Evaluating Mental Health and Psychosocial Support Outcomes of the Self-Efficacy and Knowledge (SEEK) Community-Based Randomized Controlled Trial in Lebanon During Active Conflict

Evaluating Mental Health and Psychosocial Support Outcomes of the Self-Efficacy and Knowledge (SEEK) Community-Based Randomized Controlled Trial in Lebanon During Active Conflict | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating Mental Health and Psychosocial Support Outcomes of the Self-Efficacy and Knowledge (SEEK) Community-Based Randomized Controlled Trial in Lebanon During Active Conflict Hady Naal, Asmaa El Dakdouki, Zahraa Chamseddine, Veloshnee Govender, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7684112/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Adolescent girls and young women (AGYW) affected by forced displacement are at high risk of poorer mental health and psychosocial wellbeing due to intersecting stressors. In humanitarian contexts like Lebanon, mental health challenges are exacerbated by protracted crises, including the 2024 war. In response to such challenges, the World Health Organization developed the Self-Efficacy and Knowledge (SEEK) package which is a low-resource, low-intensity community-based intervention designed to improve wellbeing and sexual reproductive health in an integrated manner. This study evaluates the effectiveness of SEEK in improving mental health and psychosocial outcomes among Syrian AGYW refugees in Lebanon. Methods: A single-blinded randomized controlled trial was conducted with 267 Syrian AGYW (15–24 years old), randomly assigned to intervention or waitlisted control groups. The intervention comprised eight weekly sessions covering various topics including SRH, emotional regulation, problem-solving among others, delivered at two primary healthcare centers. Outcomes were assessed at baseline (T0), immediately post-intervention (T1), and three months post-intervention (T2), using validated tools to measure wellbeing (WHO-5), self-efficacy (GSES), coping (RWCCL), social support (MSPSS-AW), Interpersonal Communication Competency Skills (ICCS), anxiety and depression (HSCL-25), and emotional regulation (DERS-SF). Results: Participants in the intervention group experienced significant improvements in wellbeing (T1: β=3.33, p<0.001; T2: β=6.66, p=0.035), self-efficacy at only T1 (β=3.44, p<0.001), coping (T1: β=3.28, p<0.01; T2: β=2.82, p<0.01), communication skills only at T2 (β=4.48, p<0.01) and perceived social support (T1: β=3.82, p=0.020; T2: β=4.39, p=0.021). No statistically significant improvements were found for anxiety, depression, or emotional regulation. Conclusion: SEEK demonstrated effectiveness in enhancing wellbeing, self-efficacy, coping, and communication skills, and social support among Syrian AGYW during a period of active conflict, but did not significantly impact anxiety, depression, or emotional regulation. These findings support the potential of integrated community-based approaches in humanitarian settings, while highlighting the need for further research under more stable conditions to evaluate effects on clinical mental health outcomes. Trial Registration : Clinical Trial Number NCT07008950 initial release on February 28th 2025 and last release on June 5th 2025 with the clinical trial registry at National Institute of Health (NIH) protocol registration system. Trial mental health psychosocial support conflict refugees women and girls Introduction Humanitarian crises, such as conflict, war, and political instabilities, have a substantial effect on the mental health and psychosocial well-being (1-4). Refugees are especially vulnerable due to various intersecting stressors including forced displacement, discrimination, economic hardships, harsh living conditions, and exposure to violence and trauma among others (5-9). These experiences often involve losses of loved ones, autonomy, identity, and social support essential for coping with emotional and social adversities (10). Displacement also restricts access to critical services, including education, healthcare, and mental health and psychosocial support, which may lead to poor mental health outcomes (6, 11-14). According to the World Health Organization (WHO), mental health is a state of mental well-being that allows individuals to handle stressors, achieve their potential, and participate meaningfully in their community (15). It encompasses aspects such as self-efficacy, autonomy, and competence, which are essential for human functioning (16-18). As such, mental health is increasingly recognized as an essential human right and a critical component of overall well-being (16, 19). That said, in settings experiencing protracted instability, such as in the Eastern Mediterranean Region (EMR)—one of the most crisis-affected regions worldwide (4, 20)—mental health remains of concern, especially for women and girls (20-22). This is especially true in Lebanon, an EMR country that hosts over 1.5 million Syrian refugees (23, 24) and where many refugees experience psychological stress (25), high rates of depression, especially in women (26, 27), post-traumatic stress disorder (PTSD) (28), and isolation and insecurity (29). Recognizing these challenges, humanitarian actors have increasingly included mental health and psychosocial support (MHPSS) in their responses (30-32). Community-delivered strategies, including peer-led models, are promising and have shown efficacy, feasibility, and cost-effectiveness (33-35), with growing evidence supporting their implementation to enhance mental health and well-being among refugees (10). Studies have demonstrated that such interventions can alleviate PTSD symptoms, enhance psychosocial factors, strengthen coping with anxiety and anger, and foster social support (35, 36). While community-based approaches have shown potential in enhancing mental health, addressing mental health in isolation is insufficient (37), as MHPSS may be integrated across various response types (38), especially in humanitarian settings, where AGYW experience several intersecting vulnerabilities (39). In such contexts, SRH challenges, such as sexual violence, unwanted pregnancies, sexually transmitted infections (STIs), and limited access to contraception, are closely linked to adverse mental health (40-43). Although SRH and mental health are interdependent (50), research has traditionally targeted these areas in isolation (51). Moreover, even though integrated PSS-SRH interventions can enhance access to healthcare and well-being, evaluation and documentation of their effectiveness, particularly in humanitarian settings, remains limited (22, 52, 53). In response, WHO developed a low-intensity, low-resource integrated PSS-SRH package to improve SRH, Family Planning (FP), and wellbeing among AGYW in such contexts (52). This intervention - the Self-Efficacy and Knowledge (SEEK) package – addresses, in an integrated manner the aforementioned topics through psycho-education, SRH education, and other modules related to general life skills, communication, problem solving, and emotional regulation, and it is designed to be delivered by non-specialists (52). In this manuscript, we report findings from the Randomized Controlled Trial (RCT) focusing on MHPSS outcomes among Syrian AGYW refugees in Lebanon over time. Findings from this study will provide key evidence for developing adolescent-friendly PSS-SRH programs in humanitarian settings. Methods Trial design This study employed a single-blinded, community-based RCT design to assess the effectiveness of SEEK among Syrian AGYW refugees aged 15-24 years in Lebanon. Participants were randomly assigned to either an experimental group (EG), which received the intervention, or a waitlist control group (CG), which did not receive the intervention during the study period. All outcomes, including those related to mental health, were assessed at baseline (T0) and immediately post-intervention (T1), with a follow-up at three months post-intervention (T2). Instrument development and testing To thoroughly assess the impact and effectiveness of the intervention on mental health and psychosocial outcomes, various psychometrically tested tools were utilized as described below: World Health Organization Well-Being 5-item Index (WHO-5) The World Health Organization Well-Being 5-item Index (WHO-5) is a short 5-item screening instrument, to measure self-reported psychological well-being. It is used extensively worldwide, and it is translated and validated into different languages, including Arabic. Each of the 5 items is positively framed, and is rated on a 6-point Likert scale ranging from 0 (at no time) to 5 (all of the time). The survey yields a final score ranging from 0 to 25 with the percentage score being the summed score multiplied by 4. A final score of < 13 indicates poor wellbeing or low mood. General Self-Efficacy Scale (GSES) Self-Efficacy was assessed via the General Self-Efficacy Scale (GSES), which is a 10-item scale designed to assess a person’s optimistic self-beliefs in relation to their perceived skills to cope with life’s demands. The GSES has been used in numerous studies and has been validated as a unidimensional construct for adults and adolescents in several single- and multi-country studies. The tool is available in English and has been translated and validated in Arabic. The GSES is rated on a 4-point Likert scale with answers ranging from 1 (not at all true) to 4 (exactly true), and yielding a final score ranging from 10 to 40, with higher scores indicating stronger self-efficacy. The score is not dichotomized but may be used for comparative purposes. Revised Ways of Coping Checklist (RWCCL) Coping, problem solving, and decision making, were assessed using the Revised Ways of Coping Checklist (RWCCL), which measures different types of coping. It enables the evaluation of the structure of interpersonal or individual social supports as well as their collective or networked social supports. The RWCCL is a widely used multidimensional coping measure with satisfactory reliability and validity. The tool is available in English and was translated and validated in Arabic. Each item is rated on a 4-point Likert scale with answers ranging from 0 (does not apply or not used), to 3 (used a great deal). The final score is not dichotomized, but may be used for comparative purposes. Depression and Anxiety using Hopkins Symptom Checklist 25 (HSCL 25) The Hopkins Symptom Checklist 25 was used to measure depression through 15 items and anxiety through 10 items. This tool screens for presence of anxiety and depression symptoms and was not designed to be used for diagnostic purposes. Responses are rated on a 4-point Likert scale ranging from 1 (not at all) to 4 (extremely). A mean score of over or equal to 1.75 indicates concerning symptoms of anxiety or depression. The tool is available in English and was translated and validated Arabic Difficulties in Emotion Regulation Scale Short Form (DERS-SF) The Difficulties in Emotion Regulation Scale Short Form (DERS-SF) was used to assess emotional regulation. The DERS-SF consists of 18-items, with participants rating their answers in the past week on a scale from 1 (almost never) to 5 (almost always). Total scores range from 18 to 90, with higher scores indicating more difficulty in emotional regulation. The tool is available in English and was translated and validated in Arabic. Multidimensional Scale of Perceived Social Support for Arab Women (MSPSS-AW) The Multidimensional Scale of Perceived Social Support for Arab Women (MSPSS-AW) was used to assess social support. This tool is tailored to reflect social support networks relevant to Arab women at multiple levels including the family, friends, significant other, and the community level. Responses are rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). The final score is obtained by averaging all items, with higher scores indicating higher perceived social support. The tool is available in English and was translated and adapted to Arabic (54). Refer to Table 1 below for a detailed description of each tool. [insert table 1] Intervention and Control Recruitment The target population of the study was Syrian refugee AGYW (aged 15–24 years) residing in Lebanon. Inclusion criteria included: (1) being a Syrian refugee girl or woman, (2) aged 15–24, (3) having resided in Lebanon for at least 6 months, and (4) being willing to participate in the study by signing an informed consent form (for participants aged 18 or older) or by their legal guardian providing a signed consent form on their behalf (for those aged 15–17). Participants were excluded if they (1) were currently pregnant and/or lactating, (2) had chronic health conditions interfering with their ability to follow the intervention protocol, or (3) presented with high levels of anxiety and/or depression, suicidal ideation or attempts during screening, a current diagnosis of a severe mental illness, or were undergoing specialist psychiatric treatment. The recruitment process was coordinated with selected primary healthcare centers (PHC) where the study took place. These centers were chosen following recommendations from the Ministry of Public Health – department of Primary Healthcare – based on their (1) capacity to reach the target population, (2) their provision of SRH services, and (3) their capacity to hold space for all intervention-related activities. To identify potentially eligible participants, the research team, in coordination with the centers, prepared a list of PHC patients who may, most closely be potentially eligible, and proceeded with calling them and inviting them to participate in the study using an invitation script. Following baseline screening and data collection, participants were randomized into either EG or CG. Participants in the CG were waitlisted to receive the same information as the EG in a more concise format once all data collection activities were completed. Blinding To minimize potential bias, the trial employed a blinded design in which data collectors and participants remained unaware of group allocation. Participants were not informed about the existence of the alternate study arm, ensuring that their responses and engagement were not influenced by knowledge of the study design. Similarly, data collectors were blinded to participants’ group assignments to reduce measurement bias during data collection and analysis. That said, the implementation staff was aware of group allocation due to the nature of the study design. Intervention Once participants were randomized into intervention arms, the EG were further divided into subgroups to participate in the intervention sessions. The intervention package was delivered at the selected PHCs, whereby each subgroups attended 1 session per week for eight consecutive weeks. Each session lasted approximately 90 minutes and covered various topics related to MH and SRH as delivered by trained paraprofessionals (also known as community health workers). Prior to the intervention, these paraprofessionals received a 20-day comprehensive training facilitated by a clinical psychologist and a midwife. The training equipped them with the necessary skills and knowledge to effectively deliver the intervention content in a standardized manner and to address any concerns or questions that may arise during the sessions. Importantly, the intervention was carried out during a period of critical instability in Lebanon, that included active conflict. This ultimately disrupted the interventions in many ways by causing delays, higher than expected attrition, and other disruptions associated with implementation as described in a subsequent section below. Ethical Considerations The trial received ethical approval from the Institutional Review Board (IRB) at the American University of Beirut (AUB) and the World Health Organization (WHO) Ethical Review Committee. Informed consent was obtained from all participants after they were provided with detailed information regarding the study’s aims, participants’ rights, and their ability to withdraw from the study at any time without affecting their access to PHC services or any other benefits they may have been entitled to. To uphold ethical standards, trained field coordinators supervised all procedures, ensuring protocol adherence and participant safety. An on-site psychologist addressed any session-related distress, and participants identified as potentially having mental health concerns received direct support or NGO referrals for more severe cases. All intervention materials were adapted to Arabic, and only female data collectors were trained and deployed to collect data to promote accessibility and comfort. All staff were rigorously trained in confidentiality, risk identification, and ethical data collection. Moreover, to guarantee anonymity, all personal identifiers were replaced with unique codes during data collection and analysis. Protocol Deviation Given the displaced nature of the studied population, protocol deviations were anticipated and systematically recorded. These deviations included delays in intervention initiation, participant non-adherence, withdrawals, delayed or irregular attendance, cross-group attendance, where some participants attended sessions outside their assigned intervention group due to scheduling conflicts, and permanent group switches. The escalation of the conflict in Lebanon during the study period exacerbated these challenges, contributing to interruption in intervention delivery and increased participant displacement. To mitigate the impact of these deviations adaptive strategies were employed, including flexible session rescheduling, phone-based follow-ups, and increased participant incentives. No deviations compromised participant safety or primary outcome validity. Statistical Analysis All analyses were conducted on the full intent-to-treat sample and evaluated based on improvements in mental health status between baseline and immediate post-intervention (T0–T1), as well as between baseline and the 3-month follow-up (T0–T2). The primary analysis compared the difference-in-differences between the intervention and control groups at each time point. Prior to this, baseline characteristics of the intervention and control groups were compared, in line with the original study design. This comparison was based on the homogeneity assumption—that each participant’s outcome is a random draw from a common distribution, independent of study site. No violation of this assumption was expected, as participants were randomly allocated to intervention or control groups using a random generator, and consistent recruitment and randomization procedures were followed across both sites. Primary and secondary outcomes were defined as changes in women’s and psychosocial outcomes from T0 to T1 and from T0 to T2. To estimate marginal treatment effects, linear regression models were used to compare improvements in the intervention group relative to the control group at each time point. All models controlled for potential sociodemographic confounders including age, education, employment status, barriers to healthcare, and previous pregnancy experience. Additional variables that either differed significantly (p < 0.05) between groups at baseline or predicted outcome changes were also included as covariates. At T2, primary and secondary outcomes were analyzed excluding approximately 23% of the sample who were only assessed at T1. To address this missing data, mixed-effects linear models were deployed. Treatment effects were estimated using maximum likelihood mixed-effects regression models with robust variance estimators. All analyses controlled for participant sex, age, marital status, and disability, along with other baseline differences or predictors of outcome change (p < 0.10). Analyses were conducted using Stata 18.0, with a 95% confidence level. Results Baseline Data A review of demographic characteristics in Table 2 identifies the baseline differences between the control and intervention group. A total of 267 women were enrolled, with 144 allocated to the control group and 123 to the intervention group. The two groups were broadly comparable across most baseline characteristics. The majority of participants in both groups had primary or intermediate education (Control: 84.7%, Intervention: 74.8%). Current employment was low in both groups, with only 9.7% of women in the control group and 20.3% in the intervention group reporting current work. Nearly all participants had been married once (95.8% in the control vs. 93.5% in the intervention group), and over 60% in both groups reported financial barriers and difficulties related to distance and safety when accessing health services. For instance, 67.1% of control participants and 61.8% of those in the intervention group cited financial difficulties, while 64.6% and 72.4%, respectively, reported not finding a suitable place to seek help. Significant baseline differences between both groups were found on two variables. Women in the intervention group were more likely to have previously been pregnant (86.9%) compared to those in the control group (76.4%; p = 0.027). Additionally, baseline emotional regulation scores were significantly lower in the intervention group (mean = 52.29 ± 12.54) than in the control group (mean = 55.68 ± 12.62; p = 0.029). All other measures, including baseline well-being, self-efficacy, coping with stress, anxiety, depression, and social support, were not significantly different across groups. [insert table 2] Treatment Effects Primary Outcomes Table 3 presents the estimated treatment effects on primary outcomes across the three assessment time points (T0, T1, and T2), using mixed-effects regression models adjusted for baseline scores. The primary outcomes were wellbeing and self-efficacy . Participants in the intervention group showed a statistically significant improvement in wellbeing scores compared to the control group. At baseline, the mean wellbeing score for the intervention group was 13.26 ± 6.82, which increased to 16.43 ± 5.88 at T1, while the control group's score slightly declined from 12.06 ± 6.61 to 11.63 ± 6.20. The intervention effect was significant at T1 (β = 3.33, 95% CI: 1.52 