A community-based system dynamics approach for understanding factors affecting mental Health and Health seeking behaviors in Beirut and Beqaa regions of Lebanon

From PubMed via Jisc Publications RouterBackground Available evidence on mental health and psychosocial problems in Lebanon is limited. Recent quantitative data suggests a high prevalence among Syrian refugees and their Lebanese host communities, with significant treatment gaps in both populations. This study aims to determine how Lebanese host and Syrian refugee communities perceive mental health, and identify health seeking behaviors and barriers to health access in two contrasting contexts of fragility.Methods A comparative qualitative study design was adopted whereby a total of 36 semi-structured interviews with Lebanese host and Syrian refugees’ community members were conducted, followed by a series of four participatory group model building (GMB) sessions. Participants were recruited from two contrasting fragility contexts: Beirut and Beqaa regions. During these sessions, causal loop diagrams were elicited depicting shared understandings of factors prompting the onset of mental health and psychosocial issues; health seeking behaviors, pathways and elements affecting the rate of health improvement and maintenance were also identified.Results Community members in both settings had similar perceptions of factors contributing to mental health. Participants named long-term effects of exposure to wars, political and social effects of conflicts, and financial constraints at the household level as precipitating factors prompting the onset of mental health and psychosocial stressors. Gender and integration related challenges between communities were identified as factors that affect condition onset and associated care seeking. Pathways for health seeking were found to be shaped by trust, the advice and support of loved ones, and the need to ensure confidentiality of affected individuals. Recurrent themes in discussion highlighted major barriers to healthcare access including significant delays in health care seeking from the formal health system, widespread social stigma, prohibitive service costs, lack of health coverage, limited awareness of mental health service availability and limited trust in the quality of services available.Conclusion Mental health and psychosocial support strategies need to be gender- and integration-sensitive, primarily focused on condition prevention and awareness raising in order to strengthen health-seeking behaviors.This research was funded by the National Institute for Health Research (NIHR) Global Health Research programme 16/136/100.The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health and Social Care.16pubpu

Readiness to deliver person‐focused care in a fragile situation: The case of Mental Health Services in Lebanon

From Springer Nature via Jisc Publications RouterBackground: Evidence suggests wide variability in the provision of mental healthcare across countries. Countries experiencing fragility related risks suffer from a high burden of mental-ill health and additionally have limited capacity to scale up mental health services given financial and human resource shortages. Integration of mental health services into routine primary care is one potential strategy for enhancing service availability, however little is known about the experiences of currently active health care providers involved in mental health and psychosocial support service (MHPSS) provision at primary care level. This study aims to determine how healthcare providers offering MHPSS services at primary care levels in Lebanon perceive mental health and the health system’s ability to address the rising mental ill-health burden with a view to identify opportunities for strengthening MHPSS service implementation geared towards integrated person focused care model.Methods: A qualitative study design was adopted including 15 semi-structured interviews and 2 participatory group model-building workshops with health care providers (HCPs) involved in mental healthcare delivery at primary care level. Participants were recruited from two contrasting fragility contexts (Beirut and Beqaa). During workshops, causal loop diagrams depicting shared understandings of factors leading to stress and mental ill health, associated health seeking behaviors, and challenges and barriers within the health system were elicited. This research is part of a larger study focused on understanding the dynamics shaping mental health perceptions and health seeking behaviours among community members residing in Lebanon.Results: Findings are organized around a causal loop diagram depicting three central dynamics as described by workshop participants. First, participants linked fnancial constraints at household levels and the inability to secure one’s livelihood with contextual socio-political stressors, principally referring to integration challenges between host communities and Syrian refugees. In a second dynamic, participants linked exposure to war, confict and displacement to the occurrence of traumatic events and high levels of distress as well as tense family and community relations. Finally, participants described a third dynamic linking cultural norms and patriarchal systems to exposure to violence and intergenerational trauma among Lebanon’s populations. When describing help-seeking pathways, participants noted the strong infuence of social stigma within both the community and among health professionals; the latter was noted to negatively afect patient-provider relationships. Participants additionally spoke of difculties in the delivery of mental health services and linked this to the design of the health system itself, noting the current system being geared towards patient centered care, which focuses on the patient’s experiences with a disease only, rather than person focused care where providers and patients acknowledge broader structural and social infuences on health and work together to reach appropriate decisions for tackling health and other social needs. Barriers to delivery of person focused care include the lack of coherent mental health information systems, limited human capacity to deliver MHPSS services among primary health care staf and inadequate service integration and coordination among the many providers of mental health services in our study contexts. Critically however, provider accounts demonstrate readiness and willingness of health professionals to engage with integrated person focused care models of care.Conclusions: Mental ill health is a major public health problem with implications for individual health and wellbeing; in a fragile context such as Lebanon, the burden of mental ill health is expected to rise and this presents substantive challenges for the existing health system. Concrete multi-sectoral eforts and investments are required to (1) reduce stigma and improve public perceptions surrounding mental ill health and associated needs for care seeking and (2) promote the implementation of integrated person focused care for addressing mental health.Health Research (NIHR) Global Health Research Programme; Grant(s): 16/136/10015pubpu

