PM+ for Sexual & Gender MinorityRefugees in Nairobi, Kenya

Mental health needs remain largely unmet in most low-income countries -- particularly in vulnerable communities - due to a lack of attention, funding and skilled professionals. Sexual and gender minority (SGM) refugees have a disproportionately high burden of mental health issues due to discrimination, abuse and violence associated with their SGM and refugee status. Low-cost, high-impact interventions like Problem Management Plus (PM+) that can be delivered at the community-level by trained community health workers or lay helpers hold great promise to address gaps in access to quality mental health services and improve the well-being and functioning of SGM refugees. Our solution team -- comprising experts in health and development, mental health and SGM health -- is ideally suited to implement and evaluate PM+ as a solution in this highly stigmatized community.

Kenya is a known transit country for sexual and gender minority (SGM) asylum seekers and refugees from Eastern and Central Africa fleeing violence and persecution in neighboring countries. Kenya is relatively more liberal regarding SGMs, yet these individuals are doubly marginalized as foreigners and SGMs in Kenya and integrated support systems are weak in camp and urban settings. A recent American Rescue Committee (ARC) fact-finding mission in Kakuma and Nairobi revealed the urgent need to address pervasive human rights violations and protection gaps faced by this community.

SGM asylum seekers and refugees often lack familial and community support systems that can promote mental health and address distress. A recent assessment reported low levels of social support received and high levels of depression (>30%) in the community. ARC reported that 100% of community members cited the immediate need for safe mental health and psychosocial support network (MHPSS) services. Yet, mental health care resources are severely lacking in this context, particularly for SGM asylum seekers, and improved access to service providers and additional MHPSS community training is needed. Innovative, low-cost, accessible approaches to mental health care services are critical to meeting the substantial mental health needs in this marginalized population.

SGM refugees generally migrate to urban settings. There are over 470,000 asylum seekers and refugees residing in Kenya, over 700 of whom identify as SGMs. They hail predominantly from Uganda, with others from Burundi, Congo, Ethiopia, Rwanda and Somalia. Of this population, approximately 500 identify as gay/bi/queer men, 200 as lesbian/bi/queer women, and 80 as trans persons. However, these numbers are likely underestimated due to structural and cultural barriers related to SGM identity disclosure and lack of registration. Most SGM refugees live in cramped accommodation in the poorest neighborhoods/slums and surrounding towns of urban Nairobi. 

These individuals have experienced violence and threats to safety in Kenya. Following violent attacks on SGM asylum seekers and refugees in Kakuma in December 2018, the vast majority of Kakuma-based asylum seekers and refugees openly identifying as SGM to asylum officials were moved to a transit centre in Nairobi. Since the attack, these SGMs are sleeping outside the UNHCR complex and face serious protection concerns if they enter the camp. In February, the group was attacked again by police officials, and ARC has received reports of several incidents of sexual and physical violence since the beginning of the year.

Our solution is to introduce to this population a scalable psychological intervention to address psychological distress among individuals exposed to adversity -- the World Health Organization (WHO)’s Problem Management Plus (PM+) -- by partnering with a local NGO and community health workers to gauge feasibility and efficacy, adapt the intervention to the local context, and build capacity at the local NGO. The project will take a mixed-methods approach, and take approximately 6 months to complete. Brief, structured surveys administered to 30-50 clients pre-intervention, weekly and post-intervention (6 weeks later) will examine the burden (prevalence) of exposure to adversity (stressors and potentially traumatic events) and perceived stress, emotional distress (general psychological distress, depression, post-traumatic stress disorder [PTSD]), and mental health-related disability using locally validated screening instruments such as the Patient Health Questionnaire (PHQ-9) and the WHO Disability Assessment Scale (WHO-DAS). These measures will also allow for assessment of mental health needs and eligibility in the PM+ demonstration project, as well as improvement before and after implementation of the PM+ intervention. Key informant interviews among clients who participated in the survey will elicit respondent attitudes about mental health needs; treatment and barriers to care; the PM+ intervention; and feasibility of delivering the intervention via mobile technology. Respondents will also be asked to comment on any concerns about confidentiality and safety when seeking care. In-depth interviews covering the above topics will be administered by trained community health workers, supervised by the solution team. Respondents will be asked in an open-ended manner to respond to each query, and follow-up probes will be used to elucidate domains salient to the topic. We will also consult with long-time partners MedicMobile to develop prompts relevant to the feasibility of delivering PM+ as an mHealth intervention. Interviews will be audiotaped, transcribed, and translated into English. This project will inform the adaptation and scaling of a validated intervention -- with future potential for mobile technology delivery of the intervention -- to effectively address salient mental health needs and increase access to quality mental health care in this vulnerable and marginalized population. 

