Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon.

INTRODUCTION: Despite rapidly growing academic and policy interest in health system resilience, the empirical literature on this topic remains small and focused on macrolevel effects arising from single shocks. To better understand health system responses to multiple shocks, we conducted an in-depth case study using qualitative system dynamics. We focused on routine childhood vaccination delivery in Lebanon in the context of at least three shocks overlapping to varying degrees in space and time: large-scale refugee arrivals from neighbouring Syria; COVID-19; and an economic crisis. METHODS: Semistructured interviews were performed with 38 stakeholders working at different levels in the system. Interview transcripts were analysed using purposive text analysis to generate individual stakeholder causal loop diagrams (CLDs) mapping out relationships between system variables contributing to changes in coverage for routine antigens over time. These were then combined using a stepwise process to produce an aggregated CLD. The aggregated CLD was validated using a reserve set of interview transcripts. RESULTS: Various system responses to shocks were identified, including demand promotion measures such as scaling-up community engagement activities and policy changes to reduce the cost of vaccination to service users, and supply side responses including donor funding mobilisation, diversification of service delivery models and cold chain strengthening. Some systemic changes were introduced-particularly in response to refugee arrivals-including task-shifting to nurse-led vaccine administration. Potentially transformative change was seen in the integration of private sector clinics to support vaccination delivery and depended on both demand side and supply side changes. Some resilience-promoting measures introduced following earlier shocks paradoxically increased vulnerability to later ones. CONCLUSION: Flexibility in financing and human resource allocation appear key for system resilience regardless of the shock. System dynamics offers a promising method for ex ante modelling of ostensibly resilience-strengthening interventions under different shock scenarios, to identify-and safeguard against-unintended consequences.

Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: a cross-sectional study from Lebanon.

OBJECTIVES: Assess and describe the health service use and delivery patterns for non-communicable disease (NCD) services in two contrasting fragility contexts and by other principal equity-related characteristics including gender, nationality and health coverage. SETTING: Primary healthcare centres located in the urbanised area of Greater Beirut and the rural area of the Beqaa Valley. DESIGN: This is a cross-sectional study using a structured survey tool between January and September 2020. PARTICIPANTS: 1700 Lebanese and Syrian refugee patients seeking primary care for hypertension and diabetes. PRIMARY AND SECONDARY OUTCOMES: The main outcome is the comprehensiveness of service delivery comparing differences in use and service delivery patterns by fragility setting, gender, nationality and health coverage. RESULTS: Compliance with routine NCD care management (eg, counselling, immunisations, diagnostic testing and referral rates) was significantly better in Beirut compared with Beqaa. Women were significantly less likely to be offered lifestyle counselling advice and referral to cardiologists (58.4% vs 68.3% in Beqaa and 58.1% vs 62% in Beirut) and ophthalmologists, compared with men. Across both settings, there was a significant trend for Lebanese patients to receive more services and more advice related to nutrition and diabetes management (89.8% vs 85.2% and 62.4% vs 55.5%, respectively). Similarly, referral rates were higher among Lebanese refugees compared with Syrian refugees. Immunisation and diagnostic testing were significantly higher in Beirut among those who have health coverage compared with Beqaa. CONCLUSIONS: The study discovered significant differences in outpatient service use by setting, nationality and gender to differentials. A rigorous and comprehensive appraisal of NCD programmes and services is imperative for providing policy makers with evidence-based recommendations to guide the design, implementation and evaluation of targeted programmes and services necessary to ensure equity in health services delivery to diabetic and hypertensive patients. Such programmes are an ethical imperative considering the protracted crises and compounded fragility.

Evaluating a capacity building program on women's health for displaced community health workers in fragile settings in Lebanon.