to 5.25, p < 0.001) and remained significant at T2 (β = 6.66, 95% CI: 2.44 to 15.78, p = 0.035), with higher scores observed, indicating sustained and improved gains over time. Similarly, self-efficacy scores improved significantly in the intervention group at T1 (β = 3.44, 95% CI: 1.78 to 5.11, p < 0.001), rising from a baseline of 27.30 ± 6.77 to 30.10 ± 5.53. However, this effect diminished by T2 and was no longer statistically significant (β = 1.42, 95% CI: –0.40 to 3.26, p = 0.127), suggesting the possibility of regression toward baseline levels post-intervention. [Insert table 3] Secondary Outcomes Among the secondary outcomes, coping with stress exhibited consistent and significant improvement. Mean scores in the intervention group increased from 19.83 ± 6.23 at baseline to 22.60 ± 5.13 at T1, compared to a modest change in the control group (20.77 ± 6.04 to 20.42 ± 5.22). The corresponding effect estimates were statistically significant at both T1 (β = 3.28, 95% CI: 1.60 to 4.96, p < 0.001) and T2 (β = 2.82, 95% CI: 0.73 to 4.90, p = 0.008). Social support also improved following the intervention, with scores increasing from 59.30 ± 11.08 at baseline to 66.80 ± 11.95 at T1. The control group remained relatively stable. The intervention yielded a significant effect at T1 (β = 3.82, 95% CI: 0.59 to 7.05, p = 0.020), and this improvement was sustained at T2 (β = 4.39, 95% CI: 0.68 to 8.10, p = 0.021). For anxiety and depression , no statistically significant differences were observed between groups. Anxiety scores in the intervention group changed minimally (from 2.63 ± 0.71 to 2.56 ± 0.74), with nonsignificant effect estimates at both T1 (β = 0.24, p = 0.810) and T2 (β = –0.03, p = 0.745). Depression scores also remained stable, with no meaningful difference observed across time points. Emotional regulation showed an upward trend in raw scores in the intervention group (52.29 ± 12.54 at T0 to 63.29 ± 29.06 at T2), however the associated treatment effects were not statistically significant at either T1 or T2, likely due to large within-group variability. Sensitivity Analysis Table 4 presents the results of linear mixed-effects models with random intercepts for participants. The interaction terms between time and group were examined to assess whether the intervention effect differed across time between the intervention and control groups. Results indicated that the intervention led to significant improvements in wellbeing, coping with stress, and social support over time. For the primary outcomes, the interaction between time and group was significant for wellbeing (β=0.681, 95% CI: 0.343–1.705, p=0.019), indicating that changes in wellbeing over time differed between with greater improvements observed in the intervention group. For the secondary outcomes, a significant interaction was observed for coping with stress (β=1.651, 95% CI: 0.741–2.561, p<0.001), showing that coping with stress improved more in the intervention group compared with the control group over time. Similarly, for social support, the interaction effect was significant (β=2.211, 95% CI: 0.551–3.871, p=0.009), suggesting that participants in the intervention group reported greater increases in social support across time compared to controls. Discussion This study is the first to assess the MHPSS and wellbeing outcomes associated with the SEEK intervention at 3 time points. At the time of intervention delivery, this period coincided with the 2024 conflict that had severe impacts on several areas in Lebanon, one of which was the Beqaa where the intervention package was delivered. Although the conflict had detrimental impact on the country and especially on vulnerable groups, and while the implementation team faced several challenges to maintain delivery of the intervention, the latter was still successfully completed with some adjustments to the methodology. That said, and while mindfully acknowledging the inevitable impacts of the conflict as an extraneous variable when assessing outcomes related to the intervention effects, in general, multivariate analyses suggest that the intervention was largely effective in improving psychosocial and wellbeing outcomes although no improvements were observed in relation to mental health outcomes. For instance, results showed significant improvements in overall wellbeing among the experimental group when compared to the control group that were sustained at endline and 3 months after the intervention. Wellbeing, as defined by the Center for Disease Control and Prevention (CDC), involves experiencing positive emotions, absence of negative feelings, and having a sense of satisfaction with life, fulfillment, and effective functioning (61). It is possible that due to the intervention’s content being focused on delivering practical and real-world applications, and its delivery format being community-driven and led by paraprofessionals who share similar cultural backgrounds, SEEK had important impacts on attending participants. Evidence shows that community-based interventions have been found to be effective in enhancing wellbeing and individual’s willingness to seek or accept support (62). When communities are engaged as resources, and to some extent, as facilitators, interventions become more culturally acceptable and relevant (63). For instance, a classroom-based intervention implemented in a conflict-affected setting showed improvements in social behavior and positive elements of wellbeing, when delivered by trained community members (64). Likewise, a randomized controlled trial in Zimbabwe found that adolescents receiving support from community adolescent treatment supporters (CATS) showed significantly greater improvements in confidence, self-esteem, and quality of life compared to those received standard care (65). Similarly, study findings showed significant improvements in self-efficacy to manage problems, however this was only the case at endline, whereby 3-months post intervention this difference between experimental and control groups was not significant. This suggests that self-efficacy may require additional booster sessions for practices, and guidance to be sustained. As self-efficacy is known to develop through social learning and continues to evolve as individuals acquire new skills, experiences, and understanding over the course of their lives (80, 81), sustaining it likely requires ongoing support. Bandura identifies four primary sources through which self-efficacy beliefs are shaped: mastery experience, vicarious learning through observing others, social persuasion, and the interpretation of emotional and physiological states (82). Consistent with this, recent evidence highlights that structured training and education strengthen general self-efficacy (83), and more coaching sessions was associated with greater improvements (84). Sustaining this gain requires continuous practice, progress monitoring, and periodic goal adjustment (85, 86) On the other hand, SEEK significantly improved participants’ skills to cope with challenging situations, and their perceived social support, by the end of the intervention and 3 months after the intervention. It may be that SEEK provided a safe space for participants to explore and discuss their thoughts and feelings, which may have improved their sense of belonging to a support system of peers and experts. All throughout, participants were encouraged to share experiences and to learn from each other, which likely strengthened interpersonal bonds and facilitated peer-exchange. Our finding that communication skills also improved significantly as a result of this intervention further supports and complements these results as communication skills as key to facilitate building and maintaining stronger relationships. Evidence consistently highlights the critical role of social support during crisis (66, 67). As Drury et al. note, people have always turned to one another for emotional and practical support in emergencies (68). Social support helps mitigate stress and promote trauma recovery by fostering cognitive restructuring and reinforcing coping mechanisms (69, 70). Additionally, peer-based initiatives, reduce stigma, offer culturally grounded support, and improve distress management (71, 72). These dynamics are importantly relevant for adolescents, who are more likely to seek helps from peers than professionals, and are responsive to peer influence (73, 74). Shared group experiences and collective identity further enhance comfort, resilience and the ability to manage adversity effectively (75–79). Importantly, improvements were sustained over time despite on-going conflict, and this suggests that coping skills can be learned through this community-based intervention, and potentially to last over time. Similarly, 3-months post intervention sustained improvements in perceived social support also suggest that networks and peer support developed by participants during the intervention may last beyond the duration of the intervention. That said, results did not show statistical improvements on key mental health outcomes such as anxiety, depression, and emotional regulation. It is possible that this group of refugees, especially during an acute time of active conflict in Lebanon, may have experienced much distress that exacerbated pre-existing vulnerabilities associated with harsh living conditions and which may have superseded expected influences of SEEK on mental health outcomes. During times of active conflict, all participants may have experienced increased vigilance and concerns over survival which may have required other types of support on the mental health level. While supportive approaches like psychoeducation and problem-solving counselling have been applied in conflict-affected settings, their effectiveness in improving clinical symptoms remains limited. For instance, intervention in Aceh, Nepal, and Uganda demonstrated improvements in functioning or coping, but showed little to no effect on reducing symptoms of depression, anxiety, or PTSD (87-89). It is likely that in such environments, symptoms of depression and anxiety are exacerbated by ongoing stressors like unsafety and uncertainty (79, 90, 91). Moreover, mental health responses in humanitarian contexts are often non-holistic, externally driven, and poorly adapted to local realities, resulting in low sustainability (92). Thus, in such settings, psychosocial interventions may offer short-term relief, but sustained improvements in mental health outcomes are unlikely without parallel efforts to restore safety, stability, and social inclusion (92-96). It may also be that integration of SRH and MH diluted MH content whereby improvements were seen on wellbeing and psychosocial factors, but not for symptom relief. Limitation Results of this study should be interpreted in light of several limitations. Most importantly, outcomes examined may have been significantly impacted by the 2024 conflict in Lebanon, as implementation coincided with active conflict. Ultimately it may be difficult to isolate the effects of SEEK from this broader contextual challenge impacting participants mental health and wellbeing. Should that not have been the case, we may have observed changes in mental health outcomes for example, however in this study we did not. Second, as this is the first pilot implementation of SEEK in a humanitarian setting, it is unclear the extent to which results are sustainable over a longer period of time, especially since our follow-up was limited to 3 months post intervention. Sustained impact may require longer follow-up periods. Third, our sample was limited to two PHCs in one geographical area in Lebanon which may limit external validity of study findings. Nevertheless, Syrian refugee populations are largely homogenous in Lebanon. Conclusion In conclusion, the SEEK intervention package, based on initial evidence from this community-based trial regarding its effectiveness, improves wellbeing, self-efficacy, coping, communication skills, and perceived social support among refugee women and girls during times of active conflict. However, while wellbeing, coping, and perceived social support improvements were sustained over time, this was not the case for self-efficacy which may require additional efforts to be sustained beyond the period of intervention delivery. That said, SEEK was found to not cause any changes in mental health outcomes such as anxiety, depression, and emotional regulation. Further research is needed to better establish the effectiveness of SEEK on mental health outcomes by examining its impact in a humanitarian context not experiencing active conflict. Declarations Declarations 1. Ethics Approval & Consent to Participate: This study was approved by the Institutional Review Board at the American University of Beirut and by the Ethics Review Committee at the World Health Organization. All participants provided informed written consent prior to participation. For participants under 18, they parents or guardians were required to sign a consent form on their behalf. 2 . Consent for Publication : Not Applicable 4. Competing Interests: The authors declare that they have no competing interests Additional Disclaimers Author affiliations Dr Lale Say, Unit Head, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland Dr Veloshnee Govender, Scientist, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland Disclaimer for WHO staff The named authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions or the policies of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) or the World Health Organization (WHO). Introduction Humanitarian crises, such as conflict, war, and political instabilities, have a substantial effect on the mental health and psychosocial well-being (1–4). Refugees are especially vulnerable due to various intersecting stressors including forced displacement, discrimination, economic hardships, harsh living conditions, and exposure to violence and trauma among others (5–9). These experiences often involve losses of loved ones, autonomy, identity, and social support essential for coping with emotional and social adversities (10). Displacement also restricts access to critical services, including education, healthcare, and mental health and psychosocial support, which may lead to poor mental health outcomes (6, 11–14). According to the World Health Organization (WHO), mental health is a state of mental well-being that allows individuals to handle stressors, achieve their potential, and participate meaningfully in their community (15). It encompasses aspects such as self-efficacy, autonomy, and competence, which are essential for human functioning (16–18). As such, mental health is increasingly recognized as an essential human right and a critical component of overall well-being (16, 19). That said, in settings experiencing protracted instability, such as in the Eastern Mediterranean Region (EMR)—one of the most crisis-affected regions worldwide (4, 20)—mental health remains of concern, especially for women and girls (20–22). This is especially true in Lebanon, an EMR country that hosts over 1.5 million Syrian refugees (23, 24) and where many refugees experience psychological stress (25), high rates of depression, especially in women (26, 27), post-traumatic stress disorder (PTSD) (28), and isolation and insecurity (29). Recognizing these challenges, humanitarian actors have increasingly included mental health and psychosocial support (MHPSS) in their responses (30–32). Community-delivered strategies, including peer-led models, are promising and have shown efficacy, feasibility, and cost-effectiveness (33–35), with growing evidence supporting their implementation to enhance mental health and well-being among refugees (10). Studies have demonstrated that such interventions can alleviate PTSD symptoms, enhance psychosocial factors, strengthen coping with anxiety and anger, and foster social support (35, 36). While community-based approaches have shown potential in enhancing mental health, addressing mental health in isolation is insufficient (37), as MHPSS may be integrated across various response types (38), especially in humanitarian settings, where AGYW experience several intersecting vulnerabilities (39). In such contexts, SRH challenges, such as sexual violence, unwanted pregnancies, sexually transmitted infections (STIs), and limited access to contraception, are closely linked to adverse mental health (40–43). Although SRH and mental health are interdependent (50), research has traditionally targeted these areas in isolation (51). Moreover, even though integrated PSS-SRH interventions can enhance access to healthcare and well-being, evaluation and documentation of their effectiveness, particularly in humanitarian settings, remains limited (22, 52, 53). In response, WHO developed a low-intensity, low-resource integrated PSS-SRH package to improve SRH, Family Planning (FP), and wellbeing among AGYW in such contexts (52). This intervention - the Self-Efficacy and Knowledge (SEEK) package – addresses, in an integrated manner the aforementioned topics through psycho-education, SRH education, and other modules related to general life skills, communication, problem solving, and emotional regulation, and it is designed to be delivered by non-specialists (52). In this manuscript, we report findings from the Randomized Controlled Trial (RCT) focusing on MHPSS outcomes among Syrian AGYW refugees in Lebanon over time. Findings from this study will provide key evidence for developing adolescent-friendly PSS-SRH programs in humanitarian settings. Methods Trial design This study employed a single-blinded, community-based RCT design to assess the effectiveness of SEEK among Syrian AGYW refugees aged 15–24 years in Lebanon. Participants were randomly assigned to either an experimental group (EG), which received the intervention, or a waitlist control group (CG), which did not receive the intervention during the study period. All outcomes, including those related to mental health, were assessed at baseline (T0) and immediately post-intervention (T1), with a follow-up at three months post-intervention (T2). Instrument development and testing To thoroughly assess the impact and effectiveness of the intervention on mental health and psychosocial outcomes, various psychometrically tested tools were utilized as described below: World Health Organization Well-Being 5-item Index (WHO-5) The World Health Organization Well-Being 5-item Index (WHO-5) is a short 5-item screening instrument, to measure self-reported psychological well-being. It is used extensively worldwide, and it is translated and validated into different languages, including Arabic. Each of the 5 items is positively framed, and is rated on a 6-point Likert scale ranging from 0 (at no time) to 5 (all of the time). The survey yields a final score ranging from 0 to 25 with the percentage score being the summed score multiplied by 4. A final score of < 13 indicates poor wellbeing or low mood. General Self-Efficacy Scale (GSES) Self-Efficacy was assessed via the General Self-Efficacy Scale (GSES), which is a 10-item scale designed to assess a person’s optimistic self-beliefs in relation to their perceived skills to cope with life’s demands. The GSES has been used in numerous studies and has been validated as a unidimensional construct for adults and adolescents in several single- and multi-country studies. The tool is available in English and has been translated and validated in Arabic. The GSES is rated on a 4-point Likert scale with answers ranging from 1 (not at all true) to 4 (exactly true), and yielding a final score ranging from 10 to 40, with higher scores indicating stronger self-efficacy. The score is not dichotomized but may be used for comparative purposes. Revised Ways of Coping Checklist (RWCCL) Coping, problem solving, and decision making, were assessed using the Revised Ways of Coping Checklist (RWCCL), which measures different types of coping. It enables the evaluation of the structure of interpersonal or individual social supports as well as their collective or networked social supports. The RWCCL is a widely used multidimensional coping measure with satisfactory reliability and validity. The tool is available in English and was translated and validated in Arabic. Each item is rated on a 4-point Likert scale with answers ranging from 0 (does not apply or not used), to 3 (used a great deal). The final score is not dichotomized, but may be used for comparative purposes. Depression and Anxiety using Hopkins Symptom Checklist 25 (HSCL 25) The Hopkins Symptom Checklist 25 was used to measure depression through 15 items and anxiety through 10 items. This tool screens for presence of anxiety and depression symptoms and was not designed to be used for diagnostic purposes. Responses are rated on a 4-point Likert scale ranging from 1 (not at all) to 4 (extremely). A mean score of over or equal to 1.75 indicates concerning symptoms of anxiety or depression. The tool is available in English and was translated and validated Arabic Difficulties in Emotion Regulation Scale Short Form (DERS-SF) The Difficulties in Emotion Regulation Scale Short Form (DERS-SF) was used to assess emotional regulation. The DERS-SF consists of 18-items, with participants rating their answers in the past week on a scale from 1 (almost never) to 5 (almost always). Total scores range from 18 to 90, with higher scores indicating more difficulty in emotional regulation. The tool is available in English and was translated and validated in Arabic. Multidimensional Scale of Perceived Social Support for Arab Women (MSPSS-AW) The Multidimensional Scale of Perceived Social Support for Arab Women (MSPSS-AW) was used to assess social support. This tool is tailored to reflect social support networks relevant to Arab women at multiple levels including the family, friends, significant other, and the community level. Responses are rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). The final score is obtained by averaging all items, with higher scores indicating higher perceived social support. The tool is available in English and was translated and adapted to Arabic (54). Refer to Table 1 below for a detailed description of