Arabic-language digital interventions for depression in German routine health care are acceptable, but intervention adoption remains a challenge

doi:10.21203/rs.3.rs-3127525/v1

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Arabic-language digital interventions for depression in German routine health care are acceptable, but intervention adoption remains a challenge

https://doi.org/10.21203/rs.3.rs-3127525/v1

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published 12 Jun, 2024

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Migrants face many barriers to mental health care, such as different cultural concepts of distress, unfamiliar pathways to care, and language. Digital mental health interventions are effective and scalable in multi-language versions. However, their implementation into routine care is in its infancy. Here, we report on the Arabic- and German-language implementation of two digital interventions in Germany: The iFightDepression® website, providing information about depression to the public, and the iFightDepression® tool, offering guided self-management for depression. Their acceptability (time on page, usage behavior) was comparable between the two user groups. The website penetration of the target populations was nine times lower among Arab migrants in Germany than Germans (89 vs. 834 unique page views/ 100,000). The adoption of the tool was lower among Arabic than German users (conversion rate from invitation to completed registration: 30.8% vs. 59.0%, p < .001). Our results show that uptake of digital interventions for migrants requires facilitation.

Health sciences/Diseases/Psychiatric disorders/Depression

Health sciences/Health care/Health services

Treatment gaps for mental disorders are painfully present in today’s health care systems¹. Undertreatment for instance has been documented for people living with depressive disorders in 21 countries, showing that only 1 in 5 people in high-resource and

1 in 27 in low-resource settings receive minimally adequate treatment². In addition, the long time lag between evidence and implementation of innovations into practice exacerbates gaps in health care services³. Global challenges, such as the COVID-19 pandemic or mass migration following armed conflicts, place increasing pressure on societies and health care systems to find timely responses and deliver treatment for mental disorders during crisis and in times of increased need⁴. Internet-delivered treatments for mental disorders have existed for at least 20 years and may serve as a vehicle for innovation⁵. They can improve access to care for many and shall pave the way for more equity in healthcare, ensuring that those who have not been engaged with the health care system will have access to high quality care⁶. In this report, we will showcase the implementation of evidence-informed digital interventions for depression (DID) in Arabic language in Germany as a response to a mental health crisis.

The 2015 Syrian refugee crisis will serve as an example of a mental health crisis calling for imminent action. Applications for asylum peaked as a result, with Germany currently hosting around 1.3 million forcedly displaced persons, i.e., the most asylum seekers and refugees (ASR) in the European Union (www.unhcr.org/refugee-statistics). A refugee is a person who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion. An asylum seeker is someone who has requested sanctuary in another country and is awaiting a decision on their application (www.unhcr.org/asylum-seekers). By 2021, over six million refugees from Syria had been registered internationally following the armed conflict (www.unhcr.org/syria-emergency). Aside from post-traumatic stress disorders (PTSD), depressive disorders are the most frequent mental health disorders among ASR⁷. A recent meta-analysis reported prevalence rates of 31.5% for both PTSD and depressive disorders in ASR⁸, which is considerably higher than in the German general population⁹. Prevalence rates for depressive disorders varied between subgroups of ASR depending on visa status (asylum seekers: 30.1% vs. refugees: 26.7%), origin (Middle East: 28.6%, Asia: 1.9%, Africa: 23.3%, Europe: 35.8%, mixed: 31.8%), and residence (30.1% community vs. 23.5% refugee/ asylum seeker accommodation)⁸. Syrian ASR are a subgroup within the broader picture of over one million adult migrants from Arab states living in Germany (i.e., also considering first-generation labor migrants, persons joining their family from abroad, foreign students; www.destatis.de). While little is known about the mental health of this broader group in Germany, we do know that high-income labor migrants originating from Arab states experience higher rates of depressive symptoms compared to non-migrant Arabs in Qatar¹⁰. Current literature on the association between depression and migration shows that around one in four migrants globally suffer from depression, which exceeds the prevalence of depression reported by community samples in different nations and demonstrates a need for culturally fitting and targeted responses from migrant host nations and their serving clinicians¹¹.

