Pilot study: Evaluation of the referral pathway to Problem Management Plus (PM+) in Nakuru County, Kenya: GBV survivors’ and stakeholders’ statement: A tale of PM+

Pilot study: Evaluation of the referral pathway to Problem Management Plus (PM+) in Nakuru County, Kenya: GBV survivors’ and stakeholders’ statement: A tale of PM+ | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pilot study: Evaluation of the referral pathway to Problem Management Plus (PM+) in Nakuru County, Kenya: GBV survivors’ and stakeholders’ statement: A tale of PM+ Jeske Moerenhout, Cathrine B. Oksholm, Shr-Jie S. Wang, Leslie C. Rono, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6604618/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Introduction Gender-based violence (GBV) is a widespread human rights issue with significant mental health consequences. Organizations such as MIDRIFT-HURINET and the Danish Institution Against Torture (DIGNITY) implemented a structured referral pathway to support survivors, incorporating two mental health and psychosocial support (MHPSS) interventions: Psychological First Aid (PFA) and Problem Management Plus (PM+) in Nakuru County, Kenya. This study examines stakeholder perspectives on the referral system, focusing on its functionality and impact on GBV survivors. Methodology A qualitative research design involving in-depth interviews with survivors and focus group discussions with community health volunteers and professionals was used. Thematic analysis was conducted via NVIVO14 software. Ethical guidelines were strictly followed to ensure participants' safety, privacy, and compliance with Kenyan law. Results Cultural norms significantly impact engagement with mental health programs such as PM+, particularly for men, who often avoid seeking support due to societal expectations of stoicism. Stigma, especially among older adults, further discourages participation. Effective engagement in mental health programs requires culturally relevant strategies, such as involving community leaders and using context-specific messaging. Harmful practices and economic dependencies hinder reporting and accessing services, although awareness is gradually improving. Financial constraints and socioeconomic barriers limit access to mental health services, emphasizing the need for expanded community and government support. Conclusion The referral pathway between PFA and PM+ is widely recognized for its effectiveness, demonstrating strong collaboration between state and nonstate actors. However, challenges such as access barriers, financial constraints, and limited awareness continue to impact its functionality. Despite these obstacles, the system has been instrumental in empowering GBV survivors in Nakuru County. Strengthening community-based mental health services and enhancing collaboration between health providers could further expand and improve mental health care delivery in similar contexts. Key message Cultural and Financial Barriers, Community Initiatives and Support Networks, Economic Empowerment and Holistic Approaches, Health System Strengthening, Community-Based Care. Background Gender-based violence (GBV) is a critical human rights issue officially defined in 1993 by the UN’s Declaration on the Elimination of Violence against Women(1). Since then, global frameworks have emerged to address GBV, particularly in lower-income settings(1). In Kenya, GBV most commonly manifests as emotional, physical, and sexual abuse. The Kenya Demographic and Health Survey revealed that 34% of women have faced physical violence since the age of 15, and 42% of women aged 15–49 have experienced physical or sexual violence from a partner(2). Informal settlements in Kenya face heightened GBV risks due to poverty and limited access to services. A study in Nakuru County emphasized the need for mental health and psychosocial support (MHPSS) for GBV survivors, highlighting that service gaps are worsened by urbanization, rapid population growth, and unemployment(2,3). Kenya’s health system, organized into six levels, integrates mental health services from community care to specialized facilities(4). Despite efforts, mental health remains a growing concern, with noncommunicable diseases, including mental health conditions, being the second leading cause of disability and death⁵. Community-based interventions, such as Psychological First Aid (PFA) and Problem Management Plus (PM+), are implemented at the primary care level(4,5). Interventions that Address GBV in Nakuru County In response to the severe GBV challenges in Nakuru County's informal settlements, the MIDRIFT-Human Rights Network, in partnership with a Danish organization, the Danish Institution Against Torture (DIGNITY), initiated a rehabilitation project aimed at supporting survivors of torture and GBV in 2020. The project employs Problem Management Plus (PM+), a tool that the WHO developed to help people in communities facing adversity(6). MIDRIFT launched PM+ implementation in 2020. In 2021, MIDRIFT launched PFA services during the COVID-19 pandemic as the second step. Currently, both PM+ and PFA services are being gradually expanded by training additional Community Health Providers (CHPs) to deliver these services. (DIGNITY, personal communication, May 28, 2024). Problem Management Plus (PM+) PM+ is a structured, psychological intervention designed to address common mental health problems, such as depression, anxiety, and stress, particularly in communities exposed to adversity(6). In the context of Nakuru County, PM+ offers survivors a series of 5 sessions aimed at improving their mental health. After completing these sessions, survivors have the option to join support groups for continued assistance. Throughout the PM+ process, continuous communication between the helper and supervisor ensures proper case management, addressing the specific needs of each survivor. This collaboration helps ensure that survivors receive tailored and effective care, enhancing the overall efficacy of the intervention. Psychological First Aid (PFA) During the COVID-19 pandemic, the project expanded to include PFA, a mental health intervention designed to offer immediate support to individuals in crisis(7). PFA created synergy with the existing PM+ project, enhancing the referral system to ensure that survivors received the necessary support (DIGNITY, personal communication, May 28, 2024). Referral System for GBV Survivors Various entry points within Nakuru County allow for the identification and referral of GBV survivors. Typically, survivors are referred by a Community Health Provider (CHP) to a community leader, gender desk officer, chief, or medical service, with cross-referrals occurring between these roles. In some cases, CHPs may serve dual roles as PFA providers and PM+ helpers, allowing them to self-refer survivors (MIDRIFT-HURINET, personal communication, May 14, 2024). Referral Pathway and Case Management Survivors who opt for PM+ undergo 5 sessions, with assessments for suicide at the beginning and at the end. After the sessions, they can voluntarily join a support group for up to three months. The referral pathway may vary on the basis of community dynamics. For example, a gender desk report could trigger an intervention by Nyumba Kumi, a community leader responsible for 10 households in a village, followed by a PFA referral and PM+ sessions. If specialized care is needed, the PM+ helper refers the client to a supervisor, who may involve MIDRIFT psychologists for further support. In cases of child abuse, referrals are directed to the children's office, as PFA and PM+ services are currently limited to adults. Aim of the study This article explores the referral pathway between PFA and PM+ and investigates the functionality of this system and the impact of these interventions in encouraging GBV survivors. It examines the experiences of key stakeholders in Nakuru County, Kenya, providing insights into the effectiveness of the referral process. Methodology This qualitative study uses in-depth interviews and focus groups to gather data from GBV survivors and state and nonstate actors in Nakuru County, Kenya. The study was conducted between January and February 2024. Additionally, all interview guides for the in-depth interviews and FGDs were developed for this specific study. In-depth interviews The study adheres to the COREQ 32-item checklist to ensure transparent reporting of the in-depth interviews conducted(8). Ten GBV survivors consented to participate in the interview, representing a mix of genders and age groups. The interviews were conducted in local hospitals and facilitated by a psychologist and a researcher, with sessions lasting 30-50 minutes. All interviews were recorded, anonymized, and securely stored. The interviewer had no prior relationship with the participants, and all interviews had prior training in in-depth interviews. The participants in the in-depth interviews had to be at least 18 years old, have survived or been affected by GBV (as defined in the introduction), live in intervention areas (Nakuru Town East, Nakuru Town West, and Naivasha), plan to stay for 12 months, and be current or former participants of the PM+ program. They needed to comprehend basic questions, follow instructions from the PM+ Helper, score ≥17 on the WHO Disability Assessment Schedule (WHODAS) 2.0(9) and ≥3 on the General Health Questionnaire (GHQ-12)(10,11), and have the ability to communicate in English or Swahili. The exclusion criteria included acute medical conditions, such as serious suicide risk (e.g., a plan to act within 2 weeks as per the PM+ manual(6)), severe cognitive or neurological impairments (ICD-10 diagnoses F2x, F30.1–F31.9), neurodegenerative disorders (e.g., Alzheimer’s or Parkinson’s), or severe substance abuse disorders (F1x.24–F1x.26)(12). Focus Group Discussion (FGD) Two focus groups were held, each with 5 participants, including CHPs, police officers, and religious leaders. Discussions were held in local hospitals, recorded for analysis, and lasted approximately 1 hour(13). The participants were selected on the basis of the following inclusion criteria: Must be a community member, such as police officers, gender officers, religious leaders, chiefs, clinical officers, teachers, PFA providers and PM+ helpers, etc. Must reside in Karagita (Naivasha) and Rhonda (Nakuru Town West) Experience with case detection and referral in the community and at the county level Data analysis All the in-depth interviews and FGDs were recorded and transcribed verbatim. Thematic analysis was used to analyze the data via NVIVO-14, identifying key patterns and themes from the interviews and focus groups(14–18). In total, 5 rounds of coding were conducted for the in-depth interviews, and 4 rounds were conducted for the focus groups. Ethical considerations Kenyan authorities, including the County Ethics Committee, Kabarak University, and the National Commission for Science, Technology and Innovation, granted ethical approval, with MIDRIFT-HURINET comanaging the process. Research with GBV survivors followed strict ethical protocols to minimize harm. The participants had completed the PM+ programme 6–12 months earlier to reduce retraumatization risks, with PFA available if needed. Informed consent was obtained, ensuring the right to withdraw at any time, and the data were anonymized and securely stored. Results of the in-depth interviews Cultural norms and financial and socioeconomic obstacles for survivors The in-depth interviews with GBV survivors in the informal settlements of Karagita and Rhonda revealed substantial barriers to discussing mental health. Many survivors fear that sharing their struggles will lead to gossip or stigma, particularly among their close-knit communities. In both settlements, discussing mental health is uncommon, especially for GBV survivors, who worry about confidentiality and judgement. In Karagita, many prefer to keep their challenges private, fearing that disclosure could lead to gossip and a lack of trust, even with professionals. “I did not have anyone I could share my problems with, I felt if I shared with anyone... (…) They would go and say things out there, (…). I used to think that the helper would go out and talk about my problems to people who would know what I am going through, yes.” (Interviewee 1, Karagita) In Rhonda, survivors face similar challenges, often choosing silence due to low confidence in those around them to maintain privacy. Many women hesitate to open up, fear judgments or misunderstandings, and often worry that even community health volunteers may not protect their privacy. This fear of exposure prevents many from seeking help, deepening their sense of isolation. “It was not easy because I did not want my issues to be known. He listened and just said its not usual for me to be in this state; there must be something wrong, something bothering you on the inside, so he slowly prompted followed up on me and I opened up.” (Interviewee 6, Rhonda) Cultural expectations of masculinity create additional challenges for male survivors, who often feel shame or weakness about disclosing emotional struggles. Some men avoid sharing with female health providers, and expanding access to gender-sensitive mental health support and promoting awareness of male survivor experiences can help address these challenges. “If we had these people, like the service providers in our group, you know boys do not like to share with a woman. (…) yeah… And you see men nowadays if they don’t talk… they resort to suicide.” (Interviewee 3, Karagita) Unemployment also exacerbates the mental health challenges of GBV survivors, especially young people, who may engage in risky behaviors as a coping mechanism. For women, joblessness increases their vulnerability to exploitation, with some