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    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, Sophie
    This 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.
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    Barriers and Opportunities for WHO ‘Best Buys’ Non-Communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review
    (Maad Rayan Publishing Company, 2023-12-31) Loffreda, Giulia; Arakelyan, Stella; Bou-Orm, Ibrahim; Holmer, Hampus; Allen, Luke N.; Witter, Sophie; Ager, Alastair; Diaconu, Karin
    Background: Improving the adoption and implementation of policies to curb noncommunicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policymakers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation. Methods: We conducted a complex systematic review of articles discussing the adoption and implementation of WHO's ‘best buys' NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria. Results: Our CLD highlights a central feedback loop encompassing three vital variables: 1) the ability to define, (re)shape and pass appropriate policy into law; 2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); 3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies. Conclusion: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.
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    Political Economy of Non-Communicable Disease (NCD) prevention and control in Lebanon: identifying challenges and opportunities for policy change and care provision reforms
    (BioMed Central, 2023-12-18) Bou-Orm, Ibrahim; Loffreda, Giulia; Diaconu, Karin; Witter, Sophie; deVos, Pol
    Introduction: Lebanon is a middle-income country facing substantial fragility features. Its health profile shows a high burden of NCD morbidity and mortality. This paper intends to analyse the political economy of NCD prevention and control in Lebanon. Methods: This study adopted a literature-based case study research design using a problem-driven political economy analysis framework. A total of 94 peer-reviewed articles and documents from the grey literature published before June 2019 were retrieved and analysed. Results: Lebanon’s political instability and fragile governance negatively affect its capacity to adapt a Health-in-All-Policies approach to NCD prevention and enable the blocking of NCD prevention policies by opposed stakeholders. Recent economic crises limit the fiscal capacity to address health financing issues and resulting health inequities. NCD care provision is twisted by powerful stakeholders towards a hospital-centred model with a powerful private sector. Stakeholders like the MOPH, UN agencies, and NGOs have been pushing towards changing the existing care model towards a primary care model. An incremental reform has been adopted to strengthen a network of primary care centres, support them with health technologies and improve the quality of primary care services. Nevertheless, outpatient services that are covered by other public funds remain specialist-led without much institutional regulation. Conclusion: Our study revealed a locked equilibrium in NCD prevention policymaking in Lebanon, but with an incremental progress in service delivery reforms towards a primary care model. Advocacy and close monitoring by policy entrepreneurs (such as civil society) could initiate and sustain the implementation of policy change and care model reforms.
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    Provision of mental health and psychosocial support services to health workers and community members in conflict-affected Northwest Syria: a mixed-methods study
    (BioMed Central, 2023-10-04) Bou-Orm, Ibrahim; Moussallem, Marianne; Karam, Joelle; deLara, Manuel; Varma, Vinod; Diaconu, Karin; Apaydin, Murat Can Birand; Van den Bergh, Rafael; Ager, Alastair; Witter, Sophie
    Background: Northwest Syria (NWS) is a conflict area with challenging political, economic, demographic and social dynamics. The region has a high number of internally displaced persons with increasingly disrupted delivery of basic services, including healthcare. Mental health needs have been increasing in the region while the infrastructure and capacity of the health sector has been negatively affected by the conflict. This study aimed to explore the provision of mental health and psychosocial support (MHPSS) services to communities in NWS (including healthcare workers) and to assess the experiences of beneficiaries with MHPSS services. Methods: The study followed a mixed-methods research design that included qualitative and participatory methods (44 semi-structured interviews and a group model building workshop with 15 participants) as well as a survey with 462 beneficiaries. Results: Findings suggested an improvement of MHPSS services in the region over the last few years due to the creation of a specific Technical Working Group for MHPSS that contributed to assessment of community needs and support of the MHPSS response. The key elements of this response were: (1) training non-specialized health workers to address the shortage in specialized providers; (2) securing funding and coordination of services between different organizations; and (3) addressing gaps in the availability and geographical distribution of other needed resources, such as medicines. While those elements contributed to improving access to services and the quality of services—especially among health workers seeking MHPSS services—findings suggested gaps in the sustainability of services and a need to scale up those interventions in an integrated approach. Conclusion: The study findings add to the evidence base on the challenges in scaling up MHPSS interventions and their long-term sustainability concerns. Priority actions should address the intermittent funding of the MHPSS response, incorporate MHPSS outputs and outcomes in the reimbursement of routine services, improve coordination between health partners and non-health actors in order to expand the scope of MHPSS response, and address the inequitable availability of resources in the region.
