Psychological flexibility in South Sudanese female refugees in Uganda as a mechanism for change within a guided self-help intervention.

OBJECTIVE: To examine the role of psychological flexibility as a potential mediator in the relationship between involvement in a guided self-help intervention, Self-Help Plus, and psychological distress in a sample of South Sudanese refugee women living in northern Uganda. METHOD: We conducted secondary analysis of data from a cluster randomized controlled trial conducted in 2018. We used multilevel mediation modeling to explore the relationship of psychological flexibility, as measured by the Acceptance and Action Questionnaire (AAQ-II), as a mediating factor in the relationship between Self-Help Plus involvement and general psychological distress as measured by the Kessler Psychological Distress Scale-6 (K6). RESULTS: We found strong multilevel mediation of decreased K6 scores in the treatment group by AAQ-II scores (multilevel b = -3.28). A more pronounced mediation effect was discovered immediately post intervention (b = -1.09) compared to 3-month follow-up (b = -0.84). This is in line with the current literature that demonstrates the role of psychological flexibility as a primary mechanism of change in ACT-based interventions. CONCLUSIONS: Psychological flexibility is a contributing component in the theory of change for this ACT-based intervention. Identifying the core components of interventions allows for more effective adaptation and implementation of relevant services, especially in low-resource contexts. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychological Interventions for Survivors of Intimate Partner Violence in Humanitarian Settings: An Overview of the Evidence and Implementation Considerations.

This paper provides an analytical overview of different types of psychological interventions that have demonstrated efficacy in low-income and/or humanitarian settings and points to special considerations that may be needed if used with women who have been subjected to gender-based violence (GBV). This paper reviews diverse therapeutic modalities and contrasts them across several domains, including their conventional use and principles; their documented use and efficacy in humanitarian settings; any special considerations or modifications necessary for GBV-affected clients; and any additional resources or implementation concerns when working in low-income contexts. By examining the evidence base of multiple interventions, we hope to provide clinicians and GBV-prevention advocates with an overview of tools/approaches to provide survivor-centered, trauma-informed responses to GBV survivors. This analysis responds to the growing recognition that gender-based violence, in particular intimate partner violence and sexual violence, is strongly associated with mental health problems, including anxiety, depression, and post-traumatic stress. This is likely to be exacerbated in humanitarian contexts, where people often experience multiple and intersecting traumatic experiences. The need for mental health services in these settings is increasingly recognized, and a growing number of psychological interventions have been shown to be effective when delivered by lay providers and in humanitarian settings.

The end of the trial: Perspectives on cognitive processing therapy from community-based providers in the Democratic Republic of Congo.

Despite calls forincreased mental health programming in low-resource and humanitarian contexts and effectiveness trials of psychotherapy in these settings, little research exists on the extent to which providers and recipients continue to practice skills learned during trials of these programs. To understand if and how providers continued to use mental health intervention skills without ongoing institutional support following the completion of randomized controlled trials (RCTs), we analyzed data from semistructured interviews with six of seven providers who participated in an RCT of cognitive processing therapy (CPT) in the Democratic Republic of Congo 7 years prior. Provider interviews revealed continued knowledge of and, in some cases, the practice of core CPT skills as well as efforts to keep meeting with women in the community and a strong desire to learn new skills. Although financial limitations sometimes prohibited providers from formally convening CPT groups with women in need, participants maintained knowledge and skill use. Providers also reported feeling more valued in their communities, and they continued providing services beyond the planned intervention period despite a lack of ongoing support. In addition, participants described a strong desire to continue psychosocial interventions for trauma and learn more about this type of intervention. Reframing the evaluation of psychological interventions as program development and maintaining a strong working relationship with community partners may allow for increased sustainability of mental health services beyond the end of academic research studies in low-resource contexts.

Maintenance of intervention effects: long-term outcomes for participants in a group talk-therapy trial in the Democratic Republic of Congo.

Background: Despite the growth of psychotherapy trials in low- and middle-income countries, there have been limited follow-up studies of more than 2 years. This study follows up female sexual violence survivors approximately 6 years after completing a 12-session group cognitive processing therapy (CPT) program in the eastern Democratic Republic of Congo. Methods: Baseline trial data were collected in December 2010 from 134 women in 7 study villages randomly allocated to CPT. Study women were over 18 years, reported personally experiencing or witnessing sexual violence, and reported elevated depression, anxiety and/or posttraumatic stress symptoms. Women were followed up (1) post-treatment (6-months after baseline); (2) 6 months later; (3) 12 months later; and (4) in March 2017 (6.3 years after baseline). At the long-term follow-up, 103 women (77%) in 6 of 7 CPT villages were re-assessed; one village was not visited due to ongoing insecurity. Results: We found strong continued intervention effects; nearly all women maintained treatment impacts over the first two years; at long-term follow-up, approximately half continued to maintain low symptom scores. Relapse rates for probable PTSD and probable depression and anxiety were 20%. Conclusions: This study extends prior research to show that treatment impacts can be maintained for several years despite experiences of ongoing trauma. The women described continuing to meet with the women in their therapy group and using the skills they learned in the psychotherapy, providing evidence of the potential for these programs to provide valuable social supports and skills that people use as they continue to face adversity.