Mental health disorders in ASR in particular, and migrants in general, frequently remain untreated¹². Potential barriers to health services occur at different levels: the patient, the provider, and at the system level¹³. While language is by no means the only factor that may act as a barrier and is, per se, not crucial for the successful delivery of mental health interventions¹⁴, limited access to interpreting services has been shown to curtail migrant health care throughout Europe^15,16. In this case, DID may provide an opportunity for overcoming linguistic barriers to health care provision, as they can be offered and scaled up in different language versions¹⁷. While the effectiveness of DID is well established¹⁸ and their cost-effectiveness likely^19,20, their implementation into routine care is still in its infancy. On the one hand there are successful examples of routine care implementations²¹, on the other hand intervention adoption seems to stay below expectations and usage behavior may vary from that reported in controlled trials²². And while the DID for ASR seem to be well accepted in trial settings^23–25, their implementation into routine health and social care has not yet been systematically studied.

In view of the high influx of Arabic-speaking ASR in Germany (www.unhcr.org/refugee-statistics), the high prevalence of depressive disorders in this group and in migrants in general, and the difficulties to provide imminent and scalable Arabic-language mental health care, Arabic versions of two previously established DID were created: the publicly available iFightDepression® Awareness Website (short: iFD website) and the iFightDepression® tool (short: iFD tool). Both interventions were first developed within an EU-funded project²⁶ and have been provided by the European Alliance Against Depression (EAAD) to the public free-of-charge in 19 (iFD website) and 16 (iFD tool) different language versions (www.ifightdepression.com). The iFD website provides evidence-based information about depression and its treatment for different target groups (e.g., young adults, family and friends, physicians and pharmacists). We consider this to be a crucial step as previous research has shown that the majority of ASR with mental health problems in Europe did not utilize mental health care services²⁷. In Syria and neighbouring countries, the explicit labelling of distress as a mental health problem constitutes a source of shame, embarrassment and fear of scandal, with the potential shame extending from patients to their families and affecting the use of mental health services²⁸. Providing information about depression to the public may help combat stigma, a main barrier to mental health care. Stigma is negatively associated with help-seeking for mental health related problems; ethnic minorities and males were disproportionally deterred by it²⁹. Furthermore, migrants frequently lack knowledge of health services in the host country³⁰ and most ASR did not have clear or defined expectations concerning appropriate mental health treatment possibilities³¹. Further, first generation immigrants showed remarkable differences in health care utilization compared to native-born Germans and second generation immigrants: they were less likely to contact medical specialists, but used general practitioners in primary care more frequently³². The iFD tool is a guided, web-based intervention for depressive disorders. It provides elements of cognitive behavioural therapy for use in self-management of mild to moderate forms of depression and can be offered in primary care or by mental health care professionals. Its efficacy has been established³³. An expert panel of 12 regional stakeholders and scientists guided the translation into Arabic language and the corresponding cultural adaptation of both interventions. Figure 1 gives an impression of the iFD tool in Arabic language.

This article reports on the implementation of the two Arabic-language DID in public and routine health care in Germany, covering an implementation time span of three years. It seeks to answer the following research questions (RQs):

How well were the Arabic versions of the iFD website and the iFD tool adopted in the Arabic-speaking population in Germany over time, in relation to the adoption of the German versions?

How appropriate was the iFD tool, a DID that was developed for mild to moderate forms of depression, for Arabic-speaking users compared to German-speaking users in Germany?

How acceptable was the content of the iFD website and the iFD tool to Arabic-speaking users compared to German-speaking users and compared to health-related content on the internet in general?

How much did the iFD website penetrate the Arabic-speaking population in Germany, in relation to the penetration of the iFD website in the German-speaking population?

How sustainable were the implementation activities over time?

Regarding RQ1, we expected that visits to the iFD website would increase in the first two years of implementation, in the case where the iFD website was well adopted by the target group. For the iFD tool, we assessed whether conversion rates from invitation to completed registration differed between Arabic and two different German subgroups of users. In this report, data from these three different iFD tool subsamples were used: Arabic-speaking users (guided use), German-speaking users from routine health care (guided use), and German-speaking users who had registered for the unguided use of the iFD tool during the early days of the COVID-19 pandemic (open use, see below). Regarding RQ2, we assessed whether there were any differences between subgroups of users in depression severity upon first iFD tool registration to determine if the intervention was reaching the intended target population. Regarding RQ3, we assessed whether users spent different amounts of time on pages of the Arabic iFD website compared to the German iFD website and other websites presenting health-related content on the internet. For the iFD tool, we assessed whether there were any differences in usage behaviour within the tool between user subgroups. Regarding RQ4, we assessed whether page views per 100,000 inhabitants in the most current year of implementation differed between the Arabic- and German-speaking populations in Germany. Regarding RQ5 with the aim of gaining an understanding about the sustainability of implementation activities beyond the first two years, we assessed for both language versions whether the page views of the iFD website were still increasing or stable in the third year of implementation compared to the previous years.

