Moving a digital mental health intervention from research to a national scale in Lebanon.

Abstract

Digital mental health interventions (DMHIs) have emerged as a potentially effective and affordable option for delivering mental health care and a promising solution to help reduce the mental health treatment gap. Nonetheless, their uptake remains a challenge. Literature on their effectiveness and uptake in crisis-affected low- to middle-income countries (LMICs) is limited, and little is known about their implementation and scale-up pathways in unstable and fragmented settings where the need is highest. This dissertation investigated whether and how these interventions survive, adapt, and integrate in volatile settings. This thesis provided empirical evidence on the phased implementation pathway of a World Health Organization (WHO) scalable digital intervention for depression called Step-by-Step (SbS) in Lebanon, an LMIC facing protracted crises. Following the Medical Research Council (MRC) framework, the research started with a community-driven cultural adaptation process, followed by an uncontrolled pilot to test the feasibility and acceptability of SbS in Lebanon, a feasibility RCT to test the research methods, a qualitative evaluation of the RCT that explored the views of users, staff, and stakeholders with SbS in Lebanon, and an implementation pilot of the scale-up of SbS in the real-world setting. This dissertation provided a rare end-to-end implementation of the full MRC framework combined with RE-AIM to guide the scale-up phases of a DMHI in a crisis-affected LMIC. The learnings generated offer broader implications to the implementation science field and the scale-up of DMHIs in similar settings. The first learning is that cultural adaptation is an iterative process and that cultural expressions of distress are highly shaped by contextual challenges rather than culture alone. Another key learning was that reporting of attrition rates in DMHIs should distinguish between starters and non-starters. Furthermore, the public health impact of DHMIs must be captured using mixed methods, beyond the usage metrics typically used to evaluate uptake. Engagement is structurally shaped, not merely motivational. Additionally, it provided a practical example of how effectiveness and endorsement alone are not sufficient to secure adoption and maintenance of the DHMI in a healthcare system. Successful integration requires organizational embedding, harmonization with existing protocols, and sustained legal and financial frameworks, as well as political commitment.