Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
Open accessAbstract
Implementing evidence-based psychological interventions in low-resource refugee settings is challenging, because of the need for an extensive workforce of trainers, supervisors and facilitators1, 2. Self-Help Plus (SH+) was developed by the World Health Organization (WHO) as a tool potentially applicable in those settings3. SH+ is a guided self-help intervention consisting of five audio-recorded sessions and an illustrated self-help manual3. It can be provided to large groups (20 to 30 participants) and facilitated by lay helpers with minimal training. It aims to reduce psychological distress in people with a range of common mental disorders and subthreshold symptoms. It is based on acceptance and commitment therapy, a third wave cognitive behavioral therapy focused on enhancing psychological flexibility4. We adapted SH+ for South Sudanese refugees and conducted a feasibility cluster randomized controlled trial of the intervention in Rhino Camp, a refugee settlement area in northern Uganda5. Our focus in this study was on women, since prior intervention adaptation and piloting had shown the need for separate evaluation efforts with men and women. We randomly allocated one village to SH+ and one to enhanced usual care. Within each village, we randomly selected households and screened one Juba Arabic-speaking consenting woman (age ≥18 years) until 25 eligible women were identified per village. We screened for moderate psychological distress using the Kessler 6 (K6) (primary outcome, cut-off ≥5)6. We assessed exclusion criteria (imminent risk of suicide; observable signs of severe mental disorder; severe cognitive impairment) using structured questionnaires. With eligible and consenting women, we assessed secondary outcomes: disability (WHO Disability Assessment Schedule 2.0, WHODAS 2.0); self-defined psychosocial concerns (Psychological Outcome Profiles instrument, PSYCHLOPS); depression symptoms (Patient Health Questionnaire, PHQ-9); post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist Civilian, PCL-6); hazardous alcohol use (two survey questions); feelings of anger (shortened explosive anger index); inter-ethnic relations (three survey questions); subjective wellbeing (WHO Wellbeing Index, WHO-5); psychological flexibility (Acceptance and Action Questionnaire, AAQ-II). We also assessed attendance, health service use, cost indicators, and exposure to potentially traumatic events. The SH+ workshops were facilitated by four Juba Arabic-speaking Ugandan women from the settlement area without prior mental health training. Facilitators were trained by international experts (KC, FB) over a four-day period and supervised weekly by a Ugandan social worker. Enhanced usual care consisted of one psychoeducation session focused on psychological distress delivered by a trained community health worker, which included information on where to access existing mental health services delivered by the implementing organization, the Peter C. Alderman Foundation. Assessors were blinded to allocation of villages to study condition, and conducted interviews one week pre- and post-intervention. All participants provided written or verbal informed consent. Ethical procedures were approved by the WHO Ethics Review Committee, the MildMay Uganda Research Ethics Commission, and the Uganda National Council for Science and Technology. We screened 50 women, all of whom were eligible and consented. Their mean age was 29.5±8.5 years and 68% of them were married. Half of participants were managing households; 60% had no schooling or completed primary school. Fidelity checks (clinical supervisor attending 10% of sessions) showed that all sections of the audio were delivered correctly at each session. Weekly supervision was provided to SH+ facilitators and covered reporting of any adverse events, requests for additional help from participants or problems in running the course. Few problems were reported and supervision was brief. Attendance was good (90% of women attended each session). We found that our research protocol was feasible. Randomization resulted in balanced groups at baseline despite the small sample. We did not find differences between groups at baseline on socio-demographic characteristics. There were larger mean post-intervention differences for the SH+ condition on all outcome measures. These were statistically significant for the K6 (p<0.05) and the WHO-5 (p<0.001). Blinding was maintained: assessors guessed correctly which participants were part of which study condition at chance level (50% of cases). Similarly, contamination did not appear to be a major concern: none of the participants in the control condition had seen the SH+ self-help book, attended workshops, nor heard about SH+. Only two women receiving enhanced usual care were lost to follow-up – an attrition of 4%. In conclusion, we found that the SH+ intervention and research protocols were feasible in Uganda among South Sudanese refugees, with promising res
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- Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
The groups did not differ at baseline in socio-demographic characteristics.
“We did not find differences between groups at baseline on socio-demographic characteristics.”
Quote in the paperSubstantial claim - Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
On every outcome measure, the SH1 condition showed larger mean differences after the intervention.
“There were larger mean post-intervention differences for the SH1 condition on all outcome measures.”
Quote in the paperSubstantial claim - Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
Attendance was good, with 90% of women attending each session.
