Whose Knowledge Counts? Promoting Epistemic Justice in Cross-cultural Supervision

Mental health remains among the top 10 leading causes of disease burden globally, and there is a significant treatment gap due to limited resources, stigma, limited accessibility, and low perceived need for treatment. Problem Management Plus, a World Health Organization-endorsed brief psychological intervention for mental health disorders, has been shown to be effective and cost-effective in various countries globally but faces implementation challenges, such as quality control in training, supervision, and delivery. While digital technologies to foster mental health care have the potential to close treatment gaps and address the issues of quality control, their development requires context-specific, interdisciplinary, and participatory approaches to enhance impact and acceptance. We aimed to co-produce Technology-Assisted Problem Management Plus (TA-PM+) for "lady health workers" (LHWs; this is the terminology used by the Lady Health Worker Programme for lay health workers) to efficiently deliver sessions to women with symptoms of common mental health disorders within the community settings of Pakistan and conducted usability testing in community settings. A 3-stage framework was used for co-producing and prototyping the intervention. Stage 1 (evidence review and stakeholder consultation) included 3 focus group discussions with 32 LHWs and 7 in-depth interviews with key stakeholders working in the health system or at the health policy level. Thematic analyses using the Capability, Opportunity, and Motivation for Behavioral Change (COM-B) model were conducted. Stage 2 included over eight online workshops, and a multidisciplinary intervention development group co-produced TA-PM+. Stage 3 (prototyping) involved 2 usability testing rounds. In round 1 conducted in laboratory settings, 6 LHWs participated in role plays and completed the 15-item mHealth Usability App Questionnaire (MUAQ) (score range 0-7). In round 2 conducted in community settings, trained LHWs delivered the intervention to 6 participants screened for depression and anxiety. Data were collected using the MUAQ completed by LHWs and the Patient Satisfaction Questionnaire (PSQ) (score range 0-46) completed by participants. Qualitative analysis indicated that a lack of digital skills among LHWs, high workload, resource scarcity for digitization (specifically internet bandwidth in the community), and need for comprehensive training were barriers for TA-PM+ implementation in the community through LHWs. Training, professional support, user guidance, an easy and automated interface, offline functionalities, incentives, and strong credibility among communities were perceived to enhance the capability, opportunity, and motivation of LHWs to implement TA-PM+. TA-PM+ was co-produced with features like an automated interface, a personal dashboard, guidance videos, and a connected supervisory panel. The mean MUAQ score was 5.62 in round 1 of usability testing and improved to 5.96 after incorporating LHW feedback in round 2. The mean PSQ score for TA-PM+ was 40 in round 2. Co-production of TA-PM+ for LHWs balanced context and evidence. The 3-stage iterative development approach resulted in high usability and acceptability of TA-PM+ for LHWs and participants.

With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up. To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au). We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores. The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262-4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434-820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394-77 399) (US$517), compared with PKR 10 705 (95% CI 7731-15 627) (US$102.93) using a local supervisor. The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.

Objectives Psychological distress encompasses a range of mental health issues, including anxiety, depression and PTSD, which significantly impact well-being. Problem Management Plus (PM+), a scalable and adaptable intervention, has shown promise. This study conducted a meta-analysis, assessing the efficacy of PM+ and evaluating it across diverse settings. Method A thorough search was conducted across PubMed, s, PsycINFO, Scopus, MEDLINE, CINAHL, CNKI and grey literature sources, including the WHO website and the first 10 pages of Google Scholar. Keywords related to PM+, anxiety, depression, psychological distress and PTSD were used, and studies in English and Chinese were included. Results After screening 3,122 studies, 23 met the inclusion criteria, involving 1,737 participants in the PM+ groups and 1,766 in the control groups. PM+ significantly improved mental health outcomes, including anxiety, depression, psychological distress and PTSD. These results suggest that PM+ is effective in enhancing mental health. Conclusion PM+ effectively improves mental health, showing clear benefits for anxiety, depression, psychological distress and PTSD. The variability in effect sizes across different studies highlights the need for more detailed, long-term studies to assess the consistency and sustainability of PM+ interventions.

