Waterman 2018.

Study characteristics
Methods	Design: implementation and evaluation of intervention. Qualitative interviews with intervention providers Country: Sierra Leone Study aims: to assess the feasibility of training a national team to deliver a CBT–based group intervention to identify key barriers and enablers to implementation of and engagement with this intervention to evaluate the effectiveness of the overall intervention within this population Study recruitment details: study comprised 3 phases of intervention. Participants completing 1 phase were screened and, if appropriate, referred to the next phase. In addition a number of new participants entered the study direct into Phase 2. In addition, 9 people involved in delivery of the group CBT were recruited for an interview to explore barriers and enablers. Setting: ETCs set up across Sierra Leone and staffed by a combination of national and international HCWs Epidemic/pandemic disease: EVD Phase of disease outbreak: during the outbreak
Participants	Total study population: people trained to facilitate group CBT: 12 (9 were interviewed). Phase 1: 3273 invited to attend. 1533 attended. Phase 2: 1170 referred from phase 1 + 1720 joined at this point. Total participants attending sessions = 2533. Phase 3: 523 screened, 298 referred, 253 attended intervention, 157 completing post‐intervention assessment. Inclusion criteria: ETC staff member from 1 of the 6 ETCs within Sierra Leone Exclusion criteria: none stated Type (profession) of staff: not reported for Phase 1 or 2. For Phase 3 ‐ "136 were unemployed (53.80%), 80 were employed (31.60%) and 32 (12.60%) were students." Profession not stated Length of time in the profession: not reported Previous experience of working in the frontline during an epidemic/pandemic: not reported Details of who the frontline staff were providing care for: patients attending ETCs. There were 6 ETCs ‐ 5 were 100‐bed facilities and 1 had 62 beds
Interventions	1. Name of intervention: (Phase 1, n = 1533; Phase 2, n = 2533; Phase 3, n = 157 completers; attended all 3 phases, n = 75) Type of intervention: psychological support interventions Materials: for Phase 3 ‐ "Every session was supplemented by a booklet, which was adapted for the Sierra Leonean context. There was an additional low‐literacy version, including more diagrams and images to depict CBT concepts." Procedures: 6‐week group CBT programme for depression and anxiety modelled on the evidence‐based low‐intensity interventions delivered in the UK Provided by: 12 national ex‐ETC staff were trained to facilitate the delivery of this intervention with their peers. All 12 CBT facilitators received weekly support and coaching from a UK‐based psychologist or psychotherapist via Skype. ("The team were trained together using a package specifically developed for the study, which included pre‐prepared PowerPoint workshops. The UK trainers worked collaboratively with the in‐country facilitators to make cultural adaptations as required, and although the materials were in English, which is the official language of Sierra Leone, the facilitators presented workshops in a combination of English and the local language of the staff, usually Krio. Following this training, each set of facilitators conducted observed sessions and were given feedback from their peers and the UK clinicians about what they needed to improve.") Delivery: "A group‐based intervention, delivered by peers, was developed for the purpose of this study. All phases were based on psycho‐education and simple CBT principles, which have been shown to be beneficial within UK adult population for the treatment of anxiety and depression". Phase 1 intervention: "The 2‐hour workshop was based on the concept of Psychological First Aid (Alexander, 2014–2015), a model of debriefing that allowed ETC staff the chance to discuss challenges of their work and the impact of this, their ways of coping and their achievements. The capacity per workshop was 50 participants." 81 sessions were delivered over 6 weeks. Phase 2 intervention: "2‐hour workshops, which focused on one of the six different common mental health difficulties. Each of the Phase 2 workshops focused on psycho‐education about the specific problem, followed by discussion of a range of simple coping strategies based on behavioural and cognitive approaches that staff could use as self‐help". 180 sessions were delivered over 10 weeks. Phase 3 intervention: "participants were in small groups and met on a weekly basis with their facilitators who guided them through a low‐intensity CBT programme that included behavioural activation, minimising avoidance, problem solving and coping with anxiety." These small CBT groups involved "6 sessions [over a 6‐week period] of a UK validated group CBT programme for anxiety and depression.....Groups were capped at 14 members...."Regimen:All staff were invited to attend Phase 1 intervention. Staff scoring > 7 on the well‐being screening tool were referred to a Phase 2 workshop. Staff who were most symptomatic on the screening were re‐screened using GAD7 and PHQ9 after Phase 2, and those "still scoring within the moderate‐severe clinical range on either measure" were invited to attend the Phase 3 intervention. Tailoring: some evidence of individual tailoring ‐ "Participants were referred from phase 1 [to phase 2], but could attend 0‐6 sessions maximum, as they were able to attend sessions on other topics if they wanted". Modification: some evidence of modification ‐ during Phase 3: "During training, further changes were made to the booklets by request of the facilitators to enhance cultural appropriateness." Adherence: not reported Details of any adverse events/unintended consequence: barriers (and enablers) to implementation of the intervention were explored during the qualitative interviews with providers
Outcomes	Outcomes: 7‐item well‐being screening tool concerning stress, sleep, anxiety, depression, relationship difficulties, behavioural changes and PTSD Post‐traumatic stress checklist Perceived stress scale Insomina severity index GAD7 PHQ9 Relationship questionnaire Behavioural questionnaire Data collection: 7‐item well‐being screening tool was assessed before Phase 1 Other outcomes were measured at the start of Phase 2, at the start of Phase 3, and 2 weeks after completion of Phase 3. "Participants who had been the most symptomatic at Phase 1 were re‐screened using GAD7 and PHQ9 2 months after the completion of Phase 2". In addition there was data from 9 interviews (45‐60 min long).
Funding	Funding statement: financial support was received from the UK Public Health Rapid Support Team, funded by the UK Government, the UK Department for International Development and the Maudsley Charity. This report is independent research by the UK Public Health Rapid Support Team Conflict of interest: study authors report no conflict of interest
Notes	Included in the review of qualitative evidence synthesis. Classified as a 'descriptive study', as descriptive data were used from this mixed‐method study. Methodological assessment: assessed using WEIRD tool Overall assessment: minor limitations. For details of assessment see Table 10, and for support for judgements see Appendix 14.

AHP: allied health professional; CASP: Critical Appraisal Skills Programme; CBT: cognitive behavioural therapy; CDC: Centers for Disease Control and Prevention; CD‐RISC: Connor Davidson Resilience Scale; DSRT: Deployment Safety Resilience Team; ED: emergency department; ETC: Ebola treatment centres; EVD: Ebola virus disease; GAD‐7: General Anxiety Disorder‐7; HCW: healthcare worker; ICU: intensive care unit; IES(‐R): Impact of Event Scale (‐Revised); K‐10: Kessler Psychological Distress Scale (10‐item); MERS: Middle East respiratory syndrome; MBI: Maslach Burn‐out Inventory; PC‐PTSD: Primary Care Post‐traumatic Stress Disorder Screen; PFA: psychological first aid; PHQ‐9: Patient Health Questionnaire‐9; PPE: personal protective equipment; PPI: personal and public involvement; ProQOL 5: Professional Quality of Life scale; PTSD: post‐traumatic stress disorder; SARS: severe acute respiratory syndrome; SD: standard deviation; VRE: virtual reality environment; WEIRD: Ways of Evaluating Important and Relevant Data; WHO: World Health Organization