Implementation outcomes and clinical indicators relevant to further implementation will be reported in the following for both DID. For the iFD website, we report on adoption, acceptability, penetration, and sustainability of the intervention. For the iFD tool, we report on adoption, appropriateness, and acceptability. Please refer to Table 1 for implementation indicators for the iFD website and Table 2 for sociodemographic, clinical, and usage behavior characteristics of iFD tool users.

Table 1

Implementation indicators for the iFD website by implementation year and language.
		Arabic version		German version
		count	% compared ^a	count	% compared ^a
Page views (N)	1st year	128	-	352,357	-
	2nd year	1,092	853%	836,196	237%
	3rd year	2,469	226%	855,324	102%
Unique page views (N)	1st year	97	-	259,825	-
Unique page views (N)	2nd year	802	827%	601,916	232%
	3rd year	1,708	213%	601,887	100%
Average time on page (sec.)	1st year	118	236%	80	160%
Average time on page (sec.)	2nd year	71	142%	77	154%
	3rd year	71	142%	67	134%
Note. The 1st year of implementation started on the 1st of April 2019 for the Arabic version and on the 1st of June 2018 for the German version of the iFD website.
^a % compared to previous year for page views and unique page views, compared to benchmark of 50 sec. for average time on page.

Table 2

Sociodemographic, clinical, and usage behavior characteristics for the iFD tool by subsample.
	Subsample			Test statistics
	Arabic	German (guided)	German (open)	Arabic vs. German (guided)	Arabic vs. German (open)
Invited users
Number of active guides	37	919	1 centre ^a
Number of invited users (n_inv)	78	7,895	13,911
Invited users per active guide (median)	1	3	-
Registered users (n_reg)	24	4,661	10,622
Mean age (s.d., range)	31.0 (9.8, 19–60)	37.3 (13.4, 18–84)	38.0 (12.2, 18–87)	U = 41,707, p = .031, d = 0.25 [0.07; 0.42]	U = 172,853, p = .002, d = 0.36 [0.14; 0.54]
n (%) female	5 (20.8%)	2,870 (61.6%)	7,574 (71.3%)	Chi²(2) = 16.96, p < .001	Chi²(1) = 29.74, p < .001
n (%) current psychotherapy	9 (37.5%)	2,522 (54.1%)	3,861 (36.3%)	Chi²(1) = 2.65, p = .207	Chi²(1) = 0.01, p = .907
n (%) current antidepressant medication	11 (45.8%)	2,245 (48.2%)	3,755 (35.4%)	Chi²(1) = 0.05, p = .820	Chi²(1) = 1.15, p = .567
Conversion rate (invitation to registration)	30.8%	59.0%	76.4%	Chi²(1) = 24.32, p < .001	Chi²(1) = 86.15, p < .001
Matching 1: Age & sex
n	24	48	48
Mean age (s.d., range)	31.0 (9.8, 19–60)	31.0 (9.7, 19–60)	31.0 (9.7, 19–60)
n (%) female	5 (20.8%)	10 (20.8%)	10 (20.8%)
Initial PHQ-9 sum score (s.d., range)	16.5 (6.8, 1–27)	12.6 (5.6, 1–23)	12.8 (5.3, 3–23)	t(38.99) = 2.41, p = .027, g = 0.64 [0.13; 1.14]	t(37.70) = 2.31, p = .027, g = 0.62 [0.11; 1.12]
Matching 2: Age, sex, & depression severity
n	24	48	48
Mean age (s.d., range)	31.0 (± 9.8, 19–60)	30.6 (10.7, 18–78)	30.7 (9.7, 18–60)
n (%) female	5 (20.8%)	10 (20.8%)	10 (20.8%)
Initial PHQ-9 sum score (s.d.)	16.5 (6.8, 1–27)	16.3 (5.8, 3–25)	16.3 (5.4, 7–27)
Number of completed workshops (s.d.)	0.8 (1.1, 0–4)	1.1 (1.4, 0–6)	0.7 (1.2, 0–6)	U = 472, p = .376, d = 0.18 [-0.08; 0.42]	U = 601, p = .743, d = 0.04 [-0.22; 0.30]
Note. n_inv = number of users that have been invited to use the iFD tool or who contacted the German Depression Foundation during the COVID-19 pandemic, n_reg = number of users who registered in the iFD tool and completed a baseline assessment. For age, the subsample mean in years is given. PHQ-9 = sum score of Patient Health Questionnaire-9, s.d. = standard deviation. Welch t-tests for unequal variances were applied where necessary, all p-values were corrected with fdr correction for two tests, as differences concerning one variable were tested in two comparisons each. 95% confidence intervals are provided in [] for effect sizes (d = Cliff’s Delta, g = Hedge’s g). Statistically significant results are printed in bold.
^a All users who self-registered for the unguided use of the iFD tool during the early days of the COVID-19 pandemic were administered by the coordination centre of the German Depression Foundation in Leipzig, Germany.

