Feasibility and acceptability of technology-assisted problem management plus (TA-PM+) in community settings in Pakistan: a pre-post mixed-methods study

Problem Management Plus (PM+) effectively reduces symptoms of depression, anxiety, and psychological distress, demonstrating efficacy and cost-effectiveness in over 23 randomized controlled trials. However, real-world implementation through lay health workers often encounters significant challenges, particularly concerning intervention fidelity and feasible delivery. To address these challenges, Technology-assisted Problem Management Plus (TA-PM+), a digital adaptation of PM+, was co-developed. This study aims to evaluate the feasibility and acceptability of delivering TA-PM+ through government-employed primary healthcare outreach lay health workers known as Lady Health Workers (LHWs), in Pakistan. A pre-post, non-randomized feasibility study was conducted in Islamabad, Pakistan, involving 12 LHWs delivering TA-PM+ face-to-face to 77 women experiencing psychological distress. TA-PM+ is digital intervention designed to support LHWs in delivering five sessions of PM+, featuring psychoeducational videos for patients, automated assessments, and a guiding interface to enhance participant engagement and experience while ensuring intervention fidelity. Feasibility was assessed through session completion rates, participant retention, and qualitative interviews exploring implementation barriers and facilitators. Fidelity was evaluated using the ENhancing Assessment of Common Therapeutic factors (ENACT) checklist and digital automated session logs. Psychological distress was measured using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) at baseline and post-intervention. Data analysis included descriptive statistics, paired t-tests, and thematic analysis of qualitative data. TA-PM+ demonstrated high feasibility, with 92% of participants completing all five sessions. Fidelity was high, with a mean ENACT score of 48 out of 54. Over 60% of the sessions met the minimum threshold with a mean session length of 45 to 50 min. Psychological distress showed preliminary improvements, with reduction in PHQ-9 (mean reduction: 6.07, p < 0.0001) and GAD-7 (mean reduction: 5.25, p < 0.0001). Participants valued structured sessions and psychoeducational videos. Identified challenges included internet connectivity issues, difficulties aligning session times with participants' household responsibilities, and cognitive fatigue among health workers. TA-PM+ intervention delivery by government-employed primary healthcare outreach staff was feasible, acceptable, and preliminary effective in reducing psychological distress among women in a community setting in Pakistan. The digital adaptation maintained high fidelity and efficiently reduced session durations, indicating its strong potential for scale-up within primary healthcare systems. Further research is necessary to examine long-term outcomes and cost-effectiveness.