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Item 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, ShadiThis 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.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 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 Effect of contributing factors on the incidence of non-communicable diseases among adults with common mental health disorders: a systematic review(National Institute for Health and Care Research, 2024-05) Jamal, Zeina; Horn, Rebecca; Ager, AlastairBackground Individual, social and environmental factors play a dynamic role in determining mental health outcomes. The linkage between mental health and non-communicable disease is widely noted, but the mechanisms are poorly understood. The current systematic review aims to identify common contributing factors linking mental health to non-communicable disease incidence among adults to inform planned preventive interventions for high-risk non-communicable disease and mental ill-health populations. Methods MEDLINE, PsycINFO, EMBASE and CINAHL were searched from February to August 2019 for case-control and longitudinal studies of adults with common mental health disorders (depression and anxiety) assessing the causal effect of individual, environmental and social factors on the incidence of common non-communicable diseases (cancers, cardiovascular diseases, chronic obstructive pulmonary disease and diabetes mellitus). There were no geographical restrictions for the selected studies and the results were generated utilising a narrative synthesis. Results Of 15,266 unique documents identified by search terms, 419 met criteria for full-text review and 11 studies met inclusion criteria for data extraction. None of the identified studies had the onset of chronic obstructive pulmonary disease as an outcome. The majority of the studies showed a significant effect of depression and/or post-traumatic stress disorder on non-communicable disease incidence. The chronicity of mental health disorders appears to exacerbate their effect on non-communicable disease onset. Older age, higher body mass index, female sex, smoking status and number of cigarettes smoked, low educational attainment and ethnicity were found to exert a significant effect on the association between mental health disorders and non-communicable disease onset. Conclusion Findings from this review provide evidence to guide health practice and policy to reduce the burden of non-communicable diseases and mental health disorders. Interventions targeted towards identifying and treating mental health illnesses and the factors linking mental and physical health lower the burden of mental disorders and prevent the subsequent development of non-communicable diseases. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Global Health Research programme (NIHR award ref: 16/136/100). A plain language summary of this research article is available on the NIHR Journals Library Website https://doi.org/10.3310/CTDH4677.Item Mental health and psychosocial support in humanitarian settings: research priorities for 2021-30.(2023-04-25) Tol, Wietse A; Le, PhuongThao D; Harrison, Sarah L; Galappatti, Ananda; Annan, Jeannie; Baingana, Florence K; Betancourt, Theresa S; Bizouerne, Cecile; Eaton, Julian; Engels, Michelle; Hijazi, Zeinab; Horn, Rebecca; Jordans, Mark J D; Kohrt, Brandon A; Koyiet, Phiona; Panter-Brick, Catherine; Pluess, Michael; Rahman, Atif; Silove, Derrick; Tomlinson, Mark; Uribe-Restrepo, José Miguel; Ventevogel, Peter; Weissbecker, Inka; Ager, Alastair; van Ommeren, MarkWe describe an effort to develop a consensus-based research agenda for mental health and psychosocial support (MHPSS) interventions in humanitarian settings for 2021-30. By engaging a broad group of stakeholders, we generated research questions through a qualitative study (in Indonesia, Lebanon, and Uganda; n=101), consultations led by humanitarian agencies (n=259), and an expert panel (n=227; 51% female participants and 49% male participants; 84% of participants based in low-income and middle-income countries). The expert panel selected and rated a final list of 20 research questions. After rating, the MHPSS research agenda favoured applied research questions (eg, regarding workforce strengthening and monitoring and evaluation practices). Compared with research priorities for the previous decade, there is a shift towards systems-oriented implementation research (eg, multisectoral integration and ensuring sustainability) rather than efficacy research. Answering these research questions selected and rated by the expert panel will require improved partnerships between researchers, practitioners, policy makers, and communities affected by humanitarian crises, and improved equity in funding for MHPSS research in low-income and middle-income countries. [Abstract copyright: Copyright © 2023 World Health Organization. Published by Elsevier Ltd. All rights reserved. This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products, or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.]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.