Evaluating the Effectiveness of WHO Self-Help Plus (SH+): A Scoping Review of Populations, Adaptations, and Outcomes

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Dr. Mehreen Nasir, Dr Shaza Shahid, Dr Afshan Shahid, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9461113/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study aims to describe the evidence on effectiveness of Self-Help Plus (SH+) intervention including targeted populations, adaptations made, mode of delivery, outcomes and barriers. Methods A scoping review was conducted following the Arksey and O’Malley framework. Four electronic databases (PubMed, APA PsycINFO, DOAJ, and Google Scholar) were searched for peer-reviewed studies published between 2016 and January 2026 using the keywords “Self Help Plus” and “intervention”. Grey literature was excluded. Two reviewers screened studies and tabulated data independently on the characteristics of the studies, mode of delivery, adaptations, outcomes and obstacles to implementation. Results Out of 83 potential records identified, 17 studies met the inclusion criteria. Approximately 60% of the studies included were conducted in low- and middle-income countries. Half of the studies (52.9%) were conducted on refugees and asylum seekers. Effectiveness studies showed that SH+ can reduce psychological distress, depression, anxiety, and post-traumatic stress symptoms, and improve wellbeing, functioning, and psychological skills, with some variability depending on trauma exposure and adherence. Reported implementation barriers included logistical constraints, literacy and comprehension issues, funding challenges, and the need for booster sessions. Conclusion Self-Help Plus (SH+) is a feasible and acceptable low-intensity psychological approach that can enhance mental wellbeing and coping skills in diverse populations. Effectiveness may be influenced by trauma exposure, adherence, and implementation barriers such as logistics, literacy, technology, and funding need to be addressed. Preventive Medicine Self-Help Plus Mental Health Feasibility Studies Refugees Low- and Middle-Income Countries Figures Figure 1 Introduction Mental health disorders are major public health concern globally. It is characterized by disturbance in person’s cognition, behavior or emotional regulation. One in seven people suffer from mental disorders in some part of their life ( 1 ). The United Nations Sustainable Development Goals recognize mental health fundamental for human development. Goal 3: Good Health and Well-Being is geared towards healthy life and wellbeing of everyone. The question concerning mental health is thus not only crucial in decreasing disease burden but also the realization of other health, social and economic targets on a global scale. ( 2 ). Most common mental health disorders are anxiety and depression. There are preventive and treatment options available for them. However, many people with mental health disorders don’t have access to treatment. ( 3 ) World health organization surveys show that only 13.7% people with mental health disorders in low middle income countries and 36.8% in high-income countries received treatment ( 4 ). Although mental health conditions have affected many people, it has not been observed that the world has experienced a notable decrease in the burden of such disorders since 1990. ( 5 ). There are multiple interrelated factors responsible for treatment gaps for mental health disorders. Firstly, there are gaps in system level including limited funding, shortage of human resources for health and inadequate service delivery. Secondly, cultural gaps include stigma, discrimination, cultural beliefs, language barriers and low mental health literacy. Thirdly, individual level gaps include financial constraints, competing priorities, logistical challenges and difficulty adhering to treatment. Finally, intervention-level factors include limited accessibility of psychological therapies, dependence on specialists and issues with sustaining long-term benefits.( 4 , 6 ) Evidence based strategies delivered by specialists are effective but difficult to scale up. Consequently, there is a growing emphasis on scalable, low-intensity interventions that can reach vulnerable populations( 7 ). In 2016, World Health Organization designed Self-Help Plus (SH+) which is a low intensity psychological intervention for reducing stress among populations affected by adversity. SH+ consists of five sessions delivered in large groups (up to 30 participants) by briefly trained non-specialist facilitators, using pre-recorded audio materials and illustrated guides. Each session lasts for 90 to 100 minutes. Sessions have a structured format including welcoming participants and listening to the audio, introduction and review of previous skills, practice of a new skill and commitment to practice SH+ skills between sessions. This intervention has shown to reduce psychological distress and prevent the onset of mental disorders ( 8 ). Self-help plus can recently been adapted for online delivery via mobile based applications ( 9 ). Although evidence on self-help plus is increasing but literature about its global application, adaptations, target populations, and implementation challenges remain scattered. A scoping review is thus essential to chart the scope, extent and character of study on SH+, identify gaps in evidence and summarize its effectiveness, feasibility and barriers in contexts. This can steer the policymakers and health professionals on the capability of SH + to address the global mental health treatment gap. Aims of the review This scoping review aims to describe the evidence base for the Self-Help Plus (SH+) intervention and distil key information pertaining to the targeted populations, adaptations made, mode of delivery, outcomes and barriers. Specific research questions included: The population in which SH+ intervention has been implemented Mode of delivery of the SH+ intervention in these settings Adaptations (digital, contextual) made to original self-help plus Outcomes of self-help plus Barriers of SH+ Methodology This scoping review was conducted by methodology laid by Arksey and O’Malley and enhanced by Levac et al. ( 10 , 11 ). To ensure transparency and completeness in reporting, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist. ( 12 ) Protocol Registration Protocol Registration The protocol was drafted using Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) which was revised by the research team. The final protocol was registered prospectively with the Open Science Framework on 04, March 2026 via registration Doi 10.17605/OSF.IO/QDXY6 . Identification of relevant studies In this scoping review peer reviewed articles were included. The aim was to assess application of self-help plus intervention across the globe. Self-help plus intervention has been developed by World Health Organization with aim of reducing stress. It consists of 5 session courses which are delivered by facilitators to participants in groups. The facilitators receive short training course and deliver stress management skills using prerecorded audio and illustrated guide to conduct group activity.( 13 ) It was developed by WHO in 2016 so all articles from January 2016 to January 2026 were included. Language restrictions were not applied. Search Strategy Electronic databases were used to find literature on self-help plus. The databases included PubMed, Google Scholar, APA PsycINFO, and the Directory of Open Access Journals. The keyword in all databases was self-help plus and intervention. Full string search was (“Self Help Plus” OR “SH+”) AND (intervention OR trial OR feasibility) The search results were uploaded and saved in Zotero. Date of last search was 01.03.2026. ( 14 ) Study selection Duplicates were removed before starting the two-stage selection process. In the first stage: titles and abstracts were reviewed for eligibility. The screening was done independently by two authors (AS and MN). Discrepancies were solved by discussion. Then results were reviewed by the team. Full-text articles were retrieved and thereafter assessed for eligibility. Inclusion Criteria The inclusion criteria for this review were: Study population : Articles were eligible regardless of age and Population. Outcome measures : Articles were included if they reported findings specifically on the Self-Help Plus (SH+) intervention development, pilot testing, implementation or secondary analysis. Geographic location : Studies conducted in any country or region worldwide were included. Study design : We considered any type of original empirical intervention research, including pilot studies, feasibility studies, uncontrolled trials, randomized controlled trials (RCTs), quasi-experimental studies, qualitative studies, mixed-methods studies, secondary analysis of studies. Exclusion Criteria The exclusion criteria of this review were: Non-empirical studies : Editorials, commentaries, letters, protocols, conference abstracts without full data, narrative reviews, or theoretical papers were excluded. Irrelevant interventions : Studies reporting on psychological interventions other than Self-Help Plus (SH+) were excluded. Data Extraction Data extraction form was developed in Microsoft Excel 365 and reviewed by study team. Data extraction was done by two reviewers. In case of discrepancies, reviewers resolved differences with consensus. The data extraction sheet included the following categories: Authors name, Year of publication, country, study design, population, adaptation, implementation setting and outcomes. Summarizing and reporting the results Extracted data were synthesized using a descriptive and narrative approach, consistent with scoping review methodology. Findings were organized according to key thematic domains aligned with the review objectives, including study design and setting, target populations, adaptation, intervention format and implementation and clinical effectiveness outcomes. Results were reported narratively to map the extent, range, and nature of evidence on the Self-Help Plus (SH+) intervention across contexts. As this was a scoping review, no formal risk of bias assessment or meta-analysis was conducted. Search Results The PRISMA flowchart highlighting the study identification and selection process for studies is shown in Fig. 1 . Electronic databases identified 83 articles from Pubmed, APA PscyINFO, Google Scholar and Directory of Open Access Journals. After