Step-by-step: e-mental health in Lebanon

Innovation summary

The mental health treatment gap has been estimated to be >90% in Lebanon due to limited resources, the effects of the refugee crisis, and high levels of stigma. Much of the country’s mental health care is provided privately and concentrated in Beirut, resulting in grave inequalities in access to care. An innovative approach is needed to reach those in need.

Step-by-Step, called “Khoutweh Khoutweh” in Lebanon, is an electronic mental health intervention with 15 minutes per week of remote (phone or message) guidance by a trained non-specialist “e-helper”. The intervention will firstly be feasibility tested among 200 beneficiaries in 2017-2018 to determine its suitability for Lebanese nationals and refugees living in situations of adversity in Lebanon, before larger randomized controlled trials (RCTs) in 2018-2019.

The intervention goal is to reduce the mental health treatment gap for Lebanese, Syrian, and Palestinian communities living in Lebanon. Proposed as part of a stepped care system, Step-by-step could in the future increase accessibility to evidence-based care using smartphones in Lebanon.

Impact summary

Key indicators of impact will be:

Coverage: Number of participants who complete the intervention
Outcome: Change in outcome measure scores (Primary outcome PHQ-9, Secondary outcomes WHODASS, WHO5, PSYCHLOPS and GAD-7)
Acceptability: Participant satisfaction questionnaire and qualitative user testing and process evaluation findings

During user testing of content:

"I would start and continue the program. I want to change for the better and don’t want to go back to hopelessness; I would access the website on my phone at home, it would be easy…”

- Syrian, Female, 38, North Lebanon

"The application on the phone is very good, especially if it is private. The participant wouldn’t have to go see a psychiatrist and feel uncomfortable about it"

- Lebanese, Male, 53, North

“Whenever we have any problem, we search online on Google for example, but the information might not be credible, so having this trusted program would be good”

- Lebanese Female, 31, Beirut

Innovation details

To increase access to evidence based interventions, WHO is exploring the feasibility of delivering scalable psychological interventions using information technology to communities affected by adversity. Lebanon, a middle income country with reasonably good internet coverage, high literacy rates, and a new mental health plan supportive of e-health, is the pilot site for this e-intervention. The project is led by WHO in close collaboration with the Ministry of Public Health in Lebanon and is funded by Fondation d’Harcourt.

Step-by-step adopts a predominantly behavioral activation therapeutic approach that is delivered in the form of a five session illustrated story with an interactive component. It also uses psychoeducation, relaxation techniques, positive self-talk, and garnering social support. Step-by-step was inspired by the existing WHO face-to-face intervention Problem Management Plus, but it has minimal emphasis on problem solving.

Step-by-involves a narrative story of an individual who has undergone treatment for depression and who shares their experiences and techniques in overcoming their depression. Each weekly session lasts for around 25-30 minutes and the user is encouraged to practice techniques in their own life. The intervention is minimally guided, whereby participants will receive weekly support by trained non-specialists called “e-helpers” for around 15 minutes per week using email or telephone. It has been adapted to be suitable for Lebanese, Syrian, and Palestinian communities living in adversity in Lebanon and showing depressive symptoms as screened by the PHQ-9. The intervention is not designed to be used with clients at imminent risk of suicide.

The intervention is fully computerized; the sessions (story and illustrations) can be accessed through smartphones, computers, or tablets that are connected to internet. The study information, consent forms and pre-post tests and all content will be available in Arabic and English electronically through the website. All content has been systematically translated, reviewed and adapted to the cultural setting of Lebanese, Syrians and Palestinians residing in Lebanon. Diverse stakeholder groups were engaged and informed the adaptation process.

The intervention will be pilot tested, recruiting through the wider community, several primary health care centers across Lebanon, and in the family medicine departments of two Beirut hospitals. 200 participants diverse communities will be able to participate in the feasibility study. Participants can use the intervention at home from their private devices, or in private rooms equipped with tablets and wifi in some of the participating health centers. The intervention will be tested through two large randomized controlled trials in 2018.

Key drivers

The programme has not been implemented yet but we draw attention to the following likely drivers:

Fostering relationships and high quality local project coordination
Responsibility for sustainability placed with local teams with the aim to build on existing local capacity
The user-friendly and simple design and content of the intervention make it easy to use
The widespread internet coverage in Lebanon
The widespread use of smartphones across socio-economic groups in Lebanon
The high literacy rates in Lebanon
Support for e-health innovations in the National Mental Health Plan in Lebanon

Challenges

Designing intervention content relevant to the diverse communities in Lebanon has been a challenge. This has been overcome by working closely with local people and testing content ideas with many people from the target populations across Lebanon. This has resulted in using examples and storylines that could be relevant across cultural groups and to both wealthy and poor people.
Though Whatsapp and Facebook apps are used widely across all groups in Lebanon, email and internet use literacy ranges a lot. We will offer the ability to contact e-helpers for sign up support or provide pre-existing accounts for those who are unable to set up their own account on the website. For those who have the bandwidth capability, we will have information and help videos embedded within the site. For the next phase of the project (the randomized controlled trials [RCT]) we will use an app as the platform.
For those without wifi, internet usage charges may be incurred. The file sizes of the illustrations have been minimized to limit data usage and we will place a tablet with Wifi in a private room in four of the seven PHCs participating in this project.
Stigma is a major barrier to care in Lebanon. The intervention does not use medical language or labels; it uses broader terms such as problems, distress, mood, suffering.
Content has been written in easy to understand language for those with a lower literacy level.

Continuation

Following this feasibility study, pilot and definitive randomized control trials will be used to test the efficacy of an app version of the intervention among Syrian refugees in Lebanon in 2018-2019 (funded through Elhra’s R2HC initiative). The app version of the intervention will also be tested by the University Berlin in Germany, Egypt among Syrian refugees in a separate trial in 2018 (funded through EC).

The possibility of scale-up to larger populations is envisaged. If the intervention proved to be efficacious in two fully powered trials, WHO will make Step-by-Step widely available. In addition, Lebanon hopes to integrate it into the government-run mental health care system and disseminate it for use by the general public.

Partners

Fondation d’Harcourt
Ministry of Public Health, Lebanon
University of Zuerich
International Medical Corps
Association Francaise des malades Mentaux
American University of Beirut Medical Center- Family Medicine Department
Hotel Dieu de France- Family Medicine Department
Family Guidance Center- Beit Atfal Soumoud Tyr
St. Antonios Primary Health Care Center
Makhzoumi Foundation
Ministry of Social Affairs Primary Health Care Center- Bakhoun
Fondation FPSC- Zahle
Medecins du Monde
Imam El Sadr Foundation
Lebanese Welfare Asociation for the Handicapped- Nabih Berri Rehabilitation Center
Vrije Universiteit, Amsterdam

Funders

Fondation d’Harcourt (main funder)
International Medical Corps (support for local meetings and training)

Evaluation methods

This feasibility pilot is being conducted to assess the feasibility, understandability and acceptability of the intervention and its use in the Lebanese context. We will gather data on 200 participants in order to understand its potential impact. The completion rates of the intervention and the clinical improvement (pre- and post-tests) will be measured. Furthermore, key informant interviews will generate qualitative feedback data and recommendations for improvement ahead of the next phase, the RCTs.

Further pilot trials and RCTs will be conducted to formally assess the efficacy and cost-effectiveness of Step-by-step.