Dynamics of non-communicable disease prevention, diagnosis and control in Lebanon, a fragile setting.

BACKGROUND: Non-communicable diseases (NCD) present an increasing global health challenge, particularly for settings affected by fragility where access to care may be disrupted, and where high-quality continuous care delivery is difficult to achieve. This study documents the complex dynamics of NCD prevention and management in the fragile setting of rural Beqaa, Lebanon. METHODS: Participatory system dynamics methods were used, including 30 semi-structured interviews and three Group Model Building (GMB) workshops. Participants included health care providers offering NCD care, and Lebanese host- and Syrian refugees community members affected by NCDs. RESULTS: Participants across all groups articulated a shared complex understanding of both the structural and direct determinants behind NCD onset. Lebanese and Syrian community members further identified several barriers to health seeking, including restrictions in health coverage, limited availability of services in the Beqaa and perceptions of poor-quality care. Health providers and community members described a health system overtly focused on disease control and overwhelmed by delivery of care to people living with NCD across both communities. CONCLUSION: Participants across all groups agreed on the need for health promotion and primary prevention activities and identified priority interventions in these areas.

Evaluation of global health capacity building initiatives in low-and middle-income countries: A systematic review.

BACKGROUND: Low- and middle-income countries (LMICs) are in dire need to improve their health outcomes. Although Global Health Capacity Building (GHCB) initiatives are recommended approaches, they risk being ineffective in the absence of standardized evaluation methods. This study systematically reviews evaluation approaches for GHCB initiatives in LMICs. METHODS: We searched the Medline (OVID), PubMed, Scopus, and Embase.com databases for studies reporting evaluation of a GHCB initiative in a LMIC from January 1, 2009 until August 15, 2019. To differentiate them from intervention, prevention, and awareness initiatives, included articles reported at least one approach to evaluate their learning modality. We excluded cross-sectional studies, reviews, and book chapters that only assessed the effect of interventions. Data identifying the learning modality, and evaluation method, level, time interval, and approach were extracted from articles as primary outcomes. RESULTS: Of 8324 identified studies, 63 articles were eligible for analysis. Most studies stemmed from Africa and Asia (69.8%), were delivered and evaluated face-to-face (74.6% and 76.2%), mainly to professionals (57.1%) and community workers (20.6%). Although the use of online and blended modalities showed an increase over the past 4 years, only face-to-face initiatives were evaluated long-term beyond individual-level. GHCB evaluations in general lacked standardization especially regarding the tools. CONCLUSION: This is an important resource for evaluating GHCB initiatives in LMICs. It synthesizes evaluation approaches, offers recommendations for improvement, and calls for the standardization of evaluations, especially for long-term and wider impact assessment of online and blended modalities.

A systematic review of global health capacity building initiatives in low-to middle-income countries in the Middle East and North Africa region.

INTRODUCTION: Low-and Middle-Income Countries (LMICs) in the Middle East and North Africa (MENA) region are facing increasing global health challenges with a reduced ability to manage them. Global Health Capacity Building (GHCB) initiatives have the potential to improve health workforce performance and health outcomes, however little is known about the GHCB topics and approaches implemented in this region. This is the first systematic review of GHCB initiatives among LMICs in the MENA region. METHODS: An academic database search of Medline (OVID), PubMed, Scopus, Embase.com , and Open Grey was conducted for articles published between January 2009 and September 2019 in English. Next, a grey literature search following a recommended search framework was conducted. Reviewed records addressed a global health topic, had a capacity building component, looked at specific learning outcomes, and reflected an LMIC in the MENA. Primary outcomes included country, topic, modality, pedagogy, and population. RESULTS: Reports of GHCB initiatives were retrieved from grey sources (73.2%) and academic sources (26.8%). Most GHCB initiatives were mainly conducted face-to-face (94.4%) to professional personnel (57.5%) through a theoretical pedagogical approach (44.3%). Dominant global health themes were non-communicable diseases (29.2%), sexual and reproductive health (18.4%), and mental health (14.5%). When matched against the Global Burden of Disease data, important gaps were found regarding the topics of GHCB initiatives in relation to the region's health needs. There were limited reports of GHCB initiatives addressing conflict and emergency topics, and those addressing non-communicable disease topics were primarily reported from Egypt and Iran. CONCLUSION: Innovative and practicum-based approaches are needed for GHCB initiatives among LMICs in the MENA region, with a focus on training community workers. Regional and country-specific analyses of GHCB initiatives relative to their health needs are discussed in the manuscript based on the results of this review.

A community-based system dynamics approach for understanding factors affecting mental Health and Health seeking behaviors in Beirut and Beqaa regions of Lebanon.