excluding 23 duplicate records, we screened the titles and abstracts of 60 records, of which 43 were excluded. The reasons for exclusions are highlighted in Fig. 1 . At the end 17 articles were included in the scoping review. Results A total of 17 studies were included in the review. Characteristics of Included Studies The characteristics of included studies from 2018 to 2025 are shown in the Table. These studies were conducted in countries with varying income levels. There were 4 studies from Uganda ( 15 – 18 ), 4 studies from Western Europe ( 19 – 22 ), 3 studies from Italy ( 23 – 25 ), 2 studies from South Africa ( 26 , 27 ), 1 study from China ( 28 ), 1 study from India ( 9 ), one study from Ukraine ( 29 ) and 1 study from multiple countries ( 30 ). The studies showed that: eight were from Europe, 6 were from Africa, 2 were from Asia and 1 was from multiple countries. A variety of study designs were represented including 6 (35.3%) experimental trials( 16 , 17 , 19 , 20 , 23 , 27 ), 4 (23.5%) secondary analysis of randomized controlled trials( 17 , 21 , 25 , 30 ), 3 (17.6%) qualitative studies ( 15 , 18 , 26 ) and 4 (23.5%) adaptation and implementation studies ( 9 , 24 , 28 , 29 ). Sample size mean was calculated for 16 studies as one study did not report sample size ( 24 ). The sample size of included studies ranged from 18 to 1795 participants, with a mean of 397.3 (standard deviation 463.3). Population Targeted The populations included studies on refugees and asylum seekers 9 (52.9%) ( 15 – 21 , 30 , 31 ), healthcare workers 4 (23.5) ( 9 , 23 , 25 , 28 ), women who had experienced sexual violence 2(11.8%) ( 26 , 27 ), individuals undergoing opioid agonist treatment 1 (5.8%)( 29 ) and pregnant women and women with breast cancer 1(5.8%) ( 24 ). Mode of Delivery of Self-Help Plus (SH+) The delivery of self-help plus was grouped into group based and individual technology based. Majority of studies 12 (70.6%) followed group-based intervention ( 15 , 16 , 18 – 21 , 26 , 27 , 29 , 30 , 30 , 31 ) which consisted of structured group sessions supported by pre-recorded audio materials and facilitated by trained facilitators. Most of the studies implemented all self-help plus strategies. Groups comprised up to 30 participants. Most of studies had 6 sessions lasting for 90 minutes. Most of the sessions were conducted by briefly trained facilitators. While in 5 studies individual based technology enabled intervention was used ( 9 , 23 – 25 , 28 ). Digital adaptations included mobile health interventions, smartphone applications, digital learning management systems, and online platforms such as WeChat mini programs. Cultural Adaptations Language and cultural adaptations were reported in three studies. Language translation was a common strategy, with materials translated into languages such as Juba Arabic( 15 ), simplified Mandarin( 28 ), and Hindi( 9 ) to facilitate comprehension among target populations. Cultural adaptations also included modifications in examples and illustrations within the intervention according to local population. Feasibility outcomes Out of the total studies, 5 assessed feasibility( 9 , 23 , 24 , 27 , 28 ). All five studies reported positive feasibility. However, adherence barriers were concerning. Effectiveness in Mental Health symptoms Out of the total studies, 10 assessed effectiveness of self-help plus on mental health symptoms including psychological distress, depression symptoms, anxiety symptoms, post-traumatic stress symptoms and incidence of probable mental disorders. Out of them 6 reported reductions in mental health symptoms, one study reported short term improvement in symptoms, one study reported decrease in incidence of mental health disorders, and 2 studies did not show significant improvement in symptoms. Reduction in psychological distress was reported by 3 studies Tol, Turrini and Tian ( 16 , 20 , 28 ). Reduction in depression symptoms was reported by Turrini, Nöthling and Gorbunova ( 20 , 27 , 29 ). Reduction in anxiety symptoms was reported by Purgato and Gorbunova ( 25 , 29 ). Reduction in post-traumatic stress symptoms was reported by Gorbunova, Nöthling and Purgato. Reduced incidence of probable mental disorders was reported by Augustinavicius ( 17 ). Purgato reported showed that short term improvement in symptoms ( 19 ). Two studies reported reduction in symptoms, but the improvement was not statistically significant. The first trial was conducted to reduce anxiety and post-traumatic symptomatology in workers of residential nursing and care homes. At post-intervention, no difference in self-reported anxiety and post-traumatic symptomatology between the group receiving the SH + and the group engaged in an alternative activity ( 23 ). In the second study, data was 3 randomized controlled trials was pooled to observe effect on depressive symptoms which was not statistically significant between self-help plus and enhanced care as usual ( 30 ). Improvement in Wellbeing and Functioning Improvement in Wellbeing and Functioning was assessed in 3 studies. All three reported improvement in wellbeing ( 15 , 20 , 28 ). This shows self-help plus has a positive impact on wellbeing. Improvement in Psychological Skills and Resilience Tian reported improvement in psychological flexibility and Willan reported using coping skills learned in intervention ( 26 , 28 ). Effectiveness Moderated by Exposure or Adherence Serra and White reported participants with greater trauma exposure experienced reduced benefits of self-help plus indicating exposure can moderate the intervention’s effectiveness.( 21 ). Another study conducted by Barbui on refugees and asylum seekers showed higher psychological distress and trauma exposure predicted greater risk of developing mental disorders, suggesting that baseline exposure affects intervention outcomes ( 31 ). Barriers to Implementation The studies reported some commonly faced barriers to implementation of self-help plus. Firstly, barriers were related to participants being able to attend and participate in the intervention sessions. These were reported in 5 studies and main reason was barriers related to logistics. Tol (2018) reported competing daily priorities and attendance difficulties( 15 ). Wietse A Tol (2020) reported that two 2 clusters were excluded as village leaders did not allow participation( 16 ). Samantha Willan (2025) reported that reliance on public transport, childcare responsibilities and partner resistance to attending sessions and difficulty maintaining attention during long audio sessions.( 26 ). Marianna Purgato (2021) also reported partial attendance and dropout in 5 sessions ( 25 ). J. Nöthling (2025) reported that Some women felt worried or uncomfortable sharing experiences in a group.( 27 ) Secondly, there were barriers related to Literacy and Comprehension. These barriers were reported in 3 studies. Tol et al. (2018) reported literacy and comprehension challenges of Arabic( 15 ), Ritu Shrivastava (2023) reported that some aspects of the interface were hard to understand despite overall usability ( 9 ) and Fietta V (2024) reported content not personalized enough and there were limited engagement features ( 24 ). Thirdly, technological Barriers with digital or online delivery were reported in 4 studies. Tian Tian (2023) reported difficulty in adherence to intervention received via WeChat( 28 ), Ritu Shrivastava (2023) reported difficulties with app navigation and network connectivity problems ( 9 ), Fietta V (2025) reported reduced human interaction, engagement maintenance and privacy concerns ( 24 ) and Marianna Purgato (2025) reported that digital sessions difficult to adhere ( 25 ). Fourthly, one study reported crisis barrier. Viktoriia Gorbunova (2025) reported that war-time instability, overstretched services, follow-up difficulties typical of crisis settings ( 29 ). Fifthly, one study reported funding barrier. Jacqueline N. Ndlovu (2024) reported that there is short-term, fragmented funding; need to adjust content and language across sectors ( 32 ). And lastly there is one study which reported that there is need to follow on as benefit gained over by intervention reduces with time. Marianna Purgato (2021) reported difficulty maintaining effects over time without boosters ( 25 ). Table 1 Characteristics of Included Studies on Self-Help Plus (SH+): Study Design, Population, Delivery Mode, Outcomes, and Implementation Barriers Author (Year) Country Population Study Design Delivery or Adaptation Key Outcomes Barriers Tol (2018)( 15 ) Uganda South Sudanese refugees (65 participants) Qualitative evaluation Group Self-Help Plus translated into Juba Arabic Reduced stress and psychological distress and improved wellbeing Competing daily priorities, literacy challenges Tol (2020) ( 16 ) Uganda South Sudanese refugee women (694 participants) Cluster randomized controlled trial Group Self-Help Plus Reduction in psychological distress Participation restrictions in some clusters Purgato (2021) ( 19 ) Western Europe Refugees and asylum seekers (459 participants) Randomized controlled trial Group Self-Help Plus Short-term reduction in mental disorders after the intervention Dropout and partial attendance Riello (2021) ( 23 ) Italy Home workers during coronavirus disease pandemic (238 participants) Randomized controlled trial Digital Self-Help Plus No significant difference compared with control group Not reported Turrini (2022) ( 20 ) Western Europe Refugees and asylum seekers (246 participants) Randomized controlled trial Group Self-Help Plus Improvement in psychological distress, depressive symptoms and wellbeing Not reported Tian (2023)( 28 ) China Clinical nurses (28 participants) Pilot study with qualitative evaluation Digital Self-Help Plus delivered through WeChat platform &Translation into simplified Mandarin & cultural adaptation Psychological distress reduced by twenty seven percent; psychological flexibility increased by fifteen percent; wellbeing improved Adherence difficulties Shrivastava (2023)( 9 ) India Community health workers (18 participants) Intervention adaptation study Digital Self-Help Plus translated in Hindi High acceptability and relevance of adapted intervention Application navigation difficulties and poor connectivity Barbui (2023) ( 22 ) Western Europe Refugees and asylum seekers (1101 participants) Secondary analysis of randomized controlled trial data Group Self-Help Plus Psychological distress and trauma exposure predicted development of mental