Syrian refugees in Türkiye show a high prevalence of mental health problems but encounter barriers to accessing mental health services. Group Problem Management Plus (gPM+), developed by the World Health Organization, is a low-intensity psychological intervention delivered by nonspecialist facilitators. This qualitative process evaluation explores the acceptability, feasibility and perceived effectiveness of gPM+ for Syrian refugees resettled in Türkiye, as well as facilitating factors and barriers to its implementation. Twenty-three semi-structured interviews were conducted with gPM+ participants, facilitators, drop-outs, relatives of participants and key informants. Findings showed that gPM+ was well-received for its group-based format, which participants felt fostered social support, and for its content, which they reported may have led to improvements in coping skills and family relationships. Facilitators viewed the intervention as feasible to implement. However, barriers such as participants' economic struggles, practical challenges (e.g., childcare and transportation difficulties) and low mental health literacy impeded engagement. Adapting gPM+ to address social determinants like poverty may be beneficial. The need for booster sessions was emphasized to maintain long-term change and provide deeper learning of the strategies. For sustainable scaling up gPM+ within primary health care, key informants highlighted the importance of training and supervising nonprofessional facilitators and securing governmental support.

Psychological interventions that are brief, acceptable, effective and can be delivered by non-specialists are especially necessary in low- and middle-income countries, where mental health systems are unable to address the high level of psychosocial needs. Problem Management Plus (PM+) is a five-session intervention designed for those impaired by psychological distress while living in communities affected by adversity. Individual PM+ has demonstrated effectiveness in reducing distress in Kenya and Pakistan, and a group version of PM+ (Group PM+) was effective for conflict-affected women in Pakistan. This paper describes a feasibility and acceptability trial of locally adapted Group PM+ for women and men in an earthquake-affected region of rural Nepal. In this feasibility cluster randomised controlled trial, participants in the experimental arm were offered five sessions of Group PM+ and participants in the control arm received enhanced usual care (EUC), which entailed brief psycho-education and providing referral options to primary care services with health workers trained in the mental health Gap Action Programme Intervention Guide (mhGAP-IG). A mixed-methods design was used to assess the feasibility and acceptability of Group PM+. Feasibility was assessed with criteria including fidelity and retention of participants. Acceptability was assessed through in-depth interviews with participants, family members, programme staff and other stakeholders. The primary clinical outcome was depression symptoms assessed using the Patient Health Questionnaire (PHQ-9) administered at baseline and 8-8.5 weeks post-baseline (i.e. after completion of Group PM+ or EUC). We recruited 121 participants (83% women and 17% men), with equal allocation to the Group PM+ and EUC arms (1:1). Group PM+ was delivered over five 2.5-3 hour sessions by trained and supervised gender-matched local non-specialists, with an average attendance of four out of five sessions. The quantitative and qualitative results demonstrated feasibility and acceptability for non-specialists to deliver Group PM+. Though the study was not powered to assess for effectiveness, for all five key outcome measures, including the primary clinical outcome, the estimated mean improvement was larger in the Group PM+ arm than the EUC arm. The intervention and trial procedures were acceptable to participants, family members, and programme staff. The communities and participants found the intervention to be beneficial. Because feasibility and acceptability were established in this trial, a fully powered randomised controlled trial will be conducted for larger scale implementation to determine the effectiveness of the intervention in Nepal.

BackgroundThe present study examined Afghan asylum seekers’ and refugees’ self-perceived problems, and their experiences of treatment with an adapted version of the brief transdiagnostic psychological intervention “Problem Management Plus” (aPM+). Specifically, the study explored which problems trouble them most and how these problems influence their daily functioning. Further, it examined how various standardized outcome measures correlate with these subjectively perceived problems.MethodThis study is part of a larger RCT study (PIAAS study) in which 88 Afghan asylum seekers and refugees were randomly allocated either to aPM + in addition to treatment as usual (aPM+/TAU) or TAU alone. The presented study uses a multi-method approach consisting of two parts: First, we investigated participants’ self-identified problems and subjective functional impairment using quantitative and qualitative assessment in both the aPM+/TAU and TAU group (n = 88). Second, we conducted in-depth qualitative interviews with a subsample of the aPM+/TAU group (n = 24) to gain a deeper understanding of participants’ personal experiences with aPM + and to obtain suggestions for improvement. Spearman correlations were applied for quantitative data, and deductive and inductive approaches of thematic analysis were used for qualitative data.ResultsWe identified six main themes of self-perceived problems (primary post-migration living difficulties, general mental health problems, interpersonal stressors, secondary post-migration living difficulties, mental health problems specifically associated with stress, and somatic problems) and their consequences, as well as subjective functional impairment. Standardized measures of general mental health, posttraumatic psychopathology, and quality of life did not correlate with the intensity of self-perceived problems. aPM + was mostly perceived positively, and few participants had recommendations for its improvement.ConclusionThe study aimed at giving a voice to Afghan trauma survivors to inform service providers and policy makers about their needs. Based on their expertise, future interventions can be tailored to their actual needs and optimized in terms of practical use. aPM + proved to be a positively perceived intervention that reduces subjective symptom burden and facilitates daily functioning. Culture-sensitive treatments within (mental) health services should increase service utilization and improve (mental) health in the long term.