Adoption (iFD website, iFD tool)

Page views and unique page views of the Arabic iFD website increased during the first two years of implementation. The increase from the first to the second year was very steep (853% and 827% of year one’s page views/ unique page views in year two). In the German version, page views and unique page views doubled from year one to year two.

Compared to N = 919 registered, active guides using the German version of the iFD tool with their patients in routine health care, only N = 37 guides invited users to the Arabic version of the iFD tool. The median number of invited users per guide was one, while guides invited a median of three persons when using the German version. The conversion rate from invitation to completed registration was lower in the Arabic subsample (30.8%) than in both German subsamples (guided: 59.0%, open: 76.4%). The differences were statistically significant (p < .001).

Appropriateness (iFD tool)

Registered users of the iFD tool in the Arabic subsample were significantly younger

(p ≤ .05) and more likely to be male (p < .001) than users in both German subsamples. There were no differences between Arabic users and German guided und open users in the frequency of receiving antidepressant medication or psychotherapy.

After matching for age and sex, depression severity upon first registration (PHQ-9) was higher in the Arabic subsample compared to both German groups (p = .027).

Acceptability (iFD website, iFD tool)

The mean average time on page was higher for the Arabic version of the iFD website compared to the German version (86.7 sec. versus 74.7 sec.). This difference was not statistically significant (W = 5, p = 1, Cliff’s delta = 0.11 [-0.82; 0.88]). The average times on page for both language versions were not statistically different from the benchmark of 50 sec. (Arabic version: V = 6, p = .174; German version: V = 6, p = .181).

When matched for age, sex, and initial PHQ-9 sum score, the mean number of completed workshops for the Arabic-speaking subsample was not statistically different from both German-speaking subsamples (p ≥ .376).

Penetration (iFD website)

In the most recent year of implementation, there were 945 unique page views from Arabic language users located in Germany, versus 763 unique page views from Arabic language users located outside Germany (not shown in Table 1). That is, 55.3% of Arabic language website users were in Germany. The penetration of the Arabic version of the iFD website in the target population (first generation migrants holding a passport of a country where Arabic is the official language, who were living in Germany at the end of 2021) was 89 unique page views per 100,000 inhabitants.

For the German version of the iFD website, there were 502,863 unique page views from German language users located in Germany, versus 99,024 unique page views from German language users located outside Germany. That is, 83.5% of German language users were in Germany. The penetration of the German iFD website in relation to German passport holders at the end of 2021 in Germany was 834 unique page views per 100,000 inhabitants and therefore, approximately nine times higher than in the Arabic target population.

Sustainability (iFD website)

However, from year two to year three, page views and unique page views of the Arabic version still more than doubled. Whereas in the German version, page views and unique page views during year three stayed similar to that of year two.

In response to a public health crisis that followed the armed conflict which forced many people to be internationally displaced, two Arabic language DID were translated, culturally adapted, and implemented free-of-charge in Germany. Our report covered a three-year timespan of implementation and compared implementation-related and clinical characteristics of Arabic-speaking users to German-speaking users of both DID.

The implementation of the Arabic iFD website was targeted toward the general public and community, with the aim of providing information about depression to support people in accessing guideline-oriented treatment options. The publicly available iFD website was well adopted and accepted in Arabic language, with comparable or even exceeding implementation indicators compared to the German language version. However, the penetration within the German-speaking population was around nine times higher than within the Arabic-speaking population in Germany, leaving space for further implementation in this latter population. The implementation activities carried out were shown to be sustainable as indicators remained stable or continued to increase in the third year of implementation for both language versions of the iFD website. The implementation of the Arabic iFD website was even accompanied by an adoption beyond national borders, as 44.7% of unique page views for the Arabic version in the most recent year of implementation originated from outside Germany. The social return on investment, or, whether the implementation of this publicly available DID was accompanied by increased knowledge about mental disorders, reduced stigma, or even increased help-seeking behaviour among ASR in Germany, remain areas for further research.