feeling pressured into unwanted relationships for financial survival. Financial constraints further limit access to mental health services, as many avoid seeking professional help, assuming that it is unaffordable. Other NGOs fund microfinance programs in informal settlements, which some participants have participated in. Many were unaware of the programs before being offered to join. Both Karagita and Rhonda residents expressed surprise that community-based programs such as PFA and PM+ were free, having believed mental health services to be a luxury only available to wealthy people. “(...) So, I think if people will be empowered, at least those things will decrease a little bit, let's say like these young people who are unemployed, those who are idle in the streets are the ones who have situations like depression, they find stealing people's things, they smoke other things in the street because they are not there empowered. That is why they have depression. Yeah.” (Interviewee 8, Rhonda) Gasps and insights of the referral Accessing mental health services in informal settlements is difficult, leaving many survivors of GBV feeling isolated and uncertain about where to seek help. In communities such as Karagita, CHPs conduct door-to-door visits, proactively identifying individuals needing mental health support. This approach is essential for connecting survivors to support programs such as PFA and PM+, which they might otherwise overlook. “I may not know, but the way I see the CHPs moving from door to door, I think many people get help. (…) she is not able to know about others but for she is not aware.” (interviewee 1, Karagita) Survivors emphasize the pivotal role of CHPs in linking them to mental health services such as PFA and PM+. Their outreach efforts are crucial for reaching those who might suffer in silence, particularly women and youth. Mothers, often seen as central to family well-being, are noted as especially in need of targeted support. Expanding CHPs' outreach to these households is viewed as significant for enhancing access to PM+, a psychosocial program that supports mental health management. “(…). CHPs are the ones who are in those households; they can just... the way they come to talk to us, there's family planning, there's children's clinic, there's dialog like that, so, now they can reach many mothers because that is the same method they used to reach me. (…). Now, if they can find other mothers who are struggling like me and those CHPs, you know, they are the easiest because they deal with those households, then they will be the ones to tell them that PM+ can help.” (Interviewee 2, Karagita) Several survivors reported that having CHPs, family members, or friends introduce them to mental health services made seeking help less intimidating. CHPs, family, and friends created a network of trusted relationships that allowed survivors to feel safe in discussing their struggles. Many were approached during routine visits, and over time, they began to open up, finding the courage to seek support. “I was introduced to it by a CHP around. Yeah, the health people come and visit us sometimes. Yeah, yeah. So, they came. I had a lot of problems, and when they were coming to my home for their routine checkup, I opened up to one of them, and I told them how I was [thinking noise] and she introduced me to another CHP who introduced me to [psychologist’s name] it.” (Interviewee 6, Rhonda) PFA and PM+ have had notable effects on many survivors’ mental health, particularly in managing stress and developing coping skills. Techniques such as breathing exercises and stress management were frequently highlighted as helpful. Additionally, the support groups within PM+ offer a private space for survivors who have completed PM+ sessions to share their experiences and find reassurance in the company of others. “At the beginning, I did not know how to manage the stress; our mentor had introduced us to PM+. In the past, whenever I got stressed, I would go to sleep in bed, and I don’t want to talk to anyone, including my child. I would transfer all my anger to my child, I would cane him severally, remembering how his dad treated me. After joining PM+, we were taught how to manage stress, how to manage problems, and now I’m better. Whenever I am stressed, I do not beat him the way I used to, I do breathing exercises.” (Interviewee 3, Karagita) Some respondents highlighted the high demand for services, emphasizing the need for more CHPs trained as PM+ helpers. However, not all CHPs have received training to serve as PM+ helpers or PFA providers. The increasing demand burdens service providers, creating delays for those seeking timely support. Expanding the number of trained professionals is essential to ensure that all survivors can access the timely support they need. “If they can train more people in PM+ to add more people, to be trained so that they are many, even those of PFA. (…) sometimes I ask myself I have offered PFA like six people all of them are referred to [provider’s name], and it is that way but even if they are referred I am not the only one who has referred PFA, you find there are others, (…).” (Interviewee 7, Rhonda) Supporting the referral network The interviews revealed that survivors of GBV have become advocates and referral points for the PFA and PM+ programs within their communities. Having experienced personal growth and healing, they now support others who are facing similar struggles. Many shared stories provide guidance to friends and neighbors who face challenges such as unplanned pregnancies or relationship issues, helping them connect with mental health support, such as PM+. “So she was stressed; she is my neighbor (…). so I advised her (…). though so she was stressed whether to get an abortion or keep it. But I told her to do some breathing exercises first, and I told her, me too was in a similar situation, pregnant, and we were not in good terms with my baby daddy, but I had my baby, I did not have an abortion, and right now my baby is grown. I encouraged her just like that and now the child she did not have an abortion, the stress went away, and she separated from that guy.” (Interviewee 3, Karagita) The respondents described how they actively refer individuals to PM+ or PFA providers, helping expand referrals to mental health services for those unaware of available support. By offering initial guidance, they play a crucial role in linking their community to professional assistance. “(…) Because right now I can share with someone else the story with whoever is in a similar situation like mine, I refer here to PFA people yeah, they get help.” (Interviewee 7, Rhonda) Through these efforts, survivors have become informal community actors/activists, with many expressing a commitment to continue this role and aspirations to become mentors. Their PM+ experiences have equipped them with skills they now share to prevent others from feeling isolated. Some expressed a desire to broaden mental health awareness, aiming to prevent GBV and mental health crises, particularly among youth. One respondent highlighted the importance of youth ambassadors in addressing issues such as femicide, emphasizing that both men and women should be involved in these efforts. “Mostly young people, my age mates, many are being killed today (…). Lets have many ambassadors. And among those ambassadors, let us have both genders because today, many men fear, mostly its us women.” (Interviewee 3, Karagita) Results for FGDs Cultural Norms and Financial Gaps In Karagita and Rhonda, prevailing cultural norms heavily influence attitudes toward GBV, often discouraging survivors from seeking help due to stigma around abuse. For women, cultural beliefs frequently limit their options, especially if they are financially dependent on their husbands. This dependency restricts their autonomy, delaying access to essential services such as healthcare. Male survivors face additional stigma, as cultural expectations demand that they conceal their experiences, often leading to significant mental health repercussions. “Cultural beliefs, yeah someone is abused by the spouse either male or female and they can’t speak up you are not supposed to report your spouse so they don’t speak out, you may just hear it from neighbors but the real person doesn’t come around to say that they have been abused yes, so they keep it to themselves and this affects them psychologically.” (PM+ helper/community health promoter, Rhonda) The economic hardship in these communities further limits access to GBV support, as many services often require fees that survivors with limited resources cannot afford. Essential legal documents, such as the P3 form—completed by a government medical doctor to document assault cases for court proceedings—also come with costs, creating financial barriers to justice. While local organizations try to bridge these financial gaps, limited funds restrict people from accessing healthcare services, highlighting a need for increased funding to support subsidized or free access for survivors. “Just to make you understand, the types of hospitals we have, the doctors have to charge for filling the P3 Form. That becomes a big challenge, because this victim may not have a single cent. Here she is being asked to pay for the P3 to be filled so that when she goes to the police, the police will require that. So you find it is a big problem. The survivor has to look for the money; she has no money, so in some cases, they are just lost in between. And maybe the issue might not be reported because the police will not arrest if the P3 has not been filled.” (PM+ supervisor, Karagita) Community-driven initiatives work to address these combined cultural and financial barriers. In informal settlements, there are many programs, such as table banking for women and other microfinance programs. Families engage in regular awareness sessions to discuss rights, and school programs teach children about mental health and respectful relationships. Teachers act as supporters in these initiatives, helping reduce stigma at an early stage. Partnering with local healthcare providers, these programs also offer financial relief by covering essential services for low-income survivors, helping more survivors access their resources, and fostering a supportive community culture. “In schools we have done it, in our local schools there are teachers who are, they have the teachers and the guiding and counseling teachers we have empowered them, they are doing some good work there.” (Public health officer, Rhonda) Gaps and Insights in the Referral Pathway The GBV referral network in Karagita and Rhonda has achieved significant progress through strong coordination among PFA providers, PM+ helpers, and community leaders. However, demand for these services far outweighs the availability of trained providers and helpers, resulting in long wait times and delays. The shortage of personnel is a pressing challenge in ensuring a consistently accessible referral system, especially for mental health support. “The relationship is very good. For example, sometimes we receive complaints from a neighbor; maybe he/she has heard the neighbor being assaulted by the husband, and he/she fears disclosing the information directly. He might go directly to the police station, then we refer him/her to the crowd there to the PFA and the village elder who will refer them (…) the collaboration is very effective (…).” (Police officer/gender desk, Karagita) Some of the survivors changed their residences frequently for privacy, safety, or economic reasons, which disrupted the continuity of care. Providers face difficulty in maintaining contact, often need to adjust schedules or track new locations for relocated survivors. While this adaptation helps, further resources are necessary to ensure that survivors receive uninterrupted support regardless of their movements within or between settlements. “(…) a survivor who keeps on moving from one place to another and you want to give that person PM+. So you are forced to travel to see that client where you do not expect.” (PM+ helper supervisor, Karagita) In Karagita, a recently established police gender desk provides a private, safe environment for survivors to report cases without fear of exposure, significantly improving their comfort and trust in the system. This initiative benefits women and children, offering security and confidentiality. In contrast, Rhonda lacks a similar facility, which reduces the sense of privacy and security available to survivors. Setting up gender desks at Rhonda could significantly increase survivor outreach and accessibility within the referral network. Despite these challenges, providers and helpers report positive effects of PM+ and PFA on both themselves and the survivors. The program has empowered survivors to return to work, start small businesses, and engage in their communities, thereby fostering resilience and independence. For providers, the work not only has heightened awareness of GBV and mental health but also has given them a stronger sense of purpose and community impact, enhancing their capacity to support others. “And from the community we have seen cases people who are very down coming back to their feet to do business (…) they have that support group, they have support partners.” (Public health officer, Rhonda) Supporting the referral network The strength of the referral network lies in its community-driven approach, where boda boda riders, chiefs, and village elders play crucial roles in promoting GBV awareness and assisting survivors. Boda boda riders, previously viewed as potential contributors to GBV, now serve as community allies, transporting survivors to safe locations and advocating for respectful behavior. Chiefs and elders, as first