AimsDespite high levels of psychological distress, mental health service use among Syrian refugees in urban settings is low. To address the mental healthcare gap, the World Health Organization developed group problem management plus (gPM+), a scalable psychological intervention delivered by non-specialist peer facilitators. The study aimed to evaluate the effectiveness of gPM+ in reducing symptoms of depression and anxiety among Syrian refugees in Istanbul, Türkiye.MethodsA randomized controlled trial was conducted among 368 distressed (Kessler Psychological Distress Scale, K10 > 15) adult Syrian refugees with impaired functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16). Participants were recruited between August 2019 and September 2020 through a non-governmental organization providing services to refugees. Participants were randomly allocated to gPM+ and enhanced care as usual (gPM+/E-CAU) (184 participants) or E-CAU only (184 participants). Primary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist (HSCL-25)) at 3-month follow-up. Secondary outcomes were post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5; PCL-5), functional impairment (WHODAS 2.0), and self-identified problems (psychological outcome profiles).ResultsIntent-to-treat analyses showed no significant effect of gPM+ on symptoms of anxiety, depression, PTSD and self-identified problems. Yet, there was a significant reduction in functional impairment in gPM+/E-CAU compared to E-CAU at 3-month follow-up (adjusted mean difference 1.66, 95 % CI 0.04, 3.27, p = 0.045, d = 0.19). Post-hoc subgroup analyses among participants with probable baseline depression or anxiety showed that there was a small but significant reduction in depression (adjusted mean difference −0.17, 95 % CI −0.32, −0.02, p = 0.028, d = 0.27) and anxiety (adjusted mean difference −0.21, 95 % CI −0.37, −0.05, p = 0.009, d = 0.30) symptoms comparing gPM+/E-CAU to E-CAU only at 1-week post assessment, but not at 3-month follow-up. There was a significant difference between conditions on functional impairment at 3-month follow-up, favouring gPM+/E-CAU condition (adjusted mean difference −1.98, 95 % CI −3.93, −0.02, p = 0.048, d = 0.26).ConclusionIn this study in an urban setting in Türkiye, gPM+ did not alleviate symptoms of depression and anxiety among Syrian refugees experiencing psychological distress and daily living difficulties. However, participants with higher distress at baseline seemed to benefit from gPM+, but treatment gains disappeared in the long term. Current findings highlight the potential benefit of tailored psychosocial interventions for highly distressed refugees in volatile low-resource settings.

Problem Management Plus (PM+) is a psychological intervention that seeks to address common mental disorders among individuals exposed to adversity. Thus far, the potential for delivering PM+ by mobile phones has not been evaluated. To adapt PM+ for telephone delivery (ten weekly sessions of about 45 min each) and preliminarily evaluate its acceptability and feasibility with young people living with HIV (YLWH) in coastal Kenya. This was a mixed-method formative research. Qualitative data collection included consultations with stakeholders, conducting key informant interviews with HIV care providers and focus group discussions with potential end-users, i.e. YLWH. Moreover, brief exit interviews with recipients of the adapted PM+ were conducted. Quantitative acceptability and feasibility indicators and outcome measures were tracked/assessed during PM+ preliminary implementation involving 70 YLWH. From the qualitative inquiries, the adapted PM+ emerged as contextually appropriate, acceptable and feasible for mobile phone delivery, despite some concerns around missing nonverbal cues and poor network connectivity. High recruitment (85%) and fair programme retention (69%) were observed. Intervention sessions over the telephone lasted 46 min on average (range 42-55 min). Preliminary feasibility data indicated that the adapted PM+ has the potential of reducing common mental disorders among YLWH from the Kenyan coast. PM+ is acceptable and can feasibly be delivered via mobile phone to YLWH in coastal Kenya. This study sets the stage for a future fully powered, randomised controlled trial assessing the efficacy of the adapted PM+ in this or a similar setting.

