Building capacity through research: piloting SH+ with South Sudanese Refugees
Addressing the “access” and “scale” challenge: cost-effectiveness of a new WHO guided psychosocial self-help programme
On the 26th and 27th of January, the Self Help Plus (SH+) team met in Uganda to discuss the results from two previous pilot studies: one uncontrolled pilot and one feasibility randomized controlled trial. SH+ is a highly innovative programme developed by the World Health Organization (WHO) for humanitarian settings where prevalence of psychological distress is high and access to services is limited. As described in our previous blogs, SH+ combines a pre-recorded audio course and illustrated book designed for low-literacy populations which is delivered in a large group setting (20 – 30 people) by trained facilitators. It is being implemented by the Peter C. Alderman Foundation (PCAF) in Uganda as part of a World Health Organization (WHO) research project.
The goal of the meeting was to discuss lessons learned from this pilot to enhance the intervention and research design, and to finalize planning for a fully powered cluster randomized clinical trial. The clinical trial will serve as our culminating assessment of SH+ for South Sudanese refugee women living in Northern Uganda. The trial will compare women experiencing high levels of psychological distress who have volunteered to participate in SH+ sessions to similar women who have access to enhanced usual care. We are expecting to involve women from as many as 14 different villages within and around a refugee settlement in Northern Uganda called Rhino Camp.
Members of the research, intervention, and clinical referral teams from northern Uganda joined the lead SH+ trainer from WHO and the research team from the PCAF, and John Hopkins University to discuss both finer details and critical overarching strategies to make sure the trial runs smoothly from start to finish. We welcomed two new international team members.
The results from our small, feasibility, cluster randomized controlled trial were generally positive. We were excited to see a notable reduction in psychological distress from baseline to the end for those participating in SH+ program compared to a control group, as well as an increase in the psychological flexibility of participants. Psychological inflexibility has been linked to poorer psychological wellbeing, and maladaptive behaviour patterns in several populations. These results are however very preliminary as only one group was randomized to either receive SH+ or enhanced usual care.
While there are certainly continued challenges that will need to be planned for in our larger study, the team is energized and enthusiastic to meet them. We had important discussions on potential logistical problems, finalizing our measures, futher refinements to the intervention, and planning for a much larger study. Though daunting, we are confident that the discussed challenges can be addressed.
The meeting showed the results of almost two years of work translating and adapting the intervention, and conducting two pilots, and showed the benefits extend beyond a good research study. At the start of the SH+ project in Arua, northern Uganda, research capacity of the PCAF team in Arua was limited. For the first pilot a research coordinator was recruited, along with a team of research assistants and intervention faciltiators. Through training and experience over two pilots, the research and intervention team have developed strong skill sets in their areas. The local project coordinator is now running the project with support from international advisors; a researcher and facilitator have assumed management responsibilities of expanding teams; for the present trial, the lead SH+ facilitator and PCAF social worker will be further trained in delivering and supervising SH+ implementation, using a variation of the Apprenticeship model (a training and capacity building approach used for delivering psychological internvetions in low resource settings).
This increased capacity is likely to benefit any future research or intervention projects in the Rhino Camp area, even after the SH+ project ends. Should SH+ prove effective in the trial, the increased capacity also provides PCAF with the framework for quicker dissemination of the intervention with a strong monitoring and evaluation component. This could potentially make a meangingful contribution to humanitarian interventions with South Sudanese people. The work would also lead to the development of a model for dissemination in other humanitarian contexts.
Our research team is finalizing screening and recruitment procedures, preparing to train more enumerators, and establishing a detailed timeline for conducting the trial. The intervention team is expanding to accommodate the larger number of participants expected for this trial. We are planning to begin screening participants in early March 2017. We look forward to seeing the result of the trial in late 2017.
Dan Lakin, MA | SH+ Research Associate | Johns Hopkins University
Leku Marx, Self Help+ Research Team Leader, Peter C. Alderman Foundation
Dr Ken Carswell: Technical Officer, WHO.