Of 15 potential trainees, 10 were recruited into the training from the community center, identified by the chairperson. Of the five who were not, one was excluded due to misunderstanding what the training was for, and was looking to improve their English proficiency only, two were excluded due to suffering their own mental health issues, and two were unable to commit to the time to complete the training due to child care. Those who were recruited into the training were assessed with the same measures used throughout the study, to ascertain that there were no current symptoms of PTSD, depression or trauma.
All trainees were Sudanese refugees who attended the same community center, and all were bilingual, speaking both English and Sudanese Arabic proficiently. The trainees all identified as Christian, from the Nuba mountains in the Kordofan region, straddling the North and South Sudan political lines. Of the ten trainees, three were female and seven were male, aged between 26 and 42 years old. All were employed, three as teachers, two as janitors, two as waiters, one as a translator, and two as home help. None had any background working in mental health or counseling professions.
Adult Sudanese refugees were recruited by word of mouth, community meetings, and posters advertising the free therapy, which was to be provided at the community center in a private room and confidentially. Twelve people underwent initial screening, five of whom did not meet inclusion criterion of meeting DSM-V criteria for PTSD, as assessed by the researcher, a clinical psychologist in during clinical interview. One of the excluded participants displayed symptoms of psychosis (and was referred to appropriate psychiatric care), another was heavily using substances, to the extent that it was felt that therapy would not be possible, and a further three did not meet PTSD criteria according to DSM-V.
The final study sample consisted of five female and two male Sudanese refugees from the same area as the trainees. All of the participants identified as Christian, four as employed and three as unemployed. Three of the participants were widowed, one married, and three identified as single. The age of the participants ranged from 28 to 39 years old, with a mean age of 31.
This pilot study adopted a pre-post design, in which measures of PTSD, depression, and anxiety were taken before and after participants received NET, delivered by lay counselors. A focus group was also held about 6 months after the intervention ended.
All training materials, including the instructions and examples for Narrative exposure therapy (with permission from the authors), the measures and consent, and information sheets, were translated and provided in both Sudanese Arabic and English. All translations were back translated by a second bilingual native Sudanese Arabic and English speaker, similarly trained to work in psychosocial services in order to ensure correct understanding of psychological and therapeutic terminology. Prior to translation, a focus group was carried out among members of the Sudanese community group to ascertain the adaptability and appropriateness of the NET materials, as well as the assessment materials, for use among this population. To date, there are no standardized versions of any of the materials in Sudanese Arabic.
Lay counselor training
The training was planned to take part in the evenings of weekdays at the community center to accommodate the work schedules of the trainees (as well as the PI and translator). The original plan was that training would be carried out from 6 to 9 pm, three times a week, over a 3-week period. However, due to a large number of scheduling problems, the training took place over 2 months. Many of the trainees were delayed for the training sessions due to three main reasons, work commitments taking longer than expected, traffic in Cairo, issues relating to their refugee status, and, particularly for the female trainees, child care. The training followed a group format and so training started only when all trainees arrived. It was delivered in English by the first author and simultaneously in Sudanese Arabic by the project translator, who was a professionally trained Sudanese refugee who had received training as an interpreter specialized in psychosocial services through a training institute in Cairo and had been recommended to assist with the project due to his experience in the field.
After training, the lay counselors provided NET to clients under weekly supervision by the first author.
Sudan is part of the Middle East North African region (MENA), and the predominant language is Arabic. A review of 22 psychosocial and mental health treatment studies in the Middle East by Gearing et al.  identified 85% more barriers than levers to treatment efficacy. They summarized that successful treatments must consider the following nine issues: lack of awareness, gender issues, stigma, poor language competency of caregivers, financial barriers, lack of transportation, diagnosis/treatment misunderstanding, medical versus traditional models, and a mistrust of mental health services. The current study aimed to consider all of these issues when adapting the NET model and the assessments used, both linguistically and culturally. This process was aided by consulting about the study and intervention with a focus group of local community members, both male and female ranging between the ages of 23 and 52 years old.
NET by nature is a treatment developed for use with refugees and has predominantly been used in similar geographical areas. However, there were some phrases and concepts that needed to be changed to make sense linguistically and culturally. All those who took part in the study were Christians from the Moro Nuba tribe of South Sudan, reducing the need to consider sub cultures within the group, as advised by Gearing et al. . The female members of the focus group all mentioned the issue of gender-based violence and so it was agreed that there should be a mix of lay counselors in terms of gender and that females should be seen by female counselors only.
The issue of stigma and awareness was raised not only during the focus group but during the community group meetings, and in discussions with the community group leaders. The stigma around seeking psychological support at a professional clinic was raised frequently, as well as a lack of accessibility for psychological support for the community within Cairo; NET was deemed by all in discussions as an acceptable intervention that may address both of these issues.
