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CHANGE

Alcohol misuse and associated adversities among conflict affected populations

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About

CHANGE is a five-year research project which started in July 2020 and is funded by the Wellcome Trust and the Department of Health and Social Care, through the National Institute for Health Research using the UK’s Official Development Assistance Funding. CHANGE seeks to develop a transdiagnostic intervention addressing mental health comorbidities (alcohol misuse, depression, anxiety and post-traumatic stress disorders) among conflict-affected populations in Uganda and Ukraine.

Research

The aim of CHANGE is to address alcohol misuse and associated adversities among conflict-affected populations in Uganda and Ukraine. CHANGE seeks to further develop Problem Management Plus (PM+), an evidence-based psychological intervention designed for people with psychological distress who are exposed to adversity. We will complement PM+ by adding an additional psychological component addressing alcohol misuse.  

The CHANGE Partnership

CHANGE is a partnership between HealthRight International Uganda, the London School of Hygiene and Tropical Medicine, the National University of Kyiv-Mohyla, the University of Copenhagen, and WordsHelp Ukraine. CHANGE applies a participatory research approach with key stakeholders and conflict-affected populations involved in the development and implementation of the intervention.

About
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We are witnessing the highest levels of forced displacement on record, with one person forcibly displaced every two seconds as a result of conflict, violence or persecution. Conflict-affected populations are vulnerable to psychosocial distress and are at risk of considerably higher levels of mental disorders than non-conflict-affected populations including alcohol misuse. Alcohol may be used as strategy to cope with adversities which refugees and internally displaced persons might face, and may cause or result from psychosocial distress. UNHCR have highlighted that alcohol misuse among forcibly-displaced populations is a neglected problem, and that psychological inteventions addressing mental health co-morbidities including alcohol miuse are lacking.

CHANGE is a five-year research project which started in July 2020 and is funded by the NIHR–Wellcome Partnership for Global Health Research. CHANGE seeks to further develop Problem Management Plus (PM+), an evidence-based psychological intervention developed by WHO designed for people with psychological distress who are exposed to adversity. We will complement PM+ by adding an additional psychological component addressing alcohol misuse. 

The overall aim of CHANGE is to address alcohol misuse and associated adversities among conflict-affected populations in Uganda and Ukraine.  

The specific objectives of CHANGE are to:

  • To identify strategies and techniques from evidence-based alcohol use therapies which can be integrated into PM+, and to develop a new intervention called PM+A (Problem Management Plus Alcohol)
  • To adapt PM+A to local circumstances, and to examine the feasibility, acceptability, perceived effectiveness and preliminary impact of PM+A
  • To evaluate effectiveness and cost-effectiveness of PM+A through two randomised controlled trials in Uganda and Ukraine
  • To explore the process of implementation, and to identify, characterise and explain mechanisms that promote or inhibit the delivery and take-up of PM+A in both settings
  • To examine the potential for scaling-up PM+A in Uganda and Ukraine

CHANGE applies a participatory research approach with key stakeholders and conflict-affected populations involved in the development and implementation of the intervention.

Study settings and location

PM+A will be implemented among refugees from South Sudan living in the Rhino refugee settlement in Uganda; and internally displaced persons and other conflict-affected men (e.g. military veterans) in the region of Dnipro in Ukraine. These study locations have been selected because they have high levels of alcohol misuse, mental disorders, gender-based violence, and a high mental health treatment gap. These country settings represent very different socio-economic, cultural and humanitarian characteristics and populations which supports understanding of the contextual influences on adapting and implementing PM+A. The comparison of outcomes and processes between the two sites will also help inform the future development and application of PM+A with other conflict-affected populations.

Research
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CHANGE consists of six Work Packages (described below). 

Work Package One: Intervention development

The objective of Work Package One is to identify strategies and techniques from evidence-based alcohol use disorder therapies which can be integrated into PM+, and to develop the PM+A treatment manual. The research methods include literature reviews, Theory of Change workshops, community-based participatory research with conflict-affected populations in Uganda and Ukraine, and a treatment development workshop with experts in addiction and mental health.