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    Experiences of communities with Lebanon’s model of care for non-communicable diseases: a cross-sectional household survey from Greater Beirut
    (BMJ Publishing Group, 2023-09-04) Bou-Orm, Ibrahim; deVos, Pol; Diaconu, Karin
    Objectives Assess community perceptions of the Lebanese care model for non-communicable diseases (NCDs) and trust in the health system among others, and test association between them. Design Cross-sectional study using multistage random sampling and targeting adult community members living with NCDs. Setting Households in Greater Beirut—Lebanon. Participants 941 respondents including 574 Lebanese community members and 367 Syrian refugees. Primary and secondary outcomes Three main outcomes (barriers to care seeking, perceptions of the care model and trust in healthcare) were assessed including by multiple linear regressions. Results Reported NCDs were hypertension (51.3%) and diabetes (34.5%), followed by chronic respiratory conditions (21.9%) and other cardiovascular diseases (20.0%). Communities reported seeking care from different sources. While 78% of Lebanese participants had visited private clinics at least once within the 6 months preceding the survey, 56% of Syrian refugees had done so. Determinants of access to care were health coverage, gender, and employment among Lebanese, and socioeconomic status among Syrian refugees. Lebanese community members had more positive perceptions of the care model compared with Syrian refugees and determinants included sociodemographic characteristics and the type of providers. Trust in the health system was higher among Syrian compared with Lebanese participants and was significantly influenced by the care model score and barriers to care seeking. Conclusion Our 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.
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    PET/CT Scanner and Bone Marrow Biopsy in Detection of Bone Marrow Involvement in Diffuse Large B-Cell Lymphoma
    (Public Library of Science, 2017-01-18) El Karak, Fadi; Bou-Orm, Ibrahim; Ghosn, Marwan; Kattan, Joseph; Farhat, Fadi; Ibrahim, Toni; Jreige, Mario; El Cheikh, Jean; Haidar, Mohamad
    Evaluation of bone marrow involvement (BMI) is paramount in diffuse large B-cell lymphoma (DLBCL) for prognostic and therapeutic reasons. PET/CT scanner (PET) is now a routine examination for the staging of DLBCL with prognostic and therapeutic implications. This study evaluates the role of PET for detecting marrow involvement compared to bone marrow biopsy (BMB). This monocentric study included 54 patients diagnosed with DLBCL between 2009 and 2013 and who had FDG PET/CT in a pre-treatment setting. A correlation analysis of the detection of BMI by PET and BMB was performed. A prognostic evaluation of BMI by BMB and/or PET/CT and correlation with an overall 2-year survival were analyzed. PET was more sensitive for the detection of BMI than BMB (92.3% vs. 38.5%). It can be considered a discriminatory Pre-BMB test with a negative predictive value of 97.6%. In addition, BMI by PET had a prognostic value with strong correlation with progression-free survival (PFS) (HR = 3.81; p = 0.013) and overall survival (OS) (HR = 4.12; p = 0.03) while the BMB had not. PET shows superior performance to the BMB for the detection of marrow involvement in DLBCL. It may be considered as the first line examination of bone marrow instead of the biopsy.
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    Patterns and determinants of mammography screening in Lebanese women
    (Elsevier, 2016-12-23) Elias, Nadia; Bou-Orm, Ibrahim; Adib, Salim M.
    The associations of ever using and/or repeating a mammography test with psychosocial and socio-demographic factors were surveyed in 2014 among Lebanese women ≥ 40. A sample of 2400 women was selected across Lebanon. Variables with significant bivariate associations with various types of behaviors were entered in multivariate analysis. Of the total, 105 women (4·4%) had never heard of mammography as a tool for early breast cancer detection. Among the remaining 2295, 45% had ever used it, of whom 10% had obtained it for the first time within the 12 months preceding the survey. Repeaters were 67% of 926 women who had the time opportunity to do so (median lifetime frequency: 2). Older age, higher socio-economic status (SES) and living within the Greater Beirut (GB) area were significantly associated with ever-use. Within GB, psychosocial factors such as perceived susceptibility and benefits were most strongly associated with ever-use. Outside GB, socio-economic advantage seemed to mostly affect ever-use. Only 4% reported opposition from husbands to their mammography, and husband's support was significant for adherence to mammography guidelines mostly outside GB. Higher education emerged also as a significant socio-demographic determinant for ever-repeating in all regions. Perceived comfort of the previous test strongly affected the likelihood of repeating it. Providing mammography free-of-charge may alleviate some obstacles among women with socio-economic disadvantage. Stressing that good results one year do not make the cancer less likely or repeating the test less important, as well as improving the comfort of mammography testing could ensure test repeating.