The second DID implemented in Arabic language was the iFD tool, a web-based, guided intervention offering elements of cognitive behavioural therapy as well as information about resilience and the German health care system to individuals with mild to moderate forms of depression. The adoption of the iFD tool stayed thus far below expectations. Despite the scientific community and public institutions calling, via policy statements and funding opportunities, for low threshold interventions for ASR, only a relatively small number of guides offered the iFD tool to their Arabic-speaking patients. The current study further showed that the conversion rate, i.e., the transition from invitation by a guide to user registration and use of the iFD tool, was lower among Arabic-speaking users compared to German-speaking users (of both the guided and unguided version that was offered during the early days of the COVID-19 pandemic). Difficulties in reaching the target populations and managing dropout rates have also been faced by other DID for ASR³⁴. The acceptability of the content of the iFD tool was, however, comparable between user groups, even when all subsamples showed higher depressive symptom burden than the study sample of the efficacy study³³. Hypothesis about possible barriers to the adoption of this DID among ASR in Germany include, but are not limited to, individual and cultural aspects, as well as aspects concerning the post-migration living situation in Germany, taking into account that the current report investigated the implementation of a DID in regular health and social care (and not a controlled study setting). User behavior in DID may differ greatly when compared between study setting and real-world usage³⁵. Apart from stigma associated with mental health problems (see above), a general sense of mistrust as a result of traumatic experiences³⁶ might hinder ASR to engage with a guided DID. A lack of technology literacy among ASR has been identified as another challenge associated with using DID^23,37, but also technological and network issues were causing delay and poor quality of DID²³ and problems with accessing the internet was identified as a common barrier toward DID in Syrian refugees³⁷. These barriers are partially related to housing conditions; most ASR start in transitional housing³⁸. In shared accommodation, low privacy whilst using a DID might be a concern as computers for common use are often located in community rooms and bedrooms are frequently shared by multiple persons. As of January 2017, hundreds of thousands of ASR continued to live in temporary shelters after the 2015 influx³⁹. A possible solution to this problem might be an app version (instead of the current web-based iFD tool) that could allow content download locally to a mobile phone and less frequent synchronising so that Wi-Fi access and location would be less of a problem when using the iFD tool. Another reason for a low adoption of the iFD tool might be differing help-seeking preferences to what a DID can offer. For instance, a study showed that Arab Australians preferred face-to-face over internet-delivered treatment for psychological distress⁴⁰. Arabic-speaking users of a guided DID in Sweden noted though that a DID in Arabic language was preferrable to face-to-face therapy with an interpreter⁴¹. Future research needs to assess whether these findings are applicable to migrants from the Arab states living in Germany.

Our straightforward implementation approach of two evidence-informed DID showcased how the research to practice gap can be reduced in the context of a public mental health crisis. Experts guided the translation and cultural adaptation of the previously established DID. The degree of such adaptations proved to be associated with higher efficacy among guided self-help interventions⁴². Some limitations need to be considered though. The DID were evidence-informed, but have not been assessed for efficacy in their Arabic language and culturally adapted versions. There is, however, strong evidence for the efficacy of similar DID in Arabic language²⁴ and for the iFD tool itself³³ including an assessment of possible negative effects⁴³. Patients and ASR representatives were not part of the expert group guiding the translation and adaptation process. The parsimonious usage of log-data for the evaluation of the implementation activities did not provide the opportunity to distinguish between residence status of Arabic language users, i.e., we cannot know whether the users of the iFD tool were indeed part of the target group of ASR living in Germany or whether other individuals proficient in the Arabic language were reached. The comparability between the assessed language versions was not fully given as the German iFD website existed in a previous version and therefore, we need to have in mind that it might have started with higher page views and unique page views after its relaunch, whilst the Arabic version was first launched in 2019. The German version was nonetheless chosen as a comparator for the current report for reasons of temporal and spatial proximity to the implementation activities of the Arabic DID in Germany. Other implementation outcomes (e.g., feasibility, fidelity, costs), service outcomes (e.g., effectiveness), and client outcomes (e.g., satisfaction, function) were not assessed. The level of human guidance in digital interventions can induce a significant moderation effect on outcomes⁴⁴, but the fidelity of iFD tool guides regarding their compliance with guidance standards was not assessed and consequently not compared between language versions. We can also not report on the penetration of the interventions within the narrower target group of social and health services for ASR in Germany. Symptom improvement within the iFD tool users has not been assessed due to the small case numbers of Arabic-language users. Finally, the implementation protocol has not been preregistered.