Fragile, handle with care: Refining a key concept for global health and development

Karin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Sophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Arek Dakessian - ORCID: 0000-0001-7792-6862 https://orcid.org/0000-0001-7792-6862Giulia Loffreda - ORCID: 0000-0003-4895-1051 https://orcid.org/0000-0003-4895-1051Alastair Ager - ORCID: 0000-0002-9474-3563 https://orcid.org/0000-0002-9474-3563inpressinpres

Political Economy of Non-Communicable Disease (NCD) prevention and control in Lebanon: identifying challenges and opportunities for policy change and care provision reforms

From Springer Nature via Jisc Publications RouterHistory: received 2023-07-03, registration 2023-11-28, accepted 2023-11-28, collection 2023-12, epub 2023-12-18, online 2023-12-18Acknowledgements: Not applicable.Publication status: PublishedFunder: National Institute for Health and Care Research; doi: http://dx.doi.org/10.13039/501100000272; Grant(s): NIHR Global Health Research programme 16/136/100, NIHR Global Health Research programme 16/136/100, NIHR Global Health Research programme 16/136/100, NIHR Global Health Research programme 16/136/100Ibrahim Bou-Orm - ORCID: 0000-0003-3563-4014 https://orcid.org/0000-0003-3563-4014Giulia Loffreda - ORCID: 0000-0003-4895-1051 https://orcid.org/0000-0003-4895-1051Karin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Sophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Introduction: Lebanon is a middle-income country facing substantial fragility features. Its health profile shows a high burden of NCD morbidity and mortality. This paper intends to analyse the political economy of NCD prevention and control in Lebanon. Methods: This study adopted a literature-based case study research design using a problem-driven political economy analysis framework. A total of 94 peer-reviewed articles and documents from the grey literature published before June 2019 were retrieved and analysed. Results: Lebanon’s political instability and fragile governance negatively affect its capacity to adapt a Health-in-All-Policies approach to NCD prevention and enable the blocking of NCD prevention policies by opposed stakeholders. Recent economic crises limit the fiscal capacity to address health financing issues and resulting health inequities. NCD care provision is twisted by powerful stakeholders towards a hospital-centred model with a powerful private sector. Stakeholders like the MOPH, UN agencies, and NGOs have been pushing towards changing the existing care model towards a primary care model. An incremental reform has been adopted to strengthen a network of primary care centres, support them with health technologies and improve the quality of primary care services. Nevertheless, outpatient services that are covered by other public funds remain specialist-led without much institutional regulation. Conclusion: Our study revealed a locked equilibrium in NCD prevention policymaking in Lebanon, but with an incremental progress in service delivery reforms towards a primary care model. Advocacy and close monitoring by policy entrepreneurs (such as civil society) could initiate and sustain the implementation of policy change and care model reforms.pubpu

Barriers and Opportunities for WHO “Best Buys” Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review

Background: Improving the adoption and implementation of policies to curb non-communicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policy-makers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation.Methods: We conducted a complex systematic review of articles discussing the adoption and implementation of WHO’s “best buys” NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria.Results: Our CLD highlights a central feedback loop encompassing three vital variables: (1) the ability to define, (re)shape and pass appropriate policy into law; (2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); and (3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies.Conclusion: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions

Understanding perceptions of recovery from psychological distress in Sierra Leone through qualitative comparative analysis