each tool. [insert table 1] Intervention and Control Recruitment The target population of the study was Syrian refugee AGYW (aged 15–24 years) residing in Lebanon. Inclusion criteria included: (1) being a Syrian refugee girl or woman, (2) aged 15–24, (3) having resided in Lebanon for at least 6 months, and (4) being willing to participate in the study by signing an informed consent form (for participants aged 18 or older) or by their legal guardian providing a signed consent form on their behalf (for those aged 15–17). Participants were excluded if they (1) were currently pregnant and/or lactating, (2) had chronic health conditions interfering with their ability to follow the intervention protocol, or (3) presented with high levels of anxiety and/or depression, suicidal ideation or attempts during screening, a current diagnosis of a severe mental illness, or were undergoing specialist psychiatric treatment. The recruitment process was coordinated with selected primary healthcare centers (PHC) where the study took place. These centers were chosen following recommendations from the Ministry of Public Health – department of Primary Healthcare – based on their (1) capacity to reach the target population, (2) their provision of SRH services, and (3) their capacity to hold space for all intervention-related activities. To identify potentially eligible participants, the research team, in coordination with the centers, prepared a list of PHC patients who may, most closely be potentially eligible, and proceeded with calling them and inviting them to participate in the study using an invitation script. Following baseline screening and data collection, participants were randomized into either EG or CG. Participants in the CG were waitlisted to receive the same information as the EG in a more concise format once all data collection activities were completed. Blinding To minimize potential bias, the trial employed a blinded design in which data collectors and participants remained unaware of group allocation. Participants were not informed about the existence of the alternate study arm, ensuring that their responses and engagement were not influenced by knowledge of the study design. Similarly, data collectors were blinded to participants’ group assignments to reduce measurement bias during data collection and analysis. That said, the implementation staff was aware of group allocation due to the nature of the study design. Intervention Once participants were randomized into intervention arms, the EG were further divided into subgroups to participate in the intervention sessions. The intervention package was delivered at the selected PHCs, whereby each subgroups attended 1 session per week for eight consecutive weeks. Each session lasted approximately 90 minutes and covered various topics related to MH and SRH as delivered by trained paraprofessionals (also known as community health workers). Prior to the intervention, these paraprofessionals received a 20-day comprehensive training facilitated by a clinical psychologist and a midwife. The training equipped them with the necessary skills and knowledge to effectively deliver the intervention content in a standardized manner and to address any concerns or questions that may arise during the sessions. Importantly, the intervention was carried out during a period of critical instability in Lebanon, that included active conflict. This ultimately disrupted the interventions in many ways by causing delays, higher than expected attrition, and other disruptions associated with implementation as described in a subsequent section below. Ethical Considerations The trial received ethical approval from the Institutional Review Board (IRB) at the American University of Beirut (AUB) and the World Health Organization (WHO) Ethical Review Committee. Informed consent was obtained from all participants after they were provided with detailed information regarding the study’s aims, participants’ rights, and their ability to withdraw from the study at any time without affecting their access to PHC services or any other benefits they may have been entitled to. To uphold ethical standards, trained field coordinators supervised all procedures, ensuring protocol adherence and participant safety. An on-site psychologist addressed any session-related distress, and participants identified as potentially having mental health concerns received direct support or NGO referrals for more severe cases. All intervention materials were adapted to Arabic, and only female data collectors were trained and deployed to collect data to promote accessibility and comfort. All staff were rigorously trained in confidentiality, risk identification, and ethical data collection. Moreover, to guarantee anonymity, all personal identifiers were replaced with unique codes during data collection and analysis. Protocol Deviation Given the displaced nature of the studied population, protocol deviations were anticipated and systematically recorded. These deviations included delays in intervention initiation, participant non-adherence, withdrawals, delayed or irregular attendance, cross-group attendance, where some participants attended sessions outside their assigned intervention group due to scheduling conflicts, and permanent group switches. The escalation of the conflict in Lebanon during the study period exacerbated these challenges, contributing to interruption in intervention delivery and increased participant displacement. To mitigate the impact of these deviations adaptive strategies were employed, including flexible session rescheduling, phone-based follow-ups, and increased participant incentives. No deviations compromised participant safety or primary outcome validity. Statistical Analysis All analyses were conducted on the full intent-to-treat sample and evaluated based on improvements in mental health status between baseline and immediate post-intervention (T0–T1), as well as between baseline and the 3-month follow-up (T0–T2). The primary analysis compared the difference-in-differences between the intervention and control groups at each time point. Prior to this, baseline characteristics of the intervention and control groups were compared, in line with the original study design. This comparison was based on the homogeneity assumption—that each participant’s outcome is a random draw from a common distribution, independent of study site. No violation of this assumption was expected, as participants were randomly allocated to intervention or control groups using a random generator, and consistent recruitment and randomization procedures were followed across both sites. Primary and secondary outcomes were defined as changes in women’s and psychosocial outcomes from T0 to T1 and from T0 to T2. To estimate marginal treatment effects, linear regression models were used to compare improvements in the intervention group relative to the control group at each time point. All models controlled for potential sociodemographic confounders including age, education, employment status, barriers to healthcare, and previous pregnancy experience. Additional variables that either differed significantly (p < 0.05) between groups at baseline or predicted outcome changes were also included as covariates. At T2, primary and secondary outcomes were analyzed excluding approximately 23% of the sample who were only assessed at T1. To address this missing data, mixed-effects linear models were deployed. Treatment effects were estimated using maximum likelihood mixed-effects regression models with robust variance estimators. All analyses controlled for participant sex, age, marital status, and disability, along with other baseline differences or predictors of outcome change (p < 0.10). Analyses were conducted using Stata 18.0, with a 95% confidence level. Results Baseline Data A review of demographic characteristics in Table 2 identifies the baseline differences between the control and intervention group. A total of 267 women were enrolled, with 144 allocated to the control group and 123 to the intervention group. The two groups were broadly comparable across most baseline characteristics. The majority of participants in both groups had primary or intermediate education (Control: 84.7%, Intervention: 74.8%). Current employment was low in both groups, with only 9.7% of women in the control group and 20.3% in the intervention group reporting current work. Nearly all participants had been married once (95.8% in the control vs. 93.5% in the intervention group), and over 60% in both groups reported financial barriers and difficulties related to distance and safety when accessing health services. For instance, 67.1% of control participants and 61.8% of those in the intervention group cited financial difficulties, while 64.6% and 72.4%, respectively, reported not finding a suitable place to seek help. Significant baseline differences between both groups were found on two variables. Women in the intervention group were more likely to have previously been pregnant (86.9%) compared to those in the control group (76.4%; p = 0.027). Additionally, baseline emotional regulation scores were significantly lower in the intervention group (mean = 52.29 ± 12.54) than in the control group (mean = 55.68 ± 12.62; p = 0.029). All other measures, including baseline well-being, self-efficacy, coping with stress, anxiety, depression, and social support, were not significantly different across groups. [insert table 2] Treatment Effects Primary Outcomes Table 3 presents the estimated treatment effects on primary outcomes across the three assessment time points (T0, T1, and T2), using mixed-effects regression models adjusted for baseline scores. The primary outcomes were wellbeing and self-efficacy. Participants in the intervention group showed a statistically significant improvement in wellbeing scores compared to the control group. At baseline, the mean wellbeing score for the intervention group was 13.26 ± 6.82, which increased to 16.43 ± 5.88 at T1, while the control group's score slightly declined from 12.06 ± 6.61 to 11.63 ± 6.20. The intervention effect was significant at T1 (β = 3.33, 95% CI: 1.52 to 5.25, p < 0.001) and remained significant at T2 (β = 6.66, 95% CI: 2.44 to 15.78, p = 0.035), with higher scores observed, indicating sustained and improved gains over time. Similarly, self-efficacy scores improved significantly in the intervention group at T1 (β = 3.44, 95% CI: 1.78 to 5.11, p < 0.001), rising from a baseline of 27.30 ± 6.77 to 30.10 ± 5.53. However, this effect diminished by T2 and was no longer statistically significant (β = 1.42, 95% CI: − 0.40 to 3.26, p = 0.127), suggesting the possibility of regression toward baseline levels post-intervention. [Insert table 3] Secondary Outcomes Among the secondary outcomes, coping with stress exhibited consistent and significant improvement. Mean scores in the intervention group increased from 19.83 ± 6.23 at baseline to 22.60 ± 5.13 at T1, compared to a modest change in the control group (20.77 ± 6.04 to 20.42 ± 5.22). The corresponding effect estimates were statistically significant at both T1 (β = 3.28, 95% CI: 1.60 to 4.96, p < 0.001) and T2 (β = 2.82, 95% CI: 0.73 to 4.90, p = 0.008). Social support also improved following the intervention, with scores increasing from 59.30 ± 11.08 at baseline to 66.80 ± 11.95 at T1. The control group remained relatively stable. The intervention yielded a significant effect at T1 (β = 3.82, 95% CI: 0.59 to 7.05, p = 0.020), and this improvement was sustained at T2 (β = 4.39, 95% CI: 0.68 to 8.10, p = 0.021). For anxiety and depression, no statistically significant differences were observed between groups. Anxiety scores in the intervention group changed minimally (from 2.63 ± 0.71 to 2.56 ± 0.74), with nonsignificant effect estimates at both T1 (β = 0.24, p = 0.810) and T2 (β = − 0.03, p = 0.745). Depression scores also remained stable, with no meaningful difference observed across time points. Emotional regulation showed an upward trend in raw scores in the intervention group (52.29 ± 12.54 at T0 to 63.29 ± 29.06 at T2), however the associated treatment effects were not statistically significant at either T1 or T2, likely due to large within-group variability. Sensitivity Analysis Table 4 presents the results of linear mixed-effects models with random intercepts for participants. The interaction terms between time and group were examined to assess whether the intervention effect differed across time between the intervention and control groups. Results indicated that the intervention led to significant improvements in wellbeing, coping with stress, and social support over time. For the primary outcomes, the interaction between time and group was significant for wellbeing (β = 0.681, 95% CI: 0.343–1.705, p = 0.019), indicating that changes in wellbeing over time differed between with greater improvements observed in the intervention group. For the secondary outcomes, a significant interaction was observed for coping with stress (β = 1.651, 95% CI: 0.741–2.561, p < 0.001), showing that coping with stress improved more in the intervention group compared with the control group over time. Similarly, for social support, the interaction effect was significant (β = 2.211, 95% CI: 0.551–3.871, p = 0.009), suggesting that participants in the intervention group reported greater increases in social support across time compared to controls. Discussion This study is the first to assess the MHPSS and wellbeing outcomes associated with the SEEK intervention at 3 time points. At the time of intervention delivery, this period coincided with the 2024 conflict that had severe impacts on several areas in Lebanon, one of which was the Beqaa where the intervention package was delivered. Although the conflict had detrimental impact on the country and especially on vulnerable groups, and while the implementation team faced several challenges to maintain delivery of the intervention, the latter was still successfully completed with some adjustments to the methodology. That said, and while mindfully acknowledging the inevitable impacts of the conflict as an extraneous variable when assessing outcomes related to the intervention effects, in general, multivariate analyses suggest that the intervention was largely effective in improving psychosocial and wellbeing outcomes although no improvements were observed in relation to mental health outcomes. For instance, results showed significant improvements in overall wellbeing among the experimental group when compared to the control group that were sustained at endline and 3 months after the intervention. Wellbeing, as defined by the Center for Disease Control and Prevention (CDC), involves experiencing positive emotions, absence of negative feelings, and having a sense of satisfaction with life, fulfillment, and effective functioning (61). It is possible that due to the intervention’s content being focused on delivering practical and real-world applications, and its delivery format being community-driven and led by paraprofessionals who share similar cultural backgrounds, SEEK had important impacts on attending participants. Evidence shows that community-based interventions have been found to be effective in enhancing wellbeing and individual’s willingness to seek or accept support (62). When communities are engaged as resources, and to some extent, as facilitators, interventions become more culturally acceptable and relevant (63). For instance, a classroom-based intervention implemented in a conflict-affected setting showed improvements in social behavior and positive elements of wellbeing, when delivered by trained community members (64). Likewise, a randomized controlled trial in Zimbabwe found that adolescents receiving support from community adolescent treatment supporters (CATS) showed significantly greater improvements in confidence, self-esteem, and quality of life compared to those received standard care (65). Similarly, study findings showed significant improvements in self-efficacy to manage problems, however this was only the case at endline, whereby 3-months post intervention this difference between experimental and control groups was not significant. This suggests that self-efficacy may require additional booster sessions for practices, and guidance to be sustained. As self-efficacy is known to develop through social learning and continues to evolve as individuals acquire new skills, experiences, and understanding over the course of their lives (80, 81), sustaining it likely requires ongoing support. Bandura identifies four primary sources through which self-efficacy beliefs are shaped: mastery experience, vicarious learning through observing others, social persuasion, and the interpretation of emotional and physiological states (82). Consistent with this, recent evidence highlights that structured training and education strengthen general self-efficacy (83), and more coaching sessions was associated with greater improvements (84). Sustaining this gain requires continuous practice, progress monitoring, and periodic goal adjustment (85, 86) On the other hand, SEEK significantly improved participants’ skills to cope with challenging situations, and their perceived social support, by the end of the intervention and 3 months after the intervention. It may be that SEEK provided a safe space for participants to explore and discuss their thoughts and feelings, which may have improved their sense of belonging to a support system of peers and experts. All throughout, participants were encouraged to share experiences and to learn from each other, which likely strengthened interpersonal bonds and facilitated peer-exchange. Our finding that communication skills also improved significantly as a result of this intervention further supports and complements these results as communication skills as key to facilitate building and maintaining stronger relationships. Evidence consistently highlights the critical role of social support during crisis (66, 67). As Drury et al. note, people have always turned to one another for emotional and practical support in emergencies (68). Social support helps mitigate stress and promote trauma recovery by fostering cognitive restructuring and reinforcing coping mechanisms (69, 70). Additionally, peer-based initiatives, reduce stigma, offer culturally grounded support, and improve distress management (71, 72). These dynamics are importantly relevant for adolescents, who are more likely to seek helps from peers than professionals, and are responsive to peer influence (73, 74). Shared group experiences and collective identity further enhance comfort, resilience and the ability to manage adversity effectively (75–79). Importantly, improvements were sustained over time despite on-going conflict, and this suggests that coping skills can be learned through this community-based intervention, and potentially to last over time. Similarly, 3-months post intervention sustained improvements in perceived social support also suggest that networks and peer support developed by participants during the intervention may last beyond the duration of the intervention. Limitation Results of this study should be interpreted in light of several limitations. Most importantly, outcomes examined may have been significantly impacted by the 2024 conflict in Lebanon, as implementation coincided with active conflict. Ultimately it may be difficult to isolate the effects of SEEK from this broader contextual challenge impacting participants mental health and wellbeing. Should that not have been the case, we may have observed changes in mental health outcomes for example, however in this study we did not. Second, as this is the first pilot implementation of SEEK in a humanitarian setting, it is unclear the extent to which results are sustainable over a longer period of time, especially since our follow-up was limited to 3 months post intervention. Sustained impact may require longer follow-up periods. Third, our sample was limited to two PHCs in one geographical area in Lebanon which may limit external validity of study findings. Nevertheless, Syrian refugee populations are largely homogenous in Lebanon. Conclusion In conclusion, the SEEK intervention package, based on initial evidence from this community-based trial regarding its effectiveness, improves wellbeing, self-efficacy, coping, communication skills, and perceived social support among refugee women and girls during times of active conflict. However, while wellbeing, coping, and perceived social support improvements were sustained over time, this was not the case for self-efficacy which may require additional efforts to be sustained beyond the period of intervention delivery. That said, SEEK was found to not cause any changes in mental health outcomes such as anxiety, depression, and emotional regulation. Further research is needed to better establish the effectiveness of SEEK on mental health outcomes by examining its impact in a humanitarian context not experiencing active conflict. 5. Funding: This work received funding from Elhrha and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). Author Contribution SS, HN, AED, VG, and LS conceived the study; HN, AED, and ZC drafted the manuscript. ZC and HT led on data management. HN, VG, AED, and ZC led on data analysis. FF, LS, SS, GHA, TB, supported in interpretation of the results and wrote different sections of the manuscript. All authors critically reviewed and approved the final version of the manuscript. 7. Acknowledgments: None Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. References Tol WA, Ager A, Bizouerne C, Bryant R, El Chammay R, Colebunders R, et al. 