“Attendance was good (90% of women attended each session).”
Quote in the paperSubstantial claim - Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
Despite the small sample, randomization produced groups that were balanced at baseline.
“Randomization resulted in balanced groups at baseline despite the small sample.”
Quote in the paperSubstantial claim - Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
Contamination seemed not to be a major issue, since no control participants had seen the SH1 self-help book, attended workshops, or heard about SH1.
“Similarly, contamination did not appear to be a major concern: none of the participants in the control condition had seen the SH1 self-help book, attended workshops, nor heard about SH1.”
Quote in the paperNot a substantial claim
- Study design and conductown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
Fidelity checks, in which a clinical supervisor attended 10% of sessions, indicated that every audio section was delivered correctly in each session.
“Fidelity checks (clinical supervisor attending 10% of sessions) showed that all sections of the audio were delivered correctly at each session.”
Quote in the paperNot a substantial claim - Study design and conductown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
Blinding was maintained, as assessors guessed correctly which participants were in which study condition at chance level (50% of cases).
“Blinding was maintained: assessors guessed correctly which participants were part of which study condition at chance level (50% of cases).”
Quote in the paperNot a substantial claim - Interpretationown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda
The research protocol was feasible.
“We found that our research protocol was feasible.”
Quote in the paperSubstantial claim
- May combine two claims. 6
- Classified as probably not a substantial claim. 5
May combine two claims.
Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaFifty women were screened, and all were eligible and consented.
“We screened 50 women, all of whom were eligible and consented.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaFor the K6 (p<0.05) and the WHO-5 (p<0.001), the post-intervention differences reached statistical significance.
“These were statistically significant for the K6 (p<0.05) and the WHO-5 (p<0.001).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaAttrition was 4%, with only two women in the enhanced usual care group lost to follow-up.
“Only two women receiving enhanced usual care were lost to follow-up -an attrition of 4%.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaSupervision was brief, and few problems were reported.
“Few problems were reported and supervision was brief.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaAssessors were blinded to the allocation of villages to study condition.
“Assessors were blinded to allocation of villages to study condition, and conducted interviews one week pre-and post-intervention.”
Quote in the paperSubstantial claimMay combine two claims.
Premisecitation§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaSH1 can be delivered to large groups of 20 to 30 participants and can be facilitated by lay helpers who have minimal training.
“It can be provided to large groups (20 to 30 participants) and facilitated by lay helpers with minimal training.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [3] source
Not checked in the free run.
Classified as probably not a substantial claim.
Premisecitation§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaSH1 is a guided self-help program made up of five audio sessions and a manual with illustrations.
“SH1 is a guided self-help intervention consisting of five audio-recorded sessions and an illustrated self-help manual 3 .”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [3] source
Not checked in the free run.
May combine two claims.
Interpretationown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaThe SH1 intervention and the research procedures were feasible among South Sudanese refugees in Uganda, and the study showed encouraging results in the feasibility domains it assessed.
“In conclusion, we found that the SH1 intervention and research protocols were feasible in Uganda among South Sudanese refugees, with promising results related to randomization, fidelity, adherence, contamination, blinding, and sensitivity to change.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown data§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaSH1 facilitators received weekly supervision that addressed reporting of adverse events, requests for extra help from participants, and difficulties in running the course.
“Weekly supervision was provided to SH1 facilitators and covered reporting of any adverse events, requests for additional help from participants or problems in running the course.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaSH1 is grounded in acceptance and commitment therapy, a third-wave cognitive behavioral therapy that focuses on enhancing psychological flexibility.
“It is based on acceptance and commitment therapy, a third wave cognitive behavioral therapy focused on enhancing psychological flexibility 4 .”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [4] source
Not checked in the free run.
Classified as probably not a substantial claim.
Premisecitation§ Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in UgandaSH1 is intended to reduce psychological distress in individuals with various common mental disorders and subthreshold symptoms.
“It aims to reduce psychological distress in people with a range of common mental disorders and subthreshold symptoms.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [3] source
Not checked in the free run.
The paper relies on this without support.
Prior intervention adaptation and piloting had shown that separate evaluation efforts with men and women were needed.
“Our focus in this study was on women, since prior intervention adaptation and piloting had shown the need for separate evaluation efforts with men and women.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
A feasibility cRCT found Self-Help Plus to be relevant, acceptable, and feasible among female South Sudanese refugees.
“A feasibility cRCT 23 found Self-Help Plus to be relevant, acceptable, and feasible among female South Sudanese refugees.”
From Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: A cluster randomised trial (2020) · cites this paper as [23]
The paper’s main text describes a feasibility cluster randomized trial of Self-Help Plus among South Sudanese refugee women in Uganda, and its conclusion says the intervention and research protocols were feasible. The main text also reports 90% attendance, but our copy does not establish that participants found the intervention relevant or explicitly conclude that it was acceptable. (LLM, conf=0.82)
Experimental — accuracy not yet measured
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“electronic delivery or self-help formats) may increase feasibility and thereby uptake by non-specialized agencies [61].”
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“This method, recommended by the WHO has been used successfully to rapidly adapt a self-help intervention for psychological distress among refugees in an African context [29].”
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“Based on the population statistics (V.Kahi, Health Information System Officer, Public Health Section, UNHCR, Geneva) and experiences in preliminary studies (Tol et al. 2018a, b), we estimate that recruiting sufficient participants from each of 14 clusters will be feasible.”
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“, South Sudanese refugee women in Uganda (65, 66), HIV-positive pregnant women in Nigeria (62), adults with epilepsy in South Africa (15), spiritually abused senior secondary public school students in Nigeria (64), adolescents with social phobia attending public secondary school in Nigeria (61), and patients diagnosed…”
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“Mental health and wellbeing was assessed using standardized tools that have been previously used in IDP/refugee settings [33, 34], namely the 5-item World Health Organization Wellbeing Index (WHO-5) and the Patient Health Questionnaire-9 (PHQ9).”
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“…mental disorders like depression (Bai, Luo, Zhang, Wu, & Chi, 2020; French, Golijani-Moghaddam, & Schröder, 2017) Thus far, SH+ has been shown to be feasible and acceptable when tested in pilot studies including refugees and people affected by war (Purgato et al., 2019; Tol et al., 2018, 2018).”
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“…al., 2015; Puffer et al., 2015; O’Callaghan et al., 2015; Puvimanasinghe and Price, 2016; Rahman et al., 2016; Hallman et al., 2018; Khan et al., 2017; Tol et al., 2018b; Sijbrandij et al., 2020; Tol et al., 2020a, 2020b), there was a predominance towards a low risk of bias for each of the domains…”
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“culty translating some terminology, we selected mental health and psychosocial measures that had been successfully piloted and used in another study among South Sudanese refugees [29].”
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“…et al., 2004, 2005) have demonstrated initial, albeit mixed, evidence of acceptability, feasibility (Eskici et al., 2023; Kananian et al., 2017; Tol et al., 2018a, 2018b), and treatment and/or preventive efficacy (Acarturk et al., 2022; Augustinavicius et al., 2023; Eskici et al., 2023;…”
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“This aligns with similar findings where primary health workers have shown reasonable satisfaction with digital interventions, yet have indicated the need for better user-friendliness or experiencing information overload (Tol et al. 2018, Brog et al. 2022).”
- Authors
- Tol, W. A., Augustinavicius, J., Carswell, K., Leku, M. R., Adaku, A., Brown, F. L., García‐Moreno, C., Ventevogel, P., White, R. G., Kogan, C. S., Bryant, R., & van Ommeren, M.
- Affiliations
- Johns Hopkins University (US)
- World Health Organization (CH)
- Peter C. Alderman Foundation Uganda
- Harvard University (US)
- World Health Organization Geneva Switzerland
- Office of the United Nations High Commissioner for Refugees (CH)
- University of Liverpool (GB)
- University of Ottawa (CA)
- UNSW Sydney (AU)
- ORCID
- Venue
- World Psychiatry
- Publisher
- Wiley
- Published
- 2018-05-24
- Volume
- 17
- Issue
- 2
- Pages
- 234-235
- ISSN
- 1723-8617 (ISSN-L)
- 2051-5545
- PMC
- PMC5980508
- OpenAlex
- W2806132415
- Semantic Scholar
- 3edce36d1c19e01be02f438ada9891f805e4cc2d
- Cited by
- 39
- References
- 6
- Citations by year
- 2025: 4 · 2024: 3 · 2023: 4 · 2022: 9 · 2021: 7 · 2020: 7 · 2019: 3 · 2018: 2
- FWCI
- 5.58
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- World Psychiatry (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- World Health Organization
- Topics
- Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- South Sudanese refugees, refugee women, psychological distress, acceptance and commitment therapy, resource-limited settings, post-traumatic stress disorder, alcohol consumption, psychological flexibility, interethnic relations, subjective well-being, refugee mental health, intervention adaptation, feasibility, cost-effectiveness
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-07.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-07.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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