The Institute for Global Health and Development
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Item Refugee integration in national health systems of low- and middle-income countries (LMICs): evidence synthesis and future research agenda(Elsevier, 2025-09-12) Olabi, Amina; Palmer, Natasha; Bertone, Maria Paola; Loffreda, Giulia; Bou-Orm, Ibrahim; Sempé, Lucas; Vera Espinoza, Marcia; Dakessian, Arek; Kadetz, Paul; Ager, Alastair; Witter, SophieThis paper reviews evidence on healthcare responses for refugees, documenting the different approaches and their effectiveness and impact in particular in relation to supporting integrating refugees into national health systems. The review adopted a purposeful, iterative approach, utilizing electronic databases, grey literature, and reference lists from relevant studies. A total of 167 studies, primarily from low- and middle-income countries (LMICs), focusing on refugees and forcibly displaced persons with empirical data, were included. The review highlights a substantial literature on refugee health and healthcare access, with well-covered areas including delivery models, access barriers, gaps in coverage, and specific health services such as psychosocial care, non-communicable diseases, mental health, and maternal and child health. However, less attention is given to integration models, health system responses, and their impact on system resilience and social cohesion. Few studies examine the costs, feasibility, or sustainability of integration models, and little research focuses on health system perspectives or comparative analyses. Moreover, the host health system's status, capacity, and needs are often underexplored. Some countries are particularly well-represented in studies, e.g. Turkey, Jordan, Lebanon, Bangladesh, Democratic Republic of Congo (DRC), and Uganda. There is however a paucity of data that would provide the basis for more quantitative or analytical evaluation from a systems perspective. This gap highlights the need for further research on effective integration models, their operational aspects, and their long-term impact on local health systems' resilience and sustainability. To support this research agenda, we propose a conceptual framework to provide analytic guidance for future research on healthcare responses for refugees and health system integration.Item Health Service Resilience in the Context of Adversity: Case Studies from Three African Countries(MIT Press, 2025) Lembani, Martina; de Pinho, Helen; Delobelle, Peter; Zarowsky, Christina; Ager, Alastair; Blanchet, Karl1. A group model building (GMB) approach to systems mapping can assist stakeholders in identifying key factors influencing specific health challenges and the dynamics of their interconnection. 2. GMB has proved a useful process to identify leverage points to mobilize and coordinate resources to address public health challenges in the process of engagements among key stakeholders. 3. Systems modeling provides a mechanism to enable stakeholders to articulate a vivid picture of the interplay of key factors seen to influence response to a crisis. 4. The GMB methodology appears promising in adapting it to use in analyzing different health systems issues and in different contexts for consolidating insights from multiple stakeholders regarding factors supporting—or undermining—health systems resilience.Item Understanding Resilience in UNRWA Health Response to the Syrian Crisis: Lessons from Causal Loop Analysis(MIT Press, 2025) Ager, Alastair; Diaconu, Karin; Jamal, Zeina; Alameddine, Mohamad; Fouad, Fouad M.; Witter, Sophie; Blanchet, Karl1. Group model building gathers key stakeholders together to develop causal loop analysis of health system responses to experienced shocks. 2. Causal loop analysis can identify important resources and strategies supporting health system resilience. 3. Evidence of absorptive, adaptive, and transformative resilience capacities was demonstrated in UNRWA health response to the Syria crisis across Jordan, Lebanon, and Syria. 4. Analysis highlights the importance of collateral pathways and redundancy; flexible governance and leadership practices; and an organizational culture that sees challenge as an opportunity for learning and innovation. 5. Such evidence has implications for other health systems seeking to integrate provision of services to refugee populations, as well as for UNRWA itself operating in a context of political instability.Item 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, ShadiBackground: 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.Item Editorial: The role of faith in the mental health and integration of forcibly displaced populations(Frontiers Media S.A., 2025-07-08) Rayes, Diana; Robinson, Courtland; Ahmad, Ayesha; Ager, AlastairItem Implementing sport and physical activity across each layer of the Mental Health and Psychosocial Support (MHPSS) pyramid for populations affected by displacement(Elsevier, 2025-06-19) Rosenbaum, Simon; Farello, Anna; Latimer, Kathleen; Vancampfort, Davy; Ventevogel, Peter; Richards, Justin; Warria, Ajwang’; Ager, Alastair; Bray, Maria; Snider, Leslie; Hermosilla, Sabrina; Clark, Jadranka Stikovac; Ferris, Jojo; Kurt, GülsahPhysical