points of contact, assess cases and guide survivors to the appropriate services, creating a trusted support environment. “(…) we have even empowered the our boda boda, the people who ride bikes. We have also involved them in different forums so that they can be our ambassadors to preach in their households including even with their clients about gender-based violence, (…).” (Public health officer, Rhonda) Microfinance programs provide survivors with economic independence, which is essential for reducing dependency on abusive partners. Survivors gain the means to start small businesses, rebuild their lives and contribute to the community’s economic health. This financial empowerment helps them break away from abusive cycles, enhancing their resilience and overall community support. “There is a lady who needed actually, had undergone SGBV, but she cannot be able because they had separated with the husband. We refer her to another organization that you know is working and can assist. Yea. We usually do that. And even for economic whatever. They would be referred to an organization where maybe women who have undergone SGBV would be taken care of, and there maybe they learn skills like beading. They bead and maybe they are able to sell their works to other people.” (PM+ helper supervisor, Karagita) Ongoing community meetings, known as Barazas, and training sessions bring together community members to discuss GBV, mental health, and economic self-reliance. These gatherings facilitate open dialog, foster deeper collective understanding, and provide a platform for leaders to reinforce mutual support and respect. Through these forums, the community can collectively address the root causes of GBV, and Barazas builds a more resilient and informed support network. This holistic approach in Karagita and Rhonda strengthens awareness and promotes well-being, offering a sustainable model that other communities could follow. “The network is very powerful. The network is very powerful. Aah You see, after we have trained these CHPs, we normally include the elders, the nyumba kumis, think you know the community focal person and the community, as a whole, we normally call them for Baraza, they are enlightened, they are trained, because they are the people living with these people in the community.” (Area assistant chief, Rhonda) Discussion This study provides novel insights into the barriers that GBV survivors face in Karagita and Rhonda, particularly with respect to cultural norms, economic limitations, and the structure of the referral network. While the findings align with the literature on GBV and mental health, they extend the existing knowledge by highlighting the unique role of local actors in referral systems, the impact of mobility on care continuity, and the practical benefits of microfinance programs in breaking dependency cycles. These contributions highlight the importance of locally adapted and economically viable interventions, such as microfinance programs, to support survivors effectively. Cultural norms significantly influence help-seeking behavior, with study participants underscoring the societal stigma surrounding GBV, particularly men. This stigma deters survivors from speaking out, driven by fears of judgment, mirroring global research findings that prejudice and lack of mental health awareness are critical barriers to help-seeking(19). However, this study uniquely highlights how patriarchal structures in these communities exacerbate dependency on abusers, further entrenching stigma and increasing GBV risk(20). The interviews revealed that this dependency extends the psychology to include financial reliance, a theme seldom explored with such depth. Educational initiatives with local teachers have emerged as promising strategies for challenging harmful norms, supporting Rappaport’s empowerment theory, which posits that social change is facilitated by knowledge and autonomy(21). These initiatives underscore the potential of culturally sensitive strategies that build trust and confidentiality in stigmatized settings(22). Importantly, the study extends this understanding by showing how empowering local actors such as teachers, public health officers, and boda boda riders through community forums (e.g., Barazas) can shift attitudes toward GBV and mental health, creating sustainable support systems(23). Economic hardships are another critical barrier, as both interviewees and FGD participants described how financial dependency hinders access to essential government services that require a fee, such as the P3 form needed for GBV prosecution. While the literature acknowledges economic barriers to justice, this study underscores their direct impact on survivors' ability to seek legal resources(24). The high cost of medical examinations and legal documentation limits access for low-income survivors, a finding that highlights the urgent need for affordable, accessible resources. Microfinance programs were discussed positively in FGDs and in-depth interviews, offering survivors financial independence through skill-building and autonomy. While the impact of microfinance in reducing GBV is well documented, this study adds new insights by illustrating how these programs foster resilience and independence for survivors. Participants who underwent microfinance programs reported increased confidence and reduced dependency, providing evidence of their dual impact in overcoming both economic and psychological barriers(25). A primary finding from the FGDs was the pivotal role of referral networks in connecting survivors to mental health and legal support. This study offers unique insight by integrating local actors, such as boda boda riders and village elders, demonstrating how informal community structures can effectively bridge gaps in the formal referral system(26). However, significant challenges remain, including a shortage of trained personnel and inconsistent resource availability. These findings highlight the need for collaborative, community-based models to sustain robust support networks. Another important finding is the recognition of survivor mobility as a critical factor in the continuity of care. Survivors frequently relocate for privacy or safety, which interrupts access to services, a barrier less explored in previous research(27). The presence of a gender desk in Karagita offering privacy for survivors to report cases demonstrates the potential of targeted facilities to improve trust and continuity. Expanding such facilities to other areas, such as Rhonda, could significantly increase survival support, as accessible and private services reduce distress among GBV survivors(24). Finally, the study underscores the power of community engagement in fostering resilience and promoting mental health awareness. Empowered community members, such as teachers and public health officers, play a critical role in challenging harmful beliefs surrounding GBV. Community forums, such as Barazas, facilitated open discussions on GBV and mental health, creating a foundation for cultural change(23). Furthermore, empowerment through support groups was shown to provide significant psychological benefits, reducing isolation and increasing survivors’ confidence. This finding reinforces the literature on the value of peer support in mental health recovery while adding new depth by linking these initiatives to the creation of a culture of resilience(28). A strength of this study was its rigorous methodological approach, which ensured reliability and credibility. Measures such as open coding, diverse participant selection, and interviews conducted in participants’ native language enhanced validity and reduced biases. Recurring themes across sessions indicated saturation, further strengthening the generalizability of the findings. To address the biases, we considered confirmation, selection, social desirability, interviewer, and recall bias. Open coding allowed findings to emerge organically, minimizing confirmation bias. Recall bias was mitigated by including GBV survivors who had completed PM + within the past 6–12 months or who were active in support groups, although some bias may have persisted. The interviews were primarily conducted in Swahili by MIDRIFT personnel, which introduced potential interviewer bias. Adjustments for clarity were made after the FGD. Social desirability bias was a concern, as the presence of MIDRIFT staff might have influenced participants’ responses about the organization’s impact. To reduce selection bias, a recruitment strategy was used to match the demographic profiles of the PM + participants, and different stakeholder perspectives were taken into account. According to a survey by MIDRIFT-HURINET (personal communication, May 14, 2023), 479 individuals participated in PM+, with 79.2% being women and 20.8% being men. Consequently, the interview sample comprised 8 women and 2 men and was further stratified by age—6 participants were under 35 years old and 4 above 35 years old—on the basis of the Kenyan Constitution’s definition of youth(29). For focus group discussions, two groups of five were formed, including 3 men and 7 women, with 3 participants under 35 years old and 7 over 35 years old. Conducting interviews in familiar settings enhanced the ecological validity of the findings. While translation issues delayed analysis due to retranslation needs, this improved data accuracy. Overall, consistent themes across sessions supported the theoretical generalizability and robustness of the findings. Recommendations for future study and implementation The main goal of research should be to look at the long-term effects of MHPSS interventions, focusing on how they change cultural attitudes, reduce stigma, and help victims of gender-based violence. Additionally, assessing the cost-effectiveness and impact of microfinance programs for GBV survivors is critical for understanding their role in enhancing mental well-being and financial independence in informal settlements. To increase awareness and reduce stigma, local communication channels such as barazas, schools, and workplaces can promote PM + programs. Expanding PFA services to children and increasing training for providers in collaboration with government agencies and NGOs can address unmet needs. Advocacy for gender desks and dedicated reporting spaces at police stations is also recommended to improve GBV responses. Conclusion This study offers a comprehensive examination of the PFA-PM + referral pathway in Nakuru County, Kenya, shedding light on its effectiveness and challenges from the perspectives of diverse stakeholders. While the system demonstrates strong collaboration and systematic processes that support GBV survivors, it also reveals barriers such as resource limitations, financial constraints, and low community awareness. These findings highlight critical areas for intervention, providing a foundation for policymakers and service providers to enhance mental health services and better support vulnerable populations. Abbreviations CBO Community–Based Organization CHP Community health promoter DIGNITY Danish Institute Against Torture FGD Focus Group Discussion GBV Gender–based Violence GHQ General Health Questionnaire Scores IGAs Income Generating Activities Ksh Kenyan shilling MHPSS Mental Health Psychosocial Services MIDRIFT HURINET –MIDRIFT–Human Rights Network NGO Nongovernmental Organization PFA Psychological First Aid PM+ Problem Management Plus PSYCHLOPS Psychological Outcome Profiles Questionnaire SDG Sustainable Development Goals UNICEF United Nations International Children’s Fund WHO World Health Organization WHODAS World Health Organization Disability Assessment Scores Declarations Ethical approval and consent to participate Ethical approval for this study was obtained from Kenyan authorities, including the County Ethics Committee, Kabarak University, and the National Commission for Science, Technology and Innovation (NACOSTI), with the process co-managed by MIDRIFT-HURINET. Research involving survivors of gender-based violence (GBV) adhered to strict ethical protocols designed to minimize harm. To reduce the risk of retraumatization, all participants had completed the PM+ programme 6–12 months prior to data collection, and Psychological First Aid (PFA) was available if needed. Informed consent was obtained from all participants, who were informed of their right to withdraw at any time. All data were anonymized and securely stored. Furthermore, the study is in compliance with the declaration of Helsinki. The Committee Reference Number: KABU01/KUREC/001/07/01/24 Consent for publication All participants provided explicit consent for the publication of anonymized data and quotations. Signed consent forms are available from the corresponding author upon reasonable request. Availability for data and materials The datasets generated and/or analysed during the current study are not publicly available due to the sensitive and confidential nature of the data, which involves personal or identifiable information. Access to the data may be granted upon reasonable request and subject to ethical approval and data protection regulations. Please contact the corresponding author for further information. Competing interests The authors declare that they have no conflicts of interest. SJW is an employee of DIGNITY. The sponsor had no involvement in the study design, data collection, or analysis. Funding This study was produced as part of a project hosted at MIDRIFT HURIENT, funded by DIGNITY – Danish Institute Against Torture. The travel of JM and CBO was supported by the University of Southern Denmark. Authors’ contributions This study was made possible through the participation and insights of GBV survivors, as well as state and nonstate actors who generously shared their time. JM and CBO did the interview guide with support from LCR. JM and CBO were the interviewers for the in-depth and FGDs, they also transcribed all interviews that were in English. The team at Midrift helped with the transcription and translation of interviews in Swahili. JM and CBO did the analysis of all the data, and wrote the manuscript with support from SJW, LEK, LCR, and EA. SJW and LEK provided invaluable supervision, guidance, and support throughout the study. JO and the team at MIDRIFT-HURINET offered critical assistance in facilitating the project. LCR, EA, MR, CM, and the Mental Health and Psychosocial Support (MPHSS) team contributed significantly by supporting ethical clearances, respondent sampling, and providing translation services during interviews. The Monitoring and Evaluation team at MIDRIFT ensured accurate transcription and translation of the interviews. N laid the groundwork for the study, which we further developed. All contributors played a vital role in ensuring the success of this research, which was conducted with care and respect for participants. Acknowledgements Jeske Moerenhout 1 [email protected] & Cathrine B. Oksholm 1 [email protected] – University of Southern Denmark (Esbjerg, Denmark), Shr-Jie S. Wang 2 [email protected] – DIGNITY-Danish Institute Against Torture (Copenhagen, Denmark), Leslie C. Rono 3 [email protected] – MIDRIFT-HURINET (Nakuru, Kenya), Elizabeth Anyango 4 [email protected] – MIDRIFT-HURINET (Nakuru, Kenya), Leena Eklund Karlsson 5 [email protected] – University of Southern Denmark (Esbjerg, Denmark). References Garcia-Moreno C, Tordrup D, Devries K, Stöckl H, Watts CAH, Abrahams N. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. [Internet]. 2013. Available from: https://www.popline.org/node/572931 MIDRIFT-HURINET. Mental Health and Psychosocial Support using the Problem Management Plus (PM+) Approach [Internet]. MIDRIFT-HURINET; 2020 Dec. Available from: https://midrifthurinet.org/download/mhpss-project-evaluation-final-report/?wpdmdl=5330&masterkey=613a1b57c1da6 Lambert JE, Denckla CA. Posttraumatic stress and depression among women in Kenya’s informal settlements: risk and protective factors. Eur J Psychotraumatology [Internet]. 2021 Jan;12(1). Available from: https://doi.org/10.1080/20008198.2020.1865671 Kamunyori SW. Tenure Security and Improved Infrastructure for Informal Settlements in Kenya’s Cities [Internet]. 2011. Available from: https://www.thegpsc.org/sites/gpsc/files/kenya.pdf Jaguga F, Kiburi SK, Temet E, Barasa J, Karanja S, Kinyua L, et al. A systematic review of substance use and substance use disorder research in Kenya. PloS One. 2022 Jun;17(6):e0269340. Organization WH. Problem Management Plus (PM+): individual psychological help for adults impaired by distress in communities exposed to adversity (generic field-trial version 1.1) [Internet]. Vol. 2. World Health Organization; 2018. Available from: https://iris.who.int/bitstream/handle/10665/375604/WHO_MSD_MER_18.5_eng.pdf?sequence=1&isAllowed=y UNICEF, Labour M of, Laos SW. Trainers’ guide: Psychological First Aid (PFA) and Mental Health and Psychosocial Support (MHPSS) training module [Internet]. 2021. Available from: https://www.unicef.org/laos/media/5641/file/UNICEF%20and%20MOLSW_PFA%20and%20MHPSS%20Training%20Manual_Eng.pdf Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care J Int Soc Qual Health Care. 2007 Dec;19(6):349–57. Organization WH. Measuring health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0) [Internet]. World Health Organization; 2010. Available from: https://iris.who.int/bitstream/handle/10665/43974/9789241547598_eng.pdf?sequence=1 del Pilar Sánchez-López M, Dresch V. The 12-Item General Health Questionnaire (GHQ-12): reliability, external validity and factor structure in the Spanish population. Psicothema. 2008 Nov;20(4):839–43. Wojujutari AK, Idemudia ES, Ugwu LE. The evaluation of the General Health Questionnaire (GHQ-12) reliability generalization: A meta-analysis. PloS One. 2024;19(7):e0304182. CDC. ICD-10-CM [Internet]. 2024 [cited 2024 May 3]. Available from: https://www.cdc.gov/nchs/icd/icd-10-cm/index.html Green J, Thorogood N. Qualitative Methods for Health Research [Internet]. 3rd ed. Sage Publications Ltd; 2014. Available from: https://us.sagepub.com/en-us/nam/qualitative-methods-for-health-research/book254905#preview Lumivero. NVIVO: Leading Qualitative Data Analysis Software | Lumivero [Internet]. 2024 [cited 2024 May 17]. Available from: https://lumivero.com/products/nvivo/ Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006 Jan;3(2):77–101. Braun V, Clarke V. Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern‐based qualitative analytic approaches. Couns Psychother Res. 2021 Oct;21(1):37–47. Byrne D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant. 2021 Jun;56(3):1391–412. Maguire M, Delahunt B. Doing a thematic analysis: A practical, step-by-step guide for learning and teaching scholars. Irel J High Educ [Internet]. 2017 Oct;9(3). Available from: https://ojs.aishe.org/index.php/aishe-j/article/view/335 Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med. 2015;45(1):11–27. Fakir AMS, Anjum A, Bushra F, Nawar N. The endogeneity of domestic violence: Understanding women empowerment through autonomy. World Dev Perspect. 2016;2:34–42. Rappaport J. Terms of empowerment/exemplars of prevention: Toward a theory for community psychology. Am J Community Psychol. 1987 Apr 1;15(2):121–48. Musyimi CW, Mutiso VN, Ndetei DM, Unanue I, Desai D, Patel SG, et al. Mental health treatment in Kenya: task-sharing challenges and opportunities among informal health providers. Int J Ment Health Syst. 2017 Aug 1;11(1):45. Mendenhall E, Silva MJD, Hanlon C, Petersen I, Shidhaye R, Jordans M, et al. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Soc Sci Med. 2014;118:33–42. Bryant RA, Schafer A, Dawson K, Anjuri D, Mulili C, Ndogoni L, et al. Effectiveness of a brief behavioural intervention on psychological distress among women with a history of gender-based violence in urban Kenya: A randomised clinical trial. PLoS Med. 2017 Aug;14(8):e1002371. Makario S, Mutui, Muhingi W. Empowerment Programmes as Strategies Mitigating Gender-Based Violence in Kibera Informal Settlement, Nairobi City County, Kenya. Int J Soc Dev Concerns IJSDC. 2023 Oct;18(5):63–90. D’Enbeau S, Kunkel A. (Mis)managed Empowerment: Exploring Paradoxes of Practice in Domestic Violence Prevention. J Appl Commun Res Appl Commun Res. 2013 May;41(2):141–59. Give C, Ndima S, Steege R, Ormel H, McCollum R, Theobald S, et al. Strengthening referral systems in community health programs: a qualitative study in two rural districts of Maputo Province, Mozambique. BMC Health Serv Res [Internet]. 2019 Apr;19(1). Available from: https://doi.org/10.1186/s12913-019-4076-3 Nelson G, Lord J, Ochocka J. Empowerment and mental health in community: narratives of psychiatric consumer/survivors. J Community Appl Soc Psychol. 2001 Mar 1;11(2):125–42. Commission KLR. Constitution of Kenya 260. Interpretation [Internet]. 2013. Available from: https://www.klrc.go.ke/index.php/constitution-of-kenya/161-chapter-seventeen-general-provisions/429-260-interpretation Additional Declarations No competing interests reported. Supplementary Files Indepthinterviewguide.pdf Focusgroupinterviewguide.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Jan, 2026 Reviews received at journal 03 Sep, 2025 Reviews received at journal 31 Aug, 2025 Reviewers agreed at journal 22 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Editor invited by journal 16 Jul, 2025 Reviewers invited by journal 12 Jun, 2025 Editor assigned by journal 02 Jun, 2025 Submission checks completed at journal 17 May, 2025 First submitted to journal 17 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6604618","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470807334,"identity":"7226c7a6-04a9-41ea-a33e-020fe4190f81","order_by":0,"name":"Jeske Moerenhout","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACxgYYSwJEVAAxO7IoQS0HzjAw8DAT0IIAIC0H24jQwtzewLrhQ8U9OXPp5mPSH+fZJO5nZj74cAaDnZwuDn2MPQfYbs44U2xsOedYmsTBbWmJPcxsyYYbGJKNzQ7g0DIjge02b1tC4oYbOWZALYeBWnjMJB8wHEjchkvL/AdALf8S6iFa5hCjZQYDUEtDQoIBWEsDVMsGfFp6EttuzjiWYLjhRlqyxZljacY9h4F+mWGA2y+G7YeP3fhQkyBvcCP54I2KGhvZ9vbmgw97KuzkcGppwB4HBtiVg4A8bqlRMApGwSgYBVAAANDNYMN9bQKyAAAAAElFTkSuQmCC","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":true,"prefix":"","firstName":"Jeske","middleName":"","lastName":"Moerenhout","suffix":""},{"id":470807336,"identity":"db8bcd6f-d2c6-496b-aae6-2206258a94e4","order_by":1,"name":"Cathrine B. Oksholm","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Cathrine","middleName":"B.","lastName":"Oksholm","suffix":""},{"id":470807340,"identity":"d901ed42-9c5c-44ea-9ad7-27eec86be596","order_by":2,"name":"Shr-Jie S. Wang","email":"","orcid":"","institution":"Danish Institute against Torture","correspondingAuthor":false,"prefix":"","firstName":"Shr-Jie","middleName":"S.","lastName":"Wang","suffix":""},{"id":470807342,"identity":"438b3d3c-bee8-4608-9b12-d240efca42b3","order_by":3,"name":"Leslie C. Rono","email":"","orcid":"","institution":"MIDRIFT-HURINET","correspondingAuthor":false,"prefix":"","firstName":"Leslie","middleName":"C.","lastName":"Rono","suffix":""},{"id":470807344,"identity":"a27d3fb0-d1d1-41dd-ae1a-a5d63b2acdc4","order_by":4,"name":"Elizabeth Anyango","email":"","orcid":"","institution":"MIDRIFT-HURINET","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Anyango","suffix":""},{"id":470807345,"identity":"ef78957a-f205-4eb3-8a7c-c76e653df684","order_by":5,"name":"Leena Eklund Karlsson","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Leena","middleName":"Eklund","lastName":"Karlsson","suffix":""}],"badges":[],"createdAt":"2025-05-06 15:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6604618/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6604618/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84686582,"identity":"136a0d1f-8ded-4a91-a3f7-0ab7534d7e45","added_by":"auto","created_at":"2025-06-16 09:00:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":705441,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6604618/v1/b7ed01cb-db34-4349-bb8e-d3a32a4a1b9e.pdf"},{"id":84684208,"identity":"f6ecd2a7-9431-41e2-bc90-8aa8927fef6a","added_by":"auto","created_at":"2025-06-16 08:44:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":64549,"visible":true,"origin":"","legend":"","description":"","filename":"Indepthinterviewguide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6604618/v1/42f3c6c32d431adacea98777.pdf"},{"id":84684211,"identity":"541f864d-5406-4421-894c-dc3f274a2145","added_by":"auto","created_at":"2025-06-16 08:44:41","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":79882,"visible":true,"origin":"","legend":"","description":"","filename":"Focusgroupinterviewguide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6604618/v1/25efee39d764301f4fc3d4d4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pilot study: Evaluation of the referral pathway to Problem Management Plus (PM+) in Nakuru County, Kenya: GBV survivors’ and stakeholders’ statement: A tale of PM+","fulltext":[{"header":"Key message ","content":"\u003cp\u003eCultural and Financial Barriers, Community Initiatives and Support Networks, Economic Empowerment and Holistic Approaches, Health System Strengthening, Community-Based Care.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eGender-based violence (GBV) is a critical human rights issue officially defined in 1993 by the UN’s Declaration on the Elimination of Violence against Women(1). Since then, global frameworks have emerged to address GBV, particularly in lower-income settings(1).\u003c/p\u003e\n\u003cp\u003eIn Kenya, GBV most commonly manifests as emotional, physical, and sexual abuse. The Kenya Demographic and Health Survey revealed that 34% of women have faced physical violence since the age of 15, and 42% of women aged 15–49 have experienced physical or sexual violence from a partner(2). Informal settlements in Kenya face heightened GBV risks due to poverty and limited access to services. A study in Nakuru County emphasized the need for mental health and psychosocial support (MHPSS) for GBV survivors, highlighting that service gaps are worsened by urbanization, rapid population growth, and unemployment(2,3).\u003c/p\u003e\n\u003cp\u003eKenya’s health system, organized into six levels, integrates mental health services from community care to specialized facilities(4). Despite efforts, mental health remains a growing concern, with noncommunicable diseases, including mental health conditions, being the second leading cause of disability and death⁵. Community-based interventions, such as Psychological First Aid (PFA) and Problem Management Plus (PM+), are implemented at the primary care level(4,5).\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eInterventions\u0026nbsp;\u003c/em\u003e\u003cem\u003ethat Address\u003c/em\u003e\u003cem\u003e\u0026nbsp;GBV in Nakuru County\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eIn response to the severe GBV challenges in Nakuru County's informal settlements, the MIDRIFT-Human Rights Network, in partnership with a Danish organization, the Danish Institution Against Torture (DIGNITY), initiated a rehabilitation project aimed at supporting survivors of torture and GBV in 2020. The project employs Problem Management Plus (PM+), a tool that the WHO developed to help people in communities facing adversity(6).\u003c/p\u003e\n\u003cp\u003eMIDRIFT launched PM+ implementation in 2020. In 2021, MIDRIFT launched PFA services during the COVID-19 pandemic as the second step. Currently, both PM+ and PFA services are being gradually expanded by training additional Community Health Providers (CHPs) to deliver these services. (DIGNITY, personal communication, May 28, 2024).