Two DID were implemented in Germany to overcome structural barriers and foster equity in health care access for individuals affected by depression. Whilst there is great general interest in the use of digital health interventions, even countries like Germany, which is relatively far along in the operationalization of necessary frameworks, are struggling with an efficient implementation⁴⁵. Our in-depth analysis of implementation outcomes helped to understand critical points within the implementation process. The analysis of the iFD website’s penetration within the target population showed that there is space for further uptake in the Arabic-speaking community in Germany. Future public relation (PR) activities might want to focus on continuing the promotion of the iFD website in the Arabic-speaking population in Germany (and beyond) to reach similar levels of penetration as with the German-speaking population. An analysis of the findability and an optimization for search machines might be important steps in addition to PR campaigns. Conversion rates in iFD tool users need to be monitored to support guides and invited users in accessing the content of the iFD tool. Next steps may include investigating differences between user groups in accessing the iFD tool and to evaluate the fidelity of different guide groups (medical doctors vs. psychotherapists vs. social workers) with the procedures required by the iFD tool in order to deliver the DID successfully to ASR in routine health and social care. In view of current – including the war against Ukraine – and future societal challenges, the provision of Ukrainian and Russian language versions of the iFightDepression® interventions have been awarded funding by the European Union (EU4Health Programme, grant number 101101460) and are already underway. Modern research designs need to support and drive the successful implementation of innovative, evidence-informed mental health interventions for so-far underserved populations.

Design

This work utilized an effectiveness-implementation type 3 hybrid approach. Hybrid effectiveness-implementation designs were proposed to allow examination of both types of outcomes, i.e., effectiveness and implementation outcomes, within one study instead of using a traditional research pipeline with a sequential approach⁴⁶. The type 3 hybrid focuses primarily on implementation outcomes, while also considering clinical indicators (e.g., symptom severity of users) and usage behaviour within the DID as they relate to the appropriateness and acceptability of the intervention. Following the terminology of implementation outcomes proposed by Proctor and colleagues⁴⁷, we reported on five outcomes (i.e., adoption, appropriateness, acceptability, penetration, and sustainability), each addressed by one RQ (see above).

The research was conducted in accordance with the principles of the Declaration of Helsinki. The protocol for the concomitant evaluation of the iFD tool was reviewed and approved by the ethics committee of the Medical Faculty, University of Leipzig on May 27, 2016 (record number: 172 − 16/ek-14032016). Informed consent was obtained from all users of the iFD tool upon registration.

Study populations

The implementation of the DID aimed to reach adult, native speakers of the Arabic language at two different population levels in Germany: i) the general public and community, and ii) patients and individuals with mild to moderate forms of depression. To approximate the target group for Arabic language implementation, the following population estimate was used: at the end of 2021, there were N = 1,060,290 adult (≥ 18 years) first generation migrants holding a passport of a country where Arabic is the official language1 and who were living in Germany⁴⁸. As a comparison group, we used the population of N = 60,312,535 adults with German nationality that were living in Germany at the same date⁴⁸.

Patients and individuals with mild to moderate forms of depression were identified by primary care and specialist physicians, psychotherapist, or other healthcare professionals and social workers involved in the support of ASR in Germany. These professionals served as guides and invited potential users to the iFD tool. An open, unguided use of the German version of the iFD tool was offered from 18 March to 01 July 2020 only. These users did not receive any face-to-face guidance, but instead received automatic weekly reminder emails during the first six weeks of using the intervention⁴⁹. Users of the iFD tool were included into the analyses when they were at least 18 years old and had given informed consent to participate in the ongoing evaluation of the tool, as required at registration.

Digital interventions

Two DID were offered for free-of-cost use in Germany. The iFD website is publicly available (www.ifightdepression.com). For the iFD tool, users gained access through active registration following an invitation by a guide (see above). The efficacy of the guided, German language version of the iFD tool has been established by a randomized controlled trial³³.

