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      Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial


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          Innovative solutions are required to provide mental health support at scale in low-resource humanitarian contexts. We aimed to assess the effectiveness of a facilitator-guided, group-based, self-help intervention (Self-Help Plus) to reduce psychological distress in female refugees.


          We did a cluster randomised trial in rural refugee settlements in northern Uganda. Participants were female South Sudanese refugees with at least moderate levels of psychological distress (cutoff ≥5 on the Kessler 6). The intervention comprised access to usual care and five 2-h audio-recorded stress-management workshops (20–30 refugees) led by briefly trained lay facilitators, accompanied by an illustrated self-help book. Villages were randomly assigned to either intervention (Self-Help Plus or enhanced usual care) on a 1:1 basis. Within 14 villages, randomly selected households were approached. Screening of women in households continued until 20–30 eligible participants were identified per site. The primary outcome was individual psychological distress, assessed using the Kessler 6 symptom checklist 1 week before, 1 week after, and 3 months after intervention, in the intention-to-treat population. All outcomes were measured at the individual (rather than cluster) level. Secondary outcomes included personally identified problems, post-traumatic stress, depression symptoms, feelings of anger, social interactions with other ethnic groups, functional impairment, and subjective wellbeing. Assessors were masked to allocation. This trial was prospectively registered at ISRCTN, number 50148022.


          Of 694 eligible participants (331 Self-Help Plus, 363 enhanced usual care), 613 (88%) completed all assessments. Compared with controls, we found stronger improvements for Self-Help Plus on psychological distress 3 months post intervention (β −1·20, 95% CI −2·33 to −0·08; p=0·04; d −0·26). We also found larger improvements for Self-Help Plus 3 months post-intervention for five of eight secondary outcomes (effect size range −0·30 to −0·36). Refugees with different trauma exposure, length of time in settlements, and initial psychological distress benefited similarly. With regard to safety considerations, the independent data safety management board responded to six adverse events, and none were evaluated to be concerns in response to the intervention.


          Self-Help Plus is an innovative, facilitator-guided, group-based self-help intervention that can be rapidly deployed to large numbers of participants, and resulted in meaningful reductions in psychological distress at 3 months among South Sudanese female refugees.


          Research for Health in Humanitarian Crises (R2HC) Programme.

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          The WHO-5 Well-Being Index: a systematic review of the literature.

          The 5-item World Health Organization Well-Being Index (WHO-5) is among the most widely used questionnaires assessing subjective psychological well-being. Since its first publication in 1998, the WHO-5 has been translated into more than 30 languages and has been used in research studies all over the world. We now provide a systematic review of the literature on the WHO-5.
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            A number of studies have computed the minimally important difference (MID) for health-related quality of life instruments. To determine whether there is consistency in the magnitude of MID estimates from different instruments. We conducted a systematic review of the literature to identify studies that computed an MID and contained sufficient information to compute an effect size (ES). Thirty-eight studies fulfilled the criteria, resulting in 62 ESs. For all but 6 studies, the MID estimates were close to one half a SD (mean = 0.495, SD = 0.155). There was no consistent relationship with factors such as disease-specific or generic instrument or the number of response options. Negative changes were not associated with larger ESs. Population-based estimation procedures and brief follow-up were associated with smaller ESs, and acute conditions with larger ESs. An explanation for this consistency is that research in psychology has shown that the limit of people's ability to discriminate over a wide range of tasks is approximately 1 part in 7, which is very close to half a SD. In most circumstances, the threshold of discrimination for changes in health-related quality of life for chronic diseases appears to be approximately half a SD.
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              Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance.

              The present research describes the development and psychometric evaluation of a second version of the Acceptance and Action Questionnaire (AAQ-II), which assesses the construct referred to as, variously, acceptance, experiential avoidance, and psychological inflexibility. Results from 2,816 participants across six samples indicate the satisfactory structure, reliability, and validity of this measure. For example, the mean alpha coefficient is .84 (.78-.88), and the 3- and 12-month test-retest reliability is .81 and .79, respectively. Results indicate that AAQ-II scores concurrently, longitudinally, and incrementally predict a range of outcomes, from mental health to work absence rates, that are consistent with its underlying theory. The AAQ-II also demonstrates appropriate discriminant validity. The AAQ-II appears to measure the same concept as the AAQ-I (r=.97) but with better psychometric consistency. Copyright © 2011. Published by Elsevier Ltd.

                Author and article information

                Lancet Glob Health
                Lancet Glob Health
                The Lancet. Global health
                30 January 2023
                February 2020
                04 February 2023
                : 8
                : 2
                : e254-e263
                Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (W A Tol PhD, D P Lakin PhD, J Augustinavicius PhD, R J Musci PhD); Peter C Alderman Program for Global Mental Health, HealthRight International, New York, NY, USA (W A Tol), and Arua, Uganda (M R Leku MA, A Adaku MB ChB); Department of Mental Health and Substance Abuse (K Carswell DClinPsy, T M Au PhD, M van Ommeren PhD), and Department of Reproductive Health & Research (C Garcia-Moreno MD), WHO, Geneva, Switzerland; Department of Psychiatry, Arua Regional Referral Hospital, Arua, Uganda (A Adaku); WarChild Holland, Amsterdam, Netherlands (F L Brown PhD); School of Psychology, University of New South Wales, Sydney, NSW, Australia (R A Bryant PhD); Public Health Section, UN High Commissioner for Refugees, Geneva, Switzerland (P Ventevogel MD); and Institute of Population Health, University of Liverpool, Liverpool, UK (R G White PhD)
                Author notes


                WAT, FLB, and MvO designed the study with inputs from KC, JA, RAB, CG-M, PV, and RGW. MRL coordinated data collection, with support from DPL, AA, and WAT. KC and FLB did Self-Help Plus training. KC and TMA provided Self-Help Plus-related technical backstopping. AA provided clinical backstopping. RJM and DPL did statistical analyses. All authors assisted in interpretation of results. WAT wrote a first draft of the Article. All authors contributed substantially to revising the Article and approved submission.

                Correspondence to: Dr Wietse A Tol, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA, wtol@ 123456jhu.edu

                This is an Open Access article published under the CC BY-NC-ND 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.



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