The South Sudanese refugee crisis is currently the largest refugee crisis in Africa. More than one million people have fled to Uganda in the South. Right now, around 250,000 of those are hosted in the Bidi Bidi camp that lies in the northern part of Uganda. In 2016, it was the largest refugee camp in the world. Like other refugee camps, Bidi Bidi has limited access to humanitarian assistance, including psychosocial support. Therefore, efforts are made to identify lower intensity interventions that require less human resources, than, for example, one-on-one therapy sessions with trained psychologist. One of these efforts has been to implement the WHO Self Help Plus or SH Plus. The SH plus is based on acceptance and commitment therapy, a form of cognitive behavioral therapy with distinct features. In the Bidi Bidi camp, stress management workshops with up to 30 people are facilitated by non-specialists through audio recordings and illustrated self-help book with minimal text. Structuring the interventions like this requires much less training and supervising of works of facilitators. I met with Professor Wietse Tol, who is a psychologist and involved in the SH Plus intervention and research in Uganda. Wietse and colleagues at Health Right International, have worked on developing and testing our guided self-help intervention in Bidi Bidi, and gave me an understanding of some of the challenges. We went through periods of translating the intervention and trying it out for the first time, piloting it, one group of men, one group of women. All very qualitative type of research approach, very open-ended, asking the main stakeholders how it was to deliver it. The piloting was done after a time of consulting with people about the intervention content and how it needed to be changed to fit the local context. After two initial pilots, we also did a second pilot to test the research procedures in a bit more detail and also make more changes to the intervention. After that, we did a randomized controlled trial with almost 700 women, comparing women who received the intervention with women who did not receive the intervention. We focused on female refugees because in our piloting we had seen that with men we would need to go on a separate adaptation study, which we're currently doing. It seems we need to combine SH Plus with an alcohol-focused component. But in our trial with women, we found positive results. In terms of limitations, language was a big question initially. There are many different languages spoken in South Sudan and amongst South Sudanese refugees. We had to consult very closely with our community advisory board to make a final decision. But still, what we chose is Juba Arabic, which is a language that is spoken by many different ethnic groups, but with various levels and dialects. That remains a challenge, but one that seems workable and the preferred option of the community advisory board. Some of the key findings of Wietse's research include that, firstly, the project resulted in significant reductions in psychological distress, as well as secondary outcomes, for example, functioning and well-being after three months. Secondly, the feasibility of the SH Plus being implemented by an NGO. This suggests that it can be implemented by non-specialists with brief training. Finally, the study also saw the high rate of engagement with 83 percent average across all sessions, which could indicate that the project is found relevant by the participants. With male refugees, we are currently conducting a study where we want to see how SH Plus can be combined with a substance use focused intervention. Because in formative research, many men told us that they use alcohol and other substances to manage the distress they are facing and running SH Plus on its own, I think would not be very productive. Because if men are drinking a lot to manage the stress, then that self-help intervention would not be very effective. With the female refugees, we found promising results in the evaluation study. There we are really interested in understanding how SH Plus can be scaled up. What we are looking at is the question of how SH Plus can be scaled up by integrating it into the work of very big organizations, organizations that are already operating at scale, like the Ministry of Health in Uganda, and like the International Rescue Committee, a large humanitarian organization. We think that the key to scaling up for SH Plus is understanding how we can transfer the experience that we have with SH Plus to large organizations like that, so that they can integrate SH Plus into their response. We've just started a research project. It's actually an implementation project with a research component, but we've started a project where we are hoping to learn how we can best do that. Often, refugees are not allowed to work when they live in camps. This limitation dramatically changes the role and self-perception, and especially for many men who are traditionally seen as the providers. They may feel like they lose their dignity when they are no longer the family head or the breadwinner. Likewise, boredom may be a critical issue that contributes to increased alcohol misuse, which in turn may contribute to higher levels of domestic violence. These issues are what the new program SH Plus men will focus on for the next years. The project combines the intervention with the problem-solving counseling approach called Problem Management Plus.
