Barriers, facilitators and proposed solutions to equitable mental health financing and service delivery for the Lebanese populations and displaced Syrians in Lebanon: Findings from a qualitative study.

Forcibly displaced populations experience an increased burden of mental illness. Scaling up mental health (MH) services places new resource demands on health systems in crises-affected settings and raises questions about how to provide equitable MH services for refugee and host populations. Our study investigates barriers, facilitators, and proposed solutions to MH financing and access for Lebanese populations and Syrian refugees in Lebanon, a protracted crisis setting. We collected qualitative data via 73 interviews and 3 focus group discussions. Participants were purposively selected from: (i) national, United Nations and NGO stakeholders; (ii) frontline MH service providers; (iii) insurance company representatives; (iv) Lebanese and Syrian adults and parents of children aged 12-17 years using MH services. Data were analysed using inductive and deductive approaches. Our results highlight challenges facing Lebanon's system of financing MH care in the face of ongoing multiple crises, including inequitable coverage, dependence on external humanitarian funds, and risks associated with short-term funding and their impact on sustainability of services. The built environment presents additional challenges to individuals trying to navigate, access and use existing MH services, and the social environment and service provider factors enable or hinder individuals accessing MH care. Registered Syrian refugees have better financial coverage to secondary MH care than Lebanese populations. However, given the economic crisis, both populations are facing similar challenges in paying for and accessing MH care at primary health care (PHC) level. Multiple crises in Lebanon have exacerbated challenges in financing MH care, dependence on external humanitarian funds, and risks and sustainability issues associated with short-term funding. Urgent reforms are needed to Lebanon's health financing system, working with government and external donors to equitably and efficiently finance and scale up MH care with a focus on PHC, and to reduce inequities in MH service coverage between Lebanese and Syrian refugee populations.

Power dynamics and participation within humanitarian coordination groups: A case study of the MHPSS Taskforce in Lebanon.

The humanitarian sector has often been criticised for its hierarchical power dynamics. Such dynamics often centre the priorities of 'international' actors, thereby marginalising the knowledge and expertise of those closest to the setting and play out in various fora, including coordination mechanisms. While guidance emphasises the importance of supporting local systems and government structures rather than creating parallel humanitarian structures, this approach is not consistently applied, creating challenges. We used a case study approach to explore how power relations influence the practice of the Mental Health and Psychosocial Support Taskforce in Lebanon, a nationally-led coordination mechanism chaired by the Ministry of Public Health with UN agencies as co-chairs. We conducted 34 semi-structured interviews with Taskforce members and other stakeholders coordinating with the Taskforce, including local non-governmental organisations (NGOs), international NGOs, United Nations agencies and government ministries. Interview transcripts were collaboratively analysed using Dedoose. We conducted feedback workshops with participants and integrated their feedback into analysis. We found that UN agencies and international NGOs are perceived as holding more decision-making power due to their access to funding and credibility-both shaped by the humanitarian system. Our findings also suggest that power dynamics arising mainly from differences in seniority, relations between 'local' and 'expat' staff, and language used in meetings may affect, to varying degrees, decision-making power and members' voices. We also show how the agenda/focus of meetings, meeting format, language, and existing relationships with Taskforce leaders can influence levels of participation and decision-making in Taskforce meetings, ranging from lack of participation through being informed or consulted about decisions to decisions made in partnership. Our findings have broader implications for coordinating service delivery within the humanitarian sector, emphasising the need to reflect upon power imbalances critically and continually and to ensure a shared understanding of decision-making processes.

The Experience of ER Nurses in Lebanese Hospitals, During the COVID-19 Outbreak: A Qualitative Study.

OBJECTIVE: The increasing number of COVID-19 cases, as well as the overwhelming workload, constitutes a serious occupational health threat to Emergency Room (ER) nurses working on the frontlines. In Lebanon, where unstable socio-economic conditions reign, the Covid-19 outbreak was added to the plethora of daily challenges faced by healthcare workers. The study's objective is to explore how Lebanese ER nurses perceived their duty on the frontlines amid the Covid-19 pandemic. METHODS: This study employed a descriptive exploratory qualitative design. 15 Lebanese ER nurses working directly with Covid-19 patients were recruited from 3 university hospitals in Beirut. Interviews were held for data collection until data saturation. Subsequent analysis was done via coding of the transcribed verbatim. RESULTS: The findings showed significant gaps related to preparedness, support, and governmental action. Similarly, the frontliners faced serious challenges that increased their stress levels both physically and mentally. Furthermore, some participants were subject to stigma and had to face irresponsible behaviors during triage. Participants emphasized the need to guarantee a safe environment at work, to provide Covid-19 patients with the needed care. CONCLUSIONS: ER nurses struggled during this pandemic while working on the frontlines. They described their experience as not satisfying, with high levels of stress, danger, and challenges.

Multi-matrix biomonitoring approach to assess exposure to metals and trace elements in the Lebanese population and associations with drinking water consumption.