Lead Abhijit Nadkarni; country leads Sergiy Bogdanov (Ukraine), Wietse Tol (Uganda)

Work Package Two: Adaptation of PM+A, including pilot RCTs

The objective of Work Package Two is to adapt PM+A to local circumstances, and to examine the feasibility, acceptability, perceived effectiveness and preliminary impact of PM+A.

More specifically, Work Package Two seeks to conduct a before/after treatment cohort to obtain guidance from refugees (Uganda) and internally displaced persons (Ukraine) on additional adaptations needed to enhance the relevance, appropriateness and acceptability of PM+A; and to conduct two pilot RCTs in Ukraine and Uganda to fine-tune methodological procedures of the intervention.

Lead Daniela Fuhr; country leads Sergiy Bogdanov (Ukraine), Wietse Tol (Uganda)

Work Package Three: Effectiveness Evaluation

The objectives of Work Package Three is to evaluate the effectiveness of PM+A through two randomised controlled trials in Uganda and Ukraine. We plan to run a parallel arm single-blind individual randomised controlled trial in Uganda and Ukraine with 500 men in each country/site randomised 1:1 to PM+A and enhanced usual care or enhanced usual care alone. Outcomes will be measured at 3- and 12-months post-recruitment.

Lead Helen Weiss; country leads Sergiy Bogdanov (Ukraine), Wietse Tol (Uganda)

Work Package Four: Cost-Effectiveness Evaluation 

The objectives of Work Package Four is to evaluate the cost-effectiveness of PM+A. We will test whether PM+A and enhanced usual care is cost-effective compared to enhanced usual care alone for populations of refugees and internally displaced persons in Uganda and Ukraine. We will assess the incremental cost per DALY averted and cost per QALY of PM+A compared to enhanced usual care from a societal perspective over a life time horizon.

Lead Anna Vassall; country leads Sergiy Bogdanov (Ukraine), Wietse Tol (Uganda)

Work Package Five: In-depth investigation on implementation processes

The objective of Work Package Five is explore the process of implementation of PM+A across the life of the project, and to identify, characterise and explain mechanisms that promote or inhibit the delivery and take-up of PM+A. We will apply a theoretical model of implementation processes, normalisation process theory, to inform fieldwork aimed at understanding the dynamics of enacting PM+A. During the intervention development phase, we will collect qualitative data through semi-structured interviews and ethnographic observation of meetings and workshops.  In the pilot RCT we will focus on understanding the ways in which the translational gap between the process of intervention design and the experience of everyday practice is understood and bridged. In the definitive trial, we will undertake qualitative semi-structured interviews with healthcare managers, clinicians, and lay healthcare workers. Interviews will be aimed at eliciting their interpretations of these data and their explanations of the processes that have led to these results.

Lead Carl May; country leads Sergiy Bogdanov (Ukraine), Wietse Tol (Uganda)

Work Package Six: Scaling up

The objective of Work Package Six is to examine the potential for scaling-up PM+A in Uganda and Ukraine. To help make PM+A widely available, we will investigate how PM+A could be scaled-up through the health system (both government and humanitarian) and also integrated within other humanitarian sector activities such as protection programmes for survivors of gender-based violence. The methods will consist of document and policy reviews, Theory of Change workshops, and key informant interviews.

Lead Bayard Roberts; country leads Sergiy Bogdanov (Ukraine), Wietse Tol (Uganda)

 

Partnerships
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CHANGE is a partnership between HealthRight International Uganda, the London School of Hygiene and Tropical Medicine, the National University of Kyiv-Mohyla, the University of Copenhagen, and WordsHelp Ukraine.