disorders Not reported Karyotaki (2023) ( 30 ) Multiple countries Refugees and asylum seekers (1795 participants) Secondary analysis Self-Help Plus compared with enhanced usual care No overall difference in reduction of depressive symptoms Not reported Augustinavicius (2023) ( 17 ) Uganda South Sudanese refugee women (694 participants) Cluster randomized controlled trial Group Self-Help Plus Lower incidence of probable mental disorders among participants receiving the intervention Not reported Fietta (2024) ( 24 ) Italy Pregnant women and women with breast cancer Intervention adaptation study Mobile health version of Self-Help Plus Positive usability and acceptability reported Limited personalization of content Ndlovu (2024) ( 18 ) Uganda Refugees and health workers (50 participants) Qualitative study Group Self-Help Plus Identified factors for scaling the intervention including adaptability and social participation Funding limitations Serra and White (2024) ( 21 ) Western Europe Refugees and asylum seekers (345 participants) Secondary analysis Group Self-Help Plus Greater trauma exposure reduced the benefits of the intervention Not reported Willan (2025) ( 26 ) South Africa Women who survived rape (108 participants) Qualitative study Group Self-Help Plus Participants reported using coping skills learned in the intervention Transport difficulties, childcare responsibilities, long audio sessions Nöthling (2025) ( 27 ) South Africa Women who survived rape (106 participants) Pilot randomized controlled trial Group based Self-Help combined with problem management plus Reduction in depression and post-traumatic stress symptoms Discomfort with sharing experiences in groups Gorbunova (2025) ( 29 ) Ukraine Participants receiving opioid agonist treatment during wartime (172 participants) Pragmatic trial Group Self-Help Plus Improvements in anxiety, depression and post-traumatic stress symptoms War-related instability and adherence difficulties Purgato (2025) ( 25 ) Italy Nursing home workers during coronavirus disease pandemic (238 participants) Secondary analysis of randomized controlled trial data Digital Self-Help Plus Reduced anxiety and post-traumatic stress symptoms among participants with good adherence Poor adherence to intervention sessions Discussion This scoping review was written from evidence generated by 17 studies which were conducted between 2018 to 2025 to map population characteristics, implementation approaches, feasibility, effectiveness and barriers related to self-help plus. The findings from the studies have been conducted in various countries showing increasing global interest in low intensity psychological interventions. However, most studies were conducted in Europe followed by Africa. This is because low intensity psychological interventions can be designed to reduce mental health gap globally particularly in low and middle income countries ( 33 , 34 ). Studies from both high and low middle countries show that self help plus is an adaptable intervention. It can be implemented across various cultural contexts. There were diverse study designs including experimental trials, qualitative research, secondary analysis of randomized controlled trials and implementation studies which show evolving base of evidence which is being generated to evaluate effectiveness and applicability. The studies were conducted on vulnerable populations most commonly on refugees and asylum seekers. This shows that self help plus has been used in populations affected by adversity or trauma. As most of the studies were conducted on refugees; this suggests that this intervention is particularly relevant in humanitarian contexts which there is limited access to mental health services. Regarding the implementation, most of the studies were delivered in group-based format facilitated by briefly trained facilitators. Group based approach is a promising approach to reach large number of participants simultaneously. The use of non-specialist facilitators in self-help plus demonstrates the scalability of intervention, particularly in settings with shortage of mental health professionals ( 35 ). This intervention can be used to address mental health gap ( 36 ). Digital delivery formats were also used to deliver self-help plus. It consisted of smartphone applications and online platforms. Digital delivery platforms were individual based. It had prerecorded audio and illustrations which could have followed with the pace of participant. This approach is particularly useful for populations in which person group participation is difficult either due to competing interests like jobs and tasks or permission issues from head of family or community. Barriers to attend group based psychological intervention include individual, family and community level factors which can be addressed by using digital platforms ( 37 , 38 ). Cultural and language adaptations were also done in some studies. Translations were done in Juba Arabic, Hindi, and simplified Mandarin which enabled accessibility across diverse populations. Examples and some illustrations were also changed according to local context which increased the relevance of self-help plus in diverse populations. Contextual relevance of psychological intervention is important to increase relevance and adaptability ( 39 ). Feasibility was assessed by 5 studies and all of them showed that self-help plus is feasible. This suggests that self-help plus can be implemented across different populations. However, there were adherence challenges. This suggests that implementation should incorporate flexible delivery models. The effectiveness outcomes showed that there was a positive impact on health outcomes including reduction in psychological distress, depression, anxiety, post-traumatic stress symptoms and incidence of probable mental disorders. Although magnitude of improvement varied. Reduction in psychological distress was seen in multiple studies. This indicates self-help plus is a stress management package ( 40 ). There were broader mental health benefits like improvement in depression and anxiety which shows self-help plus has mental health benefits beyond stress reduction. Additionally, reduction in post-traumatic stress symptoms show the effectiveness of self-help plus in trauma exposed population. There were some studies who found there was no statistically significant improvement. One such study was conducted among workers in residential nursing and care homes. There may be occupational factors influencing effectiveness of intervention ( 41 ). Similarly, another study pooled data from randomized controlled trials to demonstrate improvements in depression as result of self-help plus versus enhanced care as usual did not demonstrate statistically significant improvement. In addition to improvements in mental health systems, there were improvements in wellbeing and functionality, suggesting self-help plus improving overall functioning. Studies suggest that effectiveness of self-help plus is moderated by trauma and adverse experiences. Participants with high trauma have reduced benefits suggesting that individuals with more adverse experiences require more additional or intensive interventions. This scoping review identified barriers of implementation of self-help plus. The most common were logistic barriers including competing daily priorities, transportation difficulties, childcare responsibilities, and resistance from family members. Attendance challenges were seen which can be addressed through flexibility in schedule and supportive strategies to enhance participation. Literacy and comprehension barriers were also identified which can be reduced by making contextual adaptations. Technological barriers were difficulties related to internet connectivity, app navigation, engagement with digital platforms, and concerns regarding privacy. Another issue was reduced human interaction suggesting hybrid models could improve engagement. One study also highlighted the potential decline in intervention benefits over time, suggesting the need for booster sessions or follow-up support to maintain long-term effectiveness. Limitations There are several limitations of this scoping review. Firstly, only peer reviewed literature was included in the study which could have led to omission of relevant unpublished literature. Secondly, quality assessment of articles was not done which is limitation in scoping reviews. Thirdly, the studies varied widely in design, population, intervention delivery and outcome measures which limited the ability to draw direct comparisons. Despite these limitations, this review provides a comprehensive mapping of the extent, range, and characteristics of evidence on Self-Help Plus across diverse settings and populations. Future Research Future research should address the gaps identified in this scoping review. Firstly, more studies should be conducted in low resource settings. Secondly, studies should be conducted on populations outside refugee camps. Thirdly, research should explore long term effectiveness of self-help plus. Fourthly, there is need for cost-effective analysis and implementation research. Finally, SH + is a promising scalable intervention for managing psychological distress and preventing mental disorders in humanitarian contexts. However, future research is needed to evaluate it when integrated into broader health systems. Conclusion Self-help plus has been adapted and implemented across diverse vulnerable groups including refugees, healthcare workers, and women exposed to violence across multiple countries. This intervention is feasible and effective in reducing psychological distress, depression, anxiety, and post-traumatic stress symptoms, while improving wellbeing, functioning, and coping skills. These findings emphasize the need to build local capacity, standardize training and supervision, and carefully adapt SH + to context and population to maximize effectiveness and sustainability. Declarations Conflict of interest: The authors declare that they have no conflict of interest. Source of Funding No funds, grants, or other support was received. 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Eur J Psychotraumatology 15(1). 10.1080/20008066.2024.2355828 Barbui C, Tedeschi F, Acarturk C, Anttila M, Au T, Baumgartner J et al (2023) Risk factors for mental disorder development in asylum seekers and refugees resettled in Western Europe and Turkey: Participant-level analysis of two large prevention studies. Int J Soc Psychiatry 69(3):664–674. 