\u003c/p\u003e\n\u003ch4\u003eProblem Management Plus (PM+)\u003c/h4\u003e\n\u003cp\u003ePM+ is a structured, psychological intervention designed to address common mental health problems, such as depression, anxiety, and stress, particularly in communities exposed to adversity(6). In the context of Nakuru County, PM+ offers survivors a series of 5 sessions aimed at improving their mental health. After completing these sessions, survivors have the option to join support groups for continued assistance.\u003c/p\u003e\n\u003cp\u003eThroughout the PM+ process, continuous communication between the helper and supervisor ensures proper case management, addressing the specific needs of each survivor. This collaboration helps ensure that survivors receive tailored and effective care, enhancing the overall efficacy of the intervention.\u003c/p\u003e\n\u003ch4\u003ePsychological First Aid (PFA)\u003c/h4\u003e\n\u003cp\u003eDuring the COVID-19 pandemic, the project expanded to include PFA, a mental health intervention designed to offer immediate support to individuals in crisis(7). PFA created synergy with the existing PM+ project, enhancing the referral system to ensure that survivors received the necessary support (DIGNITY, personal communication, May 28, 2024).\u003c/p\u003e\n\u003ch4\u003eReferral System for GBV Survivors\u003c/h4\u003e\n\u003cp\u003eVarious entry points within Nakuru County allow for the identification and referral of GBV survivors.\u0026nbsp;Typically, survivors are referred by a Community Health Provider (CHP) to a community leader, gender desk officer, chief, or medical service, with cross-referrals occurring between these roles. In some cases, CHPs may serve dual roles as PFA providers and PM+ helpers, allowing them to self-refer survivors (MIDRIFT-HURINET, personal communication, May 14, 2024).\u003c/p\u003e\n\u003ch4\u003eReferral Pathway and Case Management\u003c/h4\u003e\n\u003cp\u003eSurvivors who opt for PM+ undergo 5 sessions, with assessments for suicide at the beginning and at the end. After the sessions, they can voluntarily join a support group for up to three months. The referral pathway may vary on the basis of community dynamics. For example, a gender desk report could trigger an intervention by Nyumba Kumi, a community leader responsible for 10 households in a village, followed by a PFA referral and PM+ sessions. If specialized care is needed, the PM+ helper refers the client to a supervisor, who may involve MIDRIFT psychologists for further support. In cases of child abuse, referrals are directed to the children's office, as PFA and PM+ services are currently limited to adults.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAim of the study\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis article explores the referral pathway between PFA and PM+ and investigates the functionality of this system and the impact of these interventions in encouraging GBV survivors. It examines the experiences of key stakeholders in Nakuru County, Kenya, providing insights into the effectiveness of the referral process.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis qualitative study uses in-depth interviews and focus groups to gather data from GBV survivors and state and nonstate actors in Nakuru County, Kenya. The study was conducted between January and February 2024. Additionally, all interview guides for the in-depth interviews and FGDs were developed for this specific study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn-depth interviews\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study adheres to the COREQ 32-item checklist to ensure transparent reporting of the in-depth interviews conducted(8).\u003c/p\u003e\n\u003cp\u003eTen GBV survivors consented to participate in the interview, representing a mix of genders and age groups. The interviews were conducted in local hospitals and facilitated by a psychologist and a researcher, with sessions lasting 30-50 minutes. All interviews were recorded, anonymized, and securely stored. The interviewer had no prior relationship with the participants, and all interviews had prior training in in-depth interviews.\u003c/p\u003e\n\u003cp\u003eThe participants in the in-depth interviews had to be at least 18 years old, have survived or been affected by GBV (as defined in the introduction), live in intervention areas (Nakuru Town East, Nakuru Town West, and Naivasha), plan to stay for 12 months, and be current or former participants of the PM+ program.\u0026nbsp;They needed to comprehend basic questions, follow instructions from the PM+ Helper, score ≥17 on the WHO Disability Assessment Schedule (WHODAS) 2.0(9) and ≥3 on the General Health Questionnaire (GHQ-12)(10,11), and have the ability to communicate in English or Swahili.\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria included acute medical conditions, such as serious suicide risk (e.g., a plan to act within 2 weeks as per the PM+ manual(6)), severe cognitive or neurological impairments (ICD-10 diagnoses F2x, F30.1–F31.9), neurodegenerative disorders (e.g., Alzheimer’s or Parkinson’s), or severe substance abuse disorders (F1x.24–F1x.26)(12).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFocus Group Discussion (FGD)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo focus groups were held, each with 5 participants, including CHPs, police officers, and religious leaders. Discussions were held in local hospitals, recorded for analysis, and lasted approximately 1 hour(13). The participants were selected on the basis of the following inclusion criteria:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMust be a community member, such as police officers, gender officers, religious leaders, chiefs, clinical officers, teachers, PFA providers and PM+ helpers, etc.\u003c/li\u003e\n \u003cli\u003eMust reside in Karagita (Naivasha) and Rhonda (Nakuru Town West)\u003c/li\u003e\n \u003cli\u003eExperience with case detection and referral in the community and at the county level\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll the in-depth interviews and FGDs were recorded and transcribed verbatim. Thematic analysis was used to analyze the data via NVIVO-14, identifying key patterns and themes from the interviews and focus groups(14–18). In total, 5 rounds of coding were conducted for the in-depth interviews, and 4 rounds were conducted for the focus groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKenyan authorities, including the County Ethics Committee, Kabarak University, and the National Commission for Science, Technology and Innovation, granted ethical approval, with MIDRIFT-HURINET comanaging the process. Research with GBV survivors followed strict ethical protocols to minimize harm. The participants had completed the PM+ programme 6–12 months earlier to reduce retraumatization risks, with PFA available if needed. Informed consent was obtained, ensuring the right to withdraw at any time, and the data were anonymized and securely stored.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eResults\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof the\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ein-depth interviews\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003eCultural norms and financial and socioeconomic obstacles for survivors\u003c/h3\u003e\n\u003cp\u003eThe in-depth interviews with GBV survivors in the informal settlements of Karagita and Rhonda revealed substantial barriers to discussing mental health. Many survivors fear that sharing their struggles will lead to gossip or stigma, particularly among their close-knit communities. In both settlements, discussing mental health is uncommon, especially for GBV survivors, who worry about confidentiality and judgement. In Karagita, many prefer to keep their challenges private, fearing that disclosure could lead to gossip and a lack of trust, even with professionals.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I did not have anyone I could share my problems with, I felt if I shared with anyone... (…) They would go and say things out there, (…). I used to think that the helper would go out and talk about my problems to people who would know what I am going through, yes.”\u0026nbsp;\u003c/em\u003e(Interviewee 1, Karagita)\u003c/p\u003e\n\u003cp\u003eIn Rhonda, survivors face similar challenges, often choosing silence due to low confidence in those around them to maintain privacy. Many women hesitate to open up, fear judgments or misunderstandings, and often worry that even community health volunteers may not protect their privacy. This fear of exposure prevents many from seeking help, deepening their sense of isolation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“It was not easy because I did not want my issues to be known. He listened and just said its not usual for me to be in this state; there must be something wrong, something bothering you on the inside, so he slowly prompted followed up on me and I opened up.”\u0026nbsp;\u003c/em\u003e(Interviewee 6, Rhonda)\u003c/p\u003e\n\u003cp\u003eCultural expectations of masculinity create additional challenges for male survivors, who often feel shame or weakness about disclosing emotional struggles. Some men avoid sharing with female health providers, and expanding access to gender-sensitive mental health support and promoting awareness of male survivor experiences can help address these challenges.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If we had these people, like the service providers in our group, you know boys do not like to share with a woman. (…) yeah… And you see men nowadays if they don’t talk… they resort to suicide.”\u0026nbsp;\u003c/em\u003e(Interviewee 3, Karagita)\u003c/p\u003e\n\u003cp\u003eUnemployment also exacerbates the mental health challenges of GBV survivors, especially young people, who may engage in risky behaviors as a coping mechanism. For women, joblessness increases their vulnerability to exploitation, with some feeling pressured into unwanted relationships for financial survival. Financial constraints further limit access to mental health services, as many avoid seeking professional help, assuming that it is unaffordable. Other NGOs fund microfinance programs in informal settlements, which some participants have participated in. Many were unaware of the programs before being offered to join. Both Karagita and Rhonda residents expressed surprise that community-based programs such as PFA and PM+ were free, having believed mental health services to be a luxury only available to wealthy people.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“(...) So, I think if people will be empowered, at least those things will decrease a little bit, let's say like these young people who are unemployed, those who are idle in the streets are the ones who have situations like depression, they find stealing people's things, they smoke other things in the street because they are not there empowered.\u0026nbsp;\u003c/em\u003e\u003cem\u003eThat is why they have depression. Yeah.”\u0026nbsp;\u003c/em\u003e(Interviewee 8, Rhonda)\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eGasps and insights of the referral\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eAccessing mental health services in informal settlements is difficult, leaving many survivors of GBV feeling isolated and uncertain about where to seek help. In communities such as Karagita, CHPs conduct door-to-door visits, proactively identifying individuals needing mental health support. This approach is essential for connecting survivors to support programs such as PFA and PM+, which they might otherwise overlook.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I may not know, but the way I see the CHPs moving from door to door, I think many people get help. (…) she is not able to know about others but for she is not aware.”\u0026nbsp;\u003c/em\u003e(interviewee 1, Karagita)\u003c/p\u003e\n\u003cp\u003eSurvivors emphasize the pivotal role of CHPs in linking them to mental health services such as PFA and PM+. Their outreach efforts are crucial for reaching those who might suffer in silence, particularly women and youth. Mothers, often seen as central to family well-being, are noted as especially in need of targeted support. Expanding CHPs' outreach to these households is viewed as significant for enhancing access to PM+, a psychosocial program that supports mental health management.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“(…). CHPs are the ones who are in those households; they can just... the way they come to talk to us, there's family planning, there's children's clinic, there's dialog like that, so, now they can reach many mothers because that is the same method they used to reach me. (…). Now, if they can find other mothers who are struggling like me and those CHPs, you know, they are the easiest because they deal with those households, then they will be the ones to tell them that PM+ can help.”\u0026nbsp;\u003c/em\u003e(Interviewee 2, Karagita)\u003c/p\u003e\n\u003cp\u003eSeveral survivors reported that having CHPs, family members, or friends introduce them to mental health services made seeking help less intimidating. CHPs, family, and friends created a network of trusted relationships that allowed survivors to feel safe in discussing their struggles. Many were approached during routine visits, and over time, they began to open up, finding the courage to seek support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I was introduced to it by a CHP around. Yeah, the health people come and visit us sometimes. Yeah, yeah. So, they came. I had a lot of problems, and when they were coming to my home for their routine checkup, I opened up to one of them, and I told them how I was [thinking noise] and she introduced me to another CHP who introduced me to [psychologist’s name] it.”