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Learning from implementation of a COVID case management desk guide and training: a pilot study in Sierra Leone

Sophie Witter, Guanyang Zou, Kiran Cheedella, John Walley & Haja Wurie
BMC Public Health volume 23

When the COVID pandemic hit the world, there was need for applied guides and training materials to support frontline health care staff to manage patients effectively and safely and to educate themselves and communities. This article reports on the development and piloting of such a set of materials in Sierra Leone, which were based on international evidence but adapted to the local context. Reflecting on this experience, including community and health system barriers and enablers, is important to prepare for future regional shocks.

Developing a social mobilisation intervention for salt reduction: participatory action research in Bombali district, Sierra Leone

Kiran Cheedella, Peter Conteh, Guanyang Zou, John Walley, Ajaratu Kamara, Haja Wurie & Sophie Witter
BMC Public Health volume 23

High salt intake is a major risk factor for hypertension, which in turn contributes to cardiovascular diseases, the major cause of death from non communicable diseases (NCDs). Research is limited on social mobilisation interventions to tackle NCDs, including in fragile health settings such as Sierra Leone.

Burden of non-communicable diseases among Syrian refugees: a scoping review

Farah Naja, Hibeh Shatila, Maria El Koussa, Lokman Meho, Lilian Ghandour & Shadi Saleh
BMC Public Health volume 19

The scarcity of evidence-based research on non-communicable diseases (NCDs) among Syrian refugees has hampered efforts to address the high burden of these diseases in host countries. The objective of this study is to examine published research on NCDs among Syrian refugees in order to inform future research, practice, programs, and policy.

Health systems research in fragile settings

Alastair Ager, Shadi Saleh, Haja Wurie, and Sophie Witter
Bulletin of the World Health Organization

Population health indicators have improved in recent decades. Deaths in children younger than five years have declined from over 16 million in 1970 to around 5 million in 2016 and life expectancy at birth has increased from 58 to over 70 years in the same period. However, a major constraint to such progress, and in some contexts a potential source of reversal, is fragility. Of the 10 countries with the highest rates of infant mortality, seven are classified as fragile states. 

Understanding fragility: implications for global health research and practice

Karin Diaconu, Jennifer Falconer, Nicole Vidal, Fiona O’May, Esther Azasi, Kelly Elimian, Ibrahim Bou-Orm, Cristina Sarb, Sophie Witter, Alastair Ager
Health policy and planning

Advances in population health outcomes risk being slowed-and potentially reversed-by a range of threats increasingly presented as ‘fragility’. Widely used and critiqued within the development arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first scoping review seeking to clarify the meaning, definitions and applications of the term in the global health literature.

Opportunities and challenges for delivering non-communicable disease management and services in fragile and post-conflict settings: perceptions of policy-makers and health providers in Sierra Leone

Sophie Witter, Guanyang Zou, Karin Diaconu, Reynold G. B. Senesi, Ayesha Idriss, John Walley & Haja Ramatulai Wurie
Conflict and Health, BMC

The growing burden of non-communicable diseases in low- and middle-income countries presents substantive challenges for health systems. This is also the case in fragile, post-conflict and post-Ebola Sierra Leone, where NCDs represent an increasingly significant disease burden (around 30% of adult men and women have raised blood pressure). To date, documentation of health system challenges and opportunities for NCD prevention and control is limited in such settings. This paper aims to identify opportunities and challenges in provision of NCD prevention and care and highlight lessons for Sierra Leone and other fragile states in the battle against the growing NCD epidemic.

Rural-urban health-seeking behaviours for non-communicable diseases in Sierra Leone

Ayesha Idriss, Karin Diaconu, Guanyang Zou, Reynold GB Senesi, Haja Wurie, Sophie Witter
BMJ Global Health

Non-communicable diseases (NCDs) are the leading cause of mortality globally. In Africa, they are expected to increase by 25% by 2030. However, very little is known about community perceptions of risk factors and factors influencing health-seeking behaviour, especially in fragile settings. Understanding these is critical to effectively address this epidemic, especially in low-resource settings. Methods We use participatory group model building techniques to probe knowledge and perceptions of NCD conditions and their causes, health-seeking patterns for NCDs and factors affecting these health-seeking patterns. Our participants were 116 local leaders and community members in three sites in Western Area (urban) and Bombali District (rural), Sierra Leone. Data were analysed using a prior framework for NCD care seeking developed in Ghana.

