1) The document describes a study that tested the impact of a stress management intervention on the psychological outcomes of women entrepreneurs in Ethiopia. 2) The intervention involved providing women with a self-help manual and six weekly phone-based sessions on stress management techniques. 3) The results found that the intervention led to significant improvements in psychological outcomes for treated women, including a 30% reduction in distress and 20% reductions in perceived stress and depression levels.

1. SPIR II RFSA | 2023 Learning Event
Impact of a Stress Management Intervention on
Psychological Outcomes of Women
Entrepreneurs in Ethiopia
Adiam Hagos Hailemicheal, Africa Gender Innovation Lab, World Bank Group
Research team: Naira Kalra, Adiam Hagos Hailemicheal, Kassahun Habtamu and Medhin Selamu

2. Context
• Globally, women-owned enterprises were more adversely affected by the pandemic (Birhanu et al.
2022; Goldstein et al. 2022; Kevane et al. 2021)
• Women-led micro-businesses experienced a higher drop in sales (and profits) in Ethiopia (Abebe,
Bundervoet, and Wieser, 2020; Tefera et al., 2020).
• A 33 percent prevalence of symptoms consistent with depressive disorder (Necho et al., 2020).
 a three-fold increase in probable depression compared to before the pandemic.
• Prevalence is likely to be higher amongst women even under normal circumstances (Gelaye et al.,
2012):
 25.9 percent of working women in Addis Ababa, compared to 12.4 percent of working men
 35.5 percent of working women <25 years of age report having mental distress, compared
to 16.4 percent of working men <25 years of age
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3. Background literature
• Bidirectional nature: mental health impacts productivity and income, income &
productivity in turn affects mental health (Lund et al., 2010; Ridley et al., 2020;
Gorgievski et al., 2010).
• RCTs evaluating the impact of different psychology and counselling-based interventions
found improvement in economic outcomes:
• An over-the-phone para-counseling intervention to mitigate impacts of COVID-19 decreased
moderate and sever stress, depression and food insecurity in Bangladesh (Vlassopoulos et al.
2021).
• Cognitive Processing Therapy delivered to women survivors of conflict found positive impacts on
the weekly hours worked and on per capita expenditures on food (Bass et al. 2013).
• A brief intervention based on the principles of behavioral activation reduced symptoms of
depression, and increased number of days worked (Weobong et al., 2017).
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4. Rationale
• Emerging evidence on the impact of a lay-counselor-facilitated version of Self-help +
is promising (Tol et al. 2020; Acarturk et al., 2022)
• Scale up: Due to capacity constraints and cost we should consider light-touch
interventions that are not individually tailored and/or are delivered in mass through mobile
technologies.
• A systematic review of studies on text-based interventions for mental health done by Berrouiguet et
al. (2017) found that the interventions are feasible and acceptable.
• Tol et al. 2020 find a lay counselor facilitated self help + reduces distress and improves
psychological wellbeing among refugees.
• Deady et al. (2020) tested the impact of a 30-day mobile-based behavioral activation and
mindfulness intervention to prevent depression in the workplace in Australia and found a reduction
and depression symptomology.
• Gap: The impact of Self Help + on psychological outcomes of women entrepreneurs not
explored.
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5. Study objective and outcomes
• Evaluate the impact of a lay helper-supported self-help program
on psychological outcomes for women entrepreneurs in
Ethiopia.
• The psychological outcomes under study include the following:
o Distress (Kessler 6)
o Perceived stress (Perceived stress scale)
o Psychological wellbeing (WHO5 scale)
o Indication of depression (Phq-9)
o Functionality (WHODAS)
o Self esteem (Rosenberg Scale)
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6. Intervention
• Doing What Matters at Times of Stress – a stress
management tool developed by the WHO.
o Book available online
o Has a 5 sections and exercises with pictorial
narrations
o Acceptance and Commitment Therapy
o Focused on psychological flexibility
• Adaptation:
o Translated the book into Amharic
o Adapted the graphics to the Ethiopian
context after a pre-test
o Developed a guided self-help manual
o Trained lay helpers to deliver six weekly
phone-based sessions to participating
women entrepreneurs

7. Study design
• Conducted screening survey of 1200
women entrepreneurs to identify
eligible candidates:
o Can read and speak Amharic
o Has access to a phone
o Has an operational business
o Has a Kessler score >7 & <21
• Shortlist 200 women entrepreneurs
(score 8-20)
• Randomize into a treatment and
control group (creates a
counterfactual)
1200 women
screened by phone
200 women identified as eligible
In-person baseline survey with 200
female entreprenures
Randomized into two groups
Self-help manual shared followed by
6 phone-based sessions over 6 weeks to review
handbook materials
100 women
Phone-based follow-up
survey four to six weeks after
intervention
97 women
Follow-up interview with
participants to ask about the
intervention
10 women
Wait list Control
100 women
Phone-based follow-up
survey four to six weeks
after intervention
95 women
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8. Data collection
• Screening survey:
o 1200 women entrepreneurs in Addis Ababa were interviewed to identify
women screened into the study in August 2021
• Baseline survey:
o 200 women interviewed in September 2021
o 60-minute in-person survey collecting data on demographic variables,
psychological outcome indicators, and business performance indicators
• One-month follow-up survey:
o 192 women interviewed in December 2021
o 20-minute phone survey with psychological outcome indicators
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9. Baseline characteristics and analysis
BL Characteristics:
• 68% are married.
• Average respondent is 39 years of age, has 13 years of education, and has 2
children.
• 86% are sole owners of their businesses.
• Owns 1.15 businesses and 2.6 employees on average.
Analysis:
• ANCOVA estimation on relevant psychological outcomes.
• Sensitivity analysis to check the robustness of results.
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10. Results – Psychological outcomes
• Intervention resulted in a 30 percent reduction in distress for treated
women.
• The perceived stress levels of women in the treatment group were 20
percent lower compared to the control group.
• Indication of depression was 20 percent lower for treated women.
• Psychological well-being was 14 percent higher for women in the
treatment group.
• Women in the treatment group had 9 percent lower indications of disability.
• We see improvements in self-esteem although only at 10 percent
significance level.
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11. Conclusion and next steps
• DWMTS Stress management intervention significantly improves
psychological outcomes for women entrepreneurs in the short
run.
• Lessons documented through the pilot exercise informed the
second phase of the program:
o Wider context (three more cities)
o Focuses on economic outcomes and gender-based violence
o Participants allowed to invite a household member to attend sessions
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