Using this approach, the key objectives of this project are to:

Objective 1: Assess mental health needs including stress, emotional distress and disability among SGM refugees residing in Nairobi, Kenya.

Objective 2: Adapt, pilot and evaluate Problem Management Plus (PM+) as a tool to address mental health issues among SGM refugees in Nairobi, Kenya.

 PM+ Innovation:

• Brevity: PM+ is a low-intensity intervention delivered over the course of just five weeks; lay helpers can be trained in PM+ in eight days, followed by a brief period of practice.

• Efficacy: Low-intensity interventions have been shown to demonstrate clinical benefit across a range of mental health issues in a range of settings, and PM+ has already been adapted for use in Kenya.

• Efficiency: PM+ employs a transdiagnostic approach that applies the same therapeutic principles across mental disorders, enabling a single approach to address multiple problems, as most people present with comorbidities (e.g., anxiety and depression);

• Accessibility: Employing a task shifting approach PM+ can be delivered by anyone with a high school degree in communities close to where people live.

Solution Innovation:

• Expand access: Introduce PM+ to address mental health issues facing SGM refugees, who are stigmatized for their gender identity or sexual orientation as well as their refugee status. 

• New context/community: Assess PM+ utility among SGM refugees in an urban setting.

• Scalability: Explore the possibility of adapting this intervention to group settings and to mobile health platforms.

This project capitalizes on and extends the use of an efficacious, low-intensity, brief psychological intervention developed by the WHO to reduce mental health-related impairment among individuals experiencing adversity such as violence, loss of loved ones, and lack of basic services and security common among refugees, particularly SGM refugees. PM+ is not indicated for those with severe psychological or substance use-related impairment or suicide risk; these clients will be referred to other mental health resources and will not be eligible to participate in the PM+ pilot. This intervention incorporates pre-, peri- and post-intervention psychological assessment and problem-solving and behavioral therapy techniques and can be delivered by lay helpers -- a critical feature for our project setting, where mental health clinicians are few -- and has been successfully tested in a randomized controlled trial (RCT) in Kenya. This intervention is delivered at the individual level once a week for five weeks but may include friends and family if the client so wishes. The intervention focuses on problems most salient to the client and helps the client manage the psychological impact of these problems. Prior to implementation, PM+ requires in-field training and group supervision of trainees, which will be conducted by the solution team. HealthRight has extensive experience adapting and implementing the PM+ (and other psychological interventions such as Self Help Plus) in similar settings. This project will also inform adaptation of PM+ to delivery through mobile technology using SMS/MMS messaging, to be developed and tested by our team in future collaborative projects.

We believe that by providing access to PM+, this highly stigmatized community will gain meaningful relief from common mental health issues including depression, stress, anxiety, and PTSD, and develop individual resilience and the capacity to prospectively manage the many life stressors encountered daily by SGM refugees residing in Nairobi, Kenya. Further, we anticipate secondary, longer-term effects including enhanced social capital, increased productivity and reduced interpersonal violence (not measured here). Finally, piloting PM+ among SGM refugees will provide an opportunity to document the mental health issues faced by this community, thereby addressing a key knowledge gap (there is a dearth of data on mental health issues among SGM refugees) and highlighting areas for future problem solving.

