The Institute for Global Health and Development
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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.Item Psychological distress and coping mechanisms due to the COVID-19 pandemic among the adult population in Bo Sierra Leone. A cross-sectional study(Public Library of Science, 2025-02-07) James, Peter Bai; Osborne, Augustus; Bah, Fatmata Seray; Bah, Abdulai Jawo; Kangbai, Jia Bainga; Yendewa, George A.Psychological distress is widely recognized as a significant health concern that poses a potential risk to the overall mental wellbeing of individuals. This study investigated the psychological distress associated with the COVID-19 pandemic and the coping methods employed by adults in Bo district, Sierra Leone. This research used a snapshot approach (cross-sectional design) to describe the prevalence of psychological distress during the COVID-19 pandemic among 502 adults residing in Bo district, Sierra Leone. We collected study data using a structured questionnaire that comprised of participant’s demographics, Kessler Psychological Distress Scale (K10), Fear of COVID-19Scale (FCV-19S), Brief Resilient Coping Scale (BRCS), and Duke-UNC Functional Social Support instrument. We used backward stepwise binary logistic regression to identify the key factors linked to psychological distress. The average psychological stress score was 22.96±11.35, with approximately one-third of participants (n = 160, 31.9%) exhibiting very high levels of psychological distress. The mean score for fear of COVID-19 was 29.71±6.84, with the majority (n = 420,83.7%) being fearful of COVID-19. The mean score for the Brief Resilient Coping Mechanism was 12.49±4.51, with half of the participants considered low resilient copers (n = 257,51.2%). The mean score for functional social support was 25.35±8.85, with (n = 240, 47.8%) having increased social support. Individuals with a known health condition [aOR = 4.415, 95% CI = 1.859–10.484], who provided care to a family member/patient with known/suspected COVID-19 [aOR = 4.485, 95% CI = 1.575–12.775], who knew someone who died from COVID-19 [aOR = 3.117, 95% CI = 1.579–6.154], with an increased fear of COVID-19 [aOR = 4.344, 95% CI = 2.199–8.580] had higher odds of moderate to severe psychological distress. Moderate resilient copers [aOR = 0.523, 95% CI = 0.296–0.925] had lower odds of psychological distress compared to the low resilient copers. Participants with increased social support had lower odds of psychological distress than those with low support [aOR = 0.253, 95% CI = 0.147–0.434]. A significant proportion of the study cohort residing in Bo, Sierra Leone, experienced high levels of mental stress because of the COVID-19 pandemic. This study shows the importance of designing and implementing programs that minimize COVID-19 stressors and enhance the coping skills and social support network.Item Social Sciences in Emerging Infectious Disease: The Ebola Disease Response(Springer International Publishing, 2023-01-01) James, Peter Bai; Lane, Rashon; Bah, Abdulai JawoEmerging infectious disease outbreaks are increasingly prevalent, and the need to develop or strengthen existing health systems to effectively respond to a global health threat has become more apparent. Moreover, it has become clear the critical role social science research plays in exploring human behavior, cultural, social, and political economic forces that are equally important to inform emerging infectious disease response and recovery. This chapter discusses the role of social science research in infectious disease outbreaks, looking at benefits and current barriers. It further considers Ebola as a e study to illustrate how social science research approaches are used to explain the cultural, social, and political economic forces that explain community response and inform public health response to recent Ebola outbreaks in Western and Eastern Africa. Specifically, it discusses issues surrounding the origin of the Ebola virus, community beliefs and understanding of Ebola virus disease, surveillance, burial practices, the influence of politics and conflict on Ebola response efforts, vaccine hesitancy and Ebola survivorship relating to community stigma, as well as discrimination and health-seeking behavior. © Springer Nature Switzerland AG 2023.Item Developing and validating the Sierra Leone perinatal psychological distress scale through an emic-etic approach(Elsevier, 2024-11-17) Bah, Abdulai Jawo; Wurie, Haja Ramatulai; Samai, Mohamed; Horn, Rebecca; Ager, AlastairBackground Addressing perinatal psychological distress in Sierra Leone faces challenges due to the lack of culturally appropriate assessment tools, despite recent WHO recommendations for screening during the pre- and postpartum periods. While high-income countries use tools like the Edinburgh Postnatal Depression Scale or