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Overview of Data Collection Tools Tool Name Cronbach’s Alpha Number of Questions Validated in Arabic Score Interpretation WHO-5 Wellbeing English Version: 0.858 5 questions Yes (55) The higher the better improvement. Arabic Version: 0.877 Hopkins Symptom Checklist-25 (HSCL-25) Anxiety English Anxiety 0.84 10 questions Yes (56) The higher the worsening situation. Arabic Anxiety 0.85 Hopkins Symptom Checklist-25 (HSCL-25) Depression English 0.92 15 questions Yes The higher the worsening situation. Arabic 0.88 General Self-Efficacy Scale English: 0.76 to 0.90 10 questions Yes (57) The higher the better improvement Arabic: 0.95 Multidimensional Scale of Perceived Social Support for Arab Women English Family 0.87 Friends 0.85 Significant other 0.91 Arabic Family 0.82 Friends 0.86 Significant other 0.85 12 questions Yes (58) The higher the better improvement. The Difficulties in Emotion Regulation Scale Short Form (DERS-SF) English: 0.91 18 questions Yes (59) The higher the worsening situation. Arabic: 0.71 to 0.92 Revised Ways of Coping Checklist English 0.68 Arabic 0.67 12 questions Yes (60) The higher the better improvement Table 2. Baseline Demographic Differences across the Control and Experimental G roups (n=267) Baseline Variables Control N (%) or mean± sd n=144 Experimental N (%) or mean± sd n=123 P value Education 0.161 Illiterate 14 (9.7 %) 22 (17.9 %) Primary 74 (51.4 %) 58 (47.2 %) Intermediate 48 (33.3 %) 34 (27.6 %) Secondary and higher 8 (5.6 %) 9 (7.3 %) Work Currently Yes 14 (9.7 %) 25 (20.3%) 0.393 Marriage Times One time 138 (95.8 %) 115 (93.5 %) 0.391 Barriers to Healthcare Permission to go to PHC 61 (42.4 %) 55 (44.7 %) 0.699 Financial Barrier 96 (67.1 %) 76 (61.8 %) 0.363 Distance for HC Facility 89 (61.8 %) 73 (59.4 %) 0.682 Didn’t find Place to go 93 (64.6 %) 89 (72.4 %) 0.174 Don’t want to go alone 91 (63.2 %) 81 (65.9 %) 0.651 There is no female doctor 62(43.1%) 55(44.7%) 0.785 Ever Pregnant 110 (76.4 %) 107 (86.9 %) 0.027* Current Use of Family Planning 55 (38.2 %) 51 (41.5 %) 0.586 Baseline Well Being Status 12.06± 6.61 13.26± 6.82 0.147 Baseline Self-Efficacy 25.90± 6.70 27.30± 6.77 0.090 Baseline Coping with Stress 20.77± 6.04 19.83± 6.23 0.213 Baseline Anxiety Levels 2.55±0.72 2.63± 0.71 0.194 Baseline Depression Levels 2.80±0.69 2.81±0.69 0.957 Baseline Emotional Regulation 55.68±12.62 52.29± 12.54 0.029* Baseline Social Support 60.11±11.68 59.30±11.08 0.563 Table 3. Changes in mental health and psychosocial support outcomes for experimental group compared with control group. Control Experimental Unadjusted Adjusted¶ Mean± SD Mean ± SD Betta ¥ 95% CI P value Betta ¥ 95% CI P value Mental Health Outcome Primary Outcomes Wellbeing T0 12.06± 6.61 13.26± 6.82 Ref:Control Ref:Control T1(n=267) 11.63± 6.20 16.43± 5.88 3.23 (1.36, 5.10) 0.001* 3.33 (1.52,5.25) <0.001* T2(n=215) 10.78± 7.12 13.13± 6.59 7.39 (1.68,16.48) 0.110 6.66 (2.44,15.78) 0.035* Self-efficacy T0 25.90± 6.70 27.30± 6.77 Ref:Control Ref:Control T1 25.62± 6.22 30.10± 5.53 3.43 (1.72, 5.10) <0.001* 3.44 (1.78, 5.11) <0.001* T2 25.86± 6.07 28.43± 5.94 0.86 (-0.99,2.61) 0.380 1.42 (-.40;3.26) 0.127 Secondary Outcomes Coping with stress T0 20.77± 6.04 19.83± 6.23 Ref:Control Ref:Control T1 20.42± 5.22 22.60± 5.13 3.41 (1.72,5.10) <0.001* 3.28 (1.60,4.96) <0.001* T2 17.06±5.057 19.65±5.30 2.86 (0.78,4.92) 0.007 2.82 (0.73,4.90) 0.008* Communication T0 44.53±10.55 44.86±10.20 Ref:Control Ref:Control T1 47.41±11.82 44.94±11.71 -2.471 (-5.62,0.677) 0.123 -2.469 (-5.714,0.776) 0.135 T2 56.70± 9.25 60.73±11.775 4.030 (1.194,6.865) 0.006* 4.48 (1.611,7.356) 0.002* Anxiety T0 2.55±0.72 2.63± 0.71 Ref:Control Ref:Control T1 2.47±0.74 2.56±0.74 0.20 (-1.76,2.16) 0.841 0.24 (-1.73, 2.21) 0.810 T2 2.71±0.76 2.61±0.73 -0.02 (-.25,0.20) 0.819 -0,03 ( -0.27,0.19) 0.745 Depression T0 2.80±0.69 2.81±0.69 Ref:Control Ref:Control T1 2.76±0.63 2.70±0.71 -1.04 (-3.73,1.64) 0.443 -0.98 (-3.64,1.67) 0.467 T2 2.85±060 2.85+0.68 -0.001 (-.18,0.18) 0.987 -0.001 (-.18,0.18) 0.987 Emotional Regulation T0 55.68±12.62 52.29± 12.54 Ref:Control Ref:Control T1 50.22±11.67 48.17±11.93 1.59 (-1.71,4.90) 0.334 1.43 ( -1.89,4.75) 0.397 T2 67.29±34.41 63.29±29.06 -0.58 (-9.23,7.52) 0.841 0.40 ( -8.43,8.53) 0.991 Social Support T0 60.11±11.68 59.30±11.08 Ref:Control Ref:Control T1 63.40±12.85 66.80±11.95 4.47 (1.20,7.75) 0.008* 3.82 (0.59,7.05) 0.020* T2 66.68±12.23 66.62±10.79 4.22 (0.53,7.90) 0.025* 4.39 (0.68,8.10 0.021* *Sig. at 0.05, ¶. adjusted for possible confounders including age, education , working status , barriers to health care , and previous experience of pregnancy Table 4. Linear Mixed Effect Models of Mental Health and Wellbeing Outcomes (n=267) adjustedβ (SE) 95% CI P value Primary Outcomes Wellbeing Time x Group: Intervention 0.681(.289) (0.102 1.372) 0.019* Self-Efficacy Time x Group: Intervention 0.574(.431) (-.272, 1.420) 0.184 Secondary Outcomes Coping with Stress Time x Group: Intervention 1.651(.464) (0.741 2.561) <0.001* Depression Time x Group: Intervention -0.061(.652) (-1.340 1.217) 0.925 Anxiety Time x Group: Intervention -.006(0.050) (-.106 .093) 0.898 Emotional Regulation Time x Group: Intervention 0.196(1.704) (-3.113 1.537) 0.090 Communication Time x Group: Intervention 1.852(1.079) (-.2630,3.967) 0.086 Social Support Time x Group: Intervention 2.211(.846) (0.551 3.871) 0.009* Adjusted for possible confounders including age, education, working status, barriers to health care, and previous experience of pregnancy Additional Declarations No competing interests reported. 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Refugees are especially vulnerable due to various intersecting stressors including forced displacement, discrimination, economic hardships, harsh living conditions, and exposure to violence and trauma among others (5-9). These experiences often involve losses of loved ones, autonomy, identity, and social support essential for coping with emotional and social adversities\u0026nbsp;(10). Displacement also restricts access to critical services, including education, healthcare, and mental health and psychosocial support, which may lead to poor mental health outcomes\u0026nbsp;(6, 11-14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to the World Health Organization (WHO), mental health is\u0026nbsp;a state of mental well-being that allows individuals to handle stressors, achieve their potential, and participate meaningfully in their community (15). It encompasses aspects such as self-efficacy, autonomy, and competence, which are essential for human functioning\u0026nbsp;(16-18). As such, mental health is increasingly recognized as an essential human right and a critical component of overall well-being\u0026nbsp;(16, 19). That said, in settings experiencing protracted instability, such as in the Eastern Mediterranean Region (EMR)\u0026mdash;one of the most crisis-affected regions worldwide\u0026nbsp;(4, 20)\u0026mdash;mental health remains of concern, especially for women and girls\u0026nbsp;(20-22). This is especially true in Lebanon, an EMR country that hosts over 1.5 million Syrian refugees\u0026nbsp;(23, 24)\u0026nbsp;and where many refugees experience psychological stress\u0026nbsp;(25), high rates of depression, especially in women\u0026nbsp;(26, 27), post-traumatic stress disorder (PTSD)\u0026nbsp;(28), and isolation and insecurity\u0026nbsp;(29).\u003c/p\u003e\n\u003cp\u003eRecognizing these challenges, humanitarian actors have increasingly included mental health and psychosocial support (MHPSS) in their responses (30-32).\u0026nbsp;Community-delivered strategies, including peer-led models, are promising and have shown efficacy, feasibility, and cost-effectiveness\u0026nbsp;(33-35), with growing evidence supporting their implementation to enhance mental health and well-being among refugees\u0026nbsp;(10). Studies have demonstrated that such interventions can alleviate PTSD symptoms, enhance psychosocial factors, strengthen coping with anxiety and anger, and foster social support\u0026nbsp;(35, 36).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile community-based approaches have shown potential in enhancing mental health, addressing mental health in isolation is insufficient (37), as MHPSS may be\u0026nbsp;integrated across various response types\u0026nbsp;(38), especially in humanitarian settings, where AGYW experience several intersecting vulnerabilities\u0026nbsp;(39). In such contexts, SRH challenges, such as sexual violence, unwanted pregnancies, sexually transmitted infections (STIs), and limited access to contraception,\u0026nbsp;are closely linked to adverse mental health\u0026nbsp;(40-43).\u0026nbsp;Although SRH and mental health are interdependent\u0026nbsp;(50), research has traditionally targeted these areas in isolation\u0026nbsp;(51). Moreover, even though integrated PSS-SRH interventions can enhance access to healthcare and well-being, evaluation and documentation of their effectiveness, particularly\u0026nbsp;in humanitarian settings, remains limited\u0026nbsp;(22, 52, 53).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn response, WHO developed a low-intensity, low-resource integrated PSS-SRH package to improve SRH, Family Planning (FP), and wellbeing among AGYW in such contexts (52). This intervention - the Self-Efficacy and Knowledge (SEEK) package \u0026ndash; addresses, in an integrated manner the aforementioned topics through psycho-education, SRH education, and other modules related to general life skills, communication, problem solving, and emotional regulation, and it is designed to be delivered by non-specialists (52). In this manuscript, we report findings from the Randomized Controlled Trial (RCT) focusing on MHPSS outcomes among Syrian AGYW refugees in Lebanon over time. Findings from this study will provide key evidence for developing adolescent-friendly PSS-SRH programs in humanitarian settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eTrial design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a single-blinded, community-based RCT design to assess the effectiveness of SEEK among Syrian AGYW refugees aged 15-24 years in Lebanon. Participants were randomly assigned to either an experimental group (EG), which received the intervention, or a waitlist control group (CG), which did not receive the intervention during the study period. All outcomes, including those related to mental health, were assessed at baseline (T0) and immediately post-intervention (T1), with a follow-up at three months post-intervention (T2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstrument development and testing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo thoroughly assess the impact and effectiveness of the intervention on mental health and psychosocial outcomes, various psychometrically tested tools were utilized as described below:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWorld Health Organization Well-Being 5-item Index (WHO-5)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe World Health Organization Well-Being 5-item Index (WHO-5) is a short 5-item screening instrument, to measure self-reported psychological well-being. It is used extensively worldwide, and it is translated and validated into different languages, including Arabic. Each of the 5 items is positively framed, and is rated on a 6-point Likert scale ranging from 0 (at no time) to 5 (all of the time). The survey yields a final score ranging from 0 to 25 with the percentage score being the summed score multiplied by 4. A final score of \u0026lt; 13 indicates poor wellbeing or low mood.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral Self-Efficacy Scale (GSES)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-Efficacy was assessed via the General Self-Efficacy Scale (GSES), which is a 10-item scale designed to assess a person\u0026rsquo;s optimistic self-beliefs in relation to their perceived skills to cope with life\u0026rsquo;s demands. The GSES has been used in numerous studies and has been validated as a unidimensional construct for adults and adolescents in several single- and multi-country studies. The tool is available in English and has been translated and validated in Arabic. The GSES is rated on a 4-point Likert scale with answers ranging from 1 (not at all true) to 4 (exactly true), and yielding a final score ranging from 10 to 40, with higher scores indicating stronger self-efficacy. The score is not dichotomized but may be used for comparative purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRevised Ways of Coping Checklist (RWCCL)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCoping, problem solving, and decision making,\u003cem\u003e\u0026nbsp;\u003c/em\u003ewere assessed using the Revised Ways of Coping Checklist (RWCCL), which measures different types of coping. It enables the evaluation of the structure of interpersonal or individual social supports as well as their collective or networked social supports. The RWCCL is a widely used multidimensional coping measure with satisfactory reliability and validity.\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe tool is available in English and was translated and validated in Arabic. Each item is rated on a 4-point Likert scale with answers ranging from 0 (does not apply or not used), to 3 (used a great deal). The final score is not dichotomized, but may be used for comparative purposes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepression and Anxiety using Hopkins Symptom Checklist 25 (HSCL 25)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Hopkins Symptom Checklist 25 was used to measure depression through 15 items and anxiety through 10 items. This tool screens for presence of anxiety and depression symptoms and was not designed to be used for diagnostic purposes. Responses are rated on a 4-point Likert scale ranging from 1 (not at all) to 4 (extremely). A mean score of over or equal to 1.75 indicates concerning symptoms of anxiety or depression. The tool is available in English and was translated and validated Arabic \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDifficulties in Emotion Regulation Scale Short Form (DERS-SF)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Difficulties in Emotion Regulation Scale Short Form (DERS-SF) was used to assess emotional regulation. The DERS-SF consists of 18-items, with participants rating their answers in the past week on a scale from 1 (almost never) to 5 (almost always). Total scores range from 18 to 90, with higher scores indicating more difficulty in emotional regulation. The tool is available in English and was translated and validated in Arabic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMultidimensional Scale of Perceived Social Support for Arab Women (MSPSS-AW)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u003cem\u003e\u0026nbsp;\u003c/em\u003eMultidimensional Scale of Perceived Social Support for Arab Women (MSPSS-AW) was used to assess social support. This tool is tailored to reflect social support networks relevant to Arab women at multiple levels including the family, friends, significant other, and the community level. Responses are rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). The final score is obtained by averaging all items, with higher scores indicating higher perceived social support.\u0026nbsp;The tool is\u0026nbsp;available in\u0026nbsp;English and was translated and adapted to Arabic\u0026nbsp;(54).\u003cem\u003e\u0026nbsp;\u003c/em\u003eRefer to Table 1 below for a detailed description of each tool.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[insert table 1]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention and Control Recruitment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe target population of the study was Syrian refugee AGYW (aged 15\u0026ndash;24 years) residing in Lebanon. Inclusion criteria included: (1) being a Syrian refugee girl or woman, (2) aged 15\u0026ndash;24, (3) having resided in Lebanon for at least 6 months, and (4) being willing to participate in the study by signing an informed consent form (for participants aged 18 or older) or by their legal guardian providing a signed consent form on their behalf (for those aged 15\u0026ndash;17). Participants were excluded if they (1) were currently pregnant and/or lactating, (2) had chronic health conditions interfering with their ability to follow the intervention protocol, or (3) presented with high levels of anxiety and/or depression, suicidal ideation or attempts during screening, a current diagnosis of a severe mental illness, or were undergoing specialist psychiatric treatment. The recruitment process was coordinated with selected primary healthcare centers (PHC) where the study took place. These centers were chosen following recommendations from the Ministry of Public Health \u0026ndash; department of Primary Healthcare \u0026ndash; based on their (1) capacity to reach the target population, (2) their provision of SRH services, and (3) their capacity to hold space for all intervention-related activities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo identify potentially eligible participants, the research team, in coordination with the centers, prepared a list of PHC patients who may, most closely be potentially eligible, and proceeded with calling them and inviting them to participate in the study using an invitation script. Following baseline screening and data collection, participants were randomized into either EG or CG. Participants in the CG were waitlisted to receive the same information as the EG in a more concise format once all data collection activities were completed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBlinding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo minimize potential bias, the trial employed a blinded design in which data collectors and participants remained unaware of group allocation. Participants were not informed about the existence of the alternate study arm, ensuring that their responses and engagement were not influenced by knowledge of the study design. Similarly, data collectors were blinded to participants\u0026rsquo; group assignments to reduce measurement bias during data collection and analysis. That said, the implementation staff was aware of group allocation due to the nature of the study design. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnce participants were randomized into intervention arms, the EG were further divided into subgroups to participate in the intervention sessions. The intervention package was delivered at the selected PHCs, whereby each subgroups attended 1 session per week for eight consecutive weeks. Each session lasted approximately 90 minutes and covered various topics related to MH and SRH as delivered by trained paraprofessionals (also known as community health workers). Prior to the intervention, these paraprofessionals received a 20-day comprehensive training facilitated by a clinical psychologist and a midwife. The training equipped them with the necessary skills and knowledge to effectively deliver the intervention content in a standardized manner and to address any concerns or questions that may arise during the sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eImportantly, the intervention was carried out during a period of critical instability in Lebanon, that included active conflict. This ultimately disrupted the interventions in many ways by causing delays, higher than expected attrition, and other disruptions associated with implementation as described in a subsequent section below.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe trial received ethical approval from the Institutional Review Board (IRB) at the American University of Beirut (AUB) and the World Health Organization (WHO) Ethical Review Committee. Informed consent was obtained from all participants after they were provided with detailed information regarding the study\u0026rsquo;s aims, participants\u0026rsquo; rights, and their ability to withdraw from the study at any time without affecting their access to PHC services or any other benefits they may have been entitled to. To uphold ethical standards, trained field coordinators supervised all procedures, ensuring protocol adherence and participant safety. An on-site psychologist addressed any session-related distress, and participants identified as potentially having mental health concerns received direct support or NGO referrals for more severe cases. All intervention materials were adapted to Arabic, and only female data collectors were trained and deployed to collect data to promote accessibility and comfort. All staff were rigorously trained in confidentiality, risk identification, and ethical data collection. Moreover, to guarantee anonymity, all personal identifiers were replaced with unique codes during data collection and analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProtocol Deviation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the displaced nature of the studied population, protocol deviations were anticipated and systematically recorded. These deviations included delays in intervention initiation, participant non-adherence, withdrawals, delayed or irregular attendance, cross-group attendance, where some participants attended sessions outside their assigned intervention group due to scheduling conflicts, and permanent group switches. The escalation of the conflict in Lebanon during the study period exacerbated these challenges, contributing to interruption in intervention delivery and increased participant displacement. To mitigate the impact of these deviations adaptive strategies were employed, including flexible session rescheduling, phone-based follow-ups, and increased participant incentives. No deviations compromised participant safety or primary outcome validity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted on the full intent-to-treat sample and evaluated based on improvements in mental health status between baseline and immediate post-intervention (T0\u0026ndash;T1), as well as between baseline and the 3-month follow-up (T0\u0026ndash;T2). The primary analysis compared the difference-in-differences between the intervention and control groups at each time point. Prior to this, baseline characteristics of the intervention and control groups were compared, in line with the original study design. This comparison was based on the homogeneity assumption\u0026mdash;that each participant\u0026rsquo;s outcome is a random draw from a common distribution, independent of study site. No violation of this assumption was expected, as participants were randomly allocated to intervention or control groups using a random generator, and consistent recruitment and randomization procedures were followed across both sites. \u0026nbsp;Primary and secondary outcomes were defined as changes in women\u0026rsquo;s and psychosocial outcomes from T0 to T1 and from T0 to T2. To estimate marginal treatment effects, linear regression models were used to compare improvements in the intervention group relative to the control group at each time point. All models controlled for potential sociodemographic confounders including age, education, employment status, barriers to healthcare, and previous pregnancy experience. Additional variables that either differed significantly (p \u0026lt; 0.05) between groups at baseline or predicted outcome changes were also included as covariates. At T2, primary and secondary outcomes were analyzed excluding approximately 23% of the sample who were only assessed at T1. To address this missing data, mixed-effects linear models were deployed. Treatment effects were estimated using maximum likelihood mixed-effects regression models with robust variance estimators. All analyses controlled for participant sex, age, marital status, and disability, along with other baseline differences or predictors of outcome change (p \u0026lt; 0.10). Analyses were conducted using Stata 18.0, with a 95% confidence level.