10.1177/00207640221132430 Riello M, Purgato M, Bove C, Tedeschi F, MacTaggart D, Barbui C et al (2021) Effectiveness of self-help plus (SH+) in reducing anxiety and post-traumatic symptomatology among care home workers during the COVID-19 pandemic: a randomized controlled trial. R Soc open sci 8(11):210219. 10.1098/rsos.210219 Fietta V, Rizzi S, De Luca C, Gios L, Pavesi MC, Gabrielli S et al A Chatbot-Based Version of the World Health Organization–Validated Self-Help Plus Intervention for Stress Management: Co-Design and Usability Testing (Preprint) [Internet]. 2024 [cited 2026 Jan 27]. Available from: http://preprints.jmir.org/preprint/64614 10.2196/preprints.64614 Purgato M, Tedeschi F, Barbui C, Ayuso-Mateos JL, Mediavilla R, Riello M et al (2025) Effectiveness of Self-Help Plus in its digital version in reducing anxiety and post-traumatic symptomatology among nursing home workers during the COVID-19 pandemic: secondary analysis of randomised controlled trial data. BMJ Mental Health 28(1). 10.1136/bmjment-2024-301379 Willan S, Khoza Z, Mngadi S, Nothling J, Majola T, Mabhida M et al (2025) Self-help plus and problem management plus – a qualitative study to assess acceptability and feasibility with rape and GBV survivors in South Africa. SSM - Mental Health 8:100503. 10.1016/j.ssmmh.2025.100503 Nöthling J, Willan S, Gigaba G, Chirwa E, Mhlongo S, Myers B et al (2025) Group-based Self-Help Plus, Problem Management Plus and pre-exposure prophylaxis to improve mental health and reduce HIV risk in survivors of rape in KwaZulu-Natal, South Africa: A pilot and feasabilty randomised study. SSM - Mental Health 8:100513. 10.1016/j.ssmmh.2025.100513 Tian T, Sun J, Jiang Y, Guo Q, Huang Z, Wang D et al (2023) Translation, adaptation, and initial evaluation of a guided self-help intervention to reduce psychological distress among nurses during COVID-19 in China. Front Psychiatry 14. 10.3389/fpsyt.2023.1168117 Full article Effectiveness of Self-Help plus and problem management plus interventions in providing psychological support to clients of Opioid Agonist treatment programs in Ukraine [Internet]. 2026 [cited 2026 Jan 27]. Available from: https://www.tandfonline.com/doi/full/ 10.1080/16066359.2025.2573341 Karyotaki E, Cuijpers P, Välimäki M, Purgato M, Carswell K, Acarturk C et al (2023) Self-Help Plus for refugees and asylum seekers: an individual participant data meta-analysis. BMJ Mental Health 26(1). 10.1136/bmjment-2023-300672 Barbui C, Tedeschi F, Acarturk C, Anttila M, Au T, Baumgartner J et al (2023) Risk factors for mental disorder development in asylum seekers and refugees resettled in Western Europe and Turkey: Participant-level analysis of two large prevention studies. Int J Soc Psychiatry 69(3):664–674. 10.1177/00207640221132430 Ndlovu JN, Ouizzane S, Leku MR, Okware KK, Sentongo H, Nyangwen B et al (2024) Scaling up mental health service provision through multisectoral integration: A qualitative analysis of factors shaping delivery and uptake among South Sudanese refugees and healthcare workers in Uganda. Implement Res Pract 5:26334895241288574. 10.1177/26334895241288574 Bockting CLH, Williams AD, Carswell K, Grech AE (2016) The potential of low-intensity and online interventions for depression in low- and middle-income countries. Global Mental Health 3:e25. 10.1017/gmh.2016.21 Dawson KS, Rahman A (2018) Low Intensity Interventions for Psychological Symptoms Following Mass Trauma. In: Morina N, Nickerson A, editors. Mental Health of Refugee and Conflict-Affected Populations: Theory, Research and Clinical Practice [Internet]. Cham: Springer International Publishing; [cited 2026 Mar 31]. pp. 341–56. Available from: https://doi.org/10.1007/978-3-319-97046-2_17 doi:10.1007/978-3-319-97046-2_17 AAMC [Internet] [cited 2026 Mar 31]. A growing psychiatrist shortage and an enormous demand for mental health services. Available from: https://www.aamc.org/news/growing-psychiatrist-shortage-enormous-demand-mental-health-services Prevention [Internet] [cited 2026 Mar 31]. Available from: https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks | Implementation Science | Springer Nature Link [Internet]. [cited 2026 Mar 31]. Available from: https://link.springer.com/article/ 10.1186/s13012-021-01179-z Perceived barriers to psychological treatments and their relationship to depression - Mohr – 2010 - Journal of Clinical Psychology - Wiley Online Library [Internet]. [cited 2026 Mar 31]. Available from: https://onlinelibrary.wiley.com/doi/ 10.1002/jclp.20659 Brown FL, Aoun M, Taha K, Steen F, Hansen P, Bird M et al (2020) The Cultural and Contextual Adaptation Process of an Intervention to Reduce Psychological Distress in Young Adolescents Living in Lebanon. Front Psychiatry 11. 10.3389/fpsyt.2020.00212 Epping-Jordan JE, Harris R, Brown FL, Carswell K, Foley C, García-Moreno C et al (2016) Self-Help Plus (SH+): a new WHO stress management package. World Psychiatry 15(3):295–296. 10.1002/wps.20355 Occupational intervention in mental health hospitals Study of contextual impact: Scandinavian Journal of Occupational Therapy: Vol 30, No 2 - Get Access [Internet]. [cited 2026 Mar 31]. Available from: https://www.tandfonline.com/doi/full/ 10.1080/11038128.2022.2076734 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9461113","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":625672889,"identity":"4c4f24e2-5669-4f04-b536-5b72e89a1d08","order_by":0,"name":"Dr Farah Rashid","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABMElEQVRIie3RMWuDQBTA8SeCLlezngj1KyiCEEzIV7kjYKaUQpZO6RXBLOlu6eBXuLGjRUiXdLeklLpkLnQxdOnZQhpQId1Kuf/kIT/eOw5AJvuD6QxA/frCCsNvAOTnXwagsCZB2QExkz0hRxEACx1F9Mfy/RxebPs2utoM7+ZnNjtZmbsKTo2CaGXSQtDEsxKYufz5Pgqm63zmZEZoIQKeWRDd5U0ygrDehygc09iaxhnlgHxLLEa5mGK+tkzpbdUPQUZpIkg/ntOUId+sCFx2Ehxq9RTKCkGUWKUsQz4WixGnJi2LIbzVAuSQMS9o1L+Oc8pz5AUoxO7Nuly4bdfvheoGXZBhmkzKYlcvtli6T9VgYBsP41W5bJLvnMPD/plAibtAd9rviUwmk/3DPgEd62PEmVlFuQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0006-5931-6204","institution":"National University of Sciences and Technology, Islamabad. Pakistan","correspondingAuthor":true,"prefix":"Dr","firstName":"Farah","middleName":"","lastName":"Rashid","suffix":""},{"id":625672890,"identity":"65fd02f7-1416-43d4-afb5-1caf3e4db5b0","order_by":1,"name":"2.\tDr. Mehreen Nasir","email":"","orcid":"https://orcid.org/0000-0002-1175-943X","institution":"Services Institute of Medical Sciences, Lahore, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"2.\tDr.","middleName":"Mehreen","lastName":"Nasir","suffix":""},{"id":625672891,"identity":"c4da016d-0fac-4843-b6ea-4b7714b42ad0","order_by":2,"name":"Dr Shaza Shahid","email":"","orcid":"","institution":"Intern Aga Khan University. Karachi. Pakistan","correspondingAuthor":false,"prefix":"Dr","firstName":"Shaza","middleName":"","lastName":"Shahid","suffix":""},{"id":625675719,"identity":"ea38e132-9a25-4f16-b104-664fa941e1cc","order_by":3,"name":"Dr Afshan Shahid","email":"","orcid":"https://orcid.org/0000-0002-6422-4578","institution":"Services Institute of Medical Sciences, Lahore, Pakistan","correspondingAuthor":false,"prefix":"Dr","firstName":"Afshan","middleName":"","lastName":"Shahid","suffix":""},{"id":625675720,"identity":"0670568a-1ba0-4825-8ae3-010a05de50f1","order_by":4,"name":"Dr Abid Malik","email":"","orcid":"https://orcid.org/0000-0002-9084-2185","institution":"Professor and HOD Public Mental Health","correspondingAuthor":false,"prefix":"Dr","firstName":"Abid","middleName":"","lastName":"Malik","suffix":""},{"id":625675721,"identity":"d1cdc6a2-fce7-4681-ab4c-da53c28dc1db","order_by":5,"name":"Dr Atif Rahman","email":"","orcid":"https://orcid.org/0000-0002-2066-4467","institution":"Professor of Child Psychiatry \u0026 Global Mental Health, Department of Primary Care and Mental Health Institute of Population Liverpool L69 3BX, United Kingdom","correspondingAuthor":false,"prefix":"Dr","firstName":"Atif","middleName":"","lastName":"Rahman","suffix":""}],"badges":[],"createdAt":"2026-04-19 10:05:15","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9461113/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9461113/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107415583,"identity":"fc768156-c30b-4f7c-877e-bf1178a5763f","added_by":"auto","created_at":"2026-04-21 09:45:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41059,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analysis flow chart illustrating the study selection process. WHO, World Health Organization.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9461113/v1/17326308d8364b363c64c694.png"},{"id":107705468,"identity":"fc7ef146-e4c7-4fdc-be94-509ea029d646","added_by":"auto","created_at":"2026-04-24 09:13:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":382377,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9461113/v1/b971d2ae-9ee6-4301-96ca-955627852f00.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eEvaluating the Effectiveness of WHO Self-Help Plus (SH+): A Scoping Review of Populations, Adaptations, and Outcomes\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental health disorders are major public health concern globally. It is characterized by disturbance in person\u0026rsquo;s cognition, behavior or emotional regulation. One in seven people suffer from mental disorders in some part of their life (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The United Nations Sustainable Development Goals recognize mental health fundamental for human development. Goal 3: Good Health and Well-Being is geared towards healthy life and wellbeing of everyone. The question concerning mental health is thus not only crucial in decreasing disease burden but also the realization of other health, social and economic targets on a global scale. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Most common mental health disorders are anxiety and depression. There are preventive and treatment options available for them. However, many people with mental health disorders don\u0026rsquo;t have access to treatment. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) World health organization surveys show that only 13.7% people with mental health disorders in low middle income countries and 36.8% in high-income countries received treatment (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although mental health conditions have affected many people, it has not been observed that the world has experienced a notable decrease in the burden of such disorders since 1990. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are multiple interrelated factors responsible for treatment gaps for mental health disorders. Firstly, there are gaps in system level including limited funding, shortage of human resources for health and inadequate service delivery. Secondly, cultural gaps include stigma, discrimination, cultural beliefs, language barriers and low mental health literacy. Thirdly, individual level gaps include financial constraints, competing priorities, logistical challenges and difficulty adhering to treatment. Finally, intervention-level factors include limited accessibility of psychological therapies, dependence on specialists and issues with sustaining long-term benefits.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Evidence based strategies delivered by specialists are effective but difficult to scale up. Consequently, there is a growing emphasis on scalable, low-intensity interventions that can reach vulnerable populations(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2016, World Health Organization designed Self-Help Plus (SH+) which is a low intensity psychological intervention for reducing stress among populations affected by adversity. SH+ consists of five sessions delivered in large groups (up to 30 participants) by briefly trained non-specialist facilitators, using pre-recorded audio materials and illustrated guides. Each session lasts for 90 to 100 minutes. Sessions have a structured format including welcoming participants and listening to the audio, introduction and review of previous skills, practice of a new skill and commitment to practice SH+ skills between sessions. This intervention has shown to reduce psychological distress and prevent the onset of mental disorders (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Self-help plus can recently been adapted for online delivery via mobile based applications (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough evidence on self-help plus is increasing but literature about its global application, adaptations, target populations, and implementation challenges remain scattered. A scoping review is thus essential to chart the scope, extent and character of study on SH+, identify gaps in evidence and summarize its effectiveness, feasibility and barriers in contexts. This can steer the policymakers and health professionals on the capability of SH\u0026thinsp;+\u0026thinsp;to address the global mental health treatment gap.\u003c/p\u003e"},{"header":"Aims of the review","content":"\u003cp\u003eThis scoping review aims to describe the evidence base for the Self-Help Plus (SH+) intervention and distil key information pertaining to the targeted populations, adaptations made, mode of delivery, outcomes and barriers. Specific research questions included:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eThe population in which SH+ intervention has been implemented\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMode of delivery of the SH+ intervention in these settings\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAdaptations (digital, contextual) made to original self-help plus\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOutcomes of self-help plus\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBarriers of SH+\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cp\u003e\u003c/p\u003e "},{"header":"Methodology","content":"\u003cp\u003eThis scoping review was conducted by methodology laid by Arksey and O’Malley and enhanced by Levac et al. (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). To ensure transparency and completeness in reporting, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist. (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eProtocol Registration\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eProtocol Registration\u003c/div\u003e \u003cp\u003e The protocol was drafted using Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) which was revised by the research team. The final protocol was registered prospectively with the Open Science Framework on 04, March 2026 via registration Doi \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17605/OSF.IO/QDXY6\u003c/span\u003e\u003cspan address=\"10.17605/OSF.IO/QDXY6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eIdentification of relevant studies\u003c/h3\u003e\n\u003cp\u003eIn this scoping review peer reviewed articles were included. The aim was to assess application of self-help plus intervention across the globe. Self-help plus intervention has been developed by World Health Organization with aim of reducing stress. It consists of 5 session courses which are delivered by facilitators to participants in groups. The facilitators receive short training course and deliver stress management skills using prerecorded audio and illustrated guide to conduct group activity.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) It was developed by WHO in 2016 so all articles from January 2016 to January 2026 were included. Language restrictions were not applied.\u003c/p\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eElectronic databases were used to find literature on self-help plus. The databases included PubMed, Google Scholar, APA PsycINFO, and the Directory of Open Access Journals. The keyword in all databases was self-help plus and intervention. Full string search was (\u0026ldquo;Self Help Plus\u0026rdquo; OR \u0026ldquo;SH+\u0026rdquo;) AND (intervention OR trial OR feasibility) The search results were uploaded and saved in Zotero. Date of last search was 01.03.2026. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eStudy selection\u003c/h3\u003e\n\u003cp\u003eDuplicates were removed before starting the two-stage selection process. In the first stage: titles and abstracts were reviewed for eligibility. The screening was done independently by two authors (AS and MN). Discrepancies were solved by discussion. Then results were reviewed by the team. Full-text articles were retrieved and thereafter assessed for eligibility.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Criteria\u003c/h2\u003e \u003cp\u003eThe inclusion criteria for this review were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStudy population\u003c/b\u003e: Articles were eligible regardless of age and Population.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eOutcome measures\u003c/b\u003e: Articles were included if they reported findings specifically on the Self-Help Plus (SH+) intervention development, pilot testing, implementation or secondary analysis.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGeographic location\u003c/b\u003e: Studies conducted in any country or region worldwide were included.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStudy design\u003c/b\u003e: We considered any type of original empirical intervention research, including pilot studies, feasibility studies, uncontrolled trials, randomized controlled trials (RCTs), quasi-experimental studies, qualitative studies, mixed-methods studies, secondary analysis of studies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003eThe exclusion criteria of this review were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eNon-empirical studies\u003c/b\u003e: Editorials, commentaries, letters, protocols, conference abstracts without full data, narrative reviews, or theoretical papers were excluded.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eIrrelevant interventions\u003c/b\u003e: Studies reporting on psychological interventions other than Self-Help Plus (SH+) were excluded.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eData extraction form was developed in Microsoft Excel 365 and reviewed by study team. Data extraction was done by two reviewers. In case of discrepancies, reviewers resolved differences with consensus. The data extraction sheet included the following categories: Authors name, Year of publication, country, study design, population, adaptation, implementation setting and outcomes.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSummarizing and reporting the results\u003c/h2\u003e \u003cp\u003eExtracted data were synthesized using a descriptive and narrative approach, consistent with scoping review methodology. Findings were organized according to key thematic domains aligned with the review objectives, including study design and setting, target populations, adaptation, intervention format and implementation and clinical effectiveness outcomes. Results were reported narratively to map the extent, range, and nature of evidence on the Self-Help Plus (SH+) intervention across contexts. As this was a scoping review, no formal risk of bias assessment or meta-analysis was conducted.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSearch Results\u003c/h2\u003e \u003cp\u003eThe PRISMA flowchart highlighting the study identification and selection process for studies is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Electronic databases identified 83 articles from Pubmed, APA PscyINFO, Google Scholar and Directory of Open Access Journals. After excluding 23 duplicate records, we screened the titles and abstracts of 60 records, of which 43 were excluded. The reasons for exclusions are highlighted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. At the end 17 articles were included in the scoping review.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 17 studies were included in the review.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of Included Studies\u003c/h2\u003e \u003cp\u003eThe characteristics of included studies from 2018 to 2025 are shown in the Table. These studies were conducted in countries with varying income levels. There were 4 studies from Uganda (\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), 4 studies from Western Europe (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), 3 studies from Italy (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), 2 studies from South Africa (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), 1 study from China (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), 1 study from India (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), one study from Ukraine (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and 1 study from multiple countries (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The studies showed that: eight were from Europe, 6 were from Africa, 2 were from Asia and 1 was from multiple countries.