Patient Health Questionnaire-9 (PHQ-9), their cross-cultural validity and efficacy in developing countries are uncertain. The aim of this study was to address this gap by developing a functional assessment tool, culturally appropriate screening tool for perinatal psychological distress, and validate it with the PHQ-9. Method Following scale development guidelines, the study encompassed three phases: Item Development, Scale Development, and Scale Evaluation. Data from free listing interviews (n = 96), FGDs (n = 24), and cognitive interviews (n = 8) informed the development of the Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) and a Function scale. Item reduction via exploratory factor analysis (n = 120) and validation (n = 140) were conducted in subsequent phases. Result Two screening instruments were developed: the 10-item SLPPDS and a 5-item Function scale assessing perinatal women's ability to perform daily tasks. Sensitivity/specificity values for the SLPPDS and PHQ-9 were 80.0/85.7 and 73.8/76.2 respectively. Internal consistency reliability was 0.88 for the SLPPDS and 0.81 for the PHQ-9. Confirmatory factor analysis supported a one-factor model with 54.9 % variance explained. ROC/cut-off points for SLPPDS and PHQ-9 were 0.90/0.81 and 8.0/7.0 respectively. Conclusion The PHQ-9 shows validity and reliability as a screening instrument, but the SLPPDS emerges as a potentially more salient alternative for assessing perinatal psychological distress in Sierra Leone. This implies the SLPDDS is particularly relevant, meaningful, and applicable to the specific cultural or community context it was designed for. It suggests that the tool effectively addresses the unique needs, perspectives, and experiences of the perinatal women, making it more likely to resonate with users and stakeholders. This relevance may enhance the tool's acceptance, usability, and overall impact in identifying and addressing perinatal mental health issues in Sierra Leone. These instruments could enable effective evaluation of perinatal mental health initiatives by government agencies, locals, and international NGOs.Item Do disempowered childbearing women give birth at home in Sierra Leone? A secondary analysis of the 2019 Sierra Leone demographic health survey(BioMed Central, 2023-11-22) James, Peter Bai; Yendewa, George A; Bah, Abdulai Jawo; Osborne, Augustus; Kpagoi, Satta Sylvia; Margao, Emmanuel Kamanda; Kangbai, Jia; Wardle, JonBackground: A nationwide assessment of the link between women’s empowerment and homebirth has not been fully examined in Sierra Leone. Our study examined the association between women’s empowerment and homebirth among childbearing women in Sierra Leone using the 2019 Sierra Leone Demographic Health Survey (2019 SLDHS) data. Method: We used the individual file (IR) of the 2019 SLDHS dataset for our analysis. A total of 7377 women aged 15–49 years who gave birth in the five years preceding the survey were included. Outcome variable was “home birth of their last child among women in the five years preceding the 2019 SLDHS. Women’s empowerment parameters include women’s knowledge level, economic participation, decision-making ability and power to refuse the idea of intimate partner violence. We used the complex sample command on SPSS version 28 to conduct descriptive and multivariate logistic regression analyses. Results: Three in every 20 women had home childbirth (n = 1177; 15.3%). Women with low [aOR 2.04; 95% CI 1.43–2.92] and medium [aOR 1.44; 95%CI 1.05–1.97] levels of knowledge had higher odds of giving birth at home compared to those with high levels of knowledge. Women who did not have power to refuse the idea of intimate partner violence against women were more likely to had given birth at home [aOR 1.38; 95% CI1.09-1.74]. In addition, women with no [aOR 2.71; 95% CI1.34-5.46) and less than four antenatal care visits [aOR 2.08; 95% CI:1.51–2.88] and for whom distance to a health facility was a major problem [aOR 1.95; 95% CI1.49-2.56] were more likely to have had a homebirth. However, no statistically significant association was observed between a women’s decision-making power and home birth [aOR 1.11; 95% CI 0.86–1.41]. Conclusion: Despite improvements in maternal health indicators, homebirth by unskilled birth attendants is still a public health concern in Sierra Leone. Women with low knowledge levels, who did not have power to refuse the idea of intimate partner violence against women, had less than four ANC visits and considered distance to a health facility as a major problem had higher odds of giving birth at home. Our findings reflect the need to empower women by improving their knowledge level through girl child and adult education, increasing media exposure, changing societal norms and unequal power relations that promote gender-based violence against women, and improving roads and transport