AimsProblem Management Plus (PM+) has been effective in reducing mental health problems among refugees at three-month follow-up, but there is a lack of research on its long-term effectiveness. This study examined the effectiveness of PM+ in reducing symptoms of common mental disorders at 12-month follow-up among Syrian refugees in the Netherlands.MethodsThis single-blind, parallel, controlled trial randomised 206 adult Syrians who screened positive for psychological distress and impaired functioning to either PM+ in addition to care as usual (PM+/CAU) or CAU alone. Assessments were at baseline, 1 week and 3 months after the intervention and 12 months after baseline. Outcomes were psychological distress (Hopkins Symptom Checklist [HSCL-25]), depression (HSCL-25 subscale), anxiety (HSCL-25 subscale), posttraumatic stress disorder symptoms (PCL-5), functional impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS).ResultsIn March 2019–December 2022, 103 participants were assigned to PM+/CAU and 103 to CAU of which 169 (82.0%) were retained at 12 months. Intention-to-treat analyses showed greater reductions in psychological distress at 12 months for PM+/CAU compared to CAU (adjusted mean difference −0.17, 95% CI −0.310 to −0.027; p = 0.01, Cohen’s d = 0.28). Relative to CAU, PM+/CAU participants also showed significant reductions on anxiety (−0.19, 95% CI −0.344 to −0.047; p = 0.01, d = 0.31) but not on any of the other outcomes.ConclusionsPM+ is effective in reducing psychological distress and symptoms of anxiety over a period up to 1 year. Additional support such as booster sessions or additional (trauma-focused) modules may be required to prolong and consolidate benefits gained through PM+ on other mental health and psychosocial outcomes.

Feasibility and preliminary effectiveness of a combined intimate partner violence (IPV) and mental health intervention (WINGS+PM+) for women in informal settlements in Kenya.

BackgroundSyrian refugees resettled in Turkey show a high prevalence of symptoms of mental disorders. Problem Management Plus (PM+) is an effective psychological intervention delivered by non-specialist health care providers which has shown to decrease psychological distress among people exposed to adversity. In this single-blind pilot randomised controlled trial, we examined the methodological trial procedures of Group PM+ (gPM+) among Syrian refugees with psychological distress in Istanbul, Turkey, and assessed feasibility, acceptability, perceived impact and the potential cost-effectiveness of the intervention.MethodsRefugees with psychological distress (Kessler Psychological Distress Scale, K10 > 15) and impaired psychosocial functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16) were recruited from the community and randomised to either gPM+ and enhanced care as usual (E-CAU) (n = 24) or E-CAU only (n = 22). gPM+ comprised of five weekly group sessions with eight to ten participants per group. Acceptability and feasibility of the intervention were assessed through semi-structured interviews. The primary outcome at 3-month follow-up was symptoms of depression and anxiety (Hopkins Symptoms Checklist-25). Psychosocial functioning (WHODAS 2.0), symptoms of posttraumatic stress disorder and self-identified problems (Psychological Outcomes Profiles, PSYCHLOPS) were included as secondary outcomes. A modified version of the Client Service Receipt Inventory was used to document changes in the costs of health service utilisation as well as productivity losses.ResultsThere were no barriers experienced in recruiting study participants and in randomising them into the respective study arms. Retention in gPM+ was high (75%). Qualitative analyses of the interviews with the participants showed that Syrian refugees had a positive view on the content, implementation and format of gPM+. No adverse events were reported during the implementation. The study was not powered to detect an effect. No significant difference between gPM+ and E-CAU group on primary and secondary outcome measures, or in economic impacts were found.ConclusionsgPM+ delivered by non-specialist peer providers seemed to be an acceptable, feasible and safe intervention for Syrian refugees in Turkey with elevated levels of psychological distress. This pilot RCT sets the stage for a fully powered RCT.Trial registrationClinicalTrials.gov Identifier NCT03567083; date: 25/06/2018.