\u003c/p\u003e \u003cp\u003eA variety of study designs were represented including 6 (35.3%) experimental trials(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), 4 (23.5%) secondary analysis of randomized controlled trials(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), 3 (17.6%) qualitative studies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) and 4 (23.5%) adaptation and implementation studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Sample size mean was calculated for 16 studies as one study did not report sample size (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The sample size of included studies ranged from 18 to 1795 participants, with a mean of 397.3 (standard deviation 463.3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePopulation Targeted\u003c/h2\u003e \u003cp\u003eThe populations included studies on refugees and asylum seekers 9 (52.9%) (\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), healthcare workers 4 (23.5) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), women who had experienced sexual violence 2(11.8%) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), individuals undergoing opioid agonist treatment 1 (5.8%)(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and pregnant women and women with breast cancer 1(5.8%) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMode of Delivery of Self-Help Plus (SH+)\u003c/h2\u003e \u003cp\u003eThe delivery of self-help plus was grouped into group based and individual technology based. Majority of studies 12 (70.6%) followed group-based intervention (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) which consisted of structured group sessions supported by pre-recorded audio materials and facilitated by trained facilitators. Most of the studies implemented all self-help plus strategies. Groups comprised up to 30 participants. Most of studies had 6 sessions lasting for 90 minutes. Most of the sessions were conducted by briefly trained facilitators. While in 5 studies individual based technology enabled intervention was used (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Digital adaptations included mobile health interventions, smartphone applications, digital learning management systems, and online platforms such as WeChat mini programs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCultural Adaptations\u003c/h2\u003e \u003cp\u003eLanguage and cultural adaptations were reported in three studies. Language translation was a common strategy, with materials translated into languages such as Juba Arabic(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), simplified Mandarin(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and Hindi(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) to facilitate comprehension among target populations. Cultural adaptations also included modifications in examples and illustrations within the intervention according to local population.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFeasibility outcomes\u003c/h2\u003e \u003cp\u003eOut of the total studies, 5 assessed feasibility(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). All five studies reported positive feasibility. However, adherence barriers were concerning.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness in Mental Health symptoms\u003c/h2\u003e \u003cp\u003eOut of the total studies, 10 assessed effectiveness of self-help plus on mental health symptoms including psychological distress, depression symptoms, anxiety symptoms, post-traumatic stress symptoms and incidence of probable mental disorders. Out of them 6 reported reductions in mental health symptoms, one study reported short term improvement in symptoms, one study reported decrease in incidence of mental health disorders, and 2 studies did not show significant improvement in symptoms.\u003c/p\u003e \u003cp\u003eReduction in psychological distress was reported by 3 studies Tol, Turrini and Tian (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Reduction in depression symptoms was reported by Turrini, N\u0026ouml;thling and Gorbunova (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Reduction in anxiety symptoms was reported by Purgato and Gorbunova (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Reduction in post-traumatic stress symptoms was reported by Gorbunova, N\u0026ouml;thling and Purgato. Reduced incidence of probable mental disorders was reported by Augustinavicius (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Purgato reported showed that short term improvement in symptoms (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Two studies reported reduction in symptoms, but the improvement was not statistically significant. The first trial was conducted to reduce anxiety and post-traumatic symptomatology in workers of residential nursing and care homes. At post-intervention, no difference in self-reported anxiety and post-traumatic symptomatology between the group receiving the SH\u0026thinsp;+\u0026thinsp;and the group engaged in an alternative activity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In the second study, data was 3 randomized controlled trials was pooled to observe effect on depressive symptoms which was not statistically significant between self-help plus and enhanced care as usual (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImprovement in Wellbeing and Functioning\u003c/h2\u003e \u003cp\u003eImprovement in Wellbeing and Functioning was assessed in 3 studies. All three reported improvement in wellbeing (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This shows self-help plus has a positive impact on wellbeing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eImprovement in Psychological Skills and Resilience\u003c/h2\u003e \u003cp\u003eTian reported improvement in psychological flexibility and Willan reported using coping skills learned in intervention (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness Moderated by Exposure or Adherence\u003c/h2\u003e \u003cp\u003eSerra and White reported participants with greater trauma exposure experienced reduced benefits of self-help plus indicating exposure can moderate the intervention\u0026rsquo;s effectiveness.(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Another study conducted by Barbui on refugees and asylum seekers showed higher psychological distress and trauma exposure predicted greater risk of developing mental disorders, suggesting that baseline exposure affects intervention outcomes (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eBarriers to Implementation\u003c/h2\u003e \u003cp\u003eThe studies reported some commonly faced barriers to implementation of self-help plus. Firstly, barriers were related to participants being able to attend and participate in the intervention sessions. These were reported in 5 studies and main reason was barriers related to logistics. Tol (2018) reported competing daily priorities and attendance difficulties(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Wietse A Tol (2020) reported that two 2 clusters were excluded as village leaders did not allow participation(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Samantha Willan (2025) reported that reliance on public transport, childcare responsibilities and partner resistance to attending sessions and difficulty maintaining attention during long audio sessions.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Marianna Purgato (2021) also reported partial attendance and dropout in 5 sessions (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). J. N\u0026ouml;thling (2025) reported that Some women felt worried or uncomfortable sharing experiences in a group.(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSecondly, there were barriers related to Literacy and Comprehension. These barriers were reported in 3 studies. Tol et al. (2018) reported literacy and comprehension challenges of Arabic(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), Ritu Shrivastava (2023) reported that some aspects of the interface were hard to understand despite overall usability (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and Fietta V (2024) reported content not personalized enough and there were limited engagement features (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThirdly, technological Barriers with digital or online delivery were reported in 4 studies. Tian Tian (2023) reported difficulty in adherence to intervention received via WeChat(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), Ritu Shrivastava (2023) reported difficulties with app navigation and network connectivity problems (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), Fietta V (2025) reported reduced human interaction, engagement maintenance and privacy concerns (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and Marianna Purgato (2025) reported that digital sessions difficult to adhere (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFourthly, one study reported crisis barrier. Viktoriia Gorbunova (2025) reported that war-time instability, overstretched services, follow-up difficulties typical of crisis settings (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Fifthly, one study reported funding barrier. Jacqueline N. Ndlovu (2024) reported that there is short-term, fragmented funding; need to adjust content and language across sectors (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). And lastly there is one study which reported that there is need to follow on as benefit gained over by intervention reduces with time. Marianna Purgato (2021) reported difficulty maintaining effects over time without boosters (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Included Studies on Self-Help Plus (SH+): Study Design, Population, Delivery Mode, Outcomes, and Implementation Barriers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDelivery or Adaptation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKey Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTol (2018)(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Sudanese refugees (65 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus translated into Juba Arabic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReduced stress and psychological distress and improved wellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCompeting daily priorities, literacy challenges\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTol (2020) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Sudanese refugee women (694 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCluster randomized controlled trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReduction in psychological distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eParticipation restrictions in some clusters\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePurgato (2021) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestern Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefugees and asylum seekers (459 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRandomized controlled trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eShort-term reduction in mental disorders after the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDropout and partial attendance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRiello (2021) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHome workers during coronavirus disease pandemic (238 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRandomized controlled trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDigital Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo significant difference compared with control group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurrini (2022) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestern Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefugees and asylum seekers (246 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRandomized controlled trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImprovement in psychological distress, depressive symptoms and wellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTian (2023)(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical nurses (28 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePilot study with qualitative evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDigital Self-Help Plus delivered through WeChat platform \u0026amp;Translation into simplified Mandarin \u0026amp; cultural adaptation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePsychological distress reduced by twenty seven percent; psychological flexibility increased by fifteen percent; wellbeing improved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdherence difficulties\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShrivastava (2023)(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunity health workers (18 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention adaptation study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDigital Self-Help Plus translated in Hindi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh acceptability and relevance of adapted intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eApplication navigation difficulties and poor connectivity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarbui (2023) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestern Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefugees and asylum seekers (1101 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecondary analysis of randomized controlled trial data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePsychological distress and trauma exposure predicted development of mental disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaryotaki (2023) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefugees and asylum seekers (1795 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecondary analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSelf-Help Plus compared with enhanced usual care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo overall difference in reduction of depressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAugustinavicius (2023) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Sudanese refugee women (694 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCluster randomized controlled trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLower incidence of probable mental disorders among participants receiving the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFietta (2024) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePregnant women and women with breast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention adaptation study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMobile health version of Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePositive usability and acceptability reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLimited personalization of content\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNdlovu (2024) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefugees and health workers (50 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIdentified factors for scaling the intervention including adaptability and social participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFunding limitations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerra and White (2024) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestern Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefugees and asylum seekers (345 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecondary analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGreater trauma exposure reduced the benefits of the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWillan (2025) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen who survived rape (108 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParticipants reported using coping skills learned in the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTransport difficulties, childcare responsibilities, long audio sessions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u0026ouml;thling (2025) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen who survived rape (106 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePilot randomized controlled trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup based Self-Help combined with problem management plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReduction in depression and post-traumatic stress symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDiscomfort with sharing experiences in groups\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGorbunova (2025) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUkraine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants receiving opioid agonist treatment during wartime (172 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePragmatic trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImprovements in anxiety, depression and post-traumatic stress symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWar-related instability and adherence difficulties\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePurgato (2025) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNursing home workers during coronavirus disease pandemic (238 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecondary analysis of randomized controlled trial data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDigital Self-Help Plus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReduced anxiety and post-traumatic stress symptoms among participants with good adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor adherence to intervention sessions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e This scoping review was written from evidence generated by 17 studies which were conducted between 2018 to 2025 to map population characteristics, implementation approaches, feasibility, effectiveness and barriers related to self-help plus. The findings from the studies have been conducted in various countries showing increasing global interest in low intensity psychological interventions. However, most studies were conducted in Europe followed by Africa. This is because low intensity psychological interventions can be designed to reduce mental health gap globally particularly in low and middle income countries (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Studies from both high and low middle countries show that self help plus is an adaptable intervention. It can be implemented across various cultural contexts. There were diverse study designs including experimental trials, qualitative research, secondary analysis of randomized controlled trials and implementation studies which show evolving base of evidence which is being generated to evaluate effectiveness and applicability. The studies were conducted on vulnerable populations most commonly on refugees and asylum seekers. This shows that self help plus has been used in populations affected by adversity or trauma. As most of the studies were conducted on refugees; this suggests that this intervention is particularly relevant in humanitarian contexts which there is limited access to mental health services.\u003c/p\u003e \u003cp\u003eRegarding the implementation, most of the studies were delivered in group-based format facilitated by briefly trained facilitators. Group based approach is a promising approach to reach large number of participants simultaneously. The use of non-specialist facilitators in self-help plus demonstrates the scalability of intervention, particularly in settings with shortage of mental health professionals (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This intervention can be used to address mental health gap (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Digital delivery formats were also used to deliver self-help plus. It consisted of smartphone applications and online platforms. Digital delivery platforms were individual based. It had prerecorded audio and illustrations which could have followed with the pace of participant. This approach is particularly useful for populations in which person group participation is difficult either due to competing interests like jobs and tasks or permission issues from head of family or community. Barriers to attend group based psychological intervention include individual, family and community level factors which can be addressed by using digital platforms (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Cultural and language adaptations were also done in some studies. Translations were done in Juba Arabic, Hindi, and simplified Mandarin which enabled accessibility across diverse populations. Examples and some illustrations were also changed according to local context which increased the relevance of self-help plus in diverse populations. Contextual relevance of psychological intervention is important to increase relevance and adaptability (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Feasibility was assessed by 5 studies and all of them showed that self-help plus is feasible. This suggests that self-help plus can be implemented across different populations. However, there were adherence challenges. This suggests that implementation should incorporate flexible delivery models.