All HealthRight programs are grant supported, and therefore all future projections are dependent on securing future grant funding, or on scaling within government health systems. The PM+ solution is nested within a comprehensive, stepped-care model for mental health and social service (MHSS) provision in Uganda.  

2019: We are currently serving more than 100,000 individuals in close coordination with community health volunteers across and the public health system in four sites (including two serving a population of 40,000 refugees in northern Uganda) with our comprehensive MHSS program. We are on track to provide 125 people with PM+ directly through our staff, and hundreds more through the 50+ community health workers we have trained to deliver PM+ across all HealthRight supported sites.

2020: Roll out PM+ as part of a broader MHSS program to two new sites serving 40,000 refugees in northern Uganda. Launch PM+ in 2 new sites serving marginalized populations in Kenya, including our current HIV project for men-who-have-sex-with-men and male sex workers in Kilifi, Kenya (n=250).

2024: In concert with other mental health stakeholders, push for the adoption (including financing) of low-intensity mental health solutions by provincial and national ministries of health in Kenya and Uganda, thereby reaching millions of people with this high impact, low cost mental health solution. 

Our goal over the next year is to continue to build an evidence base demonstrating that low-intensity mental health solutions, like PM+, can positively impact the most marginalized communities at low cost and without consuming significant public health resources. Within five years, we hope provincial and national ministries of health will rollout supportive mental health policies and programs enabling millions in Kenya and Uganda (including marginalized communities) to access life-saving low cost high impact solutions including PM+. HealthRight is currently launching a randomized controlled trial (RCT) of another low-intensity mental health solution called Self-Help Plus (SH+) among refugees residing in northern Uganda. 

• Financing for mental health solutions in low and middle income countries (both domestic and donor)
• Supportive mental health policies and the national and provincial levels
• Increased mental health literacy among affected communities (e.g. understanding depression, how it affects people and what can be done about it) and an accompanying lack of demand for solutions
• Lack of skilled mental health professionals
• Dearth of affordable, effective mental health interventions

As indicated above, we continue to work with our partners in academia, the NGO community, government health systems and global health institutions like the WHO to develop, test, evaluate and disseminate/publicize mental health solutions tailored to low income settings and marginalized communities. 

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HealthRight International

• Wietse Tol, PhD (Director of the Peter C. Alderman Program in Global Mental Health)

• Benson Simba, MPH (Director of Programs, HealthRight-Kenya)

• Peter Navario, PhD, MPH

Refugee Coalition of East Africa (RefCEA)

• Michael Clark, Director

• James Okoth, Deputy Director

New York University College of Global Public Health/Global Mental Health and Stigma Program (https://wp.nyu.edu/stigmainstitute/research-projects/mental-illness-stigma/)

• Emily Goldmann, PhD (Clinical Assistant Professor of Epidemiology)

• Lawrence Yang, PhD (Associate Professor of Social and Behavioral Sciences)

Our solution team includes U.S.- and Kenya-based public health practitioners with extensive experience in mental health programming and scholarship among marginalized populations. Since 1990, HealthRight has promoted health and well-being among vulnerable populations globally through developing community-driven, innovative approaches. Recently, HealthRight merged with the Peter C. Alderman Foundation, which allows the organization to address mental and physical health needs of the communities it serves in a more integrated manner. The HealthRight team has adapted and implemented PM+ in similar settings, is extremely knowledgeable about the project setting, and is well-suited to continue its partnership with RefCEA to tailor and deliver the intervention for this demonstration project.

The Refugee Coalition of East Africa (RefCEA) is a registered community organization for and by lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) migrants, refugees, and asylum-seekers. RefCEA was established to unite the various independent LGBTQI refugee organizations in East Africa under an umbrella organization in order to facilitate long-term planning, advocacy, and representation, and to provide fiscal management and fundraising support for its members. RefCEA oversees research initiatives representing the LGBTQI refugee community and works toward improving conditions for refugees during the resettlement waiting period. 