Following publication of the original article [1], the first author reported an error in referring his paper.

Background: Afghan refugees often face hardship and traumatic experiences before, during, and after migration and frequently suffer from mental health burdens. Evidence based psychological treatments for refugees mostly focus on symptoms of posttraumatic stress disorder (PTSD), however, refugees often suffer from a variety of general health problems as well as depression and anxiety. We thus aimed to evaluate the effectiveness of a transdiagnostic psychological intervention. Objective: To investigate the effectiveness of an adapted version of Problem Management Plus (aPM+) delivered by mental health professionals to adult Afghan refugees and asylum seekers. Methods: We randomly allocated 88 Afghan refugees either to aPM+ in addition to treatment as usual (aPM+/TAU) or TAU alone. APM+ comprises of six weekly 90-minute individual sessions including strategies of stress management, problem solving, behavioural activation, strengthening social support and either anger regulation or increasing self-efficacy. The primary outcome was general health (GHQ-28) post intervention. Secondary outcome measures included distress by PMLD, Complex PTSD symptoms, quality of life, self-identified problems, and integration. Results: Attrition was high: 42% of the randomized participants did not participate in the post-treatment assessment. A repeated measures per-protocol (completers only) ANCOVA evidenced a significant group × timepoint interaction for GHQ total scores [F(1, 47) = 14.80, p < .001, partial η2 = 0.24]. Post-hoc analyses showed significantly lower symptoms in the aPM+/TAU arm (n = 26) as compared to the TAU arm (n = 25) for the GHQ total scores (dz = 1.04). Most secondary outcomes significantly improved in the aPM+/TAU arm, but not in the TAU arm. Conclusion: APM+ was effective in reducing general health problems in Afghan refugees and might be considered as a first-line intervention. High drop-out rate limit the interpretations of our results, where future investigations should focus on possibilities to reduce these rates. Trial registration: Uniform Trial Number identifier: U1111-1226-3285. HIGHLIGHTS Refugees’ mental health can be strengthened with a brief psychological intervention that also focuses on skills in the context of post-migration stressors. High drop-out rates are a major challenge for future research and delivery of psychological interventions as part of health care systems to refugees and asylum seekers.

Few studies have explored a stepped care model for delivering mental health care to persons with tuberculosis (TB). Here, we evaluated depression screening and remote low-intensity mental health interventions for persons initiating TB treatment in Lima, Peru during the COVID-19 pandemic. We used the Patient Health Questionnaire 9 (PHQ-9) to screen participants for depressive symptoms (PHQ-9≥5). Participants with PHQ-9, 5-14 received remote Psychological First Aid (PFA) or Problem Management Plus (PM+). Participants were reevaluated 6months after intervention completion. We then compared the change in median PHQ-9 scores before and after intervention completion. Those with PHQ-9≥15 were referred to higher-level care. We found that 62 (45.9%) of the 135 participants had PHQ-9≥5 at baseline. Then, 54 individuals with PHQ-9, 5-9 received PFA, of which 44 (81.5%) were reevaluated. We observed significant reductions in median PHQ-9 scores from 6 to 2 (r=0.98; p<0.001). Four participants with PHQ-9, 10-14 received PM+ but were unable to be reevaluated. Four participants with PHQ-9≥15 were referred to higher-level care. Depressive symptoms were common among persons recently diagnosed with TB. We observed improvements in depressive symptoms 6months later for most participants who received remote sessions of PFA.

There are gaps in understanding in and between those who design systems of AI/ ML, those who critique them, and those positioned between these discourses. This gap can be defined in multiple ways - e.g. methodological, epistemological, linguistic, or cultural. To bridge this gap requires a set of translations: the generation of a collaborative space and a new set of shared sensibilities that traverse disciplinary boundaries. This workshop aims to explore translations across multiple fields, and translations between theory and practice, as well as how interdisciplinary work could generate new operationalizable approaches.