\u0026nbsp;\u003c/em\u003e(Interviewee 6, Rhonda)\u003c/p\u003e\n\u003cp\u003ePFA and PM+ have had notable effects on many survivors’ mental health, particularly in managing stress and developing coping skills. Techniques such as breathing exercises and stress management were frequently highlighted as helpful. Additionally, the support groups within PM+ offer a private space for survivors who have completed PM+ sessions to share their experiences and find reassurance in the company of others.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“At the beginning, I did not know how to manage the stress; our mentor had introduced us to PM+. In the past, whenever I got stressed, I would go to sleep in bed, and I don’t want to talk to anyone, including my child. I would transfer all my anger to my child, I would cane him severally, remembering how his dad treated me. After joining PM+, we were taught how to manage stress, how to manage problems, and now I’m better. Whenever I am stressed, I do not beat him the way I used to, I do breathing exercises.”\u0026nbsp;\u003c/em\u003e(Interviewee 3, Karagita)\u003c/p\u003e\n\u003cp\u003eSome respondents highlighted the high demand for services, emphasizing the need for more CHPs trained as PM+ helpers. However, not all CHPs have received training to serve as PM+ helpers or PFA providers. The increasing demand burdens service providers, creating delays for those seeking timely support. Expanding the number of trained professionals is essential to ensure that all survivors can access the timely support they need.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If they can train more people in PM+ to add more people, to be trained so that they are many, even those of PFA. (…) sometimes I ask myself I have offered PFA like six people all of them are referred to [provider’s name], and it is that way but even if they are referred I am not the only one who has referred PFA, you find there are others, (…).”\u0026nbsp;\u003c/em\u003e(Interviewee 7, Rhonda)\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eSupporting the referral network\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe interviews revealed that survivors of GBV have become advocates and referral points for the PFA and PM+ programs within their communities. Having experienced personal growth and healing, they now support others who are facing similar struggles. Many shared stories provide guidance to friends and neighbors who face challenges such as unplanned pregnancies or relationship issues, helping them connect with mental health support, such as PM+.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“So she was stressed; she is my neighbor (…). so I advised her (…). though so she was stressed whether to get an abortion or keep it. But I told her to do some breathing exercises first, and I told her, me too was in a similar situation, pregnant, and we were not in good terms with my baby daddy, but I had my baby, I did not have an abortion, and right now my baby is grown. I encouraged her just like that and now the child she did not have an abortion, the stress went away, and she separated from that guy.”\u0026nbsp;\u003c/em\u003e(Interviewee 3, Karagita)\u003c/p\u003e\n\u003cp\u003eThe respondents described how they actively refer individuals to PM+ or PFA providers, helping expand referrals to mental health services for those unaware of available support. By offering initial guidance, they play a crucial role in linking their community to professional assistance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“(…) Because right now I can share with someone else the story with whoever is in a similar situation like mine, I refer here to PFA people yeah, they get help.”\u0026nbsp;\u003c/em\u003e(Interviewee 7, Rhonda)\u003c/p\u003e\n\u003cp\u003eThrough these efforts, survivors have become informal community actors/activists, with many expressing a commitment to continue this role and aspirations to become mentors. Their PM+ experiences have equipped them with skills they now share to prevent others from feeling isolated. Some expressed a desire to broaden mental health awareness, aiming to prevent GBV and mental health crises, particularly among youth. One respondent highlighted the importance of youth ambassadors in addressing issues such as femicide, emphasizing that both men and women should be involved in these efforts.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Mostly young people, my age mates, many are being killed today (…). Lets have many ambassadors. And among those ambassadors, let us have both genders because today, many men fear, mostly its us women.” (Interviewee 3, Karagita)\u003c/em\u003e\u003c/p\u003e"},{"header":"Results for FGDs","content":"\u003ch3\u003e\u003cem\u003eCultural Norms and Financial Gaps\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eIn Karagita and Rhonda, prevailing cultural norms heavily influence attitudes toward GBV, often discouraging survivors from seeking help due to stigma around abuse. For women, cultural beliefs frequently limit their options, especially if they are financially dependent on their husbands. This dependency restricts their autonomy, delaying access to essential services such as healthcare. Male survivors face additional stigma, as cultural expectations demand that they conceal their experiences, often leading to significant mental health repercussions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Cultural beliefs, yeah someone is abused by the spouse either male or female and they can\u0026rsquo;t speak up you are not supposed to report your spouse so they don\u0026rsquo;t speak out, you may just hear it from neighbors but the real person doesn\u0026rsquo;t come around to say that they have been abused yes, so they keep it to themselves and this affects them psychologically.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(PM+ helper/community health promoter, Rhonda)\u003c/p\u003e\n\u003cp\u003eThe economic hardship in these communities further limits access to GBV support, as many services often require fees that survivors with limited resources cannot afford. Essential legal documents, such as the P3 form\u0026mdash;completed by a government medical doctor to document assault cases for court proceedings\u0026mdash;also come with costs, creating financial barriers to justice.\u0026nbsp;While local organizations try to bridge these financial gaps, limited funds restrict people from accessing healthcare services, highlighting a need for increased funding to support subsidized or free access for survivors.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Just to make you understand, the types of hospitals we have, the doctors have to charge for filling the P3 Form. That becomes a big challenge, because this victim may not have a single cent. Here she is being asked to pay for the P3 to be filled so that when she goes to the police, the police will require that. So you find it is a big problem. The survivor has to look for the money; she has no money, so in some cases, they are just lost in between. And maybe the issue might not be reported because the police will not arrest if the P3 has not been filled.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e(PM+ supervisor, Karagita)\u003c/p\u003e\n\u003cp\u003eCommunity-driven initiatives work to address these combined cultural and financial barriers. In informal settlements, there are many programs, such as table banking for women and other microfinance programs. Families engage in regular awareness sessions to discuss rights, and school programs teach children about mental health and respectful relationships. Teachers act as supporters in these initiatives, helping reduce stigma at an early stage. Partnering with local healthcare providers, these programs also offer financial relief by covering essential services for low-income survivors, helping more survivors access their resources, and fostering a supportive community culture.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In schools we have done it, in our local schools there are teachers who are, they have the teachers and the guiding and counseling teachers we have empowered them, they are doing some good work there.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Public health officer, Rhonda)\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eGaps and Insights in the Referral Pathway\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe GBV referral network in Karagita and Rhonda has achieved significant progress through strong coordination among PFA providers, PM+ helpers, and community leaders. However, demand for these services far outweighs the availability of trained providers and helpers, resulting in long wait times and delays. The shortage of personnel is a pressing challenge in ensuring a consistently accessible referral system, especially for mental health support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The relationship is very good. For example, sometimes we receive complaints from a neighbor; maybe he/she has heard the neighbor being assaulted by the husband, and he/she fears disclosing the information directly. He might go directly to the police station, then we refer him/her to the crowd there to the PFA and the village elder who will refer them (\u0026hellip;) the collaboration is very effective (\u0026hellip;).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e(Police officer/gender desk, Karagita)\u003c/p\u003e\n\u003cp\u003eSome of the survivors changed their residences frequently for privacy, safety, or economic reasons, which disrupted the continuity of care. Providers face difficulty in maintaining contact, often need to adjust schedules or track new locations for relocated survivors. While this adaptation helps, further resources are necessary to ensure that survivors receive uninterrupted support regardless of their movements within or between settlements.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) a survivor who keeps on moving from one place to another and you want to give that person PM+. So you are forced to travel to see that client where you do not expect.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(PM+ helper supervisor, Karagita)\u003c/p\u003e\n\u003cp\u003eIn Karagita, a recently established police gender desk provides a private, safe environment for survivors to report cases without fear of exposure, significantly improving their comfort and trust in the system. This initiative benefits women and children, offering security and confidentiality. In contrast, Rhonda lacks a similar facility, which reduces the sense of privacy and security available to survivors. Setting up gender desks at Rhonda could significantly increase survivor outreach and accessibility within the referral network.\u003c/p\u003e\n\u003cp\u003eDespite these challenges, providers and helpers report positive effects of PM+ and PFA on both themselves and the survivors. The program has empowered survivors to return to work, start small businesses, and engage in their communities, thereby fostering resilience and independence. For providers, the work not only has heightened awareness of GBV and mental health but also has given them a stronger sense of purpose and community impact, enhancing their capacity to support others.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;And from the community we have seen cases people who are very down coming back to their feet to do business (\u0026hellip;) they have that support group, they have support partners.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Public health officer, Rhonda)\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eSupporting the\u0026nbsp;\u003c/em\u003e\u003cem\u003ereferral network\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe strength of the referral network lies in its community-driven approach, where boda boda riders, chiefs, and village elders play crucial roles in promoting GBV awareness and assisting survivors. Boda boda riders, previously viewed as potential contributors to GBV, now serve as community allies, transporting survivors to safe locations and advocating for respectful behavior. Chiefs and elders, as first points of contact, assess cases and guide survivors to the appropriate services, creating a trusted support environment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) we have even empowered the our boda boda, the people who ride bikes. We have also involved them in different forums so that they can be our ambassadors to preach in their households including even with their clients about gender-based violence, (\u0026hellip;).\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Public health officer, Rhonda)\u003c/p\u003e\n\u003cp\u003eMicrofinance programs provide survivors with economic independence, which is essential for reducing dependency on abusive partners. Survivors gain the means to start small businesses, rebuild their lives and contribute to the community\u0026rsquo;s economic health. This financial empowerment helps them break away from abusive cycles, enhancing their resilience and overall community support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is a lady who needed actually, had undergone SGBV, but she cannot be able because they had separated with the husband. We refer her to another organization that you know is working and can assist. Yea. We usually do that. And even for economic whatever. They would be referred to an organization where maybe women who have undergone SGBV would be taken care of, and there maybe they learn skills like beading. They bead and maybe they are able to sell their works to other people.