1. Callister, Lynn Clark PhD, RN, FAAN

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There are women globally whose life experience has been different than many of our own: women who have experienced or witnessed horrible traumatic events; women who struggle with overwhelming poverty, lack of inadequate housing, and food insecurity; women who live in places where chronic endemic violence and armed conflict exists; women living in places where there are extensive humanitarian needs; and women who are displaced, forgotten, and alone.


Tragically, many of these women, our sisters worldwide, most often do not have adequate access to socio-emotional support or appropriate mental health resources. Because of these overwhelming needs, the World Health Organization (WHO) has generated low-intensity psychological interventions. Self-Help-Plus is a WHO initiative delivered by facilitators with minimal training to attempt to address mental health issues for vulnerable women. Planners acknowledged that Self-Help-Plus needed to: be effective in addressing mental health issues, promote long-term health benefits, deliverable to hard-to-reach populations in low-resource countries, and adaptable to a variety of cultures and languages. It also needed to be feasible without an extensive workforce of mental health professionals; appropriate for those having low literacy rates; and based on cognitive-behavioral therapy. After development of Self-Help-Plus by global mental health experts and humanitarian personnel, the intervention was reviewed and revised based on feedback from 43 external experts who concluded it had potential to make an important difference (Brown et al., 2018).


Tol et al. (2020) reported on a cluster randomized trial conducted with South Sudanese female refugees in Uganda to reduce their psychological distress, involving 694 participants, 331 receiving Self-Help-Plus and 363 women receiving basic psychosocial support in 14 Ugandan villages. The women were of childbearing age, with a mean age of 30.9 years, who attended 2-hour workshops for 5 weeks. Participation was high. Self-Help-Plus included a prerecorded audio course and an illustrated self-help book that had more than 400 illustrations and a limited amount of text to engage those women who had minimal literacy skills. Facilitators had brief training and were often community members, who focused on playing the recording, answering questions, and facilitating scripted exercises and small group discussions. Supervision was provided by a Ugandan social worker.


Instruments used for assessment were translated from English to Juba Arabic by a bilingual team with back translation and a review by a South Sudanese mental health expert to assess clinical validity. The K6 tool was administered as the primary outcome measure of psychological distress, given prior to the study at the screening of potential study participants, immediately after the intervention, and 3 months following receiving Self-Help-Plus. Other instruments were used such as the Psychological Outcome Profile, the PTSD Checklist, the Patient Health Questionnaire, the Acceptance and Action Questionnaire, the WHO Disability Assessment Schedule, and the WHO-5 Wellbeing Index.


Although those in the control group showed improvement in psychological wellbeing, those in the Self-Help-Plus group had significantly "larger improvements three months after intervention for lower levels of post-traumatic stress and depression, explosive anger, functional impairment and subjective wellbeing" (Tol et al., 2020, p. e-9). This was true across women with varying levels of violence exposure, length of time in the refugee camp, and baseline levels of psychological distress.


This rigorous evaluation of Self-Help-Plus documented that it could be used to assist vulnerable women in managing stress and coping with overwhelming levels of adversity in their lives. The Juba Arabic version of Self-Help is publicly available from WHO, and for those replicating the study, the English version will be made available. Innovative efforts like this can make a difference for these women.




Brown F. L., Carswell K., Augustinavicius J., Adaku A., Leku M. R., White R. G., Ventevogel P., Kogan C. S., Garcia-Moreno C., Bryant R. A., Musci R. J., van Ommeren M., Tol W. A. (2018). Self Help Plus: Study protocol for a cluster-randomised controlled trial of guided self-help with South Sudanese refugee women in Uganda. Global Mental Health, 5, e27.[Context Link]


Tol W.A., Leku M. R., Lakin D. P., Carswell K., Augustinavicius J., Adaku A., Au T. M., Brown F. L., Bryant R. A., Garcia-Moreno C., Musci R. J., Ventevogel P., White R. G., van Ommeren M. (2020). Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: A cluster randomised trial. The Lancet. Global Health, 8(2), e254-e263.[Context Link]