1. Step-by-step (خطوة خطوة): Feasibility testing an e-mental health intervention in Lebanon 
A World Health Organization minimally guided intervention in collaboration with the Lebanese Ministry of Public Health, University of Zurich, University of Berlin, International Medical Corps, Vrije Universiteit Amsterdam and Beirut-based Association Francophone pour les Malades Mentaux. Step-by-step is currently funded by Fondation d’Harcourt
Background:
As part of WHO’s work on “scalable psychological interventions”, Step-by-step has been developed in response to the enormous disease burden that depression poses globally. Despite rising literacy rates and smartphone usage, e-mental health is seldom tested or used in low-resource settings.
Lebanon has a mental health treatment gap of around 90% and hosts over 1 million refugees. It has high internet connectivity and a national mental health plan that encourages e-mental health as part of a stepped-care model for the Lebanese and for migrant populations. Step-by-step is being piloted then tested in RCTs as an innovative strategy to deliver evidence-based mental health care.
The intervention:
Evidence-based WHO intervention designed with the inputs of over 30 global mental health and e-health specialists;
Step-by-step is an illustrated narrative story with interactive components;
Comprises of 5 x 30 minute sessions online intervention;
User can choose from one of 4 characters, all with a similar story;
Uses a behavioral activation approach with stress management and social support elements;
Trained non-specialist “E-helpers” provide minutes of phone or written guidance to users each week;
An app version is currently in development at University of Berlin.
Methods:
Adaptation: Step-by-step was adapted to the 3 main cultures in the Lebanese context (Lebanese, Syrian and Palestinian) using “cognitive-interviewing” methodology through focus group discussions and key informant interviews with community members, front line workers in primary health care centers and mental health experts. Participants were selected as to represent different ethnics groups, regions and genders.
Feasibility testing: Step-by-step has been pilot tested for 6 months among adults of any socio-economic status living in Lebanon screening as depressed, but not suicidal.
Primary outcome is depression symptoms (PHQ-8) and secondary outcomes are anxiety symptoms (GAD-7), wellbeing (WHO-5), functioning (WHODAS), self-perceived problem magnitude (PSYCHLOPS) and client satisfaction (CSQ). Qualitative process evaluation has also started.
Preliminary findings:
Quantitative data so far: 123 persons enrolled in the program, 10% of which were Syrians, and the remainders were Lebanese and Palestinians (recruitment completed over 4 months and ended in )
So far, dropout rate = 50%
The qualitative process evaluation results so far show that completers, dropouts , e-helpers, front line workers and health center managers deem the project relevant, very beneficial and innovative. The e-helpers’ support and the narrative story approach were very well received by the community. They provided recommendations for the RCT phase of the project ( ).