Syrian refugees in Germany, Sweden and Egypt reshaped a WHO self-help app's interface and pacing; a 569-person randomized trial in Lebanon then found it roughly tripled depression treatment response versus usual care.
569 displaced Syrians
Participants enrolled (Dec 2019-Jul 2020)
0.48 SMD
Standardised mean difference in depression symptoms, post-treatment
0.61 SMD
Standardised mean difference, 3-month follow-up
37.1 / 13.3 % (NNT: 4)
Treatment response, intervention vs control
20.8 / 4.9 % (NNT: 6)
Remission, intervention vs control
128 Syrian refugees (Germany, Sweden, Egypt)
Refugees involved in user-centred redesign
Details
Maturity
Scaling
Promoter
World Health Organization, Lebanon National Mental Health Programme & Vrije Universiteit Amsterdam
Period
2017–2022
Keywords
digital mental health, refugee services, mHealth, psychosocial support
Context
Lebanon hosts around 1.5 million displaced Syrians, most with no access to effective mental health care. The World Health Organization had built Step-by-Step, a guided digital self-help programme using behavioural-activation techniques for depression, but its original web-based design did not fit how refugees actually access phones and data.
Activities
Before the Lebanon trial, the EU-funded STRENGTHS consortium ran a user-centred redesign with 128 Syrian refugees in Germany, Sweden and Egypt, who pushed for a WhatsApp-like interface, shorter sessions, audio options, offline functionality and faster helper responses. The redesigned app was then deployed and evaluated at national scale with Syrian refugees in Lebanon.
Results
A single-blind RCT recruited 569 displaced Syrians in Lebanon between December 2019 and July 2020. Depression symptoms improved significantly more with guided Step-by-Step than enhanced care as usual (SMD 0.48 post-treatment, 0.61 at 3-month follow-up); 37.1% of the intervention group showed a treatment response versus 13.3% of controls (NNT: 4), and 20.8% reached remission versus 4.9% (NNT: 6). The programme has since been integrated into Lebanon's national mental health system.
Conclusions
The interface changes that mattered most were designed with refugee communities outside Lebanon, not with the Lebanese-based trial participants themselves. Dropout was substantial — only 53.8% completed the post-treatment assessment and 47.3% the 3-month follow-up — which the authors flag as typical for digital interventions in humanitarian settings but still a real limitation on the effect estimates.
Implementation
Indicative cost
Medium (€50k–€500k)
Time to results
Medium (1–3 years)
Staffing & skills
World Health Organization, Lebanon National Mental Health Programme, Vrije Universiteit Amsterdam
Conditions for success
User-centred redesign with refugee communities before deployment (WhatsApp-like interface, offline functionality)
Integration into Lebanon's national mental health system after the trial
Common failure modes
Interface redesign was co-designed with refugees outside Lebanon, not the trial's own participants
Substantial dropout — only 53.8% completed post-treatment assessment, 47.3% the 3-month follow-up
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