The Institute for Global Health and Development
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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 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 Social determinants of psychological distress in Sierra Leone(Springer, 2022-04-19) Jailobaeva, Kanykey; Horn, Rebecca; Arakelyan, Stella; Diaconu, Karin; Kamara, Ajaratu; Ager, AlastairPurpose 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.Item The development of a contextually appropriate measure of psychological distress in Sierra Leone(BMC, 2021-07-21) Horn, Rebecca; Jailobaeva, Kanykey; Arakelyan, Stella; Ager, AlastairAbstract: Background: 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. Methods: The new measure consists of two instruments: the Sierra Leone Psychological Distress Scale (SLPDS) and a gendered measure of ability to carry out daily tasks—a Function scale—as an indication of the severity of distress. A three-phase mixed methods exploratory sequential study was conducted. Phase 1 was item generation and testing, leading to the development of a set of potential items for both instruments. Phase 2 was a small pilot study (N = 202) leading to the selection of the final set of items for both measures. Phase 3 was a validation phase where the SLPDS and the Function scale were administered with a larger sample of 904 respondents. Item analysis was used to assess the internal consistency of the scales, and Exploratory Factor Analysis to explore the properties of the SLPDS. Results: Exploratory factor analysis using the principal axis factoring with an oblique rotation identified a three-factor structure for the 18-item SLPDS. Internal consistency for the SLPDS (Cronbach’s alpha = 0.89) and three subscales was good (Cronbach’s alpha > 0.73). The internal reliability of the male and female versions of the Function scale was also found to be acceptable (Cronbach’s alpha = 0.90 for the female scale and 0.79 for the male scale). Conclusions: Together the SLPD and Function scales provide a locally-validated tool which will enable government bodies and local and international non-governmental organisations in Sierra Leone to assess mental health and psychosocial needs. This will support both effective service provision and the evaluation of initiatives designed to improve mental health and psychosocial wellbeing.Item Factors contributing to emotional distress in Sierra Leone: A socio-ecological analysis(BMC, 2021-06-11) Horn, Rebecca; Arakelyan, Stella; Wurie, Haja; Ager, AlastairBackground 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.Item A multilevel bioecological analysis of factors influencing the mental health and psychosocial wellbeing of refugee children(Association for Child and Adolescent Mental Health, 2020-12-05) Arakelyan, Stella; Ager, AlastairBackground: This paper revisits the themes of an influential 1993 review regarding the factors shaping the mental health and psychosocial well-being of refugee children to take stock of developments in the evidence base and conceptualisation of issues over the last 25 years.Item Expressions of psychological distress in Sierra Leone: Implications for community-based prevention and response(Cambridge University Press, 2020-07-29) Horn, Rebecca; Sesay, Simeon S.; Jalloh, Mamadu; Bayoh, Amjata; Lavally, Joan B.; Ager, AlastairBackground 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.Item Measuring the psychosocial, biological, and cognitive signatures of profound stress in humanitarian settings: Impacts, challenges, and strategies in the field(BioMed Central, 2020-06-23) Panter-Brick, Catherine; Eggerman, Mark; Ager, Alastair; Hadfield, Kristin; Dajani, Rana; This research was funded by Elrha’s Research for Health in Humanitarian Crises (R2HC) Programme (https://www.elrha.org/project/yale-psychosocial-call2/) for a total GPB 295,131 in 2015–17 (grant #14045). Elrha aims to improve health outcomes by strengthening the evidence base for public health interventions in humanitarian crises (elrha.org/r2hc). The R2HC programme is funded equally by the Wellcome Trust and the UK Government.Background: Evidence of ‘what works’ in humanitarian programming is important for addressing the disruptive consequences of conflict and forced displacement. However, collecting robust scientific evidence, and ensuring contextual relevance, is challenging. We measured the biological, psychosocial, and cognitive impacts of a structured psychosocial intervention, implemented by Mercy Corps with Syrian refugees and Jordanian host-community youth. In this paper, we present a case analysis of this evaluation study and reflect on the scientific contributions of the work, the challenges experienced in its delivery, and the strategies deployed to address them.Item Child friendly spaces impact across five humanitarian settings: A meta-analysis(BMC, 2019-05-15) Hermosilla, Sabrina; Metzler, Janna; Savage, Kevin; Musa, Miriam; Ager, AlastairBackground: Humanitarian crises present major threats to the wellbeing of children. These threats include risks of violence, abduction and abuse, emotional distress and the disruption of development. Humanitarian response efforts frequently address these threats through psychosocial programming. Systematic reviews have demonstrated the weak evidence-base regarding the impact of such interventions. This analysis assesses the impact of Child Friendly Spaces (CFS), one such commonly implemented intervention after humanitarian emergencies.