Skip to main content Accessibility help

Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda

  • W. A. Tol (a1) (a2), J. Augustinavicius (a2), K. Carswell (a3), F. L. Brown (a4) (a5), A. Adaku (a1) (a6), M. R. Leku (a1), C. García-Moreno (a7), P. Ventevogel (a8), R. G. White (a9) and M. van Ommeren (a3)...



In this period of unprecedented levels of displacement, scalable interventions are needed to address mental health concerns of forced migrants in low-resource settings. This paper describes the adaptation and piloting of a guided, multi-media, self-help intervention, Self-Help Plus (SH+), which was developed to reduce psychological distress in large groups of people affected by adversity.


Using a phased approach that included community consultations, cognitive interviewing, facilitator training, pilot implementation, and a qualitative process evaluation, we adapted SH+ for use among South Sudanese refugees in a refugee settlement in northern Uganda.


The SH+ materials, including audio-recorded sessions and an accompanying illustrated manual, were translated into Juba Arabic. Cognitive interviewing primarily resulted in adaptations to language with some minor adaptations to content. Facilitator training and supervision led to further suggested changes to delivery methods. An uncontrolled pilot study (n = 65) identified changes in the expected direction on measures of psychological distress, functional impairment, depression, wellbeing, and psychological flexibility. The process evaluation resulted in further adaptations to intervention materials and the decision to focus future effectiveness evaluations of the intervention in its current form on South Sudanese female refugees.


We found that this potentially scalable, guided self-help intervention could be adapted for and feasibly implemented among female South Sudanese refugees in northern Uganda. These findings lay the groundwork for a future rigorous evaluation of SH+ in this context.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda
      Available formats


This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

*Address for correspondence: Wietse A. Tol, PCAF Uganda, Plot 855, Mawanda Rd, PO Box 20129, Nakawa, Kampala, Uganda. (Email:


Hide All
Adaku, A, Okello, J, Lowry, B, Kane, JC, Alderman, S, Musisi, S, Tol, WA (2016). Mental health and psychosocial support for South Sudanese refugees in northern Uganda: a needs and resource assessment. Conflict and Health 10, 18.
ATLAS.ti Scientific Software Development GmbH (2016). Atlas.ti 8 for Mac. ATLAS.ti Scientific Software Development GmbH: Berlin, Germany.
Barrera, M Jr., Castro, FG, Strycker, LA, Toobert, DJ (2013). Cultural adaptations of behavioral health interventions: a progress report. Journal of Consulting and Clinical Psychology, 81, 196205.
Beatty, PC, Willis, GB (2007). Research synthesis: the practice of cognitive interviewing. Public Opinion Quarterly 71, 287311.
Benish, SG, Quintana, S, Wampold, BE (2011). Culturally adapted psychotherapy and the legitimacy of myth: a direct-comparison meta-analysis. Journal of Counseling Psychology 58, 279289.
Bennett-Levy, J, Richards, D, Farrand, P, Christensen, H, Griffiths, KM, Kavanagh, D, Klein, B, Lau, MA, Proudfoot, J, Ritterband, L, White, J, Williams, C (2010). Oxford Guide to Low Intensity CBT Interventions. Oxford University Press: Oxford.
Bernal, G, Bonilla, J, Bellido, C (1995). Ecological validity and cultural sensitivity for outcome research: issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology 23, 6782.
Bolton, P, Bass, J, Betancourt, T, Speelman, L, Onyango, G, Clougherty, KF, Neugebauer, R, Murray, L, Verdeli, H (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial. Journal of the American Medical Association 298, 519527.
Bolton, P, Bass, J, Neugebauer, R, Verdeli, H, Clougherty, KF, Wickramaratne, P, Speelman, L, Ndogoni, L, Weissman, M (2003). Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA 289, 31173124.
Carbone, ET, Campbell, MK, Honess-Morreale, L (2002). Use of cognitive interview techniques in the development of nutrition surveys and interactive nutrition messages for low-income populations. Journal of the American Dietetic Association 102, 690696.
Cavanagh, K, Strauss, C, Forder, L, Jones, F (2014). Can mindfulness and acceptance be learnt by self-help?: a systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions. Clinical Psychology Review 34, 118129.
Charlson, FJ, Flaxman, A, Ferrari, AJ, Vos, T, Steel, Z, Whiteford, HA (2016). Post-traumatic stress disorder and major depression in conflict-affected populations: an epidemiological model and predictor analysis. Global Mental Health 3, e4.
Chowdhary, N, Jotheeswaran, AT, Nadkarni, A, Hollon, SD, King, M, Jordans, MJ, Rahman, A, Verdeli, H, Araya, R, Patel, V (2014). The methods and outcomes of cultural adaptations of psychological treatments for depressive disorders: a systematic review. Psychological Medicine 44, 11311146.
Coker, EM (2004). “Traveling pains”: embodied metaphors of suffering among southern Sudanese refugees in Cairo. Culture, Medicine and Psychiatry 28, 1539.
Cuijpers, P, Donker, T, Van Straten, A, Li, J, Andersson, G (2010). Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychological Medicine 40, 19431957.
Cuijpers, P, Munoz, RF, Clarke, GN, Lewinsohn, PM (2009). Psychoeducational treatment and prevention of depression: the “coping with depression” course thirty years later. Clinical Psychology Review 29, 449458.
De Jong, JT, Komproe, IH, Van Ommeren, M (2003). Common mental disorders in postconflict settings. Lancet 361, 21282130.
Den Boer, PC, Wiersma, D, Van Den Bosch, RJ (2004). Why is self-help neglected in the treatment of emotional disorders? A meta-analysis. Psychological Medicine 34, 959971.
Epping-Jordan, JE, Harris, R, Brown, FL, Carswell, K, Foley, C, Garcia-Moreno, C, Kogan, C, Van Ommeren, M (2016). Self-Help plus (SH+): a new WHO stress management package. World Psychiatry 15, 295296.
Fairburn, CG, Patel, V (2014). The global dissemination of psychological treatments: a road map for research and practice. American Journal of Psychiatry 171, 495498.
Fledderus, M, Oude Voshaar, MA, Ten Klooster, PM, Bohlmeijer, ET (2012). Further evaluation of the psychometric properties of the acceptance and action questionnaire-II. Psychological Assessment 24, 925936.
Garcia-Moreno, C, Jansen, HA, Ellsberg, M, Heise, L, Watts, CH (2006). Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence. Lancet 368, 12601269.
Goodman, JH (2004). Coping with trauma and hardship among unaccompanied refugee youths from Sudan. Qualitative Health Research 14, 11771196.
Harper Shehadeh, M, Heim, E, Chowdhary, N, Maercker, A, Albanese, E (2016). Cultural adaptation of minimally guided interventions for common mental disorders: a systematic review and meta-analysis. JMIR Mental Health 3, e44.
Harris, R (2014). The Illustrated Happiness Trap: How to Stop Struggling and Start Living, Shambhala: Boston, MA.
Hayes, SC, Luoma, JB, Bond, FW, Masuda, A, Lillis, J (2006). Acceptance and commitment therapy: model, processes and outcomes. Behaviour Research and Therapy 44, 125.
Hayes, SC, Villatte, M, Levin, M, Hildebrandt, M (2011). Open, aware, and active: contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annual Review of Clinical Psychology 7, 141168.
Hirai, M, Clum, GA (2006). A meta-analytic study of self-help interventions for anxiety problems. Behavior Therapy 37, 99111.
Hwang, WC (2009). The formative method for adapting psychotherapy (FMAP): a community-based developmental approach to culturally adapting therapy. Professional Psychology, Research and Practice 40, 369377.