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline Data\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA review of demographic characteristics in Table 2 identifies the baseline differences between the control and intervention group. A total of 267 women were enrolled, with 144 allocated to the control group and 123 to the intervention group. The two groups were broadly comparable across most baseline characteristics. The majority of participants in both groups had primary or intermediate education (Control: 84.7%, Intervention: 74.8%). Current employment was low in both groups, with only 9.7% of women in the control group and 20.3% in the intervention group reporting current work. Nearly all participants had been married once (95.8% in the control vs. 93.5% in the intervention group), and over 60% in both groups reported financial barriers and difficulties related to distance and safety when accessing health services. For instance, 67.1% of control participants and 61.8% of those in the intervention group cited financial difficulties, while 64.6% and 72.4%, respectively, reported not finding a suitable place to seek help. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSignificant baseline differences between both groups were found on two variables. Women in the intervention group were more likely to have previously been pregnant (86.9%) compared to those in the control group (76.4%; \u003cem\u003ep\u003c/em\u003e = 0.027). Additionally, baseline emotional regulation scores were significantly lower in the intervention group (mean = 52.29 \u0026plusmn; 12.54) than in the control group (mean = 55.68 \u0026plusmn; 12.62; \u003cem\u003ep\u003c/em\u003e = 0.029). All other measures, including baseline well-being, self-efficacy, coping with stress, anxiety, depression, and social support, were not significantly different across groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[insert table 2]\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTreatment Effects\u003c/strong\u003e\u003c/h3\u003e\n\u003ch4\u003e\u003cstrong\u003ePrimary Outcomes\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eTable 3 presents the estimated treatment effects on primary outcomes across the three assessment time points (T0, T1, and T2), using mixed-effects regression models adjusted for baseline scores. The primary outcomes were \u003cstrong\u003ewellbeing\u003c/strong\u003e and \u003cstrong\u003eself-efficacy\u003c/strong\u003e. Participants in the intervention group showed a statistically significant improvement in wellbeing scores compared to the control group. At baseline, the mean wellbeing score for the intervention group was 13.26 \u0026plusmn; 6.82, which increased to 16.43 \u0026plusmn; 5.88 at T1, while the control group\u0026apos;s score slightly declined from 12.06 \u0026plusmn; 6.61 to 11.63 \u0026plusmn; 6.20. The intervention effect was significant at T1 (\u0026beta; = 3.33, 95% CI: 1.52 to 5.25, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and remained significant at T2 (\u0026beta; = 6.66, 95% CI: 2.44 to 15.78, \u003cem\u003ep\u003c/em\u003e = 0.035), with higher scores observed, indicating sustained and improved gains over time. Similarly, self-efficacy scores improved significantly in the intervention group at T1 (\u0026beta; = 3.44, 95% CI: 1.78 to 5.11, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), rising from a baseline of 27.30 \u0026plusmn; 6.77 to 30.10 \u0026plusmn; 5.53. However, this effect diminished by T2 and was no longer statistically significant (\u0026beta; = 1.42, 95% CI: \u0026ndash;0.40 to 3.26, \u003cem\u003ep\u003c/em\u003e = 0.127), suggesting the possibility of regression toward baseline levels post-intervention.\u003c/p\u003e\n\u003cp\u003e[Insert table 3]\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eAmong the secondary outcomes, \u003cstrong\u003ecoping with stress\u003c/strong\u003e exhibited consistent and significant improvement. Mean scores in the intervention group increased from 19.83 \u0026plusmn; 6.23 at baseline to 22.60 \u0026plusmn; 5.13 at T1, compared to a modest change in the control group (20.77 \u0026plusmn; 6.04 to 20.42 \u0026plusmn; 5.22). The corresponding effect estimates were statistically significant at both T1 (\u0026beta; = 3.28, 95% CI: 1.60 to 4.96, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and T2 (\u0026beta; = 2.82, 95% CI: 0.73 to 4.90, \u003cem\u003ep\u003c/em\u003e = 0.008). \u003cstrong\u003eSocial support\u003c/strong\u003e also improved following the intervention, with scores increasing from 59.30 \u0026plusmn; 11.08 at baseline to 66.80 \u0026plusmn; 11.95 at T1. The control group remained relatively stable. The intervention yielded a significant effect at T1 (\u0026beta; = 3.82, 95% CI: 0.59 to 7.05, \u003cem\u003ep\u003c/em\u003e = 0.020), and this improvement was sustained at T2 (\u0026beta; = 4.39, 95% CI: 0.68 to 8.10, \u003cem\u003ep\u003c/em\u003e = 0.021). For \u003cstrong\u003eanxiety\u003c/strong\u003e and \u003cstrong\u003edepression\u003c/strong\u003e, no statistically significant differences were observed between groups. Anxiety scores in the intervention group changed minimally (from 2.63 \u0026plusmn; 0.71 to 2.56 \u0026plusmn; 0.74), with nonsignificant effect estimates at both T1 (\u0026beta; = 0.24, \u003cem\u003ep\u003c/em\u003e = 0.810) and T2 (\u0026beta; = \u0026ndash;0.03, \u003cem\u003ep\u003c/em\u003e = 0.745). Depression scores also remained stable, with no meaningful difference observed across time points. \u003cstrong\u003eEmotional regulation\u003c/strong\u003e showed an upward trend in raw scores in the intervention group (52.29 \u0026plusmn; 12.54 at T0 to 63.29 \u0026plusmn; 29.06 at T2), however the associated treatment effects were not statistically significant at either T1 or T2, likely due to large within-group variability. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSensitivity Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 presents the results of linear mixed-effects models with random intercepts for participants. The interaction terms between time and group were examined to assess whether the intervention effect differed across time between the intervention and control groups. Results indicated that the intervention led to significant improvements in wellbeing, coping with stress, and social support over time. For the primary outcomes, the interaction between time and group was significant for wellbeing\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(\u0026beta;=0.681, 95% CI: 0.343\u0026ndash;1.705, p=0.019), indicating that changes in wellbeing over time differed between with greater improvements observed in the intervention group. For the secondary outcomes, a significant interaction was observed for coping with stress (\u0026beta;=1.651, 95% CI: 0.741\u0026ndash;2.561, p\u0026lt;0.001), showing that coping with stress improved more in the intervention group compared with the control group over time. Similarly, for social support, the interaction effect was significant (\u0026beta;=2.211, 95% CI: 0.551\u0026ndash;3.871, p=0.009), suggesting that participants in the intervention group reported greater increases in social support across time compared to controls.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to assess the MHPSS and wellbeing outcomes associated with the SEEK intervention at 3 time points. At the time of intervention delivery, this period coincided with the 2024 conflict that had severe impacts on several areas in Lebanon, one of which was the Beqaa where the intervention package was delivered. Although the conflict had detrimental impact on the country and especially on vulnerable groups, and while the implementation team faced several challenges to maintain delivery of the intervention, the latter was still successfully completed with some adjustments to the methodology.\u003c/p\u003e\n\u003cp\u003eThat said, and while mindfully acknowledging the inevitable impacts of the conflict as an extraneous variable when assessing outcomes related to the intervention effects, in general, multivariate analyses suggest that the intervention was largely effective in improving psychosocial and wellbeing outcomes although no improvements were observed in relation to mental health outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor instance, results showed significant improvements in overall wellbeing among the experimental group when compared to the control group that were sustained at endline and 3 months after the intervention. Wellbeing, as defined by the Center for Disease Control and Prevention (CDC), involves experiencing positive emotions, absence of negative feelings, and having a sense of satisfaction with life, fulfillment, and effective functioning (61). It is possible that due to the intervention\u0026rsquo;s content being focused on delivering practical and real-world applications, and its delivery format being community-driven and led by paraprofessionals who share similar cultural backgrounds, SEEK had important impacts on attending participants. Evidence shows that community-based interventions have been found to be effective in enhancing wellbeing and individual\u0026rsquo;s willingness to seek or accept support (62). When communities are engaged as resources, and to some extent, as facilitators, interventions become more culturally acceptable and relevant (63). For instance, a classroom-based intervention implemented in a conflict-affected setting showed improvements in social behavior and positive elements of wellbeing, when delivered by trained community members (64). Likewise, a randomized controlled trial in Zimbabwe found that adolescents receiving support from community adolescent treatment supporters (CATS) showed significantly greater improvements in confidence, self-esteem, and quality of life compared to those received standard care (65).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, study findings showed significant improvements in self-efficacy to manage problems, however this was only the case at endline, whereby 3-months post intervention this difference between experimental and control groups was not significant. This suggests that self-efficacy may require additional booster sessions for practices, and guidance to be sustained. As self-efficacy is known to develop through social learning and continues to evolve as individuals acquire new skills, experiences, and understanding over the course of their lives (80, 81), sustaining it likely requires ongoing support. Bandura identifies four primary sources through which self-efficacy beliefs are shaped: mastery experience, vicarious learning through observing others, social persuasion, and the interpretation of emotional and physiological states (82). Consistent with this, recent evidence highlights that structured training and education strengthen general self-efficacy (83), and more coaching sessions was associated with greater improvements (84). Sustaining this gain requires continuous practice, progress monitoring, \u0026nbsp;and periodic goal adjustment (85, 86)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOn the other hand, SEEK significantly improved participants\u0026rsquo; skills to cope with challenging situations, and their perceived social support, by the end of the intervention and 3 months after the intervention.\u003c/strong\u003e It may be that SEEK provided a safe space for participants to explore and discuss their thoughts and feelings, which may have improved their sense of belonging to a support system of peers and experts. All throughout, participants were encouraged to share experiences and to learn from each other, which likely strengthened interpersonal bonds and facilitated peer-exchange. Our finding that communication skills also improved significantly as a result of this intervention further supports and complements these results as communication skills as key to facilitate building and maintaining stronger relationships. Evidence consistently highlights the critical role of social support during crisis (66, 67). As Drury et al. note, people have always turned to one another for emotional and practical support in emergencies (68). Social support helps mitigate stress and promote trauma recovery by fostering cognitive restructuring and reinforcing coping mechanisms (69, 70). Additionally, peer-based initiatives, reduce stigma, offer culturally grounded support, and improve distress management (71, 72). These dynamics are importantly relevant for adolescents, who are more likely to seek helps from peers than professionals, and are responsive to peer influence (73, 74). Shared group experiences and collective identity further enhance comfort, resilience and the ability to manage adversity effectively (75\u0026ndash;79). Importantly, improvements were sustained over time despite on-going conflict, and this suggests that coping skills can be learned through this community-based intervention, and potentially to last over time. Similarly, 3-months post intervention sustained improvements in perceived social support also suggest that networks and peer support developed by participants during the intervention may last beyond the duration of the intervention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThat said, results did not show statistical improvements on key mental health outcomes such as anxiety, depression, and emotional regulation. It is possible that this group of refugees, especially during an acute time of active conflict in Lebanon, may have experienced much distress that exacerbated pre-existing vulnerabilities associated with harsh living conditions and which may have superseded expected influences of SEEK on mental health outcomes. During times of active conflict, all participants may have experienced increased vigilance and concerns over survival which may have required other types of support on the mental health level. While supportive approaches like psychoeducation and problem-solving counselling have been applied in conflict-affected settings, their effectiveness in improving clinical symptoms remains limited. For instance, intervention in Aceh, Nepal, and Uganda demonstrated improvements in functioning or coping, but showed little to no effect on reducing symptoms of depression, anxiety, or PTSD (87-89). It is likely that in such environments, symptoms of depression and anxiety are exacerbated by ongoing stressors like unsafety and uncertainty (79, 90, 91). Moreover, mental health responses in humanitarian contexts are often non-holistic, externally driven, and poorly adapted to local realities, resulting in low sustainability (92). Thus, in such settings, psychosocial interventions may offer short-term relief, but sustained improvements in mental health outcomes are unlikely without parallel efforts to restore safety, stability, and social inclusion (92-96). It may also be that integration of SRH and MH diluted MH content whereby improvements were seen on wellbeing and psychosocial factors, but not for symptom relief.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults of this study should be interpreted in light of several limitations. Most importantly, outcomes examined may have been significantly impacted by the 2024 conflict in Lebanon, as implementation coincided with active conflict. Ultimately it may be difficult to isolate the effects of SEEK from this broader contextual challenge impacting participants mental health and wellbeing. Should that not have been the case, we may have observed changes in mental health outcomes for example, however in this study we did not. Second, as this is the first pilot implementation of SEEK in a humanitarian setting, it is unclear the extent to which results are sustainable over a longer period of time, especially since our follow-up was limited to 3 months post intervention. Sustained impact may require longer follow-up periods. Third, our sample was limited to two PHCs in one geographical area in Lebanon which may limit external validity of study findings. Nevertheless, Syrian refugee populations are largely homogenous in Lebanon.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the SEEK intervention package, based on initial evidence from this community-based trial regarding its effectiveness, improves wellbeing, self-efficacy, coping, communication skills, and perceived social support among refugee women and girls during times of active conflict. However, while wellbeing, coping, and perceived social support improvements were sustained over time, this was not the case for self-efficacy which may require additional efforts to be sustained beyond the period of intervention delivery. That said, SEEK was found to not cause any changes in mental health outcomes such as anxiety, depression, and emotional regulation. Further research is needed to better establish the effectiveness of SEEK on mental health outcomes by examining its impact in a humanitarian context not experiencing active conflict.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclarations\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003e1. Ethics Approval \u0026amp; Consent to Participate:\u003c/strong\u003e\u003cp\u003e This study was approved by the Institutional Review Board at the American University of Beirut and by the Ethics Review Committee at the World Health Organization. All participants provided informed written consent prior to participation. For participants under 18, they parents or guardians were required to sign a consent form on their behalf.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cb\u003e2\u003c/b\u003e. \u003cb\u003eConsent for Publication\u003c/b\u003e:\u003c/strong\u003e\u003cp\u003eNot Applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003e4. Competing Interests:\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\u003c/p\u003e\u003ch2\u003e\u003cb\u003eAdditional Disclaimers\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eAuthor affiliations\u003c/strong\u003e\u003cp\u003eDr Lale Say, Unit Head, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland\u003c/p\u003e\u003cp\u003eDr Veloshnee Govender, Scientist, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDisclaimer for WHO staff\u003c/strong\u003e\u003cp\u003eThe named authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions or the policies of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) or the World Health Organization (WHO).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003cp\u003eHumanitarian crises, such as conflict, war, and political instabilities, have a substantial effect on the mental health and psychosocial well-being (1\u0026ndash;4). Refugees are especially vulnerable due to various intersecting stressors including forced displacement, discrimination, economic hardships, harsh living conditions, and exposure to violence and trauma among others (5\u0026ndash;9). These experiences often involve losses of loved ones, autonomy, identity, and social support essential for coping with emotional and social adversities (10). Displacement also restricts access to critical services, including education, healthcare, and mental health and psychosocial support, which may lead to poor mental health outcomes (6, 11\u0026ndash;14).\u003c/p\u003e\u003cp\u003eAccording to the World Health Organization (WHO), mental health is a state of mental well-being that allows individuals to handle stressors, achieve their potential, and participate meaningfully in their community (15). It encompasses aspects such as self-efficacy, autonomy, and competence, which are essential for human functioning (16\u0026ndash;18). As such, mental health is increasingly recognized as an essential human right and a critical component of overall well-being (16, 19). That said, in settings experiencing protracted instability, such as in the Eastern Mediterranean Region (EMR)\u0026mdash;one of the most crisis-affected regions worldwide (4, 20)\u0026mdash;mental health remains of concern, especially for women and girls (20\u0026ndash;22). This is especially true in Lebanon, an EMR country that hosts over 1.5\u0026nbsp;million Syrian refugees (23, 24) and where many refugees experience psychological stress (25), high rates of depression, especially in women (26, 27), post-traumatic stress disorder (PTSD) (28), and isolation and insecurity (29).\u003c/p\u003e\u003cp\u003eRecognizing these challenges, humanitarian actors have increasingly included mental health and psychosocial support (MHPSS) in their responses (30\u0026ndash;32). Community-delivered strategies, including peer-led models, are promising and have shown efficacy, feasibility, and cost-effectiveness (33\u0026ndash;35), with growing evidence supporting their implementation to enhance mental health and well-being among refugees (10). Studies have demonstrated that such interventions can alleviate PTSD symptoms, enhance psychosocial factors, strengthen coping with anxiety and anger, and foster social support (35, 36).