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 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 The bumpy trajectory of performance-based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process(BioMed Central, 2018-10-20) Bertone, Maria Paola; Wurie, Haja; Samai, Mohamed; Witter, SophieBackground - As performance-based financing (PBF) has been increasingly implemented in low-income countries, a growing literature has developed, assessing its effectiveness and, more recently, focussing on the political dynamics of PBF introduction and implementation. This study contributes to the latter body of literature by exploring decision-making processes on PBF in Sierra Leone during the 2010–2017 period. Sierra Leone presents an interesting case because of the ‘start-stop-start’ trajectory of PBF. Methods - The qualitative case study is based on a document review and 25 key informant interviews with national stakeholders and international actors. Documents and interviews were analysed based on a political economy framework focusing on actors and structure, but also making use of concepts drawn from interpretive policy analysis to look at frames. Results - Our analysis describes the process of negotiation and re-negotiation of PBF in Sierra Leone, highlighting the role of different players, both internal and external, their ideas, capacity and power relations, and the shifting narratives around PBF. It is shown that external actors driving the debate make use of ‘frames’, both actual (i.e., defining the timing and pace of the discussions, the funding available, etc.) and metaphorical (i.e., how PBF is interpreted, defined and understood) to fit in and influence the debate. This is facilitated by the lack of capacity and resources in the fragile setting. Other strategies, such as ‘venue shopping’ are employed, though they may add to fragmentation in the volatile context. Conclusions - The retrospective view of the study has an analytical advantage, but findings are also relevant to guide practice. Although power relations and rent-seeking issues are difficult to overcome in resource and capacity-constrained settings, more attention could be paid to other elements. In particular, adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the ‘actual frames’ which define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone) as well as for time to develop national capacity and ownership in order to ensure longer-term political support and better health system integration.Item What adaptation to research is needed following crises: A comparative, qualitative study of the health workforce in Sierra Leone and Nepal(BioMed Central, 2018-02-07) Raven, Joanna; Baral, Sushil; Wurie, Haja; Witter, Sophie; Samai, Mohamed; Paudel, Pravin; Subedi, Hom Nath; Martineau, Tim; Elsey, Helen; Theobald, SallyBackground: Health workers are critical to the performance of health systems; yet, evidence about their coping strategies and support needs during and post crisis is lacking. There is very limited discussion about how research teams should respond when unexpected crises occur during on-going research. This paper critically presents the approaches and findings of two health systems research projects that explored and evaluated health worker performance and were adapted during crises, and provides lessons learnt on re-orientating research when the unexpected occurs. Methods: Health systems research was adapted post crisis to assess health workers' experiences and coping strategies. Qualitative in-depth interviews were conducted with 14 health workers in a heavily affected earthquake district in Nepal and 25 frontline health workers in four districts in Ebola-affected Sierra Leone. All data were transcribed and analysed using the framework approach, which included developing coding frameworks for each study, applying the frameworks, developing charts and describing the themes. A second layer of analysis included analysis across the two contexts, whereas a third layer involved the research teams reflecting on the approaches used to adapt the research during these crises and what was learned as individuals and research teams. Results: In Sierra Leone, health workers were heavily stigmatised by the epidemic, leading to a breakdown of trust. Coping strategies included finding renewed purpose in continuing to serve their community, peer and family support (in some cases), and religion. In Nepal, individual determination, a sense of responsibility to the community and professional duty compelled staff to stay or return to their workplace. The research teams had trusting relationships with policy-makers and practitioners, which brought credibility and legitimacy to the change of research direction as well as the relationships to maximise the opportunity for findings to inform practice. Conclusions: In both contexts, health workers demonstrated considerable resilience in continuing to provide services despite limited support. Embedded researchers and institutions are arguably best placed to navigate emerging ethical and social justice challenges and are strategically positioned to support the co-production of knowledge and ensure research findings have impact.Item Retention of health workers in rural Sierra Leone: findings from life histories(BioMed Central, 2016-02) Wurie, Haja R.; Samai, Mohamed; Witter, SophieBackground Sierra Leone has faced a shortage and maldistribution of staff in its post-conflict period. This long-standing challenge is now exacerbated by the systemic shock and damage wrought by Ebola. This study aimed to investigate the importance of different motivation factors in rural areas in Sierra Leone and thus to contribute to better decisions on financial and non-financial incentive packages, here and in similar contexts. Methods This article is based on participatory life histories, conducted in 2013 with 23 health workers (doctors, nurses, midwives and Community Health Officers) in four regions of Sierra Leone who had worked in the sector since 2000. Although the interviews covered a wide range of themes, here we present findings on motivating and demotivating factors for staff, especially those in rural areas, based on thematic analysis of transcripts. Results Rural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities, etc.). Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected. By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general. Conclusions This study provides important policy-focused insights into motivation of health workers and can contribute towards building a resilient and responsive health system, incorporating the priorities and needs of health workers. Their voices and experiences should be taken into account as the post-Ebola landscape is shaped.Item A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002-2012(2014-07-23) Bertone, Maria Paola; Samai, Mohamed; Edem-Hotah, Joseph; Witter, SophieBackground: It is recognized that decisions taken in the early recovery period may affect the development of health systems. Additionally, some suggest that the immediate post-conflict period may allow for the opening of a political 'window of opportunity' for reform. For these reasons, it is useful to reflect on the policy space that exists in this period, by what it is shaped, how decisions are made, and what are their long-term implications. Examining the policy trajectory and its determinants can be helpful to explore the specific features of the post-conflict policy-making environment. With this aim, the study looks at the development of policies on human resources for health (HRH) in Sierra Leone over the decade after the conflict (2002-2012). Methods. Multiple sources were used to collect qualitative data on the period between 2002 and 2012: a stakeholder mapping workshop, a document review and a series of key informant interviews. The analysis draws from political economy and policy analysis tools, focusing on the drivers of reform, the processes, the contextual features, and the actors and agendas. Findings. Our findings identify three stages of policy-making. At first characterized by political uncertainty, incremental policies and stop-gap measures, the context substantially changed in 2009. The launch of the Free Health Care Initiative provided to be an instrumental event and catalyst for health system, and HRH, reform. However, after the launch of the initiative, the pace of HRH decision-making again slowed down. Conclusions: Our study identifies the key drivers of HRH policy trajectory in Sierra Leone: (i) the political situation, at first uncertain and later on more defined; (ii) the availability of funding and the stances of agencies providing such funds; (iii) the sense of need for radical change - which is perhaps the only element related to the post-conflict setting. It also emerges that a 'windows of opportunity' for reform did not open in the immediate post-conflict, but rather 8 years later when the Free Health Care Initiative was announced, thus making it difficult to link it directly to the features of the post-conflict policy-making environment. 2014 Bertone et al.; licensee BioMed Central Ltd.