Translation and cultural adaptations

Whilst the German DID were developed within an EU-funded project²⁶, the Arabic versions were translated and culturally adapted between December 2017 and December 2018. The DID translation and adaptation process was guided by an expert panel to ensure appropriateness of the DID for ASR. The panel consisted of 12 persons that were either regional stakeholders involved in the social and mental health care for ASR or scientists working in the following fields: affective disorders, migration, treatment of trauma and torture survivors, international or intercultural communications. Based on a literature review, an initial version of the German DID texts was adapted for populations from the Arab states and information regarding health care for ASR in Germany was added. This first version was discussed and improved via face-to-face meetings and group workshops with representatives of the expert panel. The procedure was repeated once more, before a third version was circulated via e-mail to the experts to correct mistakes and create a final version, which was then translated to the Arabic language by a translation agency. Several agencies were considered and two experts selected the agency based on prior experience in medical/ psychiatric translations and examples of prior work. The Arabic translations were then entered into the content management system of the DID and piloted with the help of four members of the expert panel to fix bugs and ensure proper functioning. During this process, two additional iFD tool workshops were created enhancing the content of the iFD tool in the Arabic version, one containing exercises on resilience (see Fig. 2) and another one as a guide to the German health care system.

Implementation process

The German iFD website was first created on 17 June 2014 and relaunched in its current version on 03 May 2018. The German version of the iFD tool was re-designed after a pilot period and has been available in its current version for routine care use in Germany since 07 October 2016. The Arabic iFD website and iFD tool were launched on 27 March 2019.

Implementation activities were focused on the first year after the launch of the respective DID and language version. The DID were promoted through national and regional press releases, the newsletter of the German Depression Foundation (13,000 subscribers), an information desk at the annual conference of the DGPPN (the largest scientific medical association focusing on mental health in Germany), and social media channels (Facebook, Instagram, LinkedIn, Twitter). For the Arabic DID, bilingual leaflets were created and a large mailing campaign was conducted from May to June 2019, addressing arrival centres, refugee centres, psychosocial centres, and health care centres. Information about the DID was also placed permanently on the websites of the European Alliance Against Depression and the German Depression Foundation.

Measures

iFD website

Indicators for the implementation of the iFD website were inferred from usage data of the website (retrieved via Google Analytics, 28 July 2022). Three 12-month-periods were assessed starting in the month after the creation of the corresponding language version. Indicators for the first year of implementation of the Arabic version were retrieved for 01 April 2019 to 31 March 2020, the second year was from 01 April 2020 to 31 March 2021, and the third year from 01 April 2021 to 31 March 2022. Measures for the German version of the iFD website were created accordingly starting on 01 June 2018 for the first year of implementation and ending on 31 May 2021 for the third year of implementation.

The following indicators were assessed:

The number of page views and unique page views (i.e., pageviews that were generated by the same user during the same session) per year was used as an indicator for the adoption of the iFD website and to assess the sustainability of implementation activities.
The average time on page was assessed to understand whether the content of the iFD website was acceptable to users.

iFD tool

Indicators for the implementation of the iFD tool were inferred by anonymized log data and self-report data that were routinely collected from invited and registered users (cut-off date: 01 August 2022). Sociodemographic information (age, sex, current treatment for depression; all self-reported) was provided from users during the registration process within the iFD tool. The following implementation indicators were assessed:

A conversion rate was calculated as the proportion of invited users (n_inv) in relation to registered users (n_reg) for each subsample. The conversion rate was used to assess whether the adoption of the iFD tool differed between the Arabic and two German subsamples.
Depression severity upon first registration was assessed to confirm the appropriateness of the iFD tool for Arabic language users. For this aim, we used the Patient Health Questionnaire-9 (PHQ-9), a short, well-validated, and widely used self-reporting questionnaire assessing symptoms of depression with nine items on a Likert scale ranging from 0-3^50,51. A sum score ranging from 0–27 was calculated with higher sum scores indicating more severe depressive symptoms. Completion of the PHQ-9 was mandatory upon registration in the iFD tool.
The number of completed workshops within the iFD tool served as a proxy for usage behavior and as an indicator for the acceptability of the DID. A workshop in the iFD tool was counted as complete if at least one entry was made in the online worksheet and either all informational texts were opened, or the audio of the informational texts was played (the latter was only available in the German version).

