Violence against women in resource-limited settings: A WHO behavioral intervention

A randomized controlled trial has shown that a brief behavioral treatment delivered by community lay workers significantly reduced psychological distress in women exposed to gender-based violence. In a study published in PLOS Medicine, Richard A. Bryant of the University of New South Wales, Australia, and colleagues tested the five-session intervention on 421 women in Kenya.

Gender-based violence, which includes actual or threatened sexual or nonsexual violence committed by an intimate partner or others, has been experienced by more than a third of women worldwide. Its adverse impacts on physical and mental health make it a global health issue. The World Health Organization has developed Problem Management Plus (PM+) as a brief 5-session intervention to treat people experiencing psychological distress following adversity. Because lay community health workers can be trained to deliver PM+, it is particularly applicable in resource-limited settings.

This study, in a peri-urban area of Nairobi, Kenya, randomly assigned 421 women who displayed distress and impaired functioning to receive either 5 individual sessions of PM+ or enhanced usual care (EUC). The primary outcome was psychological distress as measured by total score on the 12-item General Health Questionnaire (GHQ-12) assessed at 3 months after treatment. Assessments by investigators who were blind to the treatment assignment indicated that women who received PM+ reported significantly less psychological distress, with a moderate effect relative to EUC. The difference between PM+ and EUC in the change from baseline to 3 months on the GHQ-12 was 3.33 (95% CI 1.86 - 4.79, P = 0.001) in favour of PM+.

Further study is needed to evaluate the sustainability of PM+ in the community so that survivors of gender-based violence can be safely identified and treated without stigma. Limitations of the study include no long-term follow-up and a reliance on self-report rather than structured interview data. The PM+ manual is available for dissemination at the WHO website.

In an accompanying Perspective, Alexander C. Tsai of Harvard Medical School, USA, says: "The potential widespread deployment of PM+ stands at the intersection of two vital issues relevant to women's health: mental health and interpersonal violence. Until the large-scale structural forces that give rise to health disparities affecting vulnerable populations can be eliminated ... the health system will continue to play a key role in the multisectoral response to violence against women in resource-limited settings."