BACKGROUND: Displaced populations in fragile settings experience health disparities that are seldom attended to. Task-shifting, which involves training non-specialized community health workers (CHW) to deliver basic education and health services is a favorable strategy to address this problem, however very little data exist on this topic in the Middle East region. We conducted a long-term evaluation of the Women's Health Certificate delivered to Syrian refugees and host community in informal tented settlements in Lebanon under the Mobile University for Health (MUH) program. The training was delivered through a mobile classroom approach that incorporated a blended learning modality. METHODS: We collected short-term data from the 42 trained CHW (knowledge assessments and satisfaction measures) during the delivery of the intervention between March and August 2019, and long-term data (semi-structured interviews with 8 CHW and focus group discussion with 9 randomly selected community members) one year later between July and August 2020. The evaluation approach was informed by the Kirkpatrick evaluation model, and the qualitative data were analyzed using qualitative content analysis. RESULTS: Data from the CHWs and community members were triangulated, and they showed that the training enhanced access to education due to its mobile nature and provided opportunities for CHWs to engage and interact with learning material that enhanced their knowledge and favorable behaviors regarding women's health. In turn, CHWs were empowered to play an active role in their communities to transfer the knowledge they gained through educating community members and providing women's health services and referrals. Community members benefited from the CHWs and called for the implementation of more similar training programs. CONCLUSION: This is one of few studies reporting a long-term community-level evaluation of a task-shifting program on women's health among displaced populations in Lebanon. Our findings support the need to increase funding for similar programs, and to focus on delivering programs for a variety of health challenges. It is also essential to enhance the reach and length of recruitment to wider communities, to design concise, interactive, and engaging sessions, and to provide tools to facilitate circulation of learning material, and resources for referrals to health services.

Readiness to deliver person-focused care in a fragile situation: the case of Mental Health Services in Lebanon.

BACKGROUND: Evidence suggests wide variability in the provision of mental healthcare across countries. Countries experiencing fragility related risks suffer from a high burden of mental-ill health and additionally have limited capacity to scale up mental health services given financial and human resource shortages. Integration of mental health services into routine primary care is one potential strategy for enhancing service availability, however little is known about the experiences of currently active health care providers involved in mental health and psychosocial support service (MHPSS) provision at primary care level. This study aims to determine how healthcare providers offering MHPSS services at primary care levels in Lebanon perceive mental health and the health system's ability to address the rising mental ill-health burden with a view to identify opportunities for strengthening MHPSS service implementation geared towards integrated person focused care model. METHODS: A qualitative study design was adopted including 15 semi-structured interviews and 2 participatory group model-building workshops with health care providers (HCPs) involved in mental healthcare delivery at primary care level. Participants were recruited from two contrasting fragility contexts (Beirut and Beqaa). During workshops, causal loop diagrams depicting shared understandings of factors leading to stress and mental ill health, associated health seeking behaviors, and challenges and barriers within the health system were elicited. This research is part of a larger study focused on understanding the dynamics shaping mental health perceptions and health seeking behaviours among community members residing in Lebanon. RESULTS: Findings are organized around a causal loop diagram depicting three central dynamics as described by workshop participants. First, participants linked financial constraints at household levels and the inability to secure one's livelihood with contextual socio-political stressors, principally referring to integration challenges between host communities and Syrian refugees. In a second dynamic, participants linked exposure to war, conflict and displacement to the occurrence of traumatic events and high levels of distress as well as tense family and community relations. Finally, participants described a third dynamic linking cultural norms and patriarchal systems to exposure to violence and intergenerational trauma among Lebanon's populations. When describing help-seeking pathways, participants noted the strong influence of social stigma within both the community and among health professionals; the latter was noted to negatively affect patient-provider relationships. Participants additionally spoke of difficulties in the delivery of mental health services and linked this to the design of the health system itself, noting the current system being geared towards patient centered care, which focuses on the patient's experiences with a disease only, rather than person focused care where providers and patients acknowledge broader structural and social influences on health and work together to reach appropriate decisions for tackling health and other social needs. Barriers to delivery of person focused care include the lack of coherent mental health information systems, limited human capacity to deliver MHPSS services among primary health care staff and inadequate service integration and coordination among the many providers of mental health services in our study contexts. Critically however, provider accounts demonstrate readiness and willingness of health professionals to engage with integrated person focused care models of care. CONCLUSIONS: Mental ill health is a major public health problem with implications for individual health and wellbeing; in a fragile context such as Lebanon, the burden of mental ill health is expected to rise and this presents substantive challenges for the existing health system. Concrete multi-sectoral efforts and investments are required to (1) reduce stigma and improve public perceptions surrounding mental ill health and associated needs for care seeking and (2) promote the implementation of integrated person focused care for addressing mental health.