One of the most significant barriers that NET delivered by lay counselors in this population can overcome is the financial barrier to accessing services; this is particularly relevant to any refugee residing in Cairo, where there is an absolute lack of services freely available. Furthermore, by delivering the intervention within local community centers, through fellow refugees who speak with the same mother tongue, the key informants felt that the intervention would be more appealing, appropriate and accepted by the local population. This was also thought to be another benefit of such an intervention being delivered in such a way, in resolving the issue of lack of transportation.
The NET delivered in this study followed the protocol of Neuner et al. [17, 18]. Each participant was assisted by the lay counselor to construct a chronological narrative of his or her life, focusing on the traumatic events in particular. After the initial screening, those who met criteria for PTSD were invited to take part in the intervention. Participants completed the Vivo Event Checklist for War, Detention and Torture experiences , and were oriented to the intervention. which involved attending for sessions once a week for a period of 6 weeks. The intervention began with the individual and the counselor creating a time line, using materials such as rope to signify the lifeline, rocks to represent bad events, and flowers to represent good ones. The participant was asked to fill the timeline as much as possible and also to include their hopes for the next years to come. Fragmented traumatic memories were integrated into a coherent narrative and the counselors used techniques including active listening, empathy, congruency, and unconditional positive regard, to enable the participant to explore in depth the experiences they had survived. The was focus was not just on a single traumatic event, but rather could encompass as much of the lifespan as seemed helpful. At the end of the intervention, each participant was given their written biography. For those who were unable to read, a recording was offered during the last session (this was either on their mobile phone or of a trusted loved one).
All the measures were translated into Sudanese Arabic and the translation was checked and back translated into English by professional native bi-lingual Sudanese/English speakers who had received further training in providing translation for psychosocial interventions. Where appropriate, the internal consistency of the translated versions was checked using Cronbach’s alpha.
Vivo Event Checklist for War, Detention, and Torture experiences
The Vivo Event Checklist for War, Detention, and Torture experiences  was used to assess experiences of organized violence at baseline. The measure is a 45-item questionnaire requiring yes or no answers as to whether an event has been experienced. Where events are answered positively, details are requested. This measure was only given at baseline.
Screen for Post-Traumatic Stress Symptoms
The Screen for Post-Traumatic Stress Symptoms (SPTSS)  is a 17-item brief self-report screen, which is not based on a single-reported trauma model, was employed to identify individuals who may be suffering from high levels of PTSD. This measure was chosen as more appropriate for individuals who have likely experienced multiple (and ongoing) traumas. While not a diagnostic tool, the items in the SPTSS closely mirror the criteria for PTSD in the DSM-IV. Items are written in a way to aid appropriateness for a wide range of populations, using colloquial language and simple terms. Scored on an 11-point (0-10) scale using a two-week time frame, the scale is scored using the mean of all items, thus the range of scores is from 0 to 10. In a validation study by Caspi et al. , normative data for clinical populations diagnosed with PTSD indicated a mean of 7.41, with a standard deviation of 1.72. For non-clinical populations, a mean score of 2.34 with a standard deviation of 2.17 was indicated. A cut-off point of 5.50 on the SPTSS maximized classification accuracy, with associated sensitivity and specificity rates of 89% and 89%, respectively. The internal consistency of the measure in the current sample was acceptable, Cronbach’s alpha = .70. The SPTSS was administered pre and post the intervention.
Hospital Anxiety and Depression Scale
The Hospital Anxiety and Depression Scale (HADS)  is a self-report, 14-item brief report screen designed to assist clinicians and researchers in detecting possible clinical cases of depression and anxiety. The scale gives an overall or total score, as well as, a subscale for anxiety and depression. The range of scores is from 0–42 for the total score, and 0–21 for the anxiety and depression subscales. The clinical cutoffs for both the anxiety and depression subscales indicate scores of less than 7 are non-cases, scores of 8–10 indicate mild disturbance, 11–14 indicate moderate disturbance, and scores of 15–21 indicate severe disturbance. Based on normative data, a clinical population has a mean anxiety score of 8.6 (SD = 4.40), and a mean depression score of 5.9 (SD = 3.53). There are no clinical normative data for the total score (Atkins et al. ). For non-clinical norms, the respective scores are 6.14 (SD = 3.76) 3.68 (SD = 3.07), with a total score mean of 9.82 (SD = 5.98) .
While this measure has been translated into Arabic, many problems with its use have been reported, particularly with cultural understandings of phrases and activities that may or may not imply the likelihood of depression, likely leading to biased depression scores ([7, 13]; Alamri ). Therefore, a new translation was created, employing the approach described above. A reliability analysis was computed on the 14 item HADS using the data from the current population resulting in a reliable Cronbach’s alpha of .73. The HADS was administered pre and post the intervention.
Non-parametric Wilcoxon matched pairs tests were conducted to compare pre and post intervention scores on the outcome measures. All outcome measures were also examined to see if individual participants’ scores had reliably and clinically significantly changed over the course of NET . Where existing clinically cut off scores were available, these were employed; see the “Results” section for more details.