\u003c/p\u003e \u003cp\u003eThe effectiveness outcomes showed that there was a positive impact on health outcomes including reduction in psychological distress, depression, anxiety, post-traumatic stress symptoms and incidence of probable mental disorders. Although magnitude of improvement varied. Reduction in psychological distress was seen in multiple studies. This indicates self-help plus is a stress management package (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). There were broader mental health benefits like improvement in depression and anxiety which shows self-help plus has mental health benefits beyond stress reduction. Additionally, reduction in post-traumatic stress symptoms show the effectiveness of self-help plus in trauma exposed population. There were some studies who found there was no statistically significant improvement. One such study was conducted among workers in residential nursing and care homes. There may be occupational factors influencing effectiveness of intervention (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Similarly, another study pooled data from randomized controlled trials to demonstrate improvements in depression as result of self-help plus versus enhanced care as usual did not demonstrate statistically significant improvement. In addition to improvements in mental health systems, there were improvements in wellbeing and functionality, suggesting self-help plus improving overall functioning. Studies suggest that effectiveness of self-help plus is moderated by trauma and adverse experiences. Participants with high trauma have reduced benefits suggesting that individuals with more adverse experiences require more additional or intensive interventions.\u003c/p\u003e \u003cp\u003eThis scoping review identified barriers of implementation of self-help plus. The most common were logistic barriers including competing daily priorities, transportation difficulties, childcare responsibilities, and resistance from family members. Attendance challenges were seen which can be addressed through flexibility in schedule and supportive strategies to enhance participation. Literacy and comprehension barriers were also identified which can be reduced by making contextual adaptations. Technological barriers were difficulties related to internet connectivity, app navigation, engagement with digital platforms, and concerns regarding privacy. Another issue was reduced human interaction suggesting hybrid models could improve engagement. One study also highlighted the potential decline in intervention benefits over time, suggesting the need for booster sessions or follow-up support to maintain long-term effectiveness.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere are several limitations of this scoping review. Firstly, only peer reviewed literature was included in the study which could have led to omission of relevant unpublished literature. Secondly, quality assessment of articles was not done which is limitation in scoping reviews. Thirdly, the studies varied widely in design, population, intervention delivery and outcome measures which limited the ability to draw direct comparisons. Despite these limitations, this review provides a comprehensive mapping of the extent, range, and characteristics of evidence on Self-Help Plus across diverse settings and populations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eFuture Research\u003c/h2\u003e \u003cp\u003eFuture research should address the gaps identified in this scoping review. Firstly, more studies should be conducted in low resource settings. Secondly, studies should be conducted on populations outside refugee camps. Thirdly, research should explore long term effectiveness of self-help plus. Fourthly, there is need for cost-effective analysis and implementation research. Finally, SH\u0026thinsp;+\u0026thinsp;is a promising scalable intervention for managing psychological distress and preventing mental disorders in humanitarian contexts. However, future research is needed to evaluate it when integrated into broader health systems.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSelf-help plus has been adapted and implemented across diverse vulnerable groups including refugees, healthcare workers, and women exposed to violence across multiple countries. This intervention is feasible and effective in reducing psychological distress, depression, anxiety, and post-traumatic stress symptoms, while improving wellbeing, functioning, and coping skills. These findings emphasize the need to build local capacity, standardize training and supervision, and carefully adapt SH\u0026thinsp;+\u0026thinsp;to context and population to maximize effectiveness and sustainability.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ethis is a scoping review that requires no ethical approval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no competing interests.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contribution statements.\u003c/h2\u003e\n\u003cp\u003eidea for the review article, FR\u003c/p\u003e\n\u003ch2\u003eData availability statement:\u003c/h2\u003e\n\u003cp\u003eThe author confirms that all data generated or analyzed during this review are included in this published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMental disorders [Internet] [cited 2026 Mar 30]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aamc.org/news/growing-psychiatrist-shortage-enormous-demand-mental-health-services\u003c/span\u003e\u003cspan address=\"https://www.aamc.org/news/growing-psychiatrist-shortage-enormous-demand-mental-health-services\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrevention [Internet] [cited 2026 Mar 31]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme\u003c/span\u003e\u003cspan address=\"https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks | Implementation Science | Springer Nature Link [Internet]. [cited 2026 Mar 31]. 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Front Psychiatry 11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyt.2020.00212\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2020.00212\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpping-Jordan JE, Harris R, Brown FL, Carswell K, Foley C, Garc\u0026iacute;a-Moreno C et al (2016) Self-Help Plus (SH+): a new WHO stress management package. World Psychiatry 15(3):295\u0026ndash;296. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/wps.20355\u003c/span\u003e\u003cspan address=\"10.1002/wps.20355\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOccupational intervention in mental health hospitals Study of contextual impact: Scandinavian Journal of Occupational Therapy: Vol 30, No 2 - Get Access [Internet]. [cited 2026 Mar 31]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.tandfonline.com/doi/full/\u003c/span\u003e\u003cspan address=\"https://www.tandfonline.com/doi/full/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/11038128.2022.2076734\u003c/span\u003e\u003cspan address=\"10.1080/11038128.2022.2076734\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"National University of Sciences and Technology, Islamabad. Pakistan","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Self-Help Plus, Mental Health, Feasibility Studies, Refugees, Low- and Middle-Income Countries","lastPublishedDoi":"10.21203/rs.3.rs-9461113/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9461113/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aims to describe the evidence on effectiveness of Self-Help Plus (SH+) intervention including targeted populations, adaptations made, mode of delivery, outcomes and barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA scoping review was conducted following the Arksey and O’Malley framework. Four electronic databases (PubMed, APA PsycINFO, DOAJ, and Google Scholar) were searched for peer-reviewed studies published between 2016 and January 2026 using the keywords “Self Help Plus” and “intervention”. Grey literature was excluded. Two reviewers screened studies and tabulated data independently on the characteristics of the studies, mode of delivery, adaptations, outcomes and obstacles to implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of 83 potential records identified, 17 studies met the inclusion criteria. Approximately 60% of the studies included were conducted in low- and middle-income countries. Half of the studies (52.9%) were conducted on refugees and asylum seekers. Effectiveness studies showed that SH+ can reduce psychological distress, depression, anxiety, and post-traumatic stress symptoms, and improve wellbeing, functioning, and psychological skills, with some variability depending on trauma exposure and adherence. Reported implementation barriers included logistical constraints, literacy and comprehension issues, funding challenges, and the need for booster sessions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-Help Plus (SH+) is a feasible and acceptable low-intensity psychological approach that can enhance mental wellbeing and coping skills in diverse populations. Effectiveness may be influenced by trauma exposure, adherence, and implementation barriers such as logistics, literacy, technology, and funding need to be addressed.\u003c/p\u003e","manuscriptTitle":"Evaluating the Effectiveness of WHO Self-Help Plus (SH+): A Scoping Review of Populations, Adaptations, and Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-21 09:44:58","doi":"10.21203/rs.3.rs-9461113/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"06dd34ac-bb10-41a6-8399-fbd3f3884351","owner":[],"postedDate":"April 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":66594492,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2026-04-21T09:44:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-21 09:44:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9461113","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9461113","identity":"rs-9461113","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}