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 a digital mental health intervention consisting of 5 sessions that people go through on their own and have access to 15 minutes per week remote (phone or message) guidance by a trained non-specialist “e-helper”. The intervention goal is to reduce the mental health treatment gap in Lebanon.

The intervention was tested in an uncontrolled pilot, feasibility RCT and then effectiveness was evaluated in two RCTs (1 with Lebanese nationals and 1 with Syrian refugees) in Lebanon. Results of the RCTs showed that Step-by-Step is effective (Cuijpers et al 2022a; Cuijpers et al 2022b). On the basis of these results, Step-by-Step is currently being provided nationwide as part of an implementation project to further understand how to deliver Step-by-Step outside of research settings. This is demonstrating that Step-by-Step can be feasibly provided to increase accessibility to evidence-based care using digital devices (smartphone, tablet, laptop) in Lebanon.

WHO is currently preparing Step-by-Step to be available as an open access intervention for adaptation and implementation elsewhere. For further information, please contact: psych_interventions@who.int

Impact summary

Key indicators of impact:

Coverage: during the RCTs 614 people received the intervention (331 Lebanese, 283 Syrian refugees in Lebanon). Up to the end of May 2022 the implementation phase has reached 878 clients.
Outcome: the RCTs showed that people that use Step-by-Step improved on depression, impaired functioning, post-traumatic stress, anxiety, subjective well-being, and self-identified personal problems directly after the intervention and at 3 months follow-up.
Acceptability: Qualitative process evaluation data indicates that the intervention is acceptable and meaningful to end-users (paper in preparation)

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

Since 2015, WHO and partners - MoPH Lebanon; University of Zurich; Frei Universität Berlin; VU University Amsterdam; International Medical Corps; AFMM (Association Francophone pour les Malades Mentaux); Abaad; Embrace; UNHCR; local academics and clinicians; and Fondation d’Harcourt - have collaborated to develop Step-by-Step (Step-by-Step) for people in Lebanon, including Syrians in Lebanon.

Step-by-Step is an innovative approach to reducing the suffering and disability associated with mental health issues that can be used in countries of all income levels, for populations that can access the internet. Step-by-Step, is a brief (5 session) intervention for depression. Step-by-Step adopts a predominantly behavioral activation therapeutic approach that is delivered in the form of an illustrated story with an interactive component. It also uses psychoeducation, relaxation techniques, positive self-talk, and garnering social support. It has been carefully designed and comprehensively adapted for use in Lebanon (including refugees residing in Lebanon). Step-by-Step is delivered as guided self-help, with trained non-specialist “e-helpers”, providing phone or message-based support to Step-by-Step users for around 15 minutes a week. The effectiveness of Step-by-Step has been evaluated in randomized controlled trials (RCTs) with Lebanese and other populations residing in Lebanon (funded by Fondation d’Harcourt), and a parallel trial with Syrians in Lebanon (funded by R2HC). Step-by-Step was found to be effective in reducing depression, impaired functioning, posttraumatic stress, anxiety, and increasing subjective well-being in both trials. These effects were found to continue 3 months after participants had finished the intervention. These results show that a guided digital intervention can be effective in treating depression in adverse contexts. Currently, Step-by-Step is implemented as a service in Lebanon with support of Fondation d’Harcourt, to identify a sustainable implementation model for the intervention in Lebanon. WHO is currently preparing Step-by-Step for release as an open access package for adaptation and implementation elsewhere.

Key drivers

Key drivers of success during the RCTs and current implementation of Step-by-Step have been:

A highly motivated and experienced local project coordination team that has been able to address the multiple challenges associated with providing interventions in difficult contexts.
Support for digital innovations within countrywide plans for mental health, developed by the National Mental Health Programme of the Ministry of Public Health, Lebanon.
A user-friendly and simple to use intervention design
Well-trained e-helpers that receive good quality supervision to ensure quality of care and implementation
Commitment to sustainability from the local implementing team with the aim of building on existing local capacity and services.
The widespread use of smartphones across socio-economic groups in Lebanon
The high literacy rates in Lebanon

Challenges

Unpredictable socio-economic problems affecting the country.
This includes a financial crisis, deteriorating employment status and living conditions within Lebanon, and the Covid-19 pandemic.

Difficulties for staff to provide the service
The above problems led to fuel shortages, road closures, electricity cuts, security incidents and restrictions on movement (COVID-19), which impacted the ability of staff to attend the project office. Related to the economic situation, there was also a high turnover rate with the volunteer e-helper model developed for the implementation phase.

Difficulties for participants accessing the service
Electricity cuts and limited phones signal posed challenges for users to access the intervention. This led to challenges with recruiting users. More complex and severe mental health and social problems were reported by participants because of the difficult situation in Lebanon.

Continuation

For this project, one specific objective is to pilot the implementation of Step-by-Step in Lebanon outside of a research context, using implementation science methods to develop an understanding of how to scale it. Results from this will be used in WHOs wider work.

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

In phase 1 of the project, funded by Fondation d’Harcourt and finalized in May 2018, the web-based version of Step-by-Step underwent (a) translation and adaptation to the local context and (b) a small open feasibility pilot and a process evaluation. Phase 2 of the project involved feasibility randomized controlled trial (RCT), followed by fully powered (definitive) RCTs of Step-by-Step with Syrians in Lebanon (funded by R2HC) and Lebanese and other populations residing in Lebanon (funded by Fondation d’Harcourt). In the beginning of Phase 2, the Step-by-Step story was adapted based on data from phase 1 and the intervention was redesigned for use both as a smartphone app (for iOS and Android) and a website. The feasibility RCT showed a reduction of psychological distress, anxiety and posttraumatic stress and an increase in functioning and wellbeing in participants using the intervention. The process evaluation showed that participants considered Step-by-Step to be relevant and empowering. The feasibility RCT also provided useful data to refine processes for the definitive RCTs that were conducted in phase 2. We conducted two single-blind, two-arm pragmatic randomised trials (one with Syrian refugees and one with Lebanese and other populations residing in Lebanon), comparing guided Step-by-Step with enhanced care as usual (ECAU) among people suffering from depression and impaired functioning. Primary outcomes were depression (Patient Health Questionnaire 9 (PHQ-9)) and impaired functioning (WHO Disability Assessment Schedule-12 (WHODAS)) at post-treatment. Results showed that people that use Step-by-Step improved on depression, impaired functioning, post-traumatic stress, anxiety, subjective well-being, and self-identified personal problems directly after the intervention and at 3 months follow-up.

Phase 3 of the project is currently underway and is implementing Step-by-Step in Lebanon outside a research context to develop lessons learned on how to scale up the intervention and exploring sustainable implementation models. Up to the end of May 2022, 878 people have accessed Step-by-Step. Further results will be made available on conclusion of the project in 2022.

Cost of implementation

The cost-effectiveness paper is being finalized and will be submitted to an academic journal.

Impact details

In total 757 people received Step-by-Step during the evaluation of the intervention (74 in the open pilot, 69 in the feasibility RCT and 614 in the fully powered RCTs). As of May 2022, a further 878 have received Step-by-Step since its scale-up in Lebanon

The two fully powered randomized controlled trials in phase 2 found that participants that used Step-by-Step improved on depression, impaired functioning, post-traumatic stress, anxiety, subjective well-being, and self-identified personal problems directly after the intervention and at 3 months follow-up.

For more information on the results of the RCTs please see Cuijpers et al 2022a and Cuijpers et al 2022b.