Statistics

All analyses were conducted with R version 4.2.1⁵². The present analyses had explorative character and as such, shall be understood as a hypothesis-generating contribution rather than confirmatory testing⁵³. Each outcome (see Measures section) represented an independent set of hypotheses of possible differences between language versions and subsamples that were using the DID and was tested with alpha = .05 (two-tailed). If multiple tests were realized within one outcome, a false discovery rate (fdr) correction was applied.

iFD website

Descriptive statistics were reported for page views, unique page views, and average time on page for both language versions and each year of implementation. For each language version, the proportion of page views and unique page views were compared to the previous year of implementation and the differences were reported as percentages (i.e., year two compared to year one; year three compared to year two). The average time on page was not normally distributed (Shapiro-Wilk normality test: W = 0.721, p = .010). For both language versions, the mean average time on page was compared against a benchmark (expected mean) of 50 sec. using a Wilcoxon Signed Rank Test with continuity correction. This benchmark was the average time on page that was recorded in the year 2020 across multiple countries in the category “health and beauty”⁵⁴. A Mann-Whitney U-test was used to compare the average time on page of the Arabic and German version in the three years of implementation against each other; Cliff’s Delta with its 95% confidence interval is given. Unique page views that were generated by users located in Germany in the most current year of implementation were estimated per 100,000 inhabitants as an indicator of the penetration of the iFD website in the Arabic- and German-speaking populations in Germany. We worked with population estimates as reference data for the usage of the iFD website within the target groups, since it is a publicly available DID and as such, does not record or distinguish between residential status of users.

iFD tool

The number of guides who invited users for the Arabic and German versions of the iFD tool and the median number of invited users per guide were assessed. Descriptive statistics for sociodemographic, clinical, and usage behavior characteristics were reported for registered users of the iFD tool. To assess if the data followed a normal distribution, Q-Q plots and histograms were generated for visual inspection and a Shapiro-Wilk test was performed. Differences between subsamples were assessed in all registered users of the Arabic vs. both German subsamples using chi-squared tests (categorical data) or two-sample t-tests (continuous data) or Mann-Whitney U-test (non-normal continuous or ordinal data). Cliff’s Delta for Mann-Whitney-U test and hedges’ g for two sample t-test are given with their 95% confidence intervals.

To cope with the highly varying subsample sizes within the iFD tool, a matching strategy was applied to compare the baseline depression severity between subsamples. To prepare the data, all cases with missing values for age, sex, or the PHQ-9 scores were excluded. From the pool of German-language guided and unguided iFD tool users, samples matched for age and sex to the Arabic-speaking users were generated using propensity scores with nearest neighbor matching procedures from the R-package “MatchIt” and a 1:2 ratio. In a second matching procedure, the same method was applied matching for age, sex, and initial PHQ-9 scores to allow comparison of usage behavior (number of completed workshops).

[1] Algeria, Bahrain, Chad, Comoros, Djibouti, Egypt, Eritrea, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauretania, Morocco, Oman, Palestine, Qatar, Saudi-Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, Yemen.

Acknowledgments

The study was funded by the SKala initiative within the project “NImBus: New impulses, implementing the tried and tested”, granted to the German Alliance Against Depression. The funder played no role in study design, data collection, analysis and interpretation of data, or the writing of this manuscript.

The authors would like to thank all primary care and specialist physicians, psychotherapists, health care professionals, and social workers who supported the implementation of the iFD tool for Arabic-speaking individuals in routine health care in Germany. The authors would like to thank the project team, the expert panel and the translators for their excellent work in preparing and implementing the interventions.

Author contributions

HR, UH, and CO contributed to the conceptualization of the present work. CO did the data curation, HR and CO conducted the formal analysis. Funding acquisition and supervision were done by UH. Project administration was conducted by AR. The investigations were done by AR and CO. HR wrote the original draft of the manuscript. All authors contributed to review and editing of the manuscript. All authors read and approved the final manuscript.

Data Availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interests

All authors declare no financial or non-financial competing interests.

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No competing interests reported.

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Arabic-language digital interventions for depression in German routine health care are acceptable, but intervention adoption remains a challenge

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Journal Publication

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Abstract

Figures

Introduction

Results

Adoption (iFD website, iFD tool)

Appropriateness (iFD tool)

Acceptability (iFD website, iFD tool)

Penetration (iFD website)

Sustainability (iFD website)

Discussion

Methods

Design

Study populations

Digital interventions

Translation and cultural adaptations

Implementation process

Measures

iFD website

iFD tool

Statistics

iFD website

iFD tool

Declarations

Acknowledgments

Author contributions

Data Availability

Competing Interests

References

Additional Declarations

Status:

Journal Publication

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