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Abi Ramia J, Abi Hana R, Noun P, Cuijpers P, Carswell K, van't Hof E, Heim E, Zoghbi E, Sijbrandij M, El Chammay R. Feasibility and uptake of a digital mental health intervention for depression among Lebanese and Syrian displaced people in Lebanon: a qualitative study. Front Public Health 2024; 11:1293187. [PMID: 38317685 PMCID: PMC10840138 DOI: 10.3389/fpubh.2023.1293187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/22/2023] [Indexed: 02/07/2024] Open
Abstract
Introduction Digital interventions are increasingly regarded as a potential solution for the inaccessibility of mental health treatment across low-and-middle-income settings, especially for common mental disorders. Step-by-Step (SbS) is a digital, guided self-help intervention for depression found effective in two Randomized Controlled Trials (RCTs) in Lebanon. For research implementation and further scale-up, this paper reports the results of a qualitative evaluation of SbS among the Lebanese and others and displaced Syrians in Lebanon. Methods Thirty-four Key Informant Interviews (KIIs) were executed with participants of the RCTs, SbS staff members, and external stakeholders. Questions garnered feedback about the feasibility, acceptability, enabling factors, and barriers to adhering to the research, implementation, and the SbS intervention. A thematic analysis was conducted using NVivo, and key themes, topics, and recommendations, on research methods and the intervention itself, were generated and reported. Results Results showed a high level of acceptability of SbS among Lebanese and Syrians and identified sub-groups for whom acceptance or use might be lower, such as older adults and people with limited access to the internet or smartphones. Furthermore, interviews identified the main enabling factors and barriers to adherence related to the research design, content, and delivery approach. Barriers related to feasibility included lengthy assessments as part of the RCTs, and mistrust related to delays in study compensations. Other common challenges were forgetting login credentials, poor internet connection, being busy and competing needs. Enabling factors and best practices included motivating participants to use the intervention through the weekly support provided by helpers, setting an oral contract for commitment, and dividing the compensations into several installments as part of the RCTs. Recommendations regarding sustainability were given. Discussion The findings show that overall, SbS is feasible, acceptable, and much needed in Lebanon among the Lebanese and Syrians. This assessment identifies reasons for low adherence to the research and the intervention and presents improvement solutions. Recommendations generated in this paper inform the upscale of SbS and the planning, design, and implementation of future digital interventions in research and service provision settings in the mental health field.
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Affiliation(s)
- Jinane Abi Ramia
- Department of Clinical, Neuro and Developmental Psychology, World Health Organization (WHO) Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- National Mental Health Programme, Ministry of Public Health of Lebanon, Beirut, Lebanon
| | - Racha Abi Hana
- Department of Clinical, Neuro and Developmental Psychology, World Health Organization (WHO) Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- National Mental Health Programme, Ministry of Public Health of Lebanon, Beirut, Lebanon
| | - Philip Noun
- National Mental Health Programme, Ministry of Public Health of Lebanon, Beirut, Lebanon
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, World Health Organization (WHO) Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- International Institute for Psychotherapy, Babeş-Bolyai University, Cluj-Napoca, Romania
| | - Kenneth Carswell
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Edith van't Hof
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Eva Heim
- Institute of Psychology, University of Lausanne, Lausanne, Switzerland
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Edwina Zoghbi
- Country Office for Lebanon, World Health Organization, Beirut, Lebanon
| | - Marit Sijbrandij
- Department of Clinical, Neuro and Developmental Psychology, World Health Organization (WHO) Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rabih El Chammay
- National Mental Health Programme, Ministry of Public Health of Lebanon, Beirut, Lebanon
- Psychiatry Department, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
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Abi Hana R, Arnous M, Heim E, Aeschlimann A, Koschorke M, Hamadeh RS, Thornicroft G, Kohrt BA, Sijbrandij M, Cuijpers P, El-Chammay R. Mental health stigma at primary health care centres in Lebanon: qualitative study. Int J Ment Health Syst 2022; 16:23. [PMID: 35525972 PMCID: PMC9077642 DOI: 10.1186/s13033-022-00533-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Mental health-related stigma is a global public health concern and a major barrier to seeking care. In this study, we explored the role of stigma as a barrier to scaling up mental health services in primary health care (PHC) centres in Lebanon. We focused on the experiences of Healthcare Providers (HCPs) providing services to patients with mental health conditions (MHCs), the views of policy makers, and the perceptions of stigma or discrimination among individuals with MHCs. This study was conducted as part of INDIGO-PRIMARY, a larger multinational stigma reduction programme. METHODS Semi-structured qualitative interviews (n = 45) were carried out with policy makers (n = 3), PHC management (n = 4), PHC staff (n = 24), and service users (SUs) (n = 14) between August 2018 and September 2019. These interviews explored mental health knowledge, attitudes and behaviour of staff, challenges of providing treatment, and patient outcomes. All interviews were coded using NVivo and a thematic coding framework. RESULTS The results of this study are presented under three themes: (1) stigma at PHC level, (2) stigma outside PHC centres, and (3) structural stigma. SUs did not testify to discrimination from HCPs but did describe stigmatising behaviour from their families. Interestingly, at the PHC level, stigma reporting differed among staff according to a power gradient. Nurses and social workers did not explicitly report incidents of stigma but described patients with MHCs as uncooperative, underscoring their internalized negative views on mental health. General practitioners and directors were more outspoken than nurses regarding the challenges faced with mental health patients. Mental health professionals revealed that HCPs still hold implicitly negative views towards patients with MHCs however their attitude has improved recently. Our analysis highlights five layers of stigma affecting SUs. CONCLUSION This qualitative study reveals that stigma was still a key concern that affects patients with MHC. SUs reported experiencing overt stigmatising behaviour in the community but less explicit discrimination in a PHC setting. Our findings emphasise the importance of (1) combatting structural stigma through legal reform, (2) addressing interpersonal stigma, (3) committing PHC management to deliver high quality mental health integrated services, and (4) reducing intrapersonal stigma by building public empathy.