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(PM+ helper supervisor, Karagita)\u003c/p\u003e\n\u003cp\u003eOngoing community meetings, known as Barazas, and training sessions bring together community members to discuss GBV, mental health, and economic self-reliance. These gatherings facilitate open dialog, foster deeper collective understanding, and provide a platform for leaders to reinforce mutual support and respect. Through these forums, the community can collectively address the root causes of GBV, and Barazas builds a more resilient and informed support network. This holistic approach in Karagita and Rhonda strengthens awareness and promotes well-being, offering a sustainable model that other communities could follow.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The network is very powerful. The network is very powerful. Aah You see, after we have trained these CHPs, we normally include the elders, the nyumba kumis, think you know the community focal person and the community, as a whole, we normally call them for Baraza, they are enlightened, they are trained, because they are the people living with these people in the community.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Area assistant chief, Rhonda)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides novel insights into the barriers that GBV survivors face in Karagita and Rhonda, particularly with respect to cultural norms, economic limitations, and the structure of the referral network. While the findings align with the literature on GBV and mental health, they extend the existing knowledge by highlighting the unique role of local actors in referral systems, the impact of mobility on care continuity, and the practical benefits of microfinance programs in breaking dependency cycles. These contributions highlight the importance of locally adapted and economically viable interventions, such as microfinance programs, to support survivors effectively.\u003c/p\u003e \u003cp\u003eCultural norms significantly influence help-seeking behavior, with study participants underscoring the societal stigma surrounding GBV, particularly men. This stigma deters survivors from speaking out, driven by fears of judgment, mirroring global research findings that prejudice and lack of mental health awareness are critical barriers to help-seeking(19). However, this study uniquely highlights how patriarchal structures in these communities exacerbate dependency on abusers, further entrenching stigma and increasing GBV risk(20). The interviews revealed that this dependency extends the psychology to include financial reliance, a theme seldom explored with such depth.\u003c/p\u003e \u003cp\u003eEducational initiatives with local teachers have emerged as promising strategies for challenging harmful norms, supporting Rappaport\u0026rsquo;s empowerment theory, which posits that social change is facilitated by knowledge and autonomy(21). These initiatives underscore the potential of culturally sensitive strategies that build trust and confidentiality in stigmatized settings(22). Importantly, the study extends this understanding by showing how empowering local actors such as teachers, public health officers, and boda boda riders through community forums (e.g., Barazas) can shift attitudes toward GBV and mental health, creating sustainable support systems(23).\u003c/p\u003e \u003cp\u003eEconomic hardships are another critical barrier, as both interviewees and FGD participants described how financial dependency hinders access to essential government services that require a fee, such as the P3 form needed for GBV prosecution. While the literature acknowledges economic barriers to justice, this study underscores their direct impact on survivors' ability to seek legal resources(24). The high cost of medical examinations and legal documentation limits access for low-income survivors, a finding that highlights the urgent need for affordable, accessible resources.\u003c/p\u003e \u003cp\u003eMicrofinance programs were discussed positively in FGDs and in-depth interviews, offering survivors financial independence through skill-building and autonomy. While the impact of microfinance in reducing GBV is well documented, this study adds new insights by illustrating how these programs foster resilience and independence for survivors. Participants who underwent microfinance programs reported increased confidence and reduced dependency, providing evidence of their dual impact in overcoming both economic and psychological barriers(25).\u003c/p\u003e \u003cp\u003eA primary finding from the FGDs was the pivotal role of referral networks in connecting survivors to mental health and legal support. This study offers unique insight by integrating local actors, such as boda boda riders and village elders, demonstrating how informal community structures can effectively bridge gaps in the formal referral system(26). However, significant challenges remain, including a shortage of trained personnel and inconsistent resource availability. These findings highlight the need for collaborative, community-based models to sustain robust support networks.\u003c/p\u003e \u003cp\u003eAnother important finding is the recognition of survivor mobility as a critical factor in the continuity of care. Survivors frequently relocate for privacy or safety, which interrupts access to services, a barrier less explored in previous research(27). The presence of a gender desk in Karagita offering privacy for survivors to report cases demonstrates the potential of targeted facilities to improve trust and continuity. Expanding such facilities to other areas, such as Rhonda, could significantly increase survival support, as accessible and private services reduce distress among GBV survivors(24).\u003c/p\u003e \u003cp\u003eFinally, the study underscores the power of community engagement in fostering resilience and promoting mental health awareness. Empowered community members, such as teachers and public health officers, play a critical role in challenging harmful beliefs surrounding GBV. Community forums, such as Barazas, facilitated open discussions on GBV and mental health, creating a foundation for cultural change(23). Furthermore, empowerment through support groups was shown to provide significant psychological benefits, reducing isolation and increasing survivors\u0026rsquo; confidence. This finding reinforces the literature on the value of peer support in mental health recovery while adding new depth by linking these initiatives to the creation of a culture of resilience(28).\u003c/p\u003e \u003cp\u003eA strength of this study was its rigorous methodological approach, which ensured reliability and credibility. Measures such as open coding, diverse participant selection, and interviews conducted in participants\u0026rsquo; native language enhanced validity and reduced biases. Recurring themes across sessions indicated saturation, further strengthening the generalizability of the findings.\u003c/p\u003e \u003cp\u003eTo address the biases, we considered confirmation, selection, social desirability, interviewer, and recall bias. Open coding allowed findings to emerge organically, minimizing confirmation bias. Recall bias was mitigated by including GBV survivors who had completed PM\u0026thinsp;+\u0026thinsp;within the past 6\u0026ndash;12 months or who were active in support groups, although some bias may have persisted.\u003c/p\u003e \u003cp\u003eThe interviews were primarily conducted in Swahili by MIDRIFT personnel, which introduced potential interviewer bias. Adjustments for clarity were made after the FGD. Social desirability bias was a concern, as the presence of MIDRIFT staff might have influenced participants\u0026rsquo; responses about the organization\u0026rsquo;s impact.\u003c/p\u003e \u003cp\u003eTo reduce selection bias, a recruitment strategy was used to match the demographic profiles of the PM\u0026thinsp;+\u0026thinsp;participants, and different stakeholder perspectives were taken into account. According to a survey by MIDRIFT-HURINET (personal communication, May 14, 2023), 479 individuals participated in PM+, with 79.2% being women and 20.8% being men. Consequently, the interview sample comprised 8 women and 2 men and was further stratified by age\u0026mdash;6 participants were under 35 years old and 4 above 35 years old\u0026mdash;on the basis of the Kenyan Constitution\u0026rsquo;s definition of youth(29). For focus group discussions, two groups of five were formed, including 3 men and 7 women, with 3 participants under 35 years old and 7 over 35 years old. Conducting interviews in familiar settings enhanced the ecological validity of the findings. While translation issues delayed analysis due to retranslation needs, this improved data accuracy.\u003c/p\u003e \u003cp\u003eOverall, consistent themes across sessions supported the theoretical generalizability and robustness of the findings.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for future study and implementation\u003c/h2\u003e \u003cp\u003eThe main goal of research should be to look at the long-term effects of MHPSS interventions, focusing on how they change cultural attitudes, reduce stigma, and help victims of gender-based violence. Additionally, assessing the cost-effectiveness and impact of microfinance programs for GBV survivors is critical for understanding their role in enhancing mental well-being and financial independence in informal settlements.\u003c/p\u003e \u003cp\u003eTo increase awareness and reduce stigma, local communication channels such as barazas, schools, and workplaces can promote PM\u0026thinsp;+\u0026thinsp;programs. Expanding PFA services to children and increasing training for providers in collaboration with government agencies and NGOs can address unmet needs. Advocacy for gender desks and dedicated reporting spaces at police stations is also recommended to improve GBV responses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study offers a comprehensive examination of the PFA-PM\u0026thinsp;+\u0026thinsp;referral pathway in Nakuru County, Kenya, shedding light on its effectiveness and challenges from the perspectives of diverse stakeholders. While the system demonstrates strong collaboration and systematic processes that support GBV survivors, it also reveals barriers such as resource limitations, financial constraints, and low community awareness.\u003c/p\u003e \u003cp\u003eThese findings highlight critical areas for intervention, providing a foundation for policymakers and service providers to enhance mental health services and better support vulnerable populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCBO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity\u0026ndash;Based Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCHP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity health promoter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDIGNITY\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDanish Institute Against Torture\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eFGD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGBV\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGender\u0026ndash;based Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGHQ\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Health Questionnaire Scores\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIGAs\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIncome Generating Activities\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eKsh\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKenyan shilling\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMHPSS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental Health Psychosocial Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMIDRIFT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cb\u003eHURINET\u003c/b\u003e\u0026ndash;MIDRIFT\u0026ndash;Human Rights Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNGO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNongovernmental Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePFA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePsychological First Aid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePM+\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProblem Management Plus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePSYCHLOPS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePsychological Outcome Profiles Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSDG\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustainable Development Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUNICEF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Nations International Children\u0026rsquo;s Fund\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHODAS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization Disability Assessment Scores\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthical approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from Kenyan authorities, including the County Ethics Committee, Kabarak University, and the National Commission for Science, Technology and Innovation (NACOSTI), with the process co-managed by MIDRIFT-HURINET. Research involving survivors of gender-based violence (GBV) adhered to strict ethical protocols designed to minimize harm. To reduce the risk of retraumatization, all participants had completed the PM+ programme 6–12 months prior to data collection, and Psychological First Aid (PFA) was available if needed. Informed consent was obtained from all participants, who were informed of their right to withdraw at any time. All data were anonymized and securely stored. Furthermore, the study is in compliance with the declaration of Helsinki. \u003c/p\u003e\n\u003cp\u003eThe Committee Reference Number: \u003cstrong\u003eKABU01/KUREC/001/07/01/24 \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided explicit consent for the publication of anonymized data and quotations. Signed consent forms are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability for data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to the sensitive and confidential nature of the data, which involves personal or identifiable information. Access to the data may be granted upon reasonable request and subject to ethical approval and data protection regulations. Please contact the corresponding author for further information.