Masculinity and mental health treatment initiation for former political prisoners in Yangon, Myanmar - a qualitative investigation.

BACKGROUND: Men living in low- and middle-income countries are unlikely to seek mental health care, where poor healthcare infrastructure, differences in illness conceptualization, and stigma can impact treatment seeking. Vulnerable groups, such as former political prisoners, are more likely than others to experience potentially traumatic events that may lead to negative mental health outcomes. To improve the likelihood of successful engagement of vulnerable men in psychotherapy, it is necessary to identify factors that influence treatment adherence, and to better understand men's attitudes surrounding decisions to seek and initiate care. The purpose of this investigation was to explore themes of masculinity, treatment seeking, and differences between male former political prisoners who accepted and declined therapy in an urban low-income context. METHODS: We conducted a qualitative, interview-based investigation with 30 former political prisoners in Yangon, Myanmar who were eligible to receive mental health counseling provided by the non-governmental organization (NGO), Assistance Association for Political Prisoners. Men were initially screened using a composite questionnaire with items related to depression, anxiety, and posttraumatic stress symptom severity. After screening, if potential clients were identified as having probable mental health problems, they were asked if they would like to participate in a multi-session cognitive behavioral therapy program. Semi-structured, open-ended interviews were conducted with 15 participants who accepted and 15 participants who declined therapy. Interviews were transcribed and translated by local partners and thematically coded by the authors. We used thematic analysis to identify and explore differences in treatment-seeking attitudes between men who accepted and men who declined the intervention. RESULTS: Men described that being a community leader, self-reliance, morality, and honesty were defining characteristics of masculinity. A focus on self-correction often led to declining psychotherapy. A general lack of familiarity with psychological therapy and how it differed from locally available treatments (e.g. astrologists) was connected to stigma regarding mental health treatment. CONCLUSIONS: Masculinity was described in similar terms by both groups of participants. The interpretation of masculine qualities within the context of help-seeking (e.g. self-reliance as refusing help from others versus listening to others and applying that guidance) was a driving factor behind men's decision to enter psychotherapy.

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

BACKGROUND: 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. METHODS: 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. FINDINGS: 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 (ß -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. INTERPRETATION: 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. FUNDING: Research for Health in Humanitarian Crises (R2HC) Programme.

Measuring Symptoms of Psychopathology in Zambian Orphans and Vulnerable Children: Scale Validation and Psychometric Evaluation.

There is a paucity of validated mental health measures for assessing psychological well-being among HIV-affected youth. We sought to explore the psychometric properties and validity of the Achenbach Youth Self-Report and Child Posttraumatic Stress Disorder Symptom Scale among orphans and vulnerable children (OVC) living in Lusaka, Zambia. These scales were administered to 210 OVC aged 13 to 17 years via audio computer-assisted self-interview. Confirmatory factor analysis was used to assess scale structure, Cronbach's alpha for internal consistency, and correlations between scales related to mental or psychosocial health for construct validity. A known-groups validation was conducted using local identifications of youth with and without significant psychosocial problems, and test-retest reliability was assessed. Scales exhibited good internal reliability (α > .80), adequate criterion validity (area under the curve > .70), and moderate test-retest reliability (.62-.68). Findings support the utility of these symptom scales for identifying OVC experiencing significant psychosocial problems in Zambia.

Monitoring and evaluation of mental health and psychosocial support programs in humanitarian settings: a scoping review of terminology and focus.

BACKGROUND: Monitoring and evaluation of mental health and psychosocial support (MHPSS) programs is critical to facilitating learning and providing accountability to stakeholders. As part of an inter-agency effort to develop recommendations on MHPSS monitoring and evaluation, this scoping review aimed to identify the terminology and focus of monitoring and evaluation frameworks in this field. METHODS: We collected program documents (logical frameworks (logframes) and theories of change) from members of the Inter-Agency Standing Committee Reference Group on MHPSS, and systematically searched the peer-reviewed literature across five databases. We included program documents and academic articles that reported on monitoring and evaluation of MHPSS in low- and middle-income countries describing original data. Inclusion and data extraction were conducted in parallel by independent reviewers. Thematic analysis was used to identify common language in the description of practices and the focus of each monitoring and evaluation framework. Logframe outcomes were mapped to MHPSS activity categories. RESULTS: We identified 38 program documents and 89 peer-reviewed articles, describing monitoring and evaluation of a wide range of MHPSS activities. In both program documents and peer-reviewed literature there was a lack of specificity and overlap in language used for goals and outcomes. Well-validated, reliable instruments were reported in the academic literature, but rarely used in monitoring and evaluation practices. We identified six themes in the terminology used to describe goals and outcomes. Logframe outcomes were more commonly mapped to generic program implementation activities (e.g. "capacity building") and those related to family and community support, while outcomes from academic articles were most frequently mapped to specialized psychological treatments. CONCLUSIONS: Inconsistencies between the language used in research and practice and discrepancies in measurement have broader implications for monitoring and evaluation in MHPSS programs in humanitarian settings within low- and middle-income countries. This scoping review of the terminology commonly used to describe monitoring and evaluation practices and their focus within MHPSS programming highlights areas of importance for the development of a more standardized approach to monitoring and evaluation.