The NYU research team has conducted significant grant-funded quantitative and qualitative mental health research globally around the topics of stigma, psychological consequences of trauma, and development and scaling of mental health interventions. They are well-positioned to develop and administer the mental health needs assessment and key informant interviews that will inform PM+ adaptation and pilot testing.

HealthRight implements the PM+ solution in close coordination with district health teams across four sites in Uganda. HealthRight implements PM+ directly in these sites, as well as trains and mentors community health workers, primary care clinic staff and their supervisors in the implementation of PM+. Once demand has been met for the services in a site and capacity has been built within the public health system to delivery PM+ and the suite of accompanying MHSS interventions, HealthRight selects a new site. For this project, we propose to partner with the Refugee Coalition of East Africa (RefCEA) to provide mentorship and training to their member organizations in Nairobi in order to build their capacity to provide PM+ to their clients. This approach will mimic our approach to building PM+ capacity in public health systems in Uganda.  We will also train some staff to be PM+ trainers so that there are adequate supplies of trained PM+ counselors. 

HealthRight doesn't have a business model for PM+ per se. As previously stated, we seek grant funding to pilot and scale cost-effective health solutions for marginalized communities, with the ultimate goal being adoption of the solution by the public health system and/or by local civil society organizations. We partner closely with government and civil society in implementing our solutions in order to build local capacity to deliver solutions and to facilitate their adoption at a regional or national level. 

All of HealthRight’s solutions are grant-funded and our approach to sustainability across our development projects is context- and project-specific. Following successful grant-supported demonstration projects, we work with local stakeholders (government and civil society) to identify and secure grant funding to evaluate intervention(s) at scale. For larger projects/projects that don’t lend themselves to scaling, we hand solutions over to local stakeholders so they can continue the work. Examples of past projects include: 

1. Community-based Mental Health: For over five years, HealthRight built community-based mental health capacity within the public health system in Soroti, Uganda, through education and demand promotion for mental health services within the community and capacity building of frontline health workers (community health volunteers) and primary health clinics to set up a stepped care model for mental health services (including PM+). Last year we determined that adequate capacity had been built and mental health interventions fully integrated into the public health system, so we handed the project over completely to the local government in December 2018.

2. Maternal Near-Miss Reviews: HealthRight received a grant to pilot maternal near-miss reviews (to improve the quality of maternity care and reduce preventable maternal deaths) in a maternity hospital in the rural Nepalese district of Arghakanchi. After a successful pilot, HealthRight received scale-up funding from the WHO to take near-miss reviews district-wide. The project also proved successful at the district level and has since been taken up by the Ministry of Health, which is evaluating the adoption of near-miss reviews nationally. 

1. Dearth of funding opportunities: There are very few opportunities to fund the evaluation of an intervention targeting the mental health of SGM refugees, and MIT Solve is a flexible platform that accommodates a wide range of innovative health solutions targeting vulnerable populations.

2. The Solve Ecosystem: The opportunity to be connected to the MIT Solve networks with other like-minded development organizations, funders and innovators is an exciting prospect, both for this solution and potentially for others as well. 

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Funders and implementers with a similar focus on mental health and marginalized populations.

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The Innovating Together for Healthy Cities Prize will provide the resources required to achieve the solution’s objectives and build sustainable local capacity around mental health service provision. Funding will be used to train lay helpers in delivery of the intervention, compensate individuals at the local NGO who will conduct the mental health needs assessment and key informant interviews to inform the demonstration project for the PM+ intervention, and compensate clients for participation in the project. The prize will also allow the solutions team to gauge the feasibility and acceptability of adapting the PM+ to delivery through mobile technology. Understanding how to most effectively deliver the intervention in this community will ensure that low-cost, quality mental health services are sustainable and accessible to the larger community.

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