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Affiliation(s)
- Racha Abi Hana
- Ministry of Public Health, National Mental Health Programme, Beirut, Lebanon.
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Maguy Arnous
- Ministry of Public Health, National Mental Health Programme, Beirut, Lebanon
| | - Eva Heim
- Institute of Psychology, University of Lausanne, Lausanne, Switzerland
| | | | - Mirja Koschorke
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England
| | - Randa S Hamadeh
- Primary Healthcare Department at Ministry of Public Health, Beirut, Lebanon
- Global Health Team of Experts (GHTE), Beirut, Lebanon
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England
| | - Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, Division of Global Mental Health George Washington University, Washington, DC, USA
| | - Marit Sijbrandij
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
| | - Rabih El-Chammay
- Ministry of Public Health, National Mental Health Programme, Beirut, Lebanon
- Department of Psychiatry, Saint Joseph University, Beirut, Lebanon
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Koschorke M, Oexle N, Ouali U, Cherian AV, Deepika V, Mendon GB, Gurung D, Kondratova L, Muller M, Lanfredi M, Lasalvia A, Bodrogi A, Nyulászi A, Tomasini M, El Chammay R, Abi Hana R, Zgueb Y, Nacef F, Heim E, Aeschlimann A, Souraya S, Milenova M, van Ginneken N, Thornicroft G, Kohrt BA. Perspectives of healthcare providers, service users, and family members about mental illness stigma in primary care settings: A multi-site qualitative study of seven countries in Africa, Asia, and Europe. PLoS One 2021; 16:e0258729. [PMID: 34705846 PMCID: PMC8550394 DOI: 10.1371/journal.pone.0258729] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Stigma among healthcare providers is a barrier to the effective delivery of mental health services in primary care. Few studies have been conducted in primary care settings comparing the attitudes of healthcare providers and experiences of people with mental illness who are service users in those facilities. Such research is necessary across diverse global settings to characterize stigma and inform effective stigma reduction. METHODS Qualitative research was conducted on mental illness stigma in primary care settings in one low-income country (Nepal), two lower-middle income countries (India, Tunisia), one upper-middle-income country (Lebanon), and three high-income countries (Czech Republic, Hungary, Italy). Qualitative interviews were conducted with 248 participants: 64 primary care providers, 11 primary care facility managers, 111 people with mental illness, and 60 family members of people with mental illness. Data were analyzed using framework analysis. RESULTS Primary care providers endorsed some willingness to help persons with mental illness but reported not having appropriate training and supervision to deliver mental healthcare. They expressed that people with mental illness are aggressive and unpredictable. Some reported that mental illness is incurable, and mental healthcare is burdensome and leads to burnout. They preferred mental healthcare to be delivered by specialists. Service users did not report high levels of discrimination from primary care providers; however, they had limited expectations of support from primary care providers. Service users reported internalized stigma and discrimination from family and community members. Providers and service users reported unreliable psychiatric medication supply and lack of facilities for confidential consultations. Limitations of the study include conducting qualitative interviews in clinical settings and reliance on clinician-researchers in some sites to conduct interviews, which potentially biases respondents to present attitudes and experiences about primary care services in a positive manner. CONCLUSIONS Primary care providers' willingness to interact with people with mental illness and receive more training presents an opportunity to address stigmatizing beliefs and stereotypes. This study also raises important methodological questions about the most appropriate strategies to accurately understand attitudes and experiences of people with mental illness. Recommendations are provided for future qualitative research about stigma, such as qualitative interviewing by non-clinical personnel, involving non-clinical staff for recruitment of participants, conducting interviews in non-clinical settings, and partnering with people with mental illness to facilitate qualitative data collection and analysis.
