Effectiveness and cost-effectiveness of guided e-mental health care for Syrian refugees in urban Lebanon

What did this study set out to achieve?

The long-term objective of this proposal is to reduce mental suffering and improve the mental health and functioning of people affected by humanitarian crises. Adequate ability to function is important for survival and for re-building communities. WHO’s aim is to contribute to this objective by developing a suite of evidence based interventions that are scalable in humanitarian settings.

This study evaluated the effectiveness and cost-effectiveness of Step-by-Step (SbS) with Syrian refugees in Lebanon. SbS is an innovative 5-8 week guided WHO intervention designed to improve mental health care coverage, with scalability as central design feature. It is delivered remotely through either users own devices, or devices placed at health facilities.  The intervention content involves a narrative with simple language, illustrations and interactive exercises. Users receive weekly phone guidance from a helper to maintain motivation, ensure understanding of the intervention content and to prevent drop out.

This research aimed to provide a proof of concept for the use of SbS and other e-mental health intervention in humanitarian settings where (a) a meaningful proportion of the population has access to smartphones or other internet devices or (b) health and other facilities can provide access to devices and the internet. The evaluation aimed to (a) generate evidence for the decision whether or not to release this guided e-mental health intervention as a public good and (b) improve the scant evidence-base for such interventions in humanitarian settings.

What were the key findings?

• Participants who received Step-by-Step showed improvements on primary outcomes – depression and functional impairment, compared with the control group.
• Those receiving Step-by-Step also showed improved secondary outcomes: anxiety, post-traumatic stress, subjective well-being and self-identified problems.
• The intervention received positive feedback from users and other stakeholders.
• Step-by-Step appeared to be a cost-effective treatment option for Lebanon’s healthcare system.

What does this mean for policymakers and practitioners?

This randomised controlled trial demonstrates that Step-by-Step can contribute to improve mental health among Syrian refugees in Lebanon, and potentially other communities affected by adversity in humanitarian or low-income settings. However, it is important that Step-by-Step is culturally adapted to ensure that language, local idioms, etc. support the effectiveness of the intervention. For example, the ‘helper’ who appears in the Step-by-Step narrative is currently a doctor, but this will not always be appropriate.

A countrywide implementation project for all people in Lebanon is currently underway to further understand how to implement and scale up Step-by-Step. Step-by-Step is now being provided as a free-to-access national programme in Lebanon, reaching nearly 2000 people in the first 18 months of implementation.

Step-by-Step was found to support people with depressive symptoms in a context of  adversity. Some people will require specialist care and it is recommended that the intervention is implemented in an integrated mental health system with referral options to specialist support.

Following these trials, a guided self-help manual for the interventions is expected to be available in 2024.