CHANGE Partners

HealthRight International

HealthRight logo

University of Copenhagen

University of Copenhagen logo

National University of Kyiv-Mohyla

National University of Kyiv-Mohyla logo

 

Team
Team Block

Daniela
Fuhr

Associate Professor
Overall Principal Investigator
Overall Principal Investigator
Wietse Tol

Wietse Tol

University of Copenhagen, and HealthRight International, Uganda Principal Investigator
Sergiy Bogdanov

Sergiy Bogdanov

National University of Kyiv-Mohyla, Ukraine Principal Investigator

Helen
Weiss

Professor
Co-Investigator

Abhijit
Nadkarni

Associate Professor
Co-Investigator

Carl
May

Professor
Co-Investigator

Anna
Vassall

Professor
Co-Investigator

Alessandro
Massazza

Research Fellow
Eugene Kinyanda

Eugene Kinyanda

MRC/UVRI and LSHTM Uganda research unit, researcher Uganda

Daniel
Mongiardi

Project Manager
Project Manager
News and updates
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LSHTM feature on CHANGE

Our project has been featured on the London School of Hygiene and Tropical Medicine's newsfeed. The text from the article can be found below, click here for the original post.

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Every two seconds someone in the world is forcibly displaced as a result of conflict, violence or persecution. These populations affected by conflict are particularly vulnerable to psychosocial distress and much higher levels of mental disorders, including alcohol misuse, than populations who don’t experience conflict. In these settings, alcohol may be used as a coping strategy for adversities that refugees and internally displaced persons may face.

The CHANGE study is a five-year project, led by Dr Daniela Fuhr and Professor Bayard Roberts, titled ‘Alcohol use in Humanitarian settings: a programme of work to address alcohol and associated adversities among conflict-affected populations in Uganda and Ukraine’. Launched in July 2020, project partners include LSHTM, HealthRight International Uganda, the National University of Kyiv-Mohyla, WordsHelp Ukraine, and the University of Copenhagen.

CHANGE seeks to develop the first evidence-based psychological intervention with a component addressing alcohol misuse. Specifically, they seek to further develop Problem Management Plus (PM+), an intervention developed by the World Health Organization (WHO) designed for people with psychological distress who are exposed to adversity by identifying and integrating strategies and techniques from alcohol use therapies.

An expanded version of this intervention, Project Management Plus Alcohol (PM+A), can then be adapted to local circumstances, and its feasibility, acceptability, cost-effectiveness and scalability can be assessed through two randomised control trials in Uganda and Ukraine. In-depth qualitative research will be conducted throughout the project to better understand the implementation of the intervention, and how local contextual mechanisms influence outcomes.

The United Nations Higher Commission for Refugees (UNHCR) have highlighted alcohol misuse as a neglected problem among forcibly displaced populations, and that psychological interventions addressing mental health co-morbidities including alcohol misuse are lacking.

PM+A will be implemented among South Sudanese refugees living in the Rhino refugee settlement in Uganda and internally displaced persons in the Dnipro region of Ukraine. These regions have been found to have high levels of alcohol misuse, mental disorders, gender-based violence and a high mental health treatment gap.

These country settings represent varied different socio-economic, cultural and humanitarian characteristics and populations, which supports understanding of the contextual influences on adapting and implementing PM+A in differing circumstances.

Dr Fuhr, Assistant Professor in Mental Health Systems at LSHTM and project lead, said: “We are very pleased to have received this funding for the CHANGE project. Conflict-affected areas create environments where people are much more vulnerable, so psychosocial distress, mental disorders and alcohol misuse are more common in these populations.  

“By introducing a component addressing alcohol misuse to the PM+ mental health intervention, we hope to address this neglected problem and associated adversities in these populations. We are keen to develop an intervention which can be integrated into existing mental health and psychosocial support programmes.

“Our partners bring in-depth expertise about the local population, and it is very exciting for us to be able to compare outcomes and processes between our two study sites which are so very different to each other. This will inform the future development, application and scalability of PM+A with other conflict-affected populations.”

CHANGE project recruiting staff for Uganda and Ukraine sites

We are currently in the process of recruiting research staff for our sites in Uganda and Ukraine. Watch out for updates on our team page!

CHANGE project awarded funding by NIHR–Wellcome Partnership for Global Health Research

We are delighted to announce that the CHANGE project has been awarded funding by the NIHR–Wellcome Partnership for Global Health Research.

CHANGE project team