activity (PA) and sport are increasingly recognized as integral parts of mental health and psychosocial support (MHPSS) programming within humanitarian response, for people affected by forced displacement. Nonetheless, the programming and implementation of physical activity within MHPSS responses remains inconsistent and largely ad hoc.. In this Short Communication, our team of multidisciplinary authors including academics, and practitioners from disciplines of psychiatry, psychology, physical therapy and sport for development, examine the implementation of sport and PA more broadly, across each layer of the Inter Agency Standing Committee (IASC) MHPSS Pyramid. We demonstrate how PA can be implemented at each layer, to improve MHPSS outcomes in humanitarian settings. We outline examples of how PA is being implemented across the IASC MHPSS pyramid, from ensuring access to inclusive and enabling environments (Layer 1), to strengthening participation in community-based PA and sport initiatives (Layer 2), delivering targeted programs with intentional mental health outcomes (Layer 3), and providing specialized physical activity promotion within clinical mental health services (Layer 4). This Short Communication provides guidance for humanitarian actors on integrating sport and PA across each layer of the IASC MHPSS pyramid.Item Idioms of distress and ethnopsychology of pregnant women and new mothers in Sierra Leone [Working paper](Queen Margaret University, 2025-06) Bah, Abdulai Jawo; Wurie, Haja Ramatulai; Samai, Mohamed; Horn, Rebecca; Ager, AlastairStudies suggest high rates of ante- and post-natal depression in low- and middle-income countries (LMICs), yet relatively little scholarship addresses how perinatal women experience and express psychological distress in these low-resource settings. To address this gap, we conducted a rapid ethnographic study including 96 free list interviews with community members and 16 key informants (KI) pile sorts. Thematic analysis of data was supported by frequency analysis and multidimensional scaling. Participants included pregnant and new mothers, nonpregnant and non-lactating mothers, elderly women, and men in the community to gauge a diverse range of views. Twenty signs of distress were identified. The heart (at), mind (maynd)), and body (bodi) comprised the self-concept and were related to sadness, stress, loneliness, anger, worry, and thinking too much. They used the heart and mind to describe problems associated with emotions and thoughts respectively. Participants articulated several idioms of distress, including stres(stress), poil at (spoil heart), and ed nor de or e wan go off (pre-psychosis or crase), that occur within a context of poverty, marital disharmony or inter-partner conflict and gender inequality. These idioms of distress exist as discrete indicators with overlapping features, operating on a continuum of severity that could progress over time, both within and across idioms. These findings can inform mental health literacy and communications that is less stigmatizing; the development of culturally salient screening tools and interventions that are locally appropriate. This could potentially increase uptake and engagement with services, and enhance therapeutic outcomes for perinatal women with psychological distress.Item The cultural adaptation of the Friendship Bench Intervention to address perinatal psychological distress in Sierra Leone: an application of the ADAPT-ITT framework and the Ecological Validity Model(Frontiers Media S.A., 2025-02-19) Bah, Abdulai Jawo; Wurie, Haja Ramatulai; Samai, Mohamed; Horn, Rebecca; Ager, AlastairBackground: In Sierra Leone, women of reproductive age represent a significant portion of the population and face heightened mental health challenges due to the lasting effects of civil war, the Ebola epidemic, and the COVID-19 pandemic. This study aimed to culturally adapt the Friendship Bench Intervention (FBI) for perinatal psychological distress in Sierra Leone. Method: We utilized the ADAPT-ITT framework and Bernal’s Ecological Validity Model (EVM) for culturally adapting the FBI’s process and content. The adaptation stages included a formative study to assess perinatal women’s mental health needs. We screened the FBI for modifications based on the data from the formative study and EVM. The initial FBI manual was presented to mother-mother support groups (MMSGs, n=5) and primary health workers (n=3) for feedback (version 1.0). A theatre test with perinatal women (n=10) was conducted led by MMSGs, yielding further feedback (version 2.0). The revised manual was then reviewed by topical experts (n=2), whose insights were incorporated (version 3.0). Results: The Friendship Bench manual for Sierra Leone has been revised to better meet the cultural needs of perinatal women. The cover now illustrates an elderly woman conversing with a new mother, emphasizing community support. Culturally relevant idioms, such as “poil at” and “mind not steady,” replace previous terms, and new screening tools, the Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) and the Function Scale, have been introduced. The problem-solving therapy was simplified from seven to four