BACKGROUND: Available evidence on mental health and psychosocial problems in Lebanon is limited. Recent quantitative data suggests a high prevalence among Syrian refugees and their Lebanese host communities, with significant treatment gaps in both populations. This study aims to determine how Lebanese host and Syrian refugee communities perceive mental health, and identify health seeking behaviors and barriers to health access in two contrasting contexts of fragility. METHODS: A comparative qualitative study design was adopted whereby a total of 36 semi-structured interviews with Lebanese host and Syrian refugees' community members were conducted, followed by a series of four participatory group model building (GMB) sessions. Participants were recruited from two contrasting fragility contexts: Beirut and Beqaa regions. During these sessions, causal loop diagrams were elicited depicting shared understandings of factors prompting the onset of mental health and psychosocial issues; health seeking behaviors, pathways and elements affecting the rate of health improvement and maintenance were also identified. RESULTS: Community members in both settings had similar perceptions of factors contributing to mental health. Participants named long-term effects of exposure to wars, political and social effects of conflicts, and financial constraints at the household level as precipitating factors prompting the onset of mental health and psychosocial stressors. Gender and integration related challenges between communities were identified as factors that affect condition onset and associated care seeking. Pathways for health seeking were found to be shaped by trust, the advice and support of loved ones, and the need to ensure confidentiality of affected individuals. Recurrent themes in discussion highlighted major barriers to healthcare access including significant delays in health care seeking from the formal health system, widespread social stigma, prohibitive service costs, lack of health coverage, limited awareness of mental health service availability and limited trust in the quality of services available. CONCLUSION: Mental health and psychosocial support strategies need to be gender- and integration-sensitive, primarily focused on condition prevention and awareness raising in order to strengthen health-seeking behaviors.

Burden of non-communicable diseases among Syrian refugees: a scoping review.

BACKGROUND: The scarcity of evidence-based research on non-communicable diseases (NCDs) among Syrian refugees has hampered efforts to address the high burden of these diseases in host countries. The objective of this study is to examine published research on NCDs among Syrian refugees in order to inform future research, practice, programs, and policy. . METHODS: Using the scoping review framework proposed by Arksey et al., 17 different databases were searched to identify studies reporting on NCDs among Syrian refugees. The number of relevant documents found was 34, with the earliest going back to 2013-2 years after the beginning of the Syrian conflict. RESULTS: The majority of these documents were descriptive in nature and only two studies addressed the effectiveness of interventions in the management of NCDs. No studies investigated the prevention of these diseases. Furthermore, only 7 studies addressed the host community and only one research article, conducted in Lebanon, included subjects from the host community. The increasing number of documents over the past 5 years illustrates a growing interest in studying NCDs among Syrian refugees. Examination of the papers showed high prevalence of NCDs among Syrian refugees as well as unmet healthcare needs. CONCLUSION: The findings of this review highlighted the dire need for further research on the burden of NCDs among Syrian refugees. Future studies should diversify research design to include interventions, address the host community in addition to the refugees, tackle prevention as well as treatment of NCDs, and explore strategies to enhance the resilience of the host country's health system while ensuring quality of care for NCDs. The increasing momentum for research found in this review presents an opportunity to fill current knowledge gaps, which could result in preventing, controlling and ultimately reducing the burden of NCDs among Syrian refugees and their host communities.

Factors influencing physicians' choice of workplace: systematic review of drivers of attrition and policy interventions to address them.

OBJECTIVES: The movement of skilled physicians from the public to the private sector is a key constraint to achieving universal health coverage and is currently affecting health systems worldwide. This systematic review aims to assess factors influencing physicians' choice of workplace, and policy interventions for retaining physicians in the public sector. METHODS: Five literature databases were searched. Studies were included in the review if they focused on at least one of the following criteria: (i) incentives or motivators for retaining physicians in the public sector, (ii) pull factors that encouraged physicians to move to the private sector, (iii) push factors that forced physicians to leave the public sector, (iv) policy interventions or case studies that addressed physician retention in the public sector, and (v) qualitative reviews of policy interventions that were implemented in different health system settings. RESULTS: Nineteen articles met the inclusion criteria. Six major themes that affected physicians' choice of workplace were identified including: financial incentives, career development, infrastructure and staffing, professional work environment, workload and autonomy. The majority of the studies suggested that the use of financial incentives was a motivator in retaining physicians in the public sector. The review also identified policy interventions including: regulatory controls, incentives and management reforms. Regulatory controls and incentives were the two most frequently reported policy interventions. CONCLUSION: While factors affecting physicians' choice of workplace are country specific, financial incentives and professional development are core factors. Other factors are highly influenced by context, and thus, it would be useful for future cross-country research to use standardized data collection tools, allowing comparison of contextual factors as well as the examination of how context affects physician retention in the public sector.