Browsing by Person "Saleh, Shadi"

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A community-based system dynamics approach for understanding factors affecting mental Health and Health seeking behaviors in Beirut and Beqaa regions of Lebanon
(2020-03-30) Noubani, Aya; Diaconu, Karin; Ghandour, Lilian; El Koussa, Maria; Loffreda, Giulia; Saleh, Shadi
Background 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.
Attitudes towards Depression among Primary Healthcare Providers in Contrasting Fragility Contexts in Lebanon: A Cross Sectional Study [Working paper]
(Queen Margaret University, 2025-07) Noubani, Aya; Diaconu, Karin; Muhheiddine, Dina; Alameddine, Mohammad; Saleh, Shadi
Background: Depression is a leading contributor to global disability, yet significant treatment gaps persist—particularly in fragile and low-resource settings. In Lebanon, efforts such as the WHO’s Mental Health Gap Action Programme (mhGAP) and the National Mental Health Program (NMHP) aim to improve mental health integration within primary care. This study investigates the attitudes of primary healthcare providers (HCPs) toward depression in two contrasting Lebanese contexts—urban Beirut and rural Bekaa—and examines how mhGAP training influences these attitudes. Methods: A cross-sectional survey was conducted in 2020 using the 22-item Revised Depression Attitude Questionnaire (R-DAQ) was administered to 237 HCPs across 11 Ministry of Public Health (MoPH) Primary Healthcare Centers (PHCCs) in Beirut and Bekaa. Data collection included socio-demographics, mental health training background, and clinical experience. Quantitative analysis involved descriptive statistics, t-tests, ANOVA, multiple regression, and exploratory factor analysis. Results: Most participants were female (60.3%) and based in Beirut (59.9%), with nearly half being medical doctors. While 94.4% reported frequent encounters with patients experiencing mental health issues, only 40.7% had received mental health training, and less than half of those were trained on mhGAP. Overall, HCPs held neutral-to-positive attitudes toward depression (mean R-DAQ score = 79 ± 8.08), with the strongest agreement around the need for a generalist approach. Professional confidence was moderate, and therapeutic optimism was mixed, with some respondents endorsing stigmatizing beliefs. Attitudes were significantly more positive among HCPs trained in mhGAP, working in Beirut, having postgraduate education, or regularly encountering mental health patients. Multivariable analysis confirmed that mhGAP training and practice setting were key predictors of more favorable attitudes. Exploratory factor analysis validated the original three-factor structure of the R-DAQ. Conclusion: While primary care providers in Lebanon generally support integrating mental health into routine care, gaps remain in training and confidence—especially in more fragile rural settings. Scaling up evidence-based training such as mhGAP may enhance provider preparedness and reduce stigma toward depression, supporting broader mental health reform efforts in fragile health systems.
Decision-making surrounding distress, depression and suicidal ideation: findings of a vignette study with primary health care practitioners in Lebanon [Working paper]
(Queen Margaret University, 2025-07) Noubani, Aya; Loffreda, Giulia; Diaconu, Karin; Muhheiddine, Dina; Horn, Rebecca; Saleh, Shadi
This working paper presents early findings from a vignette-based study exploring how primary health care (PHC) providers in Lebanon assess and respond to cases of mental ill-health, including distress, depression, and suicidal ideation. Sixty-one healthcare providers from PHC centers in Beirut and the Bekaa participated in the study using an interactive, web-based vignette tool that simulated patient cases. Each participant reviewed three vignettes varying by patient gender, nationality, and mental health severity. Providers assessed symptom severity, selected treatment options, and chose appropriate referrals. Although detailed findings are withheld to preserve the novelty of forthcoming peer-reviewed work, general trends suggest that provider decision-making varies based on professional role, patient profile, and regional context. The study underscores the potential of PHCCs to support early mental health intervention and the feasibility of vignette-based tools for research in fragile settings.
Dynamics of non-communicable disease prevention, diagnosis and control in Lebanon, a fragile setting
(BMC, 2021-01-11) Zablith, Nadine; Diaconu, Karin; Naja, Farah; El Koussa, Maria; Loffreda, Giulia; Bou-Orm, Ibrahim; Saleh, Shadi; National Institute for Health Research (NIHR)
Abstract: 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.