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest. SJW is an employee of DIGNITY. The sponsor had no involvement in the study design, data collection, or analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was produced as part of a project hosted at MIDRIFT HURIENT, funded by DIGNITY – Danish Institute Against Torture. The travel of JM and CBO was supported by the University of Southern Denmark.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors’ contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was made possible through the participation and insights of GBV survivors, as well as state and nonstate actors who generously shared their time.\u003c/p\u003e\n\u003cp\u003eJM and CBO did the interview guide with support from LCR. JM and CBO were the interviewers for the in-depth and FGDs, they also transcribed all interviews that were in English. The team at Midrift helped with the transcription and translation of interviews in Swahili. JM and CBO did the analysis of all the data, and wrote the manuscript with support from SJW, LEK, LCR, and EA.\u003c/p\u003e\n\u003cp\u003eSJW and LEK provided invaluable supervision, guidance, and support throughout the study. JO and the team at MIDRIFT-HURINET offered critical assistance in facilitating the project. LCR, EA, MR, CM, and the Mental Health and Psychosocial Support (MPHSS) team contributed significantly by supporting ethical clearances, respondent sampling, and providing translation services during interviews. The Monitoring and Evaluation team at MIDRIFT ensured accurate transcription and translation of the interviews. N laid the groundwork for the study, which we further developed. All contributors played a vital role in ensuring the success of this research, which was conducted with care and respect for participants.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eJeske Moerenhout\u003csup\u003e1\u003c/sup\u003e [email protected] \u0026amp; Cathrine B. Oksholm\u003csup\u003e1\u003c/sup\u003e [email protected] – University of Southern Denmark (Esbjerg, Denmark), Shr-Jie S. Wang\u003csup\u003e2\u003c/sup\u003e [email protected] – DIGNITY-Danish Institute Against Torture (Copenhagen, Denmark), Leslie C. Rono\u003csup\u003e3\u003c/sup\u003e [email protected] – MIDRIFT-HURINET (Nakuru, Kenya), Elizabeth Anyango\u003csup\u003e4\u003c/sup\u003e [email protected] – MIDRIFT-HURINET (Nakuru, Kenya), Leena Eklund Karlsson\u003csup\u003e5\u003c/sup\u003e [email protected] – University of Southern Denmark (Esbjerg, Denmark).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGarcia-Moreno C, Tordrup D, Devries K, St\u0026ouml;ckl H, Watts CAH, Abrahams N. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. [Internet]. 2013. Available from: https://www.popline.org/node/572931\u003c/li\u003e\n \u003cli\u003eMIDRIFT-HURINET. Mental Health and Psychosocial Support using the Problem Management Plus (PM+) Approach [Internet]. MIDRIFT-HURINET; 2020 Dec. Available from: https://midrifthurinet.org/download/mhpss-project-evaluation-final-report/?wpdmdl=5330\u0026amp;masterkey=613a1b57c1da6\u003c/li\u003e\n \u003cli\u003eLambert JE, Denckla CA. Posttraumatic stress and depression among women in Kenya\u0026rsquo;s informal settlements: risk and protective factors. Eur J Psychotraumatology [Internet]. 2021 Jan;12(1). Available from: https://doi.org/10.1080/20008198.2020.1865671\u003c/li\u003e\n \u003cli\u003eKamunyori SW. Tenure Security and Improved Infrastructure for Informal Settlements in Kenya\u0026rsquo;s Cities [Internet]. 2011. Available from: https://www.thegpsc.org/sites/gpsc/files/kenya.pdf\u003c/li\u003e\n \u003cli\u003eJaguga F, Kiburi SK, Temet E, Barasa J, Karanja S, Kinyua L, et al. A systematic review of substance use and substance use disorder research in Kenya. PloS One. 2022 Jun;17(6):e0269340.\u003c/li\u003e\n \u003cli\u003eOrganization WH. Problem Management Plus (PM+): individual psychological help for adults impaired by distress in communities exposed to adversity (generic field-trial version 1.1) [Internet]. Vol. 2. World Health Organization; 2018. Available from: https://iris.who.int/bitstream/handle/10665/375604/WHO_MSD_MER_18.5_eng.pdf?sequence=1\u0026amp;isAllowed=y\u003c/li\u003e\n \u003cli\u003eUNICEF, Labour M of, Laos SW. Trainers\u0026rsquo; guide: Psychological First Aid (PFA) and Mental Health and Psychosocial Support (MHPSS) training module [Internet]. 2021. Available from: https://www.unicef.org/laos/media/5641/file/UNICEF%20and%20MOLSW_PFA%20and%20MHPSS%20Training%20Manual_Eng.pdf\u003c/li\u003e\n \u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care J Int Soc Qual Health Care. 2007 Dec;19(6):349\u0026ndash;57.\u003c/li\u003e\n \u003cli\u003eOrganization WH. Measuring health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0) [Internet]. World Health Organization; 2010. Available from: https://iris.who.int/bitstream/handle/10665/43974/9789241547598_eng.pdf?sequence=1\u003c/li\u003e\n \u003cli\u003edel Pilar S\u0026aacute;nchez-L\u0026oacute;pez M, Dresch V. The 12-Item General Health Questionnaire (GHQ-12): reliability, external validity and factor structure in the Spanish population. Psicothema. 2008 Nov;20(4):839\u0026ndash;43.\u003c/li\u003e\n \u003cli\u003eWojujutari AK, Idemudia ES, Ugwu LE. The evaluation of the General Health Questionnaire (GHQ-12) reliability generalization: A meta-analysis. PloS One. 2024;19(7):e0304182.\u003c/li\u003e\n \u003cli\u003eCDC. ICD-10-CM [Internet]. 2024 [cited 2024 May 3]. Available from: https://www.cdc.gov/nchs/icd/icd-10-cm/index.html\u003c/li\u003e\n \u003cli\u003eGreen J, Thorogood N. Qualitative Methods for Health Research [Internet]. 3rd ed. Sage Publications Ltd; 2014. Available from: https://us.sagepub.com/en-us/nam/qualitative-methods-for-health-research/book254905#preview\u003c/li\u003e\n \u003cli\u003eLumivero. NVIVO: Leading Qualitative Data Analysis Software | Lumivero [Internet]. 2024 [cited 2024 May 17]. Available from: https://lumivero.com/products/nvivo/\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006 Jan;3(2):77\u0026ndash;101.\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern‐based qualitative analytic approaches. Couns Psychother Res. 2021 Oct;21(1):37\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eByrne D. A worked example of Braun and Clarke\u0026rsquo;s approach to reflexive thematic analysis. Qual Quant. 2021 Jun;56(3):1391\u0026ndash;412.\u003c/li\u003e\n \u003cli\u003eMaguire M, Delahunt B. Doing a thematic analysis: A practical, step-by-step guide for learning and teaching scholars. Irel J High Educ [Internet]. 2017 Oct;9(3). Available from: https://ojs.aishe.org/index.php/aishe-j/article/view/335\u003c/li\u003e\n \u003cli\u003eClement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med. 2015;45(1):11\u0026ndash;27.\u003c/li\u003e\n \u003cli\u003eFakir AMS, Anjum A, Bushra F, Nawar N. The endogeneity of domestic violence: Understanding women empowerment through autonomy. World Dev Perspect. 2016;2:34\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eRappaport J. Terms of empowerment/exemplars of prevention: Toward a theory for community psychology. Am J Community Psychol. 1987 Apr 1;15(2):121\u0026ndash;48.\u003c/li\u003e\n \u003cli\u003eMusyimi CW, Mutiso VN, Ndetei DM, Unanue I, Desai D, Patel SG, et al. Mental health treatment in Kenya: task-sharing challenges and opportunities among informal health providers. Int J Ment Health Syst. 2017 Aug 1;11(1):45.\u003c/li\u003e\n \u003cli\u003eMendenhall E, Silva MJD, Hanlon C, Petersen I, Shidhaye R, Jordans M, et al. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Soc Sci Med. 2014;118:33\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eBryant RA, Schafer A, Dawson K, Anjuri D, Mulili C, Ndogoni L, et al. Effectiveness of a brief behavioural intervention on psychological distress among women with a history of gender-based violence in urban Kenya: A randomised clinical trial. PLoS Med. 2017 Aug;14(8):e1002371.\u003c/li\u003e\n \u003cli\u003eMakario S, Mutui, Muhingi W. Empowerment Programmes as Strategies Mitigating Gender-Based Violence in Kibera Informal Settlement, Nairobi City County, Kenya. Int J Soc Dev Concerns IJSDC. 2023 Oct;18(5):63\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eD\u0026rsquo;Enbeau S, Kunkel A. (Mis)managed Empowerment: Exploring Paradoxes of Practice in Domestic Violence Prevention. J Appl Commun Res Appl Commun Res. 2013 May;41(2):141\u0026ndash;59.\u003c/li\u003e\n \u003cli\u003eGive C, Ndima S, Steege R, Ormel H, McCollum R, Theobald S, et al. Strengthening referral systems in community health programs: a qualitative study in two rural districts of Maputo Province, Mozambique. BMC Health Serv Res [Internet]. 2019 Apr;19(1). Available from: https://doi.org/10.1186/s12913-019-4076-3\u003c/li\u003e\n \u003cli\u003eNelson G, Lord J, Ochocka J. Empowerment and mental health in community: narratives of psychiatric consumer/survivors. J Community Appl Soc Psychol. 2001 Mar 1;11(2):125\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eCommission KLR. Constitution of Kenya 260. Interpretation [Internet]. 2013. Available from: https://www.klrc.go.ke/index.php/constitution-of-kenya/161-chapter-seventeen-general-provisions/429-260-interpretation\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6604618/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6604618/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003cbr\u003e\nGender-based violence (GBV) is a widespread human rights issue with significant mental health consequences. Organizations such as MIDRIFT-HURINET and the Danish Institution Against Torture (DIGNITY) implemented a structured referral pathway to support survivors, incorporating two mental health and psychosocial support (MHPSS) interventions: Psychological First Aid (PFA) and Problem Management Plus (PM+) in Nakuru County, Kenya. This study examines stakeholder perspectives on the referral system, focusing on its functionality and impact on GBV survivors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e\u003cbr\u003e\nA qualitative research design involving in-depth interviews with survivors and focus group discussions with community health volunteers and professionals was used. Thematic analysis was conducted via NVIVO14 software. Ethical guidelines were strictly followed to ensure participants' safety, privacy, and compliance with Kenyan law.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nCultural norms significantly impact engagement with mental health programs such as PM+, particularly for men, who often avoid seeking support due to societal expectations of stoicism. Stigma, especially among older adults, further discourages participation. Effective engagement in mental health programs requires culturally relevant strategies, such as involving community leaders and using context-specific messaging. Harmful practices and economic dependencies hinder reporting and accessing services, although awareness is gradually improving. Financial constraints and socioeconomic barriers limit access to mental health services, emphasizing the need for expanded community and government support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cbr\u003e\nThe referral pathway between PFA and PM+ is widely recognized for its effectiveness, demonstrating strong collaboration between state and nonstate actors. However, challenges such as access barriers, financial constraints, and limited awareness continue to impact its functionality. Despite these obstacles, the system has been instrumental in empowering GBV survivors in Nakuru County. Strengthening community-based mental health services and enhancing collaboration between health providers could further expand and improve mental health care delivery in similar contexts.\u003c/p\u003e","manuscriptTitle":"Pilot study: Evaluation of the referral pathway to Problem Management Plus (PM+) in Nakuru County, Kenya: GBV survivors’ and stakeholders’ statement: A tale of PM+","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 08:44:37","doi":"10.21203/rs.3.rs-6604618/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-06T09:48:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-03T11:54:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-31T16:16:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111617145609098005205964848732585935167","date":"2025-08-22T04:40:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212386056465377977926079140832802431614","date":"2025-08-19T09:50:11+00:00","index":"hide","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-16T17:09:28+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-12T14:30:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-02T12:15:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-17T16:42:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-17T16:41:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2361a03a-9677-4b0d-b244-2af6e07ce6cb","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T16:54:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-16 08:44:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6604618","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6604618","identity":"rs-6604618","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}