\u003c/p\u003e\u003cp\u003eWhile community-based approaches have shown potential in enhancing mental health, addressing mental health in isolation is insufficient (37), as MHPSS may be integrated across various response types (38), especially in humanitarian settings, where AGYW experience several intersecting vulnerabilities (39). In such contexts, SRH challenges, such as sexual violence, unwanted pregnancies, sexually transmitted infections (STIs), and limited access to contraception, are closely linked to adverse mental health (40\u0026ndash;43). Although SRH and mental health are interdependent (50), research has traditionally targeted these areas in isolation (51). Moreover, even though integrated PSS-SRH interventions can enhance access to healthcare and well-being, evaluation and documentation of their effectiveness, particularly in humanitarian settings, remains limited (22, 52, 53).\u003c/p\u003e\u003cp\u003eIn response, WHO developed a low-intensity, low-resource integrated PSS-SRH package to improve SRH, Family Planning (FP), and wellbeing among AGYW in such contexts (52). This intervention - the Self-Efficacy and Knowledge (SEEK) package \u0026ndash; addresses, in an integrated manner the aforementioned topics through psycho-education, SRH education, and other modules related to general life skills, communication, problem solving, and emotional regulation, and it is designed to be delivered by non-specialists (52). In this manuscript, we report findings from the Randomized Controlled Trial (RCT) focusing on MHPSS outcomes among Syrian AGYW refugees in Lebanon over time. Findings from this study will provide key evidence for developing adolescent-friendly PSS-SRH programs in humanitarian settings.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eTrial design\u003c/strong\u003e\u003cp\u003eThis study employed a single-blinded, community-based RCT design to assess the effectiveness of SEEK among Syrian AGYW refugees aged 15\u0026ndash;24 years in Lebanon. Participants were randomly assigned to either an experimental group (EG), which received the intervention, or a waitlist control group (CG), which did not receive the intervention during the study period. All outcomes, including those related to mental health, were assessed at baseline (T0) and immediately post-intervention (T1), with a follow-up at three months post-intervention (T2).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInstrument development and testing\u003c/strong\u003e\u003cp\u003eTo thoroughly assess the impact and effectiveness of the intervention on mental health and psychosocial outcomes, various psychometrically tested tools were utilized as described below:\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eWorld Health Organization Well-Being 5-item Index (WHO-5)\u003c/strong\u003e\u003cp\u003eThe World Health Organization Well-Being 5-item Index (WHO-5) is a short 5-item screening instrument, to measure self-reported psychological well-being. It is used extensively worldwide, and it is translated and validated into different languages, including Arabic. Each of the 5 items is positively framed, and is rated on a 6-point Likert scale ranging from 0 (at no time) to 5 (all of the time). The survey yields a final score ranging from 0 to 25 with the percentage score being the summed score multiplied by 4. A final score of \u0026lt;\u0026thinsp;13 indicates poor wellbeing or low mood.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eGeneral Self-Efficacy Scale (GSES)\u003c/strong\u003e\u003cp\u003eSelf-Efficacy was assessed via the General Self-Efficacy Scale (GSES), which is a 10-item scale designed to assess a person\u0026rsquo;s optimistic self-beliefs in relation to their perceived skills to cope with life\u0026rsquo;s demands. The GSES has been used in numerous studies and has been validated as a unidimensional construct for adults and adolescents in several single- and multi-country studies. The tool is available in English and has been translated and validated in Arabic. The GSES is rated on a 4-point Likert scale with answers ranging from 1 (not at all true) to 4 (exactly true), and yielding a final score ranging from 10 to 40, with higher scores indicating stronger self-efficacy. The score is not dichotomized but may be used for comparative purposes.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eRevised Ways of Coping Checklist (RWCCL)\u003c/strong\u003e\u003cp\u003eCoping, problem solving, and decision making, were assessed using the Revised Ways of Coping Checklist (RWCCL), which measures different types of coping. It enables the evaluation of the structure of interpersonal or individual social supports as well as their collective or networked social supports. The RWCCL is a widely used multidimensional coping measure with satisfactory reliability and validity. The tool is available in English and was translated and validated in Arabic. Each item is rated on a 4-point Likert scale with answers ranging from 0 (does not apply or not used), to 3 (used a great deal). The final score is not dichotomized, but may be used for comparative purposes.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDepression and Anxiety using Hopkins Symptom Checklist 25 (HSCL 25)\u003c/strong\u003e\u003cp\u003eThe Hopkins Symptom Checklist 25 was used to measure depression through 15 items and anxiety through 10 items. This tool screens for presence of anxiety and depression symptoms and was not designed to be used for diagnostic purposes. Responses are rated on a 4-point Likert scale ranging from 1 (not at all) to 4 (extremely). A mean score of over or equal to 1.75 indicates concerning symptoms of anxiety or depression. The tool is available in English and was translated and validated Arabic\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDifficulties in Emotion Regulation Scale Short Form (DERS-SF)\u003c/strong\u003e\u003cp\u003eThe Difficulties in Emotion Regulation Scale Short Form (DERS-SF) was used to assess emotional regulation. The DERS-SF consists of 18-items, with participants rating their answers in the past week on a scale from 1 (almost never) to 5 (almost always). Total scores range from 18 to 90, with higher scores indicating more difficulty in emotional regulation. The tool is available in English and was translated and validated in Arabic.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMultidimensional Scale of Perceived Social Support for Arab Women (MSPSS-AW)\u003c/strong\u003e\u003cp\u003eThe Multidimensional Scale of Perceived Social Support for Arab Women (MSPSS-AW) was used to assess social support. This tool is tailored to reflect social support networks relevant to Arab women at multiple levels including the family, friends, significant other, and the community level. Responses are rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). The final score is obtained by averaging all items, with higher scores indicating higher perceived social support. The tool is available in English and was translated and adapted to Arabic (54). Refer to Table\u0026nbsp;1 below for a detailed description of each tool.\u003c/p\u003e\u003cp\u003e[insert table 1]\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIntervention and Control Recruitment\u003c/strong\u003e\u003cp\u003eThe target population of the study was Syrian refugee AGYW (aged 15\u0026ndash;24 years) residing in Lebanon. Inclusion criteria included: (1) being a Syrian refugee girl or woman, (2) aged 15\u0026ndash;24, (3) having resided in Lebanon for at least 6 months, and (4) being willing to participate in the study by signing an informed consent form (for participants aged 18 or older) or by their legal guardian providing a signed consent form on their behalf (for those aged 15\u0026ndash;17). Participants were excluded if they (1) were currently pregnant and/or lactating, (2) had chronic health conditions interfering with their ability to follow the intervention protocol, or (3) presented with high levels of anxiety and/or depression, suicidal ideation or attempts during screening, a current diagnosis of a severe mental illness, or were undergoing specialist psychiatric treatment. The recruitment process was coordinated with selected primary healthcare centers (PHC) where the study took place. These centers were chosen following recommendations from the Ministry of Public Health \u0026ndash; department of Primary Healthcare \u0026ndash; based on their (1) capacity to reach the target population, (2) their provision of SRH services, and (3) their capacity to hold space for all intervention-related activities.\u003c/p\u003e\u003cp\u003e To identify potentially eligible participants, the research team, in coordination with the centers, prepared a list of PHC patients who may, most closely be potentially eligible, and proceeded with calling them and inviting them to participate in the study using an invitation script. Following baseline screening and data collection, participants were randomized into either EG or CG. Participants in the CG were waitlisted to receive the same information as the EG in a more concise format once all data collection activities were completed.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eBlinding\u003c/strong\u003e\u003cp\u003eTo minimize potential bias, the trial employed a blinded design in which data collectors and participants remained unaware of group allocation. Participants were not informed about the existence of the alternate study arm, ensuring that their responses and engagement were not influenced by knowledge of the study design. Similarly, data collectors were blinded to participants\u0026rsquo; group assignments to reduce measurement bias during data collection and analysis. That said, the implementation staff was aware of group allocation due to the nature of the study design.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003cp\u003eOnce participants were randomized into intervention arms, the EG were further divided into subgroups to participate in the intervention sessions. The intervention package was delivered at the selected PHCs, whereby each subgroups attended 1 session per week for eight consecutive weeks. Each session lasted approximately 90 minutes and covered various topics related to MH and SRH as delivered by trained paraprofessionals (also known as community health workers). Prior to the intervention, these paraprofessionals received a 20-day comprehensive training facilitated by a clinical psychologist and a midwife. The training equipped them with the necessary skills and knowledge to effectively deliver the intervention content in a standardized manner and to address any concerns or questions that may arise during the sessions.\u003c/p\u003e\u003cp\u003eImportantly, the intervention was carried out during a period of critical instability in Lebanon, that included active conflict. This ultimately disrupted the interventions in many ways by causing delays, higher than expected attrition, and other disruptions associated with implementation as described in a subsequent section below.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003cp\u003e The trial received ethical approval from the Institutional Review Board (IRB) at the American University of Beirut (AUB) and the World Health Organization (WHO) Ethical Review Committee. Informed consent was obtained from all participants after they were provided with detailed information regarding the study\u0026rsquo;s aims, participants\u0026rsquo; rights, and their ability to withdraw from the study at any time without affecting their access to PHC services or any other benefits they may have been entitled to. To uphold ethical standards, trained field coordinators supervised all procedures, ensuring protocol adherence and participant safety. An on-site psychologist addressed any session-related distress, and participants identified as potentially having mental health concerns received direct support or NGO referrals for more severe cases. All intervention materials were adapted to Arabic, and only female data collectors were trained and deployed to collect data to promote accessibility and comfort. All staff were rigorously trained in confidentiality, risk identification, and ethical data collection. Moreover, to guarantee anonymity, all personal identifiers were replaced with unique codes during data collection and analysis.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eProtocol Deviation\u003c/strong\u003e\u003cp\u003eGiven the displaced nature of the studied population, protocol deviations were anticipated and systematically recorded. These deviations included delays in intervention initiation, participant non-adherence, withdrawals, delayed or irregular attendance, cross-group attendance, where some participants attended sessions outside their assigned intervention group due to scheduling conflicts, and permanent group switches. The escalation of the conflict in Lebanon during the study period exacerbated these challenges, contributing to interruption in intervention delivery and increased participant displacement. To mitigate the impact of these deviations adaptive strategies were employed, including flexible session rescheduling, phone-based follow-ups, and increased participant incentives. No deviations compromised participant safety or primary outcome validity.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003cp\u003eAll analyses were conducted on the full intent-to-treat sample and evaluated based on improvements in mental health status between baseline and immediate post-intervention (T0\u0026ndash;T1), as well as between baseline and the 3-month follow-up (T0\u0026ndash;T2). The primary analysis compared the difference-in-differences between the intervention and control groups at each time point. Prior to this, baseline characteristics of the intervention and control groups were compared, in line with the original study design. This comparison was based on the homogeneity assumption\u0026mdash;that each participant\u0026rsquo;s outcome is a random draw from a common distribution, independent of study site. No violation of this assumption was expected, as participants were randomly allocated to intervention or control groups using a random generator, and consistent recruitment and randomization procedures were followed across both sites. Primary and secondary outcomes were defined as changes in women\u0026rsquo;s and psychosocial outcomes from T0 to T1 and from T0 to T2. To estimate marginal treatment effects, linear regression models were used to compare improvements in the intervention group relative to the control group at each time point. All models controlled for potential sociodemographic confounders including age, education, employment status, barriers to healthcare, and previous pregnancy experience. Additional variables that either differed significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) between groups at baseline or predicted outcome changes were also included as covariates. At T2, primary and secondary outcomes were analyzed excluding approximately 23% of the sample who were only assessed at T1. To address this missing data, mixed-effects linear models were deployed. Treatment effects were estimated using maximum likelihood mixed-effects regression models with robust variance estimators. All analyses controlled for participant sex, age, marital status, and disability, along with other baseline differences or predictors of outcome change (p\u0026thinsp;\u0026lt;\u0026thinsp;0.10). Analyses were conducted using Stata 18.0, with a 95% confidence level.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eBaseline Data\u003c/strong\u003e\u003cp\u003eA review of demographic characteristics in Table\u0026nbsp;2 identifies the baseline differences between the control and intervention group. A total of 267 women were enrolled, with 144 allocated to the control group and 123 to the intervention group. The two groups were broadly comparable across most baseline characteristics. The majority of participants in both groups had primary or intermediate education (Control: 84.7%, Intervention: 74.8%). Current employment was low in both groups, with only 9.7% of women in the control group and 20.3% in the intervention group reporting current work. Nearly all participants had been married once (95.8% in the control vs. 93.5% in the intervention group), and over 60% in both groups reported financial barriers and difficulties related to distance and safety when accessing health services. For instance, 67.1% of control participants and 61.8% of those in the intervention group cited financial difficulties, while 64.6% and 72.4%, respectively, reported not finding a suitable place to seek help.\u003c/p\u003e\u003cp\u003eSignificant baseline differences between both groups were found on two variables. Women in the intervention group were more likely to have previously been pregnant (86.9%) compared to those in the control group (76.4%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027). Additionally, baseline emotional regulation scores were significantly lower in the intervention group (mean\u0026thinsp;=\u0026thinsp;52.29\u0026thinsp;\u0026plusmn;\u0026thinsp;12.54) than in the control group (mean\u0026thinsp;=\u0026thinsp;55.68\u0026thinsp;\u0026plusmn;\u0026thinsp;12.62; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029). All other measures, including baseline well-being, self-efficacy, coping with stress, anxiety, depression, and social support, were not significantly different across groups.\u003c/p\u003e\u003cp\u003e[insert table 2]\u003c/p\u003e\u003c/p\u003e\u003ch2\u003e\u003cb\u003eTreatment Effects\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003ePrimary Outcomes\u003c/strong\u003e\u003cp\u003eTable\u0026nbsp;3 presents the estimated treatment effects on primary outcomes across the three assessment time points (T0, T1, and T2), using mixed-effects regression models adjusted for baseline scores. The primary outcomes were wellbeing and self-efficacy. Participants in the intervention group showed a statistically significant improvement in wellbeing scores compared to the control group. At baseline, the mean wellbeing score for the intervention group was 13.26\u0026thinsp;\u0026plusmn;\u0026thinsp;6.82, which increased to 16.43\u0026thinsp;\u0026plusmn;\u0026thinsp;5.88 at T1, while the control group's score slightly declined from 12.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.61 to 11.63\u0026thinsp;\u0026plusmn;\u0026thinsp;6.20. The intervention effect was significant at T1 (β\u0026thinsp;=\u0026thinsp;3.33, 95% CI: 1.52 to 5.25, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and remained significant at T2 (β\u0026thinsp;=\u0026thinsp;6.66, 95% CI: 2.44 to 15.78, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.035), with higher scores observed, indicating sustained and improved gains over time. Similarly, self-efficacy scores improved significantly in the intervention group at T1 (β\u0026thinsp;=\u0026thinsp;3.44, 95% CI: 1.78 to 5.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), rising from a baseline of 27.30\u0026thinsp;\u0026plusmn;\u0026thinsp;6.77 to 30.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.53. However, this effect diminished by T2 and was no longer statistically significant (β\u0026thinsp;=\u0026thinsp;1.42, 95% CI: \u0026minus;\u0026thinsp;0.40 to 3.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.127), suggesting the possibility of regression toward baseline levels post-intervention.\u003c/p\u003e\u003cp\u003e[Insert table 3]\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003cp\u003eAmong the secondary outcomes, coping with stress exhibited consistent and significant improvement. Mean scores in the intervention group increased from 19.83\u0026thinsp;\u0026plusmn;\u0026thinsp;6.23 at baseline to 22.60\u0026thinsp;\u0026plusmn;\u0026thinsp;5.13 at T1, compared to a modest change in the control group (20.77\u0026thinsp;\u0026plusmn;\u0026thinsp;6.04 to 20.42\u0026thinsp;\u0026plusmn;\u0026thinsp;5.22). The corresponding effect estimates were statistically significant at both T1 (β\u0026thinsp;=\u0026thinsp;3.28, 95% CI: 1.60 to 4.96, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and T2 (β\u0026thinsp;=\u0026thinsp;2.82, 95% CI: 0.73 to 4.90, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008). Social support also improved following the intervention, with scores increasing from 59.30\u0026thinsp;\u0026plusmn;\u0026thinsp;11.08 at baseline to 66.80\u0026thinsp;\u0026plusmn;\u0026thinsp;11.95 at T1. The control group remained relatively stable. The intervention yielded a significant effect at T1 (β\u0026thinsp;=\u0026thinsp;3.82, 95% CI: 0.59 to 7.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.020), and this improvement was sustained at T2 (β\u0026thinsp;=\u0026thinsp;4.39, 95% CI: 0.68 to 8.10, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021). For anxiety and depression, no statistically significant differences were observed between groups. Anxiety scores in the intervention group changed minimally (from 2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71 to 2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74), with nonsignificant effect estimates at both T1 (β\u0026thinsp;=\u0026thinsp;0.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.810) and T2 (β = \u0026minus;\u0026thinsp;0.03, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.745). Depression scores also remained stable, with no meaningful difference observed across time points. Emotional regulation showed an upward trend in raw scores in the intervention group (52.29\u0026thinsp;\u0026plusmn;\u0026thinsp;12.54 at T0 to 63.29\u0026thinsp;\u0026plusmn;\u0026thinsp;29.06 at T2), however the associated treatment effects were not statistically significant at either T1 or T2, likely due to large within-group variability.