Evaluation of the Group Problem Management Plus (Group PM+) pilot study in Oromia and Amhara Regional States, Ethiopia

Problem Management Plus (PM+) is an intervention developed by WHO in 2013 to address common mental health problems such as depression, stress, and anxiety. It involves problem management (PM) plus (+) selected behavioral strategies to address both psychological issues (e.g., stress, fear, feelings of helplessness) and practical problems (e.g., livelihood problems, conflict in the family) (World Health Organization 2016). It was conceived initially as individual counselling composed of 5 sessions. In villages randomized to the gPM+ treatment, same-sex therapy groups of 3 to 8 individuals will be formed and facilitated by Community Health Facilitators (CHF) for women and Men’s Group Facilitators (MGF) for men.

Eligible households in villages randomized to the Cash treatment will also receive a one-time lump sum transfer worth the equivalent value in Birr of $300 USD. While the transfer is unconditional, it will be presented as a ‘livelihoods transfer’ to support income-generating activities that improve livelihoods.

2022-08-01

2022-12-23

Mental health:
- PHQ-9 – a measure of depressive symptoms – total score from 9 questions converted to standardized unit using control mean and SD
- Perceived stress scale (PSS-10) – total score from 10 questions converted to standardized unit using control mean and SD
- Post-traumatic stress, PCL-C – total score from 6 questions converted to standardized unit using control mean and SD
- General Anxiety Disorder 7 (GAD-7-) – total score from 7 questions converted to standardized unit using control mean and SD
- WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) – total score from 12 questions converted to standardized unit using control mean and SD
Economic:
- The total value of productive assets- total value transformed using inverse-hyperbolic sine transformation and then standardized using control mean and SD (1-year post endline only)
- Total value of monthly per capita expenditures – total value of food and non-food consumption transformed using inverse-hyperbolic sine transformation and then standardized using control mean and SD (1-year post endline only)
- Food insecurity experience scale- total score converted to standardized unit using control mean and SD (1-year post endline only)
- Savings- binary indicator that equals one if individual deposited any money in the last 12 months in any type of savings account, converted to standardized unit using control mean and SD (1-year post endline only)
Time use and childcare:
- Non-economic activities: total hours spent in non-economic activities in the last 24 hours, converted to standardized unit using control mean and SD
- Income generating activities: total hours spent in income generating activities in the last week, converted to standardized unit using control mean and SD
- Other activities: summation of number of other activities participated, converted to standardized unit using control mean and SD
- Childcare – total number of activities, converted to standardized unit using control mean and SD
- Child discipline: total score, converted to standardized unit using control mean and SD
- Child neglect : total score, converted to standardized unit using control mean and SD

Alcohol and Khat consumption
Tension reduction checklist
Brief Cope (shortened to 6 items) – instrument to measure coping with stressful life events
Multi-dimensional Scale of Perceived Social Support (MSPSS)
General self-efficacy
Time preference (Global preference survey)
Risk preference (Global preference survey)
Value of Investments in last 12 months
Intimate Partner Violence (WHO violence against women instrument)

The impact of gPM+ will be assessed through a two-stage cluster randomized control trial (cRCT) design. In the first stage, 70 kebeles will be randomized to receive cash or no cash. Randomization of the cash treatment is at the kebele level in order to reduce the risk of spillovers, contamination, and resentment. Randomization of kebeles will be stratified by woreda. In the second stage, within each kebele, up to 6 villages will then be randomized to receive either gPM+ or not receive it , leading to the following four intervention arms across 252 villages:
• Arm-1: control
• Arm-2: gPM+ only
• Arm-3: lump-sum cash transfer only
• Arm-4: lump-sum cash transfer and gPM+.
Study participants in all intervention arms will receive information on locally available mental health services and be PSNP public works clients. Arm 2 will additionally provide study participants with the gPM+ therapy, Arm 3 will additionally provide a one-time lump sum cash transfer, and Arm 4 will provide both the gPM+ and cash transfer.

The evaluation will include a baseline survey conducted before implementing the gPM+ or cash transfer intervention (July-August 2022). The endline survey will be conducted on the same individuals right after the gPM+ intervention but before the cash is rolled out (September-October 2022). A one-year post-intervention survey will be conducted approximately one year after the end-line, approximately one year after the gPM+ sessions and 9 months after the cash transfer (September-October 2023).

Randomization was conducted in STATA by the research team using the randtreat command. First, 70 kebeles were stratified by woreda, and randomized to either the Cash or No-Cash treatment. Second, 252 villages were stratified by kebele and randomized to either receive or not receive the gPM+ intervention. At each stage, misfits were randomly assigned within each strata, leading to slightly unequal number of villages per treatment arm.

1st stage randomization: Kebele
2nd stage randomization: Villages

Yes

70 kebeles
252 villages

3024 individuals

35 cash kebeles and 35 non-cash kebeles
63 villages in control, 63 villages in gPM+, 63 villages in cash, 63 villages in gPM+ and cash

0.22 standard deviations for PHQ-9 score 0.25 standard deviations for value of productive assets