infrastructure.Item The use of traditional medicine practitioner services for childhood illnesses among childbearing women: a multilevel analysis of demographic and health surveys in 32 sub-Saharan African countries(BioMed Central, 2023-04-29) James, Peter Bai; Gyasi, Razak M.; Kasilo, Ossy Muganga Julius; Wardle, Jon; Bah, Abdulai Jawo; Yendewa, George A.; Mwaka, Amos DeogratiusBackground: Insights into the use of traditional medicine practitioners (TMP)-for common childhood diseases such as diarrhea and respiratory infections are important to understand the role of Traditional Medicine (TM) in reducing the increasing childhood morbidity and mortality in sub-Saharan Africa (SSA). However, a comprehensive picture of TMP utilisation and its associated factors for childhood illness in SSA is lacking. This study aimed to estimate the prevalence of the use of traditional medicine practitioner services to treat childhood illnesses among women with children under five years old and to identify individual and community-level factors associated with TMP use in SSA. Methods: The analysis used Demographic and Health Surveys (DHS) dataset collected between 2010 and 2021 among 353,463 under-fives children from 32 SSA countries. Our outcome variable was the use of TMP for childhood illness, defined as having diarrhoea or fever/cough or both. Using STATA v14, we employed the random effect meta-analysis to estimate the pooled prevalence of TMP use for childhood illness and a two-level multivariable multilevel modelling to determine the individual and community-level factors associated with consultation of a TMP. Results: Approximately [2.80% (95%CI: 1.88–3.90)] women who sought healthcare for childhood illnesses utilised the service of a TMP with the highest occurring in Cote d’Ivoire [16.3% (95%CI: 13.87–19.06)] and Guinea (13.80% (95%CI: 10.74–17.57)] but the lowest in Sierra Leone [0.10%(95%CI:0.01–1.61)]. Specifically, approximately [1.95% (95%CI: 1.33–2.68)] and [1.09% (95%CI:0.67–1.60)] of women sought the service of a TMP for childhood diarrhea and fever/cough, respectively. Women with no formal education [AOR = 1.62;95%CI:1.23–2.12], no media access [AOR = 1.19;95%CI:1.02–1.39), who lived in a male-headed household [AOR = 1.64;95%CI:1.27–2.11], without health insurance [AOR = 2.37;95%CI: 1.53–3.66], who considered it a problem getting permission to visit a health facility [AOR = 1.23;95%CI:1.03–1.47] and who perceived the size of their children at birth to be above average[AOR = 1.20;95%CI:1.03–1.41] had higher odds of using TMP for childhood illnesses. Conclusions: Although the prevalence of TMP for childhood illnesses appeared low, our findings highlight that TMPs continue to play a critical role in managing childhood illnesses in SSA. It is essential that policymakers and service providers should incorporate the potential role of TMPs in the design, review and implementation of child health policies in SSA. Also, the interventions for curtailing childhood illnesses should be focused on the characteristics of women who use TMPs for childhood diseases identified in our study.Item Navigating the tension between fatherhood ideals and realities of a post-conflict setting: A phenomenological study of former child soldiers in Sierra Leone(Elsevier, 2023-01-27) Klein, Elizabeth K; Bond, Laura; McLean, Kristen E; Feika, Mahmoud; Bah, Abdulai Jawo; Betancourt, Theresa SThe concept of “fatherhood” in many African countries has traditionally been understood in terms of instrumental support to one's family, most notably, financial provision. However, in Sierra Leone and elsewhere, this narrow understanding of fatherhood is changing as a result of shifting demographic trends and in response to crises such as civil war and the recent Ebola outbreak in west Africa. Little is understood about how males formerly associated with armed forces and armed groups during childhood (Children Associated with Armed Forces and Armed Groups/CAAFAG) are navigating fatherhood as young adults. This study uses a phenomenological approach to understand 1) the meaning and importance of fatherhood for CAAFAG and war-affected fathers, 2) what fatherhood looks like normatively and ideally, with attention to norms about nurturing care and violence, and 3) how ideals of fatherhood may or may not be in tension with socioeconomic circumstances. We find that CAAFAG and war-affected fathers are committed to providing emotional support, encouragement, and a loving upbringing in addition to striving to provide financially for their families. Fathers experienced the greatest tension between their ideals of fatherhood and their structural circumstances; in other words, they felt inhibited in becoming the types of fathers they hoped to be due to the realities of living in a post-conflict, resource-constrained environment.
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