steps, and training duration was reduced from nine days to two, using visual aids to enhance comprehension for those with low literacy levels. Conclusion: Through this systematic approach, we successfully culturally adapted the FBI for treating perinatal psychological distress in Sierra Leone. The next step is to evaluate it feasibility, acceptability, and preliminary effectiveness in perinatal care settings.Item Policy and practice implications of contextual understanding of - and tools to address - mental health and psychosocial support needs in Sierra Leone(Frontiers Media S.A., 2025-02-05) Ager, Alastair; Horn, Rebecca; Bah, Abdulai Jawo; Wurie, Haja; Samai, MohamedThe last two decades have seen increased awareness of the impact of mental health issues on the population of Sierra Leone. Local capacity to respond to these needs is severely limited. In 2017, the Ministry of Health and Sanitation (MoHS) worked with staff of the College of Medicine and Allied Health Sciences (COMAHS – part of the University of Sierra Leone) and Queen Margaret University (QMU) in Edinburgh – and other stakeholders, including members of the Mental Health Coalition Sierra Leone – to define a research agenda that would support the development of community-based mental health and systems support in the community. This paper summarizes work over the course of the following six years in relation to this agenda, and indicates its relevance to ongoing and planned service developments. In terms of research advance, studies have – through participatory and ethnographically-informed methods – identified both local idioms and social determinants of distress and mapped health seeking pathways and barriers to care. This information was utilized in the development and validation of two culturally appropriate measures: the Sierra Leone Psychological Distress Scale (to assess mental health and psychosocial needs at the community level) and the Sierra Leone Perinatal Psychological Distress Scale (to identify common perinatal mental disorder in amongst pregnant and lactating mothers). For this latter population, a culturally adapted form of a problem solving intervention delivered through existing mother-to-mother supports has been shown to be feasible, acceptable and potentially effective. This work has major policy and practice implications, and early evidence of uptake is noted. This includes mental health capacity development through the online availability of training guides for the developed assessment scales and plans for incorporation of material regarding idioms and social determinants of distress in pre-and post-professional training curriculum. In terms of community-based initiatives, there has been evidence of uptake from the Mental Health Coalition Sierra Leone. In terms of policy, findings reinforce key principles regarding community-based provision, integration of mental health care into primary health care, and actions to reduce stigma associated with mental health.Item Feasibility, acceptability and preliminary effectiveness of a culturally adapted nonspecialist delivery Problem-Solving Therapy: Friendship Bench Intervention for perinatal psychological distress in Sierra Leone(Cambridge University Press, 2025-02-03) Bah, Abdulai Jawo; Wurie, Haja Ramatulai; Samai, Mohamed; Horn, Rebecca; Ager, AlastairIn low- and middle-income countries like Sierra Leone, there is a significant gap in the treatment of perinatal mental health disorders such as anxiety, depression and somatization. This study explored the feasibility, acceptability and preliminary effectiveness of a culturally adapted Problem-Solving Therapy - Friendship Bench Intervention (PST-FBI) delivered by nonspecialists, mother-to-mother support groups (MMSGs), to perinatal women experiencing psychological distress. MMSGs provide 4 weeks of home-based, individual PST-FBI, followed by a peer-led group session called col at sacul (circle of serenity). The intervention targeted peri-urban pregnant women and new mothers screened for psychological distress. This was a two-armed, pre-post, waitlist-controlled study that employed the Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) to screen and measure their outcomes. Feasibility and acceptability were examined through in-depth interviews using the Consolidated Framework for Implementation Research, analyzed thematically, while preliminary effectiveness was evaluated with chi-squared analysis for categorical and t-test for continuous variables. Twenty of the 25 women completed all four PST-FBI sessions delivered by five MMSGs. The individual PST and the peer-led session were viewed as beneficial for problem-sharing and skill building. The SLPPDS scores significantly dropped by 58.9% (17.1-8.4) in the intervention group, while the control group showed a 31.6% (18.0-12.3) decrease. The intervention's effect size was d = 0.40 (p < 0.05). The MMSG-led PST-FBI, including the col at sacul session, proved feasible, acceptable and with preliminary effectiveness in improving the mental health of peri-urban pregnant women and new mothers in Sierra Leone. Further randomized-controlled trials are recommended before nationwide implementation. © Queen Margaret University, 2025.