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSensitivity Analysis\u003c/strong\u003e\u003cp\u003eTable\u0026nbsp;4 presents the results of linear mixed-effects models with random intercepts for participants. The interaction terms between time and group were examined to assess whether the intervention effect differed across time between the intervention and control groups. Results indicated that the intervention led to significant improvements in wellbeing, coping with stress, and social support over time. For the primary outcomes, the interaction between time and group was significant for wellbeing (β\u0026thinsp;=\u0026thinsp;0.681, 95% CI: 0.343\u0026ndash;1.705, p\u0026thinsp;=\u0026thinsp;0.019), indicating that changes in wellbeing over time differed between with greater improvements observed in the intervention group. For the secondary outcomes, a significant interaction was observed for coping with stress (β\u0026thinsp;=\u0026thinsp;1.651, 95% CI: 0.741\u0026ndash;2.561, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), showing that coping with stress improved more in the intervention group compared with the control group over time. Similarly, for social support, the interaction effect was significant (β\u0026thinsp;=\u0026thinsp;2.211, 95% CI: 0.551\u0026ndash;3.871, p\u0026thinsp;=\u0026thinsp;0.009), suggesting that participants in the intervention group reported greater increases in social support across time compared to controls.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003cp\u003eThis study is the first to assess the MHPSS and wellbeing outcomes associated with the SEEK intervention at 3 time points. At the time of intervention delivery, this period coincided with the 2024 conflict that had severe impacts on several areas in Lebanon, one of which was the Beqaa where the intervention package was delivered. Although the conflict had detrimental impact on the country and especially on vulnerable groups, and while the implementation team faced several challenges to maintain delivery of the intervention, the latter was still successfully completed with some adjustments to the methodology.\u003c/p\u003e\u003cp\u003eThat said, and while mindfully acknowledging the inevitable impacts of the conflict as an extraneous variable when assessing outcomes related to the intervention effects, in general, multivariate analyses suggest that the intervention was largely effective in improving psychosocial and wellbeing outcomes although no improvements were observed in relation to mental health outcomes.\u003c/p\u003e\u003cp\u003eFor instance, results showed significant improvements in overall wellbeing among the experimental group when compared to the control group that were sustained at endline and 3 months after the intervention. Wellbeing, as defined by the Center for Disease Control and Prevention (CDC), involves experiencing positive emotions, absence of negative feelings, and having a sense of satisfaction with life, fulfillment, and effective functioning (61). It is possible that due to the intervention\u0026rsquo;s content being focused on delivering practical and real-world applications, and its delivery format being community-driven and led by paraprofessionals who share similar cultural backgrounds, SEEK had important impacts on attending participants. Evidence shows that community-based interventions have been found to be effective in enhancing wellbeing and individual\u0026rsquo;s willingness to seek or accept support (62). When communities are engaged as resources, and to some extent, as facilitators, interventions become more culturally acceptable and relevant (63). For instance, a classroom-based intervention implemented in a conflict-affected setting showed improvements in social behavior and positive elements of wellbeing, when delivered by trained community members (64). Likewise, a randomized controlled trial in Zimbabwe found that adolescents receiving support from community adolescent treatment supporters (CATS) showed significantly greater improvements in confidence, self-esteem, and quality of life compared to those received standard care (65).\u003c/p\u003e\u003cp\u003eSimilarly, study findings showed significant improvements in self-efficacy to manage problems, however this was only the case at endline, whereby 3-months post intervention this difference between experimental and control groups was not significant. This suggests that self-efficacy may require additional booster sessions for practices, and guidance to be sustained. As self-efficacy is known to develop through social learning and continues to evolve as individuals acquire new skills, experiences, and understanding over the course of their lives (80, 81), sustaining it likely requires ongoing support. Bandura identifies four primary sources through which self-efficacy beliefs are shaped: mastery experience, vicarious learning through observing others, social persuasion, and the interpretation of emotional and physiological states (82). Consistent with this, recent evidence highlights that structured training and education strengthen general self-efficacy (83), and more coaching sessions was associated with greater improvements (84). Sustaining this gain requires continuous practice, progress monitoring, and periodic goal adjustment (85, 86)\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eOn the other hand, SEEK significantly improved participants\u0026rsquo; skills to cope with challenging situations, and their perceived social support, by the end of the intervention and 3 months after the intervention.\u003c/strong\u003e\u003cp\u003e It may be that SEEK provided a safe space for participants to explore and discuss their thoughts and feelings, which may have improved their sense of belonging to a support system of peers and experts. All throughout, participants were encouraged to share experiences and to learn from each other, which likely strengthened interpersonal bonds and facilitated peer-exchange. Our finding that communication skills also improved significantly as a result of this intervention further supports and complements these results as communication skills as key to facilitate building and maintaining stronger relationships. Evidence consistently highlights the critical role of social support during crisis (66, 67). As Drury et al. note, people have always turned to one another for emotional and practical support in emergencies (68). Social support helps mitigate stress and promote trauma recovery by fostering cognitive restructuring and reinforcing coping mechanisms (69, 70). Additionally, peer-based initiatives, reduce stigma, offer culturally grounded support, and improve distress management (71, 72). These dynamics are importantly relevant for adolescents, who are more likely to seek helps from peers than professionals, and are responsive to peer influence (73, 74). Shared group experiences and collective identity further enhance comfort, resilience and the ability to manage adversity effectively (75\u0026ndash;79). Importantly, improvements were sustained over time despite on-going conflict, and this suggests that coping skills can be learned through this community-based intervention, and potentially to last over time. Similarly, 3-months post intervention sustained improvements in perceived social support also suggest that networks and peer support developed by participants during the intervention may last beyond the duration of the intervention.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eLimitation\u003c/h2\u003e\u003cp\u003eResults of this study should be interpreted in light of several limitations. Most importantly, outcomes examined may have been significantly impacted by the 2024 conflict in Lebanon, as implementation coincided with active conflict. Ultimately it may be difficult to isolate the effects of SEEK from this broader contextual challenge impacting participants mental health and wellbeing. Should that not have been the case, we may have observed changes in mental health outcomes for example, however in this study we did not. Second, as this is the first pilot implementation of SEEK in a humanitarian setting, it is unclear the extent to which results are sustainable over a longer period of time, especially since our follow-up was limited to 3 months post intervention. Sustained impact may require longer follow-up periods. Third, our sample was limited to two PHCs in one geographical area in Lebanon which may limit external validity of study findings. Nevertheless, Syrian refugee populations are largely homogenous in Lebanon.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cp\u003eIn conclusion, the SEEK intervention package, based on initial evidence from this community-based trial regarding its effectiveness, improves wellbeing, self-efficacy, coping, communication skills, and perceived social support among refugee women and girls during times of active conflict. However, while wellbeing, coping, and perceived social support improvements were sustained over time, this was not the case for self-efficacy which may require additional efforts to be sustained beyond the period of intervention delivery. That said, SEEK was found to not cause any changes in mental health outcomes such as anxiety, depression, and emotional regulation. Further research is needed to better establish the effectiveness of SEEK on mental health outcomes by examining its impact in a humanitarian context not experiencing active conflict.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003e5. Funding:\u003c/h2\u003e\u003cp\u003eThis work received funding from Elhrha and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSS, HN, AED, VG, and LS conceived the study; HN, AED, and ZC drafted the manuscript. ZC and HT led on data management. HN, VG, AED, and ZC led on data analysis. FF, LS, SS, GHA, TB, supported in interpretation of the results and wrote different sections of the manuscript. All authors critically reviewed and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003e7. Acknowledgments:\u003c/h2\u003e\u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTol WA, Ager A, Bizouerne C, Bryant R, El Chammay R, Colebunders R, et al. Improving mental health and psychosocial wellbeing in humanitarian settings: reflections on research funded through R2HC. Conflict and Health. 2020;14(1):71.\u003c/li\u003e\n\u003cli\u003eVentevogel P, Ommeren Mv, Schilperoord M, Saxena S. Improving mental health care in humanitarian emergencies. SciELO Public Health; 2015. p. 666-.\u003c/li\u003e\n\u003cli\u003eIsmail SA, McDonald A, Dubois E, Aljohani FG, Coutts AP, Majeed A, et al. Assessing the state of health research in the Eastern Mediterranean Region. 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BMC psychology. 2023;11(1):72.\u003c/li\u003e\n\u003cli\u003eAl Beainy S. Coping Strategies and Personal Growth: The Case of Palestinian Refugees in Shatila Camp, Lebanon 2022.\u003c/li\u003e\n\u003cli\u003eChutiyami M, Cheong AM, Salihu D, Bello UM, Ndwiga D, Maharaj R, et al. COVID-19 pandemic and overall mental health of healthcare professionals globally: a meta-review of systematic reviews. Frontiers in psychiatry. 2022;12:804525.\u003c/li\u003e\n\u003cli\u003eAl-Tamimi SAGA, Leavey G. Community-Based Interventions for the Treatment and Management of Conflict-Related Trauma in Low-Middle Income, Conflict-Affected Countries: a Realist Review. Journal of Child \u0026amp; Adolescent Trauma. 2022;15(2):441-50.\u003c/li\u003e\n\u003cli\u003eJoshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. Task shifting for non-communicable disease management in low and middle income countries\u0026ndash;a systematic review. PloS one. 2014;9(8):e103754.\u003c/li\u003e\n\u003cli\u003eJordans MJ, Komproe IH, Tol WA, Kohrt BA, Luitel NP, Macy RD, et al. Evaluation of a classroom‐based psychosocial intervention in conflict‐affected Nepal: A cluster randomized controlled trial. Journal of Child Psychology and Psychiatry. 2010;51(7):818-26.\u003c/li\u003e\n\u003cli\u003eWillis N, Milanzi A, Mawodzeke M, Dziwa C, Armstrong A, Yekeye I, et al. Effectiveness of community adolescent treatment supporters (CATS) interventions in improving linkage and retention in care, adherence to ART and psychosocial well-being: a randomised trial among adolescents living with HIV in rural Zimbabwe. BMC Public Health. 2019;19(1):117.\u003c/li\u003e\n\u003cli\u003eAkkermans J, Seibert SE, Mol ST. Tales of the unexpected: Integrating career shocks in the contemporary careers literature. SA Journal of Industrial Psychology. 2018;44(1):1-10.\u003c/li\u003e\n\u003cli\u003ePiankivska L. Social Support of the Individual in War Conditions: Ukrainian and International Experience. 2022;8:76-84.\u003c/li\u003e\n\u003cli\u003eDrury J, Carter H, Cocking C, Ntontis E, Tekin Guven S, Aml\u0026ocirc;t R. Facilitating Collective Psychosocial Resilience in the Public in Emergencies: Twelve Recommendations Based on the Social Identity Approach. Front Public Health. 2019;7:141.\u003c/li\u003e\n\u003cli\u003eSchwarzer R. Stress, resilience, and coping resources in the context of war, terror, and migration. Current Opinion in Behavioral Sciences. 2024;57:101393.\u003c/li\u003e\n\u003cli\u003eOzbay F, Johnson DC, Dimoulas E, Morgan CA, Charney D, Southwick S. Social support and resilience to stress: from neurobiology to clinical practice. Psychiatry (Edgmont). 2007;4(5):35-40.\u003c/li\u003e\n\u003cli\u003eAqtam I. A narrative review of mental health and psychosocial impact of the war in Gaza. Eastern Mediterranean Health Journal. 2025;31(2).\u003c/li\u003e\n\u003cli\u003eUNESCO. UNESCO is providing mental health and psychosocial support to children in the Gaza Strip. 2024.\u003c/li\u003e\n\u003cli\u003eDodd S, Widnall E, Russell AE, Curtin EL, Simmonds R, Limmer M, et al. School-based peer education interventions to improve health: a global systematic review of effectiveness. BMC Public Health. 2022;22(1):2247.\u003c/li\u003e\n\u003cli\u003eBlakemore S-J, Robbins TW. Decision-making in the adolescent brain. Nature neuroscience. 2012;15(9):1184-91.\u003c/li\u003e\n\u003cli\u003eBreustedt S, Puckering C. A qualitative evaluation of women\u0026apos;s experiences of the Mellow Bumps antenatal intervention. British Journal of Midwifery. 2013;21(3):187-94.\u003c/li\u003e\n\u003cli\u003eDunn C, Hanieh E, Roberts R, Powrie R. Mindful pregnancy and childbirth: effects of a mindfulness-based intervention on women\u0026rsquo;s psychological distress and well-being in the perinatal period. Archives of women\u0026apos;s mental health. 2012;15:139-43.\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association A, Association AP. Diagnostic and statistical manual of mental disorders: DSM-IV: American psychiatric association Washington, DC; 1994.\u003c/li\u003e\n\u003cli\u003eFrenzel SB, Junker NM, H\u0026auml;usser JA, Erkens VA, van Dick R. Team identification relates to lower burnout-Emotional and instrumental support as two different social cure mechanisms. Br J Soc Psychol. 2023;62(2):673-91.\u003c/li\u003e\n\u003cli\u003eTill FJ, Heimrich J, Frenzel SB, van Dick R, Mojzisch A, Junker NM, et al. Social Identification in Times of Crisis: How Need to Belong, Perspective Taking, and Cognitive Closure Relate to Changes in Social Identification. Journal of Applied Social Psychology. 2025;55(1):38-51.\u003c/li\u003e\n\u003cli\u003eBandura A. Social foundations of thought and action. Englewood Cliffs, NJ. 1986;1986(23-28):2.\u003c/li\u003e\n\u003cli\u003eBandura A. Exercise of personal and collective efficacy in changing societies. Self-efficacy in changing societies. 1995;15:334.\u003c/li\u003e\n\u003cli\u003eBandura A, Wessels S. Self-efficacy: Cambridge University Press Cambridge; 1997.\u003c/li\u003e\n\u003cli\u003eArghode V, Heminger S, McLean GN. Career self-efficacy and education abroad: Implications for future global workforce. European Journal of Training and Development. 2021;45(1):1-13.\u003c/li\u003e\n\u003cli\u003eBaron L, Morin L. The impact of executive coaching on self-efficacy related to management soft-skills. Leadership \u0026amp; Organization Development Journal. 2010;31:18-38.\u003c/li\u003e\n\u003cli\u003eAbraham C, Michie S. A taxonomy of behavior change techniques used in interventions. Health psychology. 2008;27(3):379.\u003c/li\u003e\n\u003cli\u003ePrestwich A, Kellar I, Parker R, MacRae S, Learmonth M, Sykes B, et al. How can self-efficacy be increased? Meta-analysis of dietary interventions. Health psychology review. 2014;8(3):270-85.\u003c/li\u003e\n\u003cli\u003eBass J, Poudyal B, Tol W, Murray L, Nadison M, Bolton P. A controlled trial of problem-solving counseling for war-affected adults in Aceh, Indonesia. Soc Psychiatry Psychiatr Epidemiol. 2012;47(2):279-91.\u003c/li\u003e\n\u003cli\u003eSalo J, Punam\u0026auml;ki R-L, Qouta S, Sarraj E. Individual and Group Treatment and Self and Other Representations Predicting Posttraumatic Recovery Among Former Political Prisoners. Traumatology. 2008;14:45-61.\u003c/li\u003e\n\u003cli\u003eNeuner F, Schauer M, Klaschik C, Karunakara U, Elbert T. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement. J Consult Clin Psychol. 2004;72(4):579-87.\u003c/li\u003e\n\u003cli\u003eBass J, Murray SM, Mohammed TA, Bunn M, Gorman W, Ahmed AM, et al. A Randomized Controlled Trial of a Trauma-Informed Support, Skills, and Psychoeducation Intervention for Survivors of Torture and Related Trauma in Kurdistan, Northern Iraq. Glob Health Sci Pract. 2016;4(3):452-66.\u003c/li\u003e\n\u003cli\u003eGayer M, Legros D, Formenty P, Connolly MA. Conflict and emerging infectious diseases. Emerging infectious diseases. 2007;13(11):1625.\u003c/li\u003e\n\u003cli\u003eWessells M. A reflection on the strengths and limits of a public health approach to mental health in humanitarian settings. Epidemiol Psychiatr Sci. 2015;24(6):495-7.\u003c/li\u003e\n\u003cli\u003eBruhn M, Laugesen H, Kromann-Larsen M, Trevino CS, Eplov L, Hjorth\u0026oslash;j C, et al. The effect of an integrated care intervention of multidisciplinary mental health treatment and employment services for trauma-affected refugees: study protocol for a randomised controlled trial. Trials. 2022;23(1):859.\u003c/li\u003e\n\u003cli\u003eVan Ommeren M, Morris J, Saxena S. Social and clinical interventions after conflict or other large disaster. American journal of preventive medicine. 2008;35(3):284-6.\u003c/li\u003e\n\u003cli\u003eNeuner F. Assisting war-torn populations\u0026ndash;Should we prioritize reducing daily stressors to improve mental health? Comment on Miller and Rasmussen (2010). Social Science \u0026amp; Medicine. 2010;71(8):1381-4.\u003c/li\u003e\n\u003cli\u003eMiller KE, Rasmussen A. Mental health and armed conflict: the importance of distinguishing between war exposure and other sources of adversity: a response to Neuner. Soc Sci Med. 2010;71(8):1385-9.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Overview of Data Collection Tools\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTool Name\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCronbach\u0026rsquo;s Alpha\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Questions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValidated in Arabic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore Interpretation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWHO-5 Wellbeing\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eEnglish Version: 0.858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e5 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eYes (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eThe higher the better improvement.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eArabic Version: 0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHopkins Symptom Checklist-25 (HSCL-25)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eEnglish\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eAnxiety 0.84\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e10 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eYes (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eThe higher the worsening situation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eArabic\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eAnxiety 0.85\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHopkins Symptom Checklist-25 (HSCL-25)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eEnglish 0.92\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e15 questions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eThe higher the worsening situation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eArabic\u0026nbsp;0.88\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral Self-Efficacy Scale\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eEnglish: 0.76 to 0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e10 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eYes (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eThe higher the better improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eArabic: 0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultidimensional Scale of Perceived Social Support for Arab Women\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eEnglish\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eFamily 0.87\u003c/li\u003e\n \u003cli\u003eFriends 0.85\u003c/li\u003e\n \u003cli\u003eSignificant other 0.91\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eArabic\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eFamily 0.82\u003c/li\u003e\n \u003cli\u003eFriends 0.86\u003c/li\u003e\n \u003cli\u003eSignificant other 0.85\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e12 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eYes (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eThe higher the better improvement.