Assessing the Effectiveness of a Self-Guided Digital Mental Health Intervention for Syrian Refugees in Egypt

Introduction

Since 2011, the Syrian conflict has led to the displacement of over 5 million people, creating one of the largest global refugee crises in recent history. Refugees from Syria have encountered profound psychological impacts due to war, displacement, and challenging living conditions in host countries. In Egypt alone, there are approximately 137,000 registered Syrian refugees who experience high rates of mental health issues, including depression, anxiety, and posttraumatic stress disorder (PTSD).

Given Egypt’s resource limitations and the dispersed nature of Syrian refugees across urban areas, providing adequate mental health support through traditional means has been challenging. Digital mental health solutions, such as the World Health Organization’s Step-by-Step (SbS) program, present a potential method for offering mental health support at scale. However, real-world studies on their effectiveness, particularly for self-guided formats without regular professional involvement, remain limited. This study, published in PLOS Medicine , a randomized controlled trial funded by the European Union’s STRENGTHS project, explores the effects of the SbS app on Syrian refugees’ mental health in Egypt, aiming to expand the evidence base for digital mental health tools in humanitarian settings.

Study Design and Methodology

The study recruited 538 Syrian refugees living in Egypt who showed signs of elevated psychological distress and impaired psychosocial functioning. To participate, individuals needed to score above a certain threshold on standardized measures, indicating distress and reduced functioning. Participants were randomly assigned to one of two groups:

• Intervention Group (SbS + CAU): This group received the Step-by-Step intervention along with care-as-usual (CAU). The SbS program includes five self-help sessions covering therapeutic techniques like behavioral activation and stress management, delivered through a user-friendly app.
• Control Group (CAU only): Participants in this group received only care-as-usual, meaning they could access any mental health services available within the community but did not receive additional intervention through the SbS app.

Each participant in the intervention group had optional access to message-based contact-on-demand (COD) support, allowing them to reach out to “e-helpers” as needed. These e-helpers were non-professional assistants trained to provide basic support and answer technical questions about the app. However, e-helper interaction was optional, allowing the intervention to remain largely self-guided. Outcome measures, including psychological distress (Hopkins Symptom Checklist 25) and psychosocial functioning (WHO Disability Assessment Schedule 2.0), were assessed at baseline, post-intervention (6 weeks), and follow-up (3 months).

Primary Outcomes and Findings

The primary outcomes of the study focused on improvements in psychological distress and daily functioning. Results indicated that participants in the SbS + CAU group showed a modest reduction in psychological distress at the three-month follow-up compared to the CAU-only group. Specifically, the intervention group demonstrated an average reduction of 0.15 points on the Hopkins Symptom Checklist 25 (HSCL-25), a standardized measure of distress, indicating a small but statistically significant effect.

For daily functioning, assessed using the WHO Disability Assessment Schedule (WHODAS 2.0), participants in the SbS + CAU group displayed an average improvement of 2.04 points compared to the control group. This effect size was also small, highlighting a slight improvement in functioning. Although these improvements were statistically significant, the effects were limited in size, indicating that while the intervention provided some benefit, it may not suffice as a standalone treatment for severe mental health concerns.

Secondary Outcomes and Limitations

The study also examined secondary outcomes, including symptoms of PTSD and participant-identified problems (assessed through the Psychological Outcomes Profiles Scale or PSYCHLOPS). No statistically significant differences were found between the intervention and control groups for PTSD symptoms or self-reported issues, suggesting that the SbS intervention may have limited impact in addressing these areas specifically. Given the high comorbidity of psychological issues within refugee populations, this finding highlights the challenge of addressing complex mental health needs through brief, self-guided digital interventions.

Additionally, the study faced a high dropout rate, with 63.2% of participants in the SbS group not completing the intervention. Most dropouts occurred during the early stages, with a substantial proportion of participants not progressing past the introductory session. This high attrition rate suggests that engagement strategies within the app may need refinement to retain participants’ interest and commitment over time. Furthermore, only 9.4% of participants utilized COD support, highlighting a possible gap in the perceived relevance or accessibility of the optional e-helper support feature.

Implications for Digital Mental Health Interventions

This study provides important insights into the real-world application of digital mental health interventions within refugee populations. Despite the modest improvements observed, the SbS program’s small effect sizes underscore the need for further adaptations to enhance effectiveness. Cultural and contextual factors likely influence participants’ engagement and the intervention’s perceived relevance, particularly in self-guided formats. To improve adherence and outcomes, future iterations of the SbS program and similar interventions could incorporate the following strategies:

• Enhanced User Engagement: The high dropout rate points to potential barriers in sustained engagement. Adding interactive elements, reminders, and personalized progress tracking could help retain participants’ interest. Regular prompts or check-ins from e-helpers might improve adherence without compromising scalability.
• Refinement of COD Support: The low utilization of COD support suggests it may not fully align with participants’ needs. A more proactive approach, where e-helpers initiate check-ins, could encourage participants to seek assistance when needed. Alternatively, a hybrid model combining automated and human-guided support could offer a more responsive experience.
• Cultural Adaptation: Understanding the unique mental health needs and cultural perceptions of Syrian refugees is essential. Tailoring intervention language to avoid medical jargon and incorporating culturally relevant examples could improve accessibility and resonance with users.

Potential for Wider Applications

Despite its limitations, the SbS study adds to a growing body of research on digital mental health interventions, particularly for hard-to-reach and underserved populations. Digital solutions offer unique advantages in contexts where access to conventional mental health resources is restricted. By providing a low-cost, accessible mental health resource, digital interventions like SbS could support large numbers of people, especially in regions facing humanitarian crises and limited healthcare infrastructure.

The results also suggest that these types of interventions might serve as an adjunct to in-person mental health services, rather than a replacement. As demonstrated by the high service utilization among study participants, many refugees with mental health needs still sought additional, often more intensive support. Therefore, digital tools could be integrated into existing health systems to extend reach, provide psychoeducational content, and offer initial support that could complement traditional services. In the long run, this integration could reduce demand on overstretched healthcare systems by offering preliminary support to individuals with mild to moderate symptoms.

Conclusion and Future Directions

While the SbS digital intervention demonstrated modest improvements in distress and functioning, its effectiveness as a standalone tool remains limited by low adherence and engagement. This trial underscores the potential and challenges of implementing digital mental health tools in humanitarian settings. To optimize these interventions for refugee populations, future research should explore alternative support models, such as structured hybrid guidance approaches that blend self-guidance with regular, automated prompts or live check-ins from support staff.

Furthermore, this study highlights the importance of understanding and addressing cultural, technological, and logistical barriers when implementing digital health solutions. Future developments could benefit from ongoing user feedback and iterative testing to refine app features and support options that align more closely with user expectations and needs. Enhancing flexibility within these digital frameworks may allow for better adaptation across diverse settings, benefiting refugee populations worldwide and other underserved groups facing similar challenges.

Ultimately, digital mental health interventions hold promise as a component of integrated support strategies for global mental health, offering accessible, scalable, and potentially transformative solutions for populations with limited healthcare access. However, further research and development are required to maximize their effectiveness and sustainability, ensuring that these tools can provide meaningful support in an equitable and culturally appropriate manner.