Health systems research in fragile settings
(World Health Organization, 2019-06-01) Ager, Alastair; Saleh, Shadi; Wurie, Haja; Witter, Sophie
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.
Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: A cross-sectional study from Lebanon
(BMJ, 2022-05-23) Saleh, Shadi; Muhieddine, Dina; Hamadeh, Randa S.; Dimassi, Hani; Diaconu, Karin; Noubani, Aya; Arakelyan, Stella; Ager, Alastair; Alameddine, Mohamad
Objectives: Assess and describe the health service use and delivery patterns for non-communicable disease (NCD) services in two contrasting fragility contexts and by other principal equity-related characteristics including gender, nationality and health coverage. Setting: Primary healthcare centres located in the urbanised area of Greater Beirut and the rural area of the Beqaa Valley. Design: This is a cross-sectional study using a structured survey tool between January and September 2020. Participants: 1700 Lebanese and Syrian refugee patients seeking primary care for hypertension and diabetes. Primary and secondary outcomes: The main outcome is the comprehensiveness of service delivery comparing differences in use and service delivery patterns by fragility setting, gender, nationality and health coverage. Results: Compliance with routine NCD care management (eg, counselling, immunisations, diagnostic testing and referral rates) was significantly better in Beirut compared with Beqaa. Women were significantly less likely to be offered lifestyle counselling advice and referral to cardiologists (58.4% vs 68.3% in Beqaa and 58.1% vs 62% in Beirut) and ophthalmologists, compared with men. Across both settings, there was a significant trend for Lebanese patients to receive more services and more advice related to nutrition and diabetes management (89.8% vs 85.2% and 62.4% vs 55.5%, respectively). Similarly, referral rates were higher among Lebanese refugees compared with Syrian refugees. Immunisation and diagnostic testing were significantly higher in Beirut among those who have health coverage compared with Beqaa. Conclusions: 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.
Readiness to deliver person‐focused care in a fragile situation: The case of Mental Health Services in Lebanon
(BMC, 2021-03-02) Noubani, Aya; Diaconu, Karin; Loffreda, Giulia; Saleh, Shadi
Background: 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.
The determinants of the quality of clinical management among diabetic and hypertensive patients in a context of fragility: A cross-sectional survey from Lebanon
(Frontiers Media S.A., 2022-07-25) Saleh, Shadi; Muhieddine, Dina; Hamadeh, Randa; Dimassi, Hani; Diaconu, Karin; Arakelyan, Stella; Ager, Alastair; Alameddine, Mohamad
Introduction: 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. Methods: We conducted a cross-sectional survey with patients accessing non-communicable disease across 11 primary care centers within the Greater Beirut and Beqaa areas. Response were received from 1,700 patients. We generated a Clinical Management Index Score as a measure of quality of care, and scores related to a range of socio-demographic characteristics and other context specific variables. Results: Significantly higher clinical management index scores (better quality of care) were associated with patients living in the semi-urban/rural context of Beqaa (compared to Greater Beirut), having health insurance coverage, aged above 60, having high levels of educational attainment, and making partial or full payment for their treatment. Relatively lower index scores (poorer quality of care) were associated with Syrian nationality (compared to Lebanese) and with patients suffering from diabetes or hypertension (compared to comorbid patients). Conclusion: The study identified a wide margin for improving quality of NCDs care in fragile contexts with particular gaps identified in referral to ophthalmology, accessing all prescribed medication and receiving counseling for smoking cessation. Additionally, findings indicate a number of predictors of comparatively poor quality of care that warrant attention, notably with regard to Syrian nationality/legal status, lack of health coverage, seeking free health provision and lower educational attachment. Although these are all relevant risk factors, the findings call on donor agencies, NGOs and provider institutions to design targeted programs and activities that especially ensure equitable delivery of services to diabetic and hypertensive patients with compounded vulnerability as a result of a number of these factors.