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    Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016
    (Elsevier, 2017-09-12) GBD 2016 SDG Collaborators; Bou-Orm, Ibrahim
    Background The UN's Sustainable Development Goals (SDGs) are grounded in the global ambition of “leaving no one behind”. Understanding today's gains and gaps for the health-related SDGs is essential for decision makers as they aim to improve the health of populations. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016), we measured 37 of the 50 health-related SDG indicators over the period 1990–2016 for 188 countries, and then on the basis of these past trends, we projected indicators to 2030. Methods We used standardised GBD 2016 methods to measure 37 health-related indicators from 1990 to 2016, an increase of four indicators since GBD 2015. We substantially revised the universal health coverage (UHC) measure, which focuses on coverage of essential health services, to also represent personal health-care access and quality for several non-communicable diseases. We transformed each indicator on a scale of 0–100, with 0 as the 2·5th percentile estimated between 1990 and 2030, and 100 as the 97·5th percentile during that time. An index representing all 37 health-related SDG indicators was constructed by taking the geometric mean of scaled indicators by target. On the basis of past trends, we produced projections of indicator values, using a weighted average of the indicator and country-specific annualised rates of change from 1990 to 2016 with weights for each annual rate of change based on out-of-sample validity. 24 of the currently measured health-related SDG indicators have defined SDG targets, against which we assessed attainment. Findings Globally, the median health-related SDG index was 56·7 (IQR 31·9–66·8) in 2016 and country-level performance markedly varied, with Singapore (86·8, 95% uncertainty interval 84·6–88·9), Iceland (86·0, 84·1–87·6), and Sweden (85·6, 81·8–87·8) having the highest levels in 2016 and Afghanistan (10·9, 9·6–11·9), the Central African Republic (11·0, 8·8–13·8), and Somalia (11·3, 9·5–13·1) recording the lowest. Between 2000 and 2016, notable improvements in the UHC index were achieved by several countries, including Cambodia, Rwanda, Equatorial Guinea, Laos, Turkey, and China; however, a number of countries, such as Lesotho and the Central African Republic, but also high-income countries, such as the USA, showed minimal gains. Based on projections of past trends, the median number of SDG targets attained in 2030 was five (IQR 2–8) of the 24 defined targets currently measured. Globally, projected target attainment considerably varied by SDG indicator, ranging from more than 60% of countries projected to reach targets for under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria, to less than 5% of countries projected to achieve targets linked to 11 indicator targets, including those for childhood overweight, tuberculosis, and road injury mortality. For several of the health-related SDGs, meeting defined targets hinges upon substantially faster progress than what most countries have achieved in the past. Interpretation GBD 2016 provides an updated and expanded evidence base on where the world currently stands in terms of the health-related SDGs. Our improved measure of UHC offers a basis to monitor the expansion of health services necessary to meet the SDGs. Based on past rates of progress, many places are facing challenges in meeting defined health-related SDG targets, particularly among countries that are the worst off. In view of the early stages of SDG implementation, however, opportunity remains to take actions to accelerate progress, as shown by the catalytic effects of adopting the Millennium Development Goals after 2000. With the SDGs' broader, bolder development agenda, multisectoral commitments and investments are vital to make the health-related SDGs within reach of all populations.
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    Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
    (Elsevier, 2017-09-16) GBD 2016 DALYs and HALE Collaborators; Bou-Orm, Ibrahim
    Background Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). Methods We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. Findings The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9–78·6) for females and 72·0 years (68·8–75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0–49·5]) and for males was in Lesotho (41·5 years [39·0–44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97–6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74–6·27) for males and 6·49 years (6·08–6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61–1·93) for males and 1·96 years (1·69–2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (–2·3% [–5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. Interpretation At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support.
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    Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
    (Elsevier, 2017-09-16) GBD 2016 Risk Factors Collaborators; Bou-Orm, Ibrahim
    Background The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context. Methods We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined. Findings Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9–11·6) decline in deaths and a 10·8% (8·3–13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7–17·5) of deaths and 6·2% (3·9–8·7) of DALYs, and population growth for 12·4% (10·1–14·9) of deaths and 12·4% (10·1–14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9–29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks. Interpretation Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.