This study is the first attempt to assess exposure to metals and trace elements in subgroups of the Lebanese population using a multi-matrix biomonitoring approach. Concentrations of 11 metals and trace elements (aluminum (Al), arsenic (As), cadmium (Cd), chromium (Cr), copper (Cu), iron (Fe), lead (Pb), manganese (Mn), selenium (Se), uranium (U), zinc (Zn)) were measured in urine, hair and toenails. Biological levels were compared according to age, sex, smoking status, socioeconomic status, geographical area and drinking water source. While most urinary and toenail concentrations of metals and trace elements were not different between males and females, measured concentrations of several elements in hair were higher in females compared to males. Urinary concentrations of some metals (Al, Cu, Se and Zn) were higher in children compared to teenagers and adults. Hair and toenail concentrations of several elements (As, Cd, Pb, Mn, Se in hair and toenails plus Al, Fe in toenails) were also significantly higher in children compared to teenagers and/or adults. Smoking status had no influence on metal and trace element concentrations. Levels of Cd, Pb and Mn were also higher in samples from subgroups with lower economic status (Cd and Pb in the three matrices and Mn in hair and toenails). Very few correlations were identified between sources of drinking water and urine, hair, and toenail concentrations of metals and trace elements. However, a correlation was observed between hair and toenails levels of As, Cd and Pb. Overall, results highlight that a special attention should be given to metal and trace element exposure in this population (including Pb, As, Cd, Mn, and Se). It could be relevant to scale up this kind of investigation with a large human biomonitoring initiative in the Lebanese population in order to generalize results, and assess trends over time.

Colorectal cancer screening knowledge and uptake in lebanon: a national survey.

OBJECTIVE: The main aim of this national survey was to identify the levels of colorectal cancer screening knowledge and uptake in Lebanon. METHODS: A total of 1200 participants were enrolled in this cross-sectional household survey targeting the Lebanese population aged 50 years and above. The sample was recruited using a two-stage stratified cluster sampling approach. RESULTS: Of the total sample, 38.3% knew about any screening test for colorectal cancer but only 7.5% had ever used any. Thirty-nine percent of the participants rated their risk of getting colorectal cancer as very low or low, and only 53.5% were confident in their ability to undertake a screening test. Almost all participants agreed that medical advice and test reimbursement would encourage them to do a screening test. At the multivariate analysis level, hearing of an awareness campaign in the last two years showed the strongest association with the knowledge of a colorectal cancer screening test with an estimated ORadj = 5.12 (95%CI: 3.67 - 7.15). Other factors that were significantly associated with this knowledge variable included: a family history of colorectal cancer, a personal history of colorectal illness, having a health coverage, and knowledge of colorectal cancer signs and symptoms. DISCUSSION: This national study highlights an alarming lack of uptake and low levels of knowledge of colorectal cancer screening tests even though it is among the most prevalent cancers in Lebanon and its prevalence has been continuously increasing in the past years. The evidence suggests that people who had an experience with colorectal cancer diagnostic tests, either personally or through a family member, and those who have heard of an awareness campaign about colorectal cancer in the last two years are more likely to know its screening tests. CONCLUSION: Colorectal cancer screening knowledge and uptake in Lebanon are limited and justify the need for public health interventions. This study gives evidence that awareness campaigns, coupled with the involvement of medical providers and the reimbursement of screening test fees, would alleviate the burden of colorectal cancer in Lebanon.

Health system governance in settings with conflict-affected populations: a systematic review.

Health system governance has been recognized as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were (1) to describe the characteristics of the eligible studies; (2) to describe the principles of health system governance; (3) to examine evidence on barriers and facilitators for stronger health system governance; and (4) to analyse the quality of available evidence. A systematic review methodology was used following Preferred Reporting Items for Systematic Review and Meta-Analysis criteria. We searched six academic databases and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by a governance framework from the literature. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonized health response, lack of clarity on stakeholder responsibilities, financial support and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.

Participation by conflict-affected and forcibly displaced communities in humanitarian healthcare responses: A systematic review.

BACKGROUND: Community participation in health responses in humanitarian crises is increasingly promoted by humanitarian actors to support adoption of measures that are relevant and effective to local needs. Our aim was to understand the role of community participation in humanitarian health responses for conflict-affected populations (including forcibly displaced populations) in low- and middle-income countries and the barriers and facilitators to community participation in healthcare responses. METHODS: Using a systematic review methodology, following the PRISMA protocol, we searched four bibliographic databases for publications reporting peer-reviewed primary research. Studies were selected if they reported how conflict-affected populations were involved in healthcare responses in low- and middle-income settings, and associated changes in healthcare responses or health outcomes. We applied descriptive thematic synthesis and assessed study quality using study design-specific appraisal tools. RESULTS: Of 18,247 records identified through the database searching, 18 studies met our inclusion criteria. Various types of community participation were observed, with participation mostly involved in implementing interventions rather than framing problems or designing solutions. Most studies on community participation focused on changes in health services (access, utilisation, quality), community acceptability and awareness, and ownership and sustainability. Key barriers and facilitators to community participation included political will at national and local level, ongoing armed conflict, financial and economic factors, socio-cultural dynamics of communities, design of humanitarian responses, health system factors, and health knowledge and beliefs. Included studies were of mixed quality and the overall strength of evidence was weak. More generally there was limited critical engagement with concepts of participation. CONCLUSION: This review highlights the need for more research on more meaningful community participation in healthcare responses in conflict-affected communities, particularly in framing problems and creating solutions. More robust research is also required linking community participation with longer-term individual and health system outcomes, and that critically engages in constructs of community participation.