From Springer Nature via Jisc Publications RouterQualitative comparative analysis (QCA) is a relatively new method that examines causal complexity. Its use in mental health research is nascent. In low-income and fragile settings, with weak mental health service provision, identifying pathways of recovery from psychological distress can inform the appropriate deployment of scarce community and public resources. This paper examines the use of QCA to identify predictors of recovery in Sierra Leone. Our study explored lay perceptions of the signs of recovery from psychological distress caused by such events as the loss of a family member, severe sickness, and loss of a relationship. The data drew upon 75 interviews with women and men, across four districts of Sierra Leone, who described the signs of recovery from psychological distress they have observed in one person known to them. The truth table generated through QCA software indicated two signs of recovery— work/study and healthy relations—to be the most prevalent across different combinations of predictive factors. Further analysis of the truth table and sub-set relations suggested that work/study and healthy relations frequently served as sufficient conditions for reported recovery from distress to occur. QCA provided a means to identify sufficient predictive factors for recovery from psychological distress to occur. The findings suggest that to enable recovery from psychological distress, support needs to be broad and bring together services that will enable individuals to improve their social and relational wellbeing. Responses to distress need to involve a wide range of community-based stakeholders who will help individuals to engage in constructive activity and strengthen relations with their family members, friends, and the broader community. QCA is potentially well-positioned to unpack complexity in mental health research.This study was funded by grant 16/136/100 from the National Institute for Health Research (NIHR) to the NIHR Global Health Research Unit on Health in Situations of Fragility.8pubpu

An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low- and middle-income countries

From Springer Nature via Jisc Publications RouterBackground: Noncommunicable diseases (NCDs), including mental health, have become a major concern in low- and middle-income countries. Despite increased attention to them over the past decade, progress toward addressing NCDs has been slow. A lack of bold policy commitments has been suggested as one of the contributors to limited progress in NCD prevention and management. However, the policies of key global actors (bilateral, multilateral, and not-for-profit organisations) have been understudied. Methods: This study aimed to map the key global actors investing in action regarding NCDs and review their policies to examine the articulation of priorities regarding NCDs. Narrative synthesis of 70 documents and 31 policy papers was completed, and related to data collated from the Global Health Data Visualisation Tool. Results: In 2019 41% of development assistance for health committed to NCDs came from private philanthropies, while that for other global health priorities from this source was just 20%. Through a range of channels, bilateral donors were the other major source of NCD funding (contributing 41% of NCD funding). The UK and the US were the largest bilateral investors in NCDs, each contributing 8%. However, NCDs are still under-prioritised within bilateral portfolios – receiving just 0.48% of US funding and 1.66% of the UK. NGOs were the key channels of funding for NCDs, spending 48% of the funds from donors in 2019. The reviewed literature generally focused on NCD policies of WHO, with policies of multilateral and bilateral donors given limited attention. The analysis of policies indicated a limited prioritisation of NCDs in policy documents. NCDs are framed in the policies as a barrier to economic growth, poverty reduction, and health system sustainability. Bilateral donors prioritise prevention, while multilateral actors offer policy options for NCD prevention and care. Even where stated as a priority, however, funding allocations are not aligned. Conclusion: The growing threat of NCDs and their drivers are increasingly recognised. However, global actors’ policy priorities and funding allocations need to align better to address these NCD threats. Given the level of their investment and engagement, more research is needed into the role of private philanthropies and NGOs in this area.This study was funded by grant 16/136/100 from the National Institute for Health Research (NIHR) to the NIHR Global Health Research Unit on Health in Situations of Fragility. The views expressed are those of the author (s) and not necessarily those of the NIHR or the Department of Health and Social Care.https://doi.org/10.1186/s12992-021-00713-417pubpu

Conflict as a macrodeterminant of non-communicable diseases: the experience of Libya.

From Europe PMC via Jisc Publications RouterHistory: ppub 2022-10-01Publication status: PublishedFunder: World Bank Grou

Dynamics of non-communicable disease prevention, diagnosis and control in Lebanon, a fragile setting

From Springer Nature via Jisc Publications RouterKarin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Abstract: Background: Non-communicable diseases (NCD) present an increasing global health challenge, particularly for settings affected by fragility where access to care may be disrupted, and where high-quality continuous care delivery is difficult to achieve. This study documents the complex dynamics of NCD prevention and management in the fragile setting of rural Beqaa, Lebanon. Methods: Participatory system dynamics methods were used, including 30 semi-structured interviews and three Group Model Building (GMB) workshops. Participants included health care providers offering NCD care, and Lebanese host- and Syrian refugees community members affected by NCDs. Results: Participants across all groups articulated a shared complex understanding of both the structural and direct determinants behind NCD onset. Lebanese and Syrian community members further identified several barriers to health seeking, including restrictions in health coverage, limited availability of services in the Beqaa and perceptions of poor-quality care. Health providers and community members described a health system overtly focused on disease control and overwhelmed by delivery of care to people living with NCD across both communities. Conclusion: Participants across all groups agreed on the need for health promotion and primary prevention activities and identified priority interventions in these areas.This research was funded by the National Institute for Health Research (NIHR) Global Health Research programme 16/136/100.The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health and Social Care.15pubpu