Kaiser, BN, Haroz, EE, Kohrt, BA, Bolton, PA, Bass, JK, Hinton, DE (2015). “Thinking too much”: a systematic review of a common idiom of distress. Social Science & Medicine (1982) 147, 170183.
Kashdan, T, Rottenberg, J (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review 30, 865878.
Kessler, RC, Barker, PR, Colpe, LJ, Epstein, JF, Gfroerer, JC, Hiripi, E, Howes, MJ, Normand, SL, Manderscheid, RW, Walters, EE, Zaslavsky, AM (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry 60, 184189.
Kroenke, K, Spitzer, RL, Williams, JB (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 16, 606613.
Lewis, C, Pearce, J, Bisson, JI (2012). Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review. The British Journal of Psychiatry: The Journal of Mental Science 200, 1521.
Lewis, MP, Simons, GF, Fennig, CD (2015) Ethnologue: Languages of South Sudan. SIL International: Dalles, Texas.
Lund, C, De Silva, M, Plagerson, S, Cooper, S, Chisholm, D, Das, J, Knapp, M, Patel, V (2011). Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. Lancet 378, 15021514.
Medical Research Council (2008) Developing and Evaluating Complex Interventions: New Guidance. Medical Research Council: London.
Melander, E, Petterson, T, Themner, L (2016). Organized violence, 1989–2015. Journal of Peace Research 53, 727742.
Prochaska, JJ, Sung, HY, Max, W, Shi, Y, Ong, M (2012). Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization. International Journal of Methods in Psychiatric Research 21, 8897.
Protection Cluster South Sudan - GBV Subcluster. (2015). Gender Based Violence Factsheet [Online]. Available: (Accessed 12 July 2016).
Silove, D, Ventevogel, P, Rees, S (2017). The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry 16, 130139.
Statacorp (2013). Stata Statistical Software: Release 13. StataCorp LP: College Station, TX.
Tol, WA, Barbui, C, Bisson, J, Cohen, J, Hijazi, Z, Jones, L, De Jong, JT, Magrini, N, Omigbodun, O, Seedat, S, Silove, D, Souza, R, Sumathipala, A, Vijayakumar, L, Weissbecker, I, Zatzick, D, Van Ommeren, M (2014). World Health Organization guidelines for management of acute stress, PTSD, and bereavement: key challenges on the road ahead. PLoS Medicine 11, e1001769.
Tol, WA, Barbui, C, Galappatti, A, Silove, D, Betancourt, TS, Souza, R, Golaz, A, Van Ommeren, M (2011). Mental health and psychosocial support in humanitarian settings: linking practice and research. Lancet 378, 15811591.
Tol, WA, Barbui, C, Van Ommeren, M (2013a). Management of acute stress, PTSD, and bereavement: WHO recommendations. JAMA 310, 477478.
Tol, WA, Greene, MC, Likindikoki, S, Misinzo, L, Ventevogel, P, Bonz, AG, Bass, JK, Mbwambo, JKK (2017). An integrated intervention to reduce intimate partner violence and psychological distress with refugees in low-resource settings: study protocol for the Nguvu cluster randomized trial. BMC Psychiatry 17, 186.
Tol, WA, Rees, SJ, Silove, DM (2013b). Broadening the scope of epidemiology in conflict-affected settings: opportunities for mental health prevention and promotion. Epidemiology and Psychiatric Sciences 22, 197203.
Topp, CW, Ostergaard, SD, Sondergaard, S, Bech, P (2015). The WHO-5 well-being index: a systematic review of the literature. Psychotherapy and Psychosomatics 84, 167176.
UNHCR (2017a). Global Trends – Forced Displacement in 2016. UNHCR: Geneva, Switzerland.
UNHCR (2017b). Refugee Settlements Health Indicators Analysis (December 2017). UNHCR: Kampala, Uganda.
UNICEF (2016). The Impact of Language Policy and Practice on Children's Learning: Evidence From Eastern and Southern Africa – South Sudan. UNICEF: New York.
Ustun, TB, Kostanjsek, S, Chatterji, S, Rehm, J (2010). Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). WHO: Geneva.
Van Ommeren, M, Sharma, B, Thapa, SB, Makaju, R, Prasain, D, Bhattarai, R, De Jong, JTVM (1999). Preparing instruments for transcultural research: use of the translation monitoring form with Nepali-speaking Bhutanese refugees. Transcult.Psychiatry 36, 285301.
Ventevogel, P, Jordans, M, Reis, R, De Jong, J (2013). Madness or sadness? Local concepts of mental illness in four conflict-affected African communities. Conflict and Health 7, 3.
Weisz, JR, Jensen, AL, McLeod, BD (2005). Development and dissemination of child and adolescent psychotherapies: milestones, methods, and a new deployment-focused model. In Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice (eds Hibbs, E. D., Jensen, P. S.), American Psychological Association: Washington, DC, pp. 939.
White, R. G., Gregg, J., Batten, S., Hayes, L. L., Kasujja, R. 2017. Contextual behavioral science and global mental health: synergies and opportunities. Journal of Contextual Behavioral Science,
WHO and UNHCR (2012). Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Humanitarian Settings Geneva. WHO: Switzerland.


Related content

Powered by UNSILO
Type Description Title
Supplementary materials

Tol et al. supplementary material
Table S4

 Word (19 KB)
19 KB

Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda

  • W. A. Tol (a1) (a2), J. Augustinavicius (a2), K. Carswell (a3), F. L. Brown (a4) (a5), A. Adaku (a1) (a6), M. R. Leku (a1), C. García-Moreno (a7), P. Ventevogel (a8), R. G. White (a9) and M. van Ommeren (a3)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.