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe Difficulties in Emotion Regulation Scale Short Form \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(DERS-SF)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eEnglish: 0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e18 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eYes (59)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eThe higher the worsening situation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eArabic: 0.71 to 0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRevised Ways of Coping Checklist\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eEnglish\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026nbsp;0.68\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eArabic\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e0.67\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e12 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eYes (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eThe higher the better improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Baseline Demographic Differences across the Control and Experimental G\u003c/strong\u003e\u003cstrong\u003eroups\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=267)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 390px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%) or mean\u0026plusmn; sd\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=144\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperimental\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%) or mean\u0026plusmn; sd\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=123\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cem\u003eIlliterate\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e14 (9.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e22 (17.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cem\u003ePrimary\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e74 (51.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e58 (47.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cem\u003eIntermediate\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e48 (33.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e34 (27.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cem\u003eSecondary and higher\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e8 (5.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e9 (7.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork Currently\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e14 (9.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e25 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarriage Times\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cem\u003eOne time\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e138 (95.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e115 (93.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.391\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers to Healthcare\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePermission to go to PHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e61 (42.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e55 (44.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.699\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinancial Barrier\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e96 (67.1 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e76 (61.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.363\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistance for HC Facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e89 (61.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e73 (59.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.682\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDidn\u0026rsquo;t find Place to go\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e93 (64.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e89 (72.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDon\u0026rsquo;t want to go alone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e91 (63.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e81 (65.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.651\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThere is no female doctor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e62(43.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e55(44.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.785\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEver Pregnant\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e110 (76.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e107 (86.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.027*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent Use of Family Planning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e55 (38.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e51 (41.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.586\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Well Being Status\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e12.06\u0026plusmn; 6.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e13.26\u0026plusmn; 6.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Self-Efficacy \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e25.90\u0026plusmn; 6.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e27.30\u0026plusmn; 6.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Coping with Stress\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e20.77\u0026plusmn; 6.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e19.83\u0026plusmn; 6.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Anxiety Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.55\u0026plusmn;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e2.63\u0026plusmn; 0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.194\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Depression Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.80\u0026plusmn;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e2.81\u0026plusmn;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.957\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Emotional Regulation \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e55.68\u0026plusmn;12.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e52.29\u0026plusmn; 12.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.029*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Social Support\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e60.11\u0026plusmn;11.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e59.30\u0026plusmn;11.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.563\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"768\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" style=\"width: 768px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Changes in mental health and psychosocial support outcomes for experimental group compared with control group.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperimental\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eUnadjusted\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAdjusted\u0026para;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBetta\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBetta\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMental Health Outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWellbeing\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT0\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e12.06\u0026plusmn; 6.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e13.26\u0026plusmn; 6.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT1(n=267)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e11.63\u0026plusmn; 6.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e16.43\u0026plusmn; 5.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e3.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(1.36, 5.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e(1.52,5.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT2(n=215)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e10.78\u0026plusmn; 7.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e13.13\u0026plusmn; 6.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e7.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(1.68,16.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(2.44,15.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.035*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-efficacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT0\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e25.90\u0026plusmn; 6.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e27.30\u0026plusmn; 6.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e25.62\u0026plusmn; 6.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e30.10\u0026plusmn; 5.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e3.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(1.72, 5.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(1.78, 5.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e25.86\u0026plusmn; 6.07\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e28.43\u0026plusmn; 5.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(-0.99,2.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.380\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(-.40;3.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoping with stress\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT0\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e20.77\u0026plusmn; 6.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e19.83\u0026plusmn; 6.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e20.42\u0026plusmn; 5.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e22.60\u0026plusmn; 5.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e3.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(1.72,5.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(1.60,4.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e17.06\u0026plusmn;5.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e19.65\u0026plusmn;5.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e2.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(0.78,4.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(0.73,4.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.008*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT0\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e44.53\u0026plusmn;10.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e44.86\u0026plusmn;10.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e47.41\u0026plusmn;11.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e44.94\u0026plusmn;11.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-2.471\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(-5.62,0.677)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e-2.469\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(-5.714,0.776)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e56.70\u0026plusmn; 9.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e60.73\u0026plusmn;11.775\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e4.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(1.194,6.865)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.006*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(1.611,7.356)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAnxiety\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT0\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2.55\u0026plusmn;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e2.63\u0026plusmn; 0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2.47\u0026plusmn;0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e2.56\u0026plusmn;0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(-1.76,2.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.841\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(-1.73, 2.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.810\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2.71\u0026plusmn;0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e2.61\u0026plusmn;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(-.25,0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.819\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e-0,03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e( -0.27,0.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.745\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDepression\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT0\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2.80\u0026plusmn;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e2.81\u0026plusmn;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2.76\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e2.70\u0026plusmn;0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(-3.73,1.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e-0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(-3.64,1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2.85\u0026plusmn;060\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e2.85+0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(-.18,0.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.987\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e-0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(-.18,0.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.987\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmotional Regulation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT0\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e55.68\u0026plusmn;12.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e52.29\u0026plusmn; 12.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e50.22\u0026plusmn;11.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e48.17\u0026plusmn;11.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(-1.71,4.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.334\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e( -1.89,4.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.397\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e67.29\u0026plusmn;34.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e63.29\u0026plusmn;29.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(-9.23,7.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.841\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e( -8.43,8.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocial Support\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT0\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e60.11\u0026plusmn;11.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e59.30\u0026plusmn;11.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eRef:Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e63.40\u0026plusmn;12.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e66.80\u0026plusmn;11.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e4.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(1.20,7.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.008*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(0.59,7.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.020*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eT2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e66.68\u0026plusmn;12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e66.62\u0026plusmn;10.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e4.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(0.53,7.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.025*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e(0.68,8.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.021*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 768px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*Sig. at 0.05,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026para;. adjusted for possible confounders including age, education , working status , barriers to health care , and previous experience of pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 499px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4. Linear Mixed Effect Models of Mental Health and Wellbeing Outcomes (n=267)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eadjusted\u0026beta; (SE)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWellbeing\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime x Group: Intervention\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.681(.289)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(0.102 1.372)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.019*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-Efficacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime x Group: Intervention\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0.574(.431)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e(-.272, 1.420)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e0.184\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoping with Stress\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime x Group: Intervention\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e1.651(.464)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e(0.741 2.561)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime x Group: Intervention\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-0.061(.652)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(-1.340 1.217)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.925\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime x Group: Intervention\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-.006(0.050)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(-.106 .093)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional Regulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime x Group: Intervention\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0.196(1.704)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e(-3.113 1.537)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime x Group: Intervention\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e1.852(1.079)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e(-.2630,3.967)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial Support\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime x Group: Intervention\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e2.211(.846)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(0.551 3.871)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.009*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 499px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted for possible confounders including age, education, working status, barriers to health care, and previous experience of pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Trial, mental health, psychosocial support, conflict, refugees, women and girls ","lastPublishedDoi":"10.21203/rs.3.rs-7684112/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7684112/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Adolescent girls and young women (AGYW) affected by forced displacement are at high risk of poorer mental health and psychosocial wellbeing due to intersecting stressors. In humanitarian contexts like Lebanon, mental health challenges are exacerbated by protracted crises, including the 2024 war. In response to such challenges, the World Health Organization developed the Self-Efficacy and Knowledge (SEEK) package which is a low-resource, low-intensity community-based intervention designed to improve wellbeing and sexual reproductive health in an integrated manner. This study evaluates the effectiveness of SEEK in improving mental health and psychosocial outcomes among Syrian AGYW refugees in Lebanon.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A single-blinded randomized controlled trial was conducted with 267 Syrian AGYW (15–24 years old), randomly assigned to intervention or waitlisted control groups. The intervention comprised eight weekly sessions covering various topics including SRH, emotional regulation, problem-solving among others, delivered at two primary healthcare centers. Outcomes were assessed at baseline (T0), immediately post-intervention (T1), and three months post-intervention (T2), using validated tools to measure wellbeing (WHO-5), self-efficacy (GSES), coping (RWCCL), social support (MSPSS-AW), Interpersonal Communication Competency Skills (ICCS), anxiety and depression (HSCL-25), and emotional regulation (DERS-SF).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Participants in the intervention group experienced significant improvements in wellbeing (T1: β=3.33, p\u0026lt;0.001; T2: β=6.66, p=0.035), self-efficacy at only T1 (β=3.44, p\u0026lt;0.001), coping (T1: β=3.28, p\u0026lt;0.01; T2: β=2.82, p\u0026lt;0.01), communication skills only at T2 (β=4.48, p\u0026lt;0.01) and perceived social support (T1: β=3.82, p=0.020; T2: β=4.39, p=0.021). No statistically significant improvements were found for anxiety, depression, or emotional regulation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e SEEK demonstrated effectiveness in enhancing wellbeing, self-efficacy, coping, and communication skills, and social support among Syrian AGYW during a period of active conflict, but did not significantly impact anxiety, depression, or emotional regulation. These findings support the potential of integrated community-based approaches in humanitarian settings, while highlighting the need for further research under more stable conditions to evaluate effects on clinical mental health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e: Clinical Trial Number NCT07008950 initial release on February 28th 2025 and last release on June 5th 2025 with the clinical trial registry at National Institute of Health (NIH) protocol registration system.\u003c/p\u003e","manuscriptTitle":"Evaluating Mental Health and Psychosocial Support Outcomes of the Self-Efficacy and Knowledge (SEEK) Community-Based Randomized Controlled Trial in Lebanon During Active Conflict","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 12:09:38","doi":"10.21203/rs.3.rs-7684112/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-06T21:01:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25555467459552842480434565663969685153","date":"2026-02-17T15:22:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T11:40:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-24T05:35:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-24T05:33:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Conflict and Health","date":"2025-09-22T11:49:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7a3170e-2dcb-4114-b03f-d021863c84e3","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-08T12:09:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 12:09:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7684112","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7684112","identity":"rs-7684112","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}