Informing adaptation strategy through mapping the dynamics linking climate change, health, and other human systems: Case studies from Georgia, Lebanon, Mozambique and Costa Rica

From PLOS via Jisc Publications RouterHistory: received 2022-11-12, collection 2023, accepted 2023-03-20, epub 2023-04-19Acknowledgements: We are deeply grateful to our workshops participants who provided their knowledge, time and expertise to develop the case studies. These include: Dr Maia Uchaneishvili, Research Unit Director, Curatio International Foundation; Dr Nia Giuashvili, Environmental Health Expert, Advisor of the National Center for Disease Control and Public Health General Director on Environmental Health; Dr Mariam Maglakelidze, Head, Department of Institutional Culture Development, Petre Shotadze Tbilisi Medical Academy; Affiliate Scholar, Institute for Advanced Sustainability Studies, Potsdam, Germany; Ina Girard, Climate Change and Human Health Expert, WHO Focal Point on the Environmental Health Issues at the National Environmental Agency; Dr Tamar Kashibadze, Public Health Specialist, NCD Department, National Center for Disease Control and Public Health; Dr Tatiana Marrufo, Instituto Nacional de Saúde (INS), National Health Observatory Technical Secretariat, Program Lead of Environmental Health; Dr Fady Asmar, Forestry Expert, Lebanon; D.E.A. Pascal Girot, Head of the School of Geography, Universidad de Costa Rica; Dr Valeria Lentini, Lecturer, School of Economics, Universidad de Costa Rica; Dr Juan Robalino, Head of the Economics Research Institute, Universidad de Costa Rica; Dr Yanira Xirinachs-Salazar, Associate Professor, School of Economics, Universidad de Costa Rica; and Dr Paola Zúñiga-Brenes, Associate Professor, School of Economics, Universidad de Costa Rica.Publication status: PublishedFunder: National Institute for Health and Care Research; funder-id: http://dx.doi.org/10.13039/501100000272; Grant(s): 16/136/100 RUHFFunder: Royal Society of Edinburgh; funder-id: http://dx.doi.org/10.13039/501100000332Alastair Ager - ORCID: 0000-0002-9474-3563 https://orcid.org/0000-0002-9474-3563Giulia Loffreda - ORCID: 0000-0003-4895-1051 https://orcid.org/0000-0003-4895-1051Data Availability: Causal loop diagrams refined during workshop discussion comprise the major data source of the study and are included in the submitted manuscript. Search terms and the extraction matrix used for the literature search to develop preliminary causal loop models are included as Supplementary material. Listing of the literature accessed and data extracted are lodged on the QMU eData repository: https://eresearch.qmu.ac.uk/handle/20.500.12289/12889.While scientific research supporting mitigation of further global temperature rise remains a major priority, CoP26 and CoP27 saw increased recognition of the importance of research that informs adaptation to irreversible changes in climate and the increasing threats of extreme weather events. Such work is inevitably and appropriately contextual, but efforts to generalise principles that inform local strategies for adaptation and resilience are likely crucial. Systems approaches are particularly promising in this regard. This study adopted a system dynamics framing to consider linkages between climate change and population health across four low- and middle-income country settings with a view to identifying priority inter-sectoral adaptation measures in each. On the basis of a focused literature review in each setting, we developed preliminary causal loop diagrams (CLD) addressing dynamics operating in Mozambique, Lebanon, Costa Rica, and Georgia. Participatory workshops in each setting convened technical experts from different disciplines to review and refine this causal loop analysis, and identify key drivers and leverage points for adaptation strategy. While analyses reflected the unique dynamics of each setting, common leverage points were identified across sites. These comprised: i) early warning/preparedness regarding extreme events (thus mitigating risk exposure); ii) adapted agricultural practices (to sustain food security and community livelihoods in changing environmental conditions); iii) urban planning (to strengthen the quality of housing and infrastructure and thus reduce population exposure to risks); iv) health systems resilience (to maintain access to quality healthcare for treatment of disease associated with increased risk exposure and other conditions for which access may be disrupted by extreme events); and v) social security (supporting the livelihoods of vulnerable communities and enabling their access to public services, including healthcare). System dynamics modelling methods can provide a valuable mechanism for convening actors across multiple sectors to consider the development of adaptation strategies.pubpu