Psychological Flexibility in South Sudanese Female Refugees in Uganda as a Mechanism for Change Within a Guided Self-Help Intervention

Lakin, Daniel P.
Cooper, Samuel E.
Andersen, Lena
Brown, Felicity L.
Augustinavicius, Jura L. S.
Carswell, Kenneth
Leku, Marx
Adaku, Alex
Au, Teresa
Bryant, Richard
Garcia-Moreno, Claudia
White, Ross G.
Tol, Wietse A.

Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
Department of Psychiatry and Behavioral Sciences, University of Texas at Austin
Department of Public Health, University of Copenhagen
Department of Research and Development, WarChild, Amsterdam, Netherlands
School of Population and Global Health, McGill University
Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
HealthRight International, Arua, Uganda
Department of Psychiatry, Arua Regional Referral Hospital, Arua, Uganda
School of Psychology, University of New South Wales
Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
Institute of Population Health, University of Liverpool

The original trial proposal was approved by the Mildmay Research Ethics Committee, the Uganda National Council for Science and Technology, and the World Health Organization’s Ethical Review Committee. All participants in this trial provided informed consent in compliance with the Helsinki Declaration.

The authors declare no competing interests. All authors provided considerable feedback, edits, and assistance with the article preparation process.

Daniel P. Lakin and Samuel E. Cooper contributed equally to this work and share first authorship.

Anonymized data and a data dictionary will be provided upon request for individual patient data meta-analyses after approval of a proposal and signed data access agreement. The analysis scripts and documentation that support the findings of this study are openly available at https://osf.io/f8vze/?view_only=c339e396119340578d3b72ef26a407de.

Daniel P. Lakin, Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway, Baltimore, MD 21205, United States [email protected]

Received March 4, 2022

revised July 18, 2022

Accepted October 5, 2022

Journal of Consulting and Clinical Psychology 91(1):p 6-13, January 2023. | DOI: 10.1037/ccp0000774

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.