The role of social movements in strengthening health systems: the experience of the National Health Forum in El Salvador (2009–2018)

Montserrat León, Marta Jiménez, Nicole Vidal, Keven Bermúdez, and Pol De Vos
International Journal of Health Services

In 2009, the newly elected FMLN government of El Salvador launched a comprehensive health reform, which gave the National Health Forum (NHF) a key role in developing community participation. This study aims to examine and analyze the content and impact of this social movement during the study period 2009–2018. The context was analyzed through relevant documents, which helped identify key stakeholders. Semi-structured interviews took place at 3 levels of decision making: the political level, the health professionals, and the community. Data were analyzed using a qualitative methodology. Participation is carried by a structure created by the Ministry of Health, the National Health Forum.

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

Aya Noubani, Karin Diaconu, Lilian Ghandour, Maria El Koussa, Giulia Loffreda & Shadi Saleh
Globalization and Health

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 behaviours and barriers to health access in two contrasting contexts of fragility.

Comprehensive primary health care and non-communicable diseases management: a case study of El Salvador

Marta Jimenez Carrillo, Montserrat León García, Nicole Vidal, Keven Bermúdez & Pol De Vos
International Journal for Equity in Health

One of today’s greatest challenges in public health worldwide – and especially its key management from Primary Health Care (PHC) – is the growing burden of non-communicable diseases (NCDs). In El Salvador, since 2009 the Minister of Health (MoH) has scaled up a national public health system based on a comprehensive PHC approach. A national multi-sectorial strategic plan for a comprehensive approach to NCDs has also been developed. This analysis explores stakeholders’ perceptions related to the management of NCDs in PHC and, in particular, the role of social participation.

Community and health staff perceptions on non-communicable disease management in El Salvador’s health system: a qualitative study

Nicole Vidal, Montserrat León-García, Marta Jiménez, Keven Bermúdez & Pol De Vos
BMC Health Services Research volume

Non-communicable Diseases (NCDs) are the leading cause of global mortality and disability with a rising burden in low- and middle-income countries. Their multifactorial aetiology, and their requirement of long-term care, implies the need for comprehensive approaches. From 2009, the Ministry of Health (MoH) in El Salvador has developed a national public health system based on comprehensive primary health care. This study aims to describe the different stakeholders’ perceptions about the management of NCDs along the pathways of care in this health system.

Adapting and implementing training, guidelines and treatment cards to improve primary care-based hypertension and diabetes management in a fragile context: results of a feasibility study in Sierra Leone

Guanyang Zou, Sophie Witter, Lizzie Caperon, John Walley, Kiran Cheedella, Reynold G. B. Senesi & Haja Ramatulai Wurie
BMC Public Health

Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). Facilitated by an international partnership, a project was developed to adapt and pilot desktop guidelines and other clinical support tools to strengthen primary care-based hypertension and diabetes diagnosis and management in Bombali district, Sierra Leone between 2018 and 2019. This study assesses the feasibility of the project through analysis of the processes of intervention adaptation and development, delivery of training and implementation of a care improvement package and preliminary outcomes of the intervention.

Expressions of psychological distress in Sierra Leone: implications for community-based prevention and response

Rebecca Horn, Simeon S. Sesay, Mamadu Jalloh, Amjata Bayoh, Joan B. Lavally and Alastair Ager
Global Mental Health

Over recent decades there has been considerable mental health research in Sierra Leone but little on local conceptualisations of mental health conditions. Understanding these is crucial both for identifying the experienced needs of the population and utilising relevant community-based resources to address them. This study took a grounded approach to identify the ways in which adults in Sierra Leone express psychological distress.

A multilevel bioecological analysis of factors influencing the mental health and psychosocial well‐being of refugee children

Stella Arakelyan, Alastair Ager
The Journal of Child Psychology and Psychiatry

This paper revisits the themes of an influential 1993 review regarding the factors shaping the mental health and psychosocial well-being of refugees to take stock of developments in the evidence base and conceptualisation of issues for refugee children over the last 25 years.

