Addressing the “access” and “scale” challenge: effectiveness of a new WHO guided psychosocial self-help programme

Purpose

The overall objective of this research was to help improve the evidence base and availability of psychosocial interventions that are scalable and accessible even when humanitarian access is limited, thus overcoming current barriers to implementation of evidence-based support. The study aimed to evaluate the effectiveness of Self Help Plus (SH+) with South Sudanese refugee women. SH+ is an innovative WHO intervention package that;

• (a) is delivered to affected people via a 5-session guided self-help multimedia course;
• (b) ensures fidelity to evidence-based techniques via pre-recorded audio visual content and illustration-based self-help book;
• (c) can be implemented in areas where humanitarian access is limited; and
• (d) is likely readily scalable.

SH+ is based on acceptance and commitment therapy (ACT), a form of cognitive-behavioural therapy, with distinct features.

Outcomes Achieved

The research was successfully undertaken. A cluster randomised controlled trial was conducted among female South Sudanese refugees living in Rhino Camp Refugee Settlement in Northern Uganda. Fourteen villages were included in the definitive cRCT with 694 participants randomised to each condition. Baseline assessment included outcome measures of psychological distress, functional impairment, depression and PTSD symptoms, feelings of anger, interethnic relations, subjective wellbeing, psychological flexibility, as well as moderators (trauma history, adherence, health service use) and cost-benefit indicators. SH+ was provided by trained lay facilitators who had 12-16 years of education (e.g. post-secondary school diploma) but no previous clinical training or experience in providing mental health care. The primary outcome –levels of psychological distress– was measured immediately after SH+ and after 3 months with the Kessler 6 (K6) Scale.

Key findings:

• SH+ was shown to be effective and feasible to provide with minimal support / supervision.
• Among female adult South Sudanese refugees living in a refugee settlement in Northern Uganda, with moderate levels and above of psychological distress, delivery of the SH+ intervention compared with enhanced usual care resulted in clinically significant reductions in general psychological distress as well as secondary outcomes (e.g. functioning, wellbeing) at 3 months.
• The project also demonstrated the feasibility of delivering SH+ by an NGO suggesting that it can be implemented within existing health and community services. For example, SH+ could be provided at local health centres by community health workers or similar personnel.
• The study noted a high rate of engagement (83% average across all sessions) which suggests that SH+ might be attractive and meaningful to participants.

Key outputs:

• Peer-reviewed article published in the Lancet Global Health
• The trial protocol paper (published in Global Mental Health)
• The feasibility RCT (published in World Psychiatry)
• The definitive cRCT (planned submission to high impact public health journal).
• Final adaptations of the SH+ package for South Sudanese populations (available on request from WHO – carswellk@who.int)
• SH+ is included on the MHIN innovations website
• Presentation of the study at a 2-day workshop held jointly by WHO / R2HC in October 2017.
• National and regional dissemination workshops held in Uganda in April 2018. A range of stakeholders attended, including Ugandan government (Ministry of Health, Office of the Prime Minister), UNHCR, and implementing agencies (e.g. War Child)
• International scientific conferences (Sexual Violence Research Initiative, International Society for Traumatic Stress Studies, Association for Contextual Behavioral Science)

Next steps

A second trial is now underway to ensure the results can be replicated with another population in another humanitarian setting (See related project below). In addition, SH+ is being tested in a trial with refugees in 6 European countries to look at its effects in preventing onset of mental disorder (funded by European Commission Horizons 2020 programme). On the basis of positive results from future research, WHO plans to disseminate and publish SH+ in a number of languages and continue to innovate ways to make the package simpler to train and scale (e.g. online training courses).

Dissemination of SH+ is also ongoing in Uganda and South Sudan including implementation research to further understand performance at scale.