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Affiliation(s)
- Mirja Koschorke
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Nathalie Oexle
- Department for Psychiatry II, Ulm University and BKH Günzburg, Günzburg, Germany
| | - Uta Ouali
- Department of Psychiatry A, Razi Hospital La Manouba, Manouba, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Anish V. Cherian
- Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Vayankarappadam Deepika
- Department of Epidemiology, Centre for Public Health, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Gurucharan Bhaskar Mendon
- Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Dristy Gurung
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Lucie Kondratova
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czechia
| | - Matyas Muller
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czechia
| | - Mariangela Lanfredi
- Unit of Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Antonio Lasalvia
- Section of Psychiatry, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | | | | | - Mario Tomasini
- Department of Mental Health, Alto Garda e Ledro Giudicarie, Arco, Italy
| | - Rabih El Chammay
- National Mental Health Programme Ministry of Public Health, Beirut, Lebanon
- Department of Psychiatry, Saint Joseph University, Beirut, Lebanon
| | - Racha Abi Hana
- National Mental Health Programme Ministry of Public Health, Beirut, Lebanon
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
| | - Yosra Zgueb
- Department of Psychiatry A, Razi Hospital La Manouba, Manouba, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fethi Nacef
- Department of Psychiatry A, Razi Hospital La Manouba, Manouba, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Eva Heim
- Institute of Psychology, University of Lausanne, Lausanne, Switzerland
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | | | | | - Maria Milenova
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Nadja van Ginneken
- Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Graham Thornicroft
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Brandon A. Kohrt
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
- Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington, DC, United States of America
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Heim E, Ramia JA, Hana RA, Burchert S, Carswell K, Cornelisz I, Cuijpers P, El Chammay R, Noun P, van Klaveren C, van Ommeren M, Zoghbi E, van't Hof E. Step-by-step: Feasibility randomised controlled trial of a mobile-based intervention for depression among populations affected by adversity in Lebanon. Internet Interv 2021; 24:100380. [PMID: 33747798 PMCID: PMC7967003 DOI: 10.1016/j.invent.2021.100380] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND E-mental health interventions may help to bridge the mental health treatment gap. Evidence on their effectiveness is compelling in high-income countries. Not enough evidence has been generated on their use with communities affected by adversity in low- and middle-income countries. The World Health Organization (WHO), the National Mental Health Programme (NMMP) at Ministry of Public Health (MoPH) in Lebanon and other partners have adapted a WHO intervention called Step-by-Step for use with Lebanese and displaced people living in Lebanon. Step-by-Step is a minimally guided, internet-based intervention for adults with depression. In this study, a feasibility randomised controlled trial (RCT) and a qualitative process evaluation were conducted to explore the feasibility and the acceptability of the research methods, and the intervention, in preparation for two fully powered trials to assess the effectiveness and cost-effectiveness of Step-by-Step in Lebanon. METHOD Participants were recruited through social media. Inclusion criteria were: being able to understand and speak Arabic or English; access to an internet connected device; aged over 18; living in Lebanon; scores above cut-off on the Patient Health Questionnaire and the WHO Disability Assessment Schedule 2.0. Participants were randomly assigned to the intervention or enhanced care as usual. They completed post-assessments eight weeks after baseline, and follow-up assessments another three months later. Primary outcomes were depression and level of functioning, secondary outcomes were anxiety, post-traumatic stress, and well-being. Qualitative interviews were conducted to evaluate the feasibility and acceptability of the research procedures and the intervention. RESULTS A total of N = 138 participants, including 33 Syrians, were recruited and randomised into two equal groups. The dropout rate was higher in the control group (73% post- and 82% follow-up assessment) than in the intervention group (63% post- and 72% follow-up assessment). The intervention was perceived as relevant, acceptable and beneficial to those who completed it. Suggestions were made to further adapt the content and to make the intervention more engaging. Statistical analyses were conducted despite the small sample size. Complete cases analysis showed a statistically significant symptom reduction in depression, anxiety, disability, and post-traumatic stress, and statistically significant improvement in well-being and functioning. Intention-to-treat analysis revealed non-significant effects. CONCLUSION The research design, methods and procedures are feasible and acceptable in the context of Lebanon and can be applied in the RCTs. Preliminary findings suggest that Step-by-Step may be effective in reducing symptoms of depression and anxiety and improving functioning and well-being.
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Affiliation(s)
- Eva Heim
- Department of Psychology, University of Zurich, Switzerland,Corresponding author at: University of Zurich, Department of Psychology, Binzmuehlestrasse 14/17, 8050 Zurich, Switzerland.
| | - Jinane Abi Ramia
- National Mental Health Programme, Ministry of Public Health, Beirut, Lebanon,Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Racha Abi Hana
- National Mental Health Programme, Ministry of Public Health, Beirut, Lebanon,Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Sebastian Burchert
- Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Kenneth Carswell
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Ilja Cornelisz
- Amsterdam Center for Learning Analytics, Research Institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Rabih El Chammay
- National Mental Health Programme, Ministry of Public Health, Beirut, Lebanon,Psychiatry Department, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Philip Noun
- National Mental Health Programme, Ministry of Public Health, Beirut, Lebanon
| | - Chris van Klaveren
- Amsterdam Center for Learning Analytics, Research Institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Mark van Ommeren
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Edwina Zoghbi
- Country Office for Lebanon, World Health Organization, Beirut, Lebanon
| | - Edith van't Hof
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
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