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

Nadine Zablith, Karin Diaconu, Farah Naja, Maria El Koussa, Giulia Loffreda, Ibrahim Bou-Orm and Shadi Saleh
Conflict and Health

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.

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

Aya Noubani, Karin Diaconu, Giulia Loffreda & Shadi Saleh
International Journal of Mental Health Systems

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.

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

Kanykey Jailobaeva, Jennifer Falconer, Giulia Loffreda, Stella Arakelyan, Sophie Witter & Alastair Ager
Globalization and Health

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.

Clinical Diagnosis and Reporting of COVID-19 in the Absence of Effective Access to Laboratory Testing in Africa

John Walley, Akaninyene Otu, Akaninyene Otu, Emmanuel Effa, Laura French, Obiageli Onwusaka
Frontiers in Public Health

In reality, in most of sub-Saharan Africa, either COVID-19 tests are unavailable or turnaround time is long or results take too long to return from distant laboratories. Even for tests now done at local laboratories, the turnaround time is longer because of the volume, frequent stockouts of reagent and sample collection kits, and power cuts. For example, in Cross River State in South-Eastern Nigeria (population 3.7 million) as of December 13, 2020, only 1993 COVID-19 RT-PCR tests have reportedly been performed since the pandemic onset (at centralized sites of the National Centre for Disease Control). This situation suits the politico-economic drivers to ease lockdown restrictions, but creates a false sense of security. Some symptoms of COVID-19 overlap with those of common infections such as malaria, dengue, and pneumonia, making diagnosis challenging without a test.

Experiences of communities with Lebanon’s model of care for non-communicable diseases: a cross-sectional household survey from Greater Beirut

Ibrahim Bou-Orm, Pol deVos, Karin Diaconu
BMJ Open

We focused on community perceptions of the Lebanese care model for non-communicable diseases (NCDs) and trust in the health system among others, and tested association between them. Three main outcomes (barriers to care seeking, perceptions of the care model and trust in healthcare) were assessed including by multiple linear regressions. In conclusion the study generated evidence about the experience of people living with NCDs with Lebanon’s care model and can inform service delivery interventions towards a more inclusive person-centred approach.

Factors contributing to emotional distress in Sierra Leone: a socio-ecological analysis

Rebecca Horn, Stella Arakelyan, Haja Wurie & Alastair Ager
International Journal of Mental Health Systems

There is increasing global evidence that mental health is strongly determined by social, economic and environmental factors, and that strategic action in these areas has considerable potential for improving mental health and preventing and alleviating mental disorders. Prevention and promotion activities in mental health must address the needs prioritised by local actors. The aim of this study was to identify stressors with the potential to influence emotional wellbeing and distress within the general population of Sierra Leone, in order to contribute to an inter-sectoral public mental health approach to improving mental health within the country.

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

Karin Diaconu, Sophie Witter, Arek Dakessian, Giulia Loffreda, Alastair Ager
BMJ Global Health

Development and global health research have long applied a binary definition of fragility. Within this, countries are either labelled fragile or not. However, the COVID-19 pandemic has thrown this distinction into question. Many settings previously thought of as fragile are now outperforming others.

Identifying opportunities to engage communities with social mobilisation activities to tackle NCDs in El Salvador in the context of the global COVID-19 pandemic

Lizzie Caperon, Stella Arakelyan, Cinzia Innocenti & Alastair Ager
International Journal for Equity in Health volume

Social mobilisation is potentially a key tool in the prevention of non-communicable diseases (NCDs) in fragile settings. This formative study addressed existing and potential social mobilisation mechanisms seeking behaviour to tackle NCDs in El Salvador, with an emphasis on the implications in the context of the current COVID-19 pandemic.

mHealth guideline training for non-communicable diseases in primary care facilities in Nigeria: a mixed methods pilot study

Akaninyene Asuquo Otu, Emmanuel E Effa, Obiageli Onwusaka, Chiamaka Omoyele, Stella Arakelyan, Okey Okuzu, John Walley
BMJ Open

A self-paced mHealth training module on an NCD desk guide was adapted to be applicable within the Nigerian context in collaboration with the Federal Ministry of Health. The training which focused on hypertension, diabetes and sickle cell disease was delivered via Android tablet devices, supplemented by quarterly onsite supervision and group support via WhatsApp. The training was evaluated with pre/post-course tests, structured observations and focus group discussions. This was an implementation pilot assessing the feasibility and potential effectiveness of mHealth training on NCD in primary care delivery.

Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: a cross-sectional study from Lebanon

Shadi Saleh, Dina Muhieddine, Randa S Hamadeh, Hani Dimassi,K Diaconu, Aya Noubani, Stella Arakelyan, Alastair Ager, Mohamad Alameddine
BMJ Open

The study discovered significant differences in outpatient service use by setting, nationality and gender to differentials. A rigorous and comprehensive appraisal of NCD programmes and services is imperative for providing policy makers with evidence-based recommendations to guide the design, implementation and evaluation of targeted programmes and services necessary to ensure equity in health services delivery to diabetic and hypertensive patients. Such programmes are an ethical imperative considering the protracted crises and compounded fragility.

Social determinants and mental health needs of Palestine refugees and UNRWA responses in Gaza during the COVID-19 pandemic: a qualitative assessment

Zeina Jamal, Zoheir ElKhatib, Shatha AlBaik, Masako Horino, Mohammed Waleed, Farah Fawaz, Giulia Loffreda, Akihiro Seita, Sophie Witter & Karin Diaconu
BMC Public Health

Due to pre-existing difficulties, refugees are especially susceptible to the negative effects of the pandemic; nonetheless, the pandemic’s effect on this group is still unclear. The purpose of this study was to determine the effects of the COVID-19 pandemic on the mental health of Palestine refugees in Gaza by identifying the role of social determinants. During the pandemic, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) enacted a number of policies and measures. The purpose of this research was to assess their efficacy and acceptability.

Social determinants of psychological distress in Sierra Leone

Kanykey Jailobaeva, Rebecca Horn, Stella Arakelyan, Karin Diaconu, Ajaratu Kamara & Alastair Ager
Social Psychiatry and Psychiatric Epidemiology

Growing evidence demonstrates that daily stressors such as family violence, unemployment, and living conditions play an important part in causing psychological distress. This paper investigates the impact of distressing events and day-to-day living conditions on psychological distress in the fragile context of Sierra Leone.

The determinants of the quality of clinical management among diabetic and hypertensive patients in a context of fragility: A cross-sectional survey from Lebanon

Shadi Saleh, Dina Muhieddine, Randa Hamadeh, Hani Dimassi, Karin Diaconu, Stella Arakelyan, Alastair Ager, Mohamad Alameddine
Frontiers in Public Health

The management of NCDs is a growing challenge in low- and middle-income settings with the increasing prevalence and the associated demands that such conditions make on health systems. Fragile settings both exacerbate the risk of NCDs and undermine systems capacity. Lebanon is a setting where strategies to address rising NCDs burden have faced particularly acute contextual challenges.

The development of a contextually appropriate measure of psychological distress in Sierra Leone

Rebecca Horn, Kanykey Jailobaeva, Stella Arakelyan & Alastair Ager
BMC Psychology

Studies of psychological distress in Sierra Leone have typically used measures which were developed for use in other contexts, and which often have not been adapted or validated for use in Sierra Leone. This has resulted in a lack of reliable information about the patterns of psychological distress within the population, which is a barrier to the development of effective and appropriate mental health services. The aim of the study was to develop a locally-appropriate measure of psychological distress for Sierra Leone.

The role of trust in health-seeking for non-communicable disease services in fragile contexts: A cross-country comparative study

Stella Arakelyan, Kanykey Jailobaeva, Arek Dakessian, Karin Diaconu, Lizzie Caperon, Alison Strang, Ibrahim R. Bou-Orm, Sophie Witter, Alastair Ager
Social Science & Medicine

Non-communicable diseases (NCDs) disproportionately affect people living in fragile contexts marked by poor governance and health systems struggling to deliver quality services for the benefit of all. This combination can lead to the erosion of trust in the health system, affecting health-seeking behaviours and the ability of individuals to sustain their health. In this cross-country multiple-case study, we analyse the role of trust in health-seeking for NCD services in fragile contexts.

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

Kanykey Jailobaeva, Rebecca Horn, Abdulai Jawo Bah, Giulia Loffreda & Alastair Ager
Humanities and Social Sciences Communications volume

Qualitative 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.