Understanding and addressing mental health needs and non-communicable disease in situations of fragility: RUHF research programme synopsis
(NIHR, 2025) Ager, Alastair; Witter, Sophie; Diaconu, Karin; Wurie, Haja; Samai, Mohamed; Saleh, Shadi
Background: Fragile settings – marked by conflict and political, environmental, social, or economic crisis – present severe challenges to population health and the delivery of services. This is particularly the case for health conditions that require continuity of care such as non-communicable disease and mental ill-health. Objectives: To understand existing patterns of health seeking in relation to noncommunicable disease and mental health and the barriers to equitable access to quality provision. To then evaluate the feasibility, effectiveness and quality of interventions designed to address these conditions in contexts of fragility. Design and methods: Building on a foundation of focused scoping reviews, we used participatory methods – including group model building – to map pathways of access to community and health system resources in relation to non-communicable diseases and mental health. We then used a range of surveys and key informant interviews to evaluate implemented interventions. In addition, we undertook a series of global reviews of relevant topics, such as conceptualisation of fragility, the role of trust in health-seeking for noncommunicable disease care in fragile settings, analysis of policy and funding priorities of global actors regarding non-communicable diseases in low- and middle-income countries, and the political economy of NCD policy adoption and implementation at national level. Setting and participants: Field studies were focused at the district or governorate level in a range of fragile settings, including Lebanon, Sierra Leone, El Salvador and, latterly, Nigeria and Gaza. Participants included service users, (formal and informal) health providers and policy makers. Interventions: Interventions addressing NCDs included treatment protocols for hypertension and diabetes (with report cards and desk guides supporting primary care-based disease management) and a local co-created salt reduction programme (featuring community drama, school outreach and radio messaging). Mental health needs were primarily addressed in relation to the provision of community-based psychosocial support either through specific interventions (including a lay-woman-led problem solving intervention for perinatal women) or the development of assessment tools (such as a Participatory Assessment Tool for Mapping Social Connections) and contextually valid screening measures (including the Sierra Leone Psychological Distress Scale and the Sierra Leone Perinatal Psychological Distress Scale) to inform interventions. The programme also developed relevant training interventions. Main outcome measures: Measures focused on access to, and utilisation and quality of, services, including user perceptions of provision. Results: We identified a range of barriers to effective health provision in fragile settings. These reflected the cultural, political, social, economic particularities of the setting and its health system. However, trust (in specific health providers, within social and community networks, and in government) was consistently found to be a key factor in securing targeted outcomes. The skills, methods and confidence of providers was also found to be an important influence on such outcomes. Providing contextually relevant training, mentorship and tools equipped health providers in primary care settings to maintain effective, evidencebased management of diabetes and hypertension despite the ongoing challenges of their fragile context. Mobilisation of community-level resources to address non-communicable disease and mental health needs was demonstrated as relevant, feasible and potentially effective in all settings. Limitations: There was great diversity across the particular settings studied, as well as ongoing gaps in knowledge in relation to these conditions in particular. Caution should be shown in generalisation of specific findings to other situations that may not share important features. The COVID 19 pandemic disrupted data collection in both Sierra Leone and Lebanon, although the targeted power of studies was generally secured. More generally, the pandemic significantly impacted health systems operations in all settings studied, an influence that is discussed in all relevant papers. Conclusions: The research programme contributed to addressing gaps in the literature regarding effective tools and strategies to strengthen provision regarding mental health and non-communicable disease in fragile settings. Assessment of needs and barriers to accessing services is an important foundation for effective working in such contexts. This is achievable with research methods (such as group model building and remote data capture) that can accommodate the diverse challenges and uncertainty associated with these settings. Incorporating such information in service design – at the level of the community, health facility or policymaker – can secure improvement in access to, and quality of, important services. Donors and policy makers need to attend not just to the drivers of fragility but also to coherent investment in public health systems and in processes of community engagement if health needs are to be meaningfully addressed. Future work: The conceptualisation of fragility (and resilience) developed through this programme is informing the design of community, health system and wider cross-sectoral interventions in fragile contexts through the ReBuild for Resilience programme in settings including Sierra Leone, Lebanon, Myanmar and Nepal. Further work across diverse contexts of fragility is required to both identify common features and principles required for health response in these settings and refine strategies and tools that can readily be adapted to the unique characteristics of any particular context.