mental health concerns”. She reported that a barrier they faced when conducting the training was the amount of time that people could be present and away from work. She continued to explain that 6 days of training was not enough for PM+ helpers, but this was the best they could do. In the future she hopes to have more time since she recognises how difficult it is to teach the material over the course of only 6 days.

A female community volunteer who is working as a nursing assistant in Honduras and volunteering to provide PM+ reported, “I use the tools to implement PM+ and find the tool very useful, and it’s a tool that tackles stress and anxiety with very easy to follow guidelines”. When asked if PM+ is a feasible intervention to scale up in her community she reported, “the tool has been useful because when clients come they are stressed and anxious, and in the beginning I did not see how the tool was going to be helpful, but after I saw clients benefit from the tool, I knew it was helpful, specifically the stress management technique”. She reported, “I have seen changes in my clients. One of them was in a situation of depression and wasn’t bathing. Now she started bathing, which is a small change but significant, and they aren’t as depressed”. The community volunteer also reported one of her clients living in a rural area must walk 3 hours to reach the place where she receives PM+ even though there is no financial incentive given. This shows dedication from the client and the effectiveness of the intervention. She finished by saying she was nervous to deliver PM+ in the beginning because it was different from her regular job, but the skills she uses as a nursing assistant helped her to provide PM+ and connect with clients.

The community psychologist delivering remote and face-to-face supervision reported, “I work to train and support medical providers to make referrals to community volunteers delivering PM+, but since it is a new intervention it takes time”. She continued to say, “the intervention (PM+) has been accepted in the community because it teaches people skills to solve their problems, and people usually go to a provider and they try and solve their problems for them”. The master supervisor requested that she conduct supervised practice cases before working as a supervisor to allow her to truly understand the intervention. She reported that this method helped her to feel comfortable supervising PM+ helpers, and she hopes that her organisation can use it in various locations.

In contrast to Ethiopia and northern Syria, PM+ was delivered by a community based volunteer workforce in Honduras, adding a diverse perspective to the evaluation of PM+. Similar to the previous two case studies, training and robust supervision were noted as an important component, with a similar time period spent conducting practice cases while receiving supervision to prepare for the delivery of PM+. It was noted that face-to-face supervision was valuable as well as group supervision compared to individually delivered supervision. This is likely due to the peer-to-peer support and problem solving that is provided during group supervision, as reported in the case study conducted in Syria. In Honduras, similar to the previous two case studies, clients and community members accepted the intervention and reported that the skills and strategies in PM+ supported them to solve problems and reduce stress.

Conclusion

Based on the information gathered from these case studies, it can be concluded that PM+ is both relevant and appropriate for use in various humanitarian settings. One of the most valuable lessons highlighted in each case study was the importance of having a robust supervision system. The rollout of PM+ and the delivery of supervision varied among the three implementing agencies, but in all three settings it was experienced as a valuable intervention and feasible to implement by the organisation.

The case studies show the importance of a strong supervision system along with rigorous practice of PM+ before it was fully delivered. To implement and scale up PM+, dedicated staff or volunteers and adequate time to conduct the initial training are required, followed directly by supervised practice cases. In addition, continuous supervision should take place once PM+ providers start seeing clients. This entire process demands dedicated time and needs to be thoughtfully planned out in order to deliver quality services at scale. It is important to note that supervision does not always have to be delivered face-to-face. Evidence from the case studies in Syria and Honduras demonstrates that remote supervision delivered online via Skype with WhatsApp groups for ad-hoc messaging is an innovative and viable option in hard to reach humanitarian contexts.

In both Syria and Honduras, the master supervisor handed over responsibility to the field supervisors once the core competencies were shown, using the WHO competency assessment. It is important to note that in all three case studies, the PM+ trainer was also the initial supervisor. It can be hypothesised that the trainer had a strong sense of the PM+ trainees’ strengths and areas that needed to be improved and could tailor the supervision sessions to individual needs in the group.

Furthermore, these case studies conveyed that there must be a culture of supervision created for PM+ to be implemented effectively. As evident in Syria, the PSWs were grateful for the supervision they received which has changed the way they work, not only in delivering PM+ but for other interventions. In order to create this culture, supervision should be supportive, encouraging and not punitive. The master supervisor in Syria emphasised that it was really the supervisees who supported one another with challenges and encouraged each other in difficult cases while he was there only to facilitate the conversation through supportive means. The case studies in all three locations show that to deliver PM+ effectively and at scale, there must be a system of people working in unison to ensure quality services are delivered while keeping fidelity to the PM+ model. In each of the three settings, PM+ was not the only intervention being delivered, but time and intentionality were dedicated to ensuring that PM+ was functional and part of the larger intervention package.

The case studies confirm that adapting and translating the generic manual will always support PM+ implementation. Adapting the manual does not always require hiring a graphic designer, and many of the adaptations to the drawings can be made by PM+ providers or community members. Translating the manual to the local language is challenging and requires more resources but is imperative for effective implementation.

Some barriers to implementing PM+ were reported as well at the different sites. It was reported that the length of the training, typically 8 days, and the length of the 90-minute PM+ sessions are a barrier for implementation in humanitarian settings. Although these factors were mentioned as barriers, through the research conducted and rollout of PM+, the timing of the training and the sessions have been carefully considered. One solution to the number of training days is to break it up over the course of 2 weeks, conducting the training for half the day and allowing trainees to return to work the other half of the day. It was also experienced that PM+ is not suitable for everyone, and sometimes the programme would have people referred to it who do not meet the inclusion criteria but still require a lower level of care. As PM+ is adopted over time by the implementing agency, it is hypothesised that staff would become more familiar with who to refer for the initial assessment to determine eligibility.

Through these case studies, we gathered meaningful examples of the different ways that PM+ can be implemented in various settings with non-specialised providers. Even though minor barriers were encountered, the case studies suggest that PM+ is a relevant and appropriate psychological intervention to deliver in humanitarian settings.

Since the case studies were written, PM+ continues to be widely used in humanitarian settings across the globe for adults impaired by distress, especially during the recent pandemic. With the recent release of Group PM+, lessons learned from the three cases studies can be utilised for future rollout using a tiered model of delivery.

¹WHO Disability Assessment Schedule 2.0. The WHODAS 2.0 is a recommended tool to measure functioning. In the PM+ manual it states, “the choice of measure depends on what measure has been locally validated”.

Financial support and sponsorship

This work was supported by Elrha.

Conflicts of interest

There are no conflicts of interest.

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