Mapping breast cancer journal publications in conflict settings in the MENA region: a scoping review.

BACKGROUND: Breast cancer is a major cause of cancer-related morbidity and mortality among women in the the Middle East and North Africa (MENA) region. Conflict and political instability in the region may affect medical research output, including that on breast cancer. This scoping review aims to systematically identify and map breast cancer publications across different stages of the cancer care pathway and across conflict-affected countries within the MENA region. The findings of this work will highlight the impact of conflict on cancer research that could be mitigated with the proper contextualised capacity strengthening intervention. METHODS: We followed the PRISMA-Scr methodology. We searched for peer-reviewed publications on topics related to breast cancer in 11 databases: Medline, PubMed, EMBASE, Web of Science, PROQUEST, CINAHL, Global Index Medicus, Arab World Searches Complete, Popline, Scopus and Google Scholar using both controlled vocabulary and keywords. Publication abstracts and full-text versions were screened for duplicates and included in our study based on pre-specified eligibility criteria: focused on breast cancer, related to the specific country of analysis and human or health system studies. We used a structured data extraction form to extract information related to the article, its methodology and the cancer care pathway being studied. RESULTS: A total of 19,215 citations were retrieved from our search. After removing duplicates, a total of 8,622 articles remained. Title and abstract screening retained 1,613 articles. Publications with first author affiliations to Turkey were consistently the highest across all categories of the cancer care pathway. Trends show an increase in articles from Lebanon, Jordan and Palestine after 2015. Early exploratory and epidemiological studies represented the majority of breast cancer research, followed by policy and implementation research and lastly experimental research. Most research conducted followed an observational study design. Important gaps were identified in the research output related to advanced breast cancer and palliative care (Libya, Syria and Yemen), mental health (Libya), and knowledge and education of breast cancer (Libya and Syria). CONCLUSION: This scoping review has identified key areas in breast cancer research that lack significant research activity in conflict MENA settings. These areas, including but are not limited to palliative care, mental health, and education, can be prioritised and developed through regional collaboration and contextualised capacity strengthening initiatives.

Parental Perception of a Dental Home for Children with Special Needs.

BACKGROUND AND OBJECTIVES: There is a major gap in the literature that addresses parental perception of acquiring a dental home for children with special healthcare needs (CSHCN). The objectives of this study are to assess parental perceptions and challenges in acquiring a dental home for their CSHCN. METHODS: Cross-sectional prospective study using a questionnaire. RESULTS: A total of 302 questionnaires were completed by caregivers. More than 70% of children had developmental delay, 20% had musculoskeletal disabilities, and the rest had respiratory compromise on non-invasive ventilation, learning disability, and visual and hearing disabilities; 75% of the caregivers do not believe pediatricians are qualified to contribute in oral hygiene. Moreover, 70% of children had not had a routine dentist visit in the 12 months preceding the interview. The reasons given for the lack of such visits included the long time of appointments (25%), difficulty in child's mobility (17%), the perception that dental care is expensive (9%), and a lack of dentist experience in dealing with children with special needs (5%). When asked what factors would encourage caregivers to choose a dental home for their children, 63% mentioned quick appointments, followed by dentists specialized in children with special needs (51%), child friendly atmosphere (21%), low cost (26.6%), close to home (20%), and others (6%). Interestingly, the majority of parents (75%) believed that the primary pediatrician of the child should initiate the dental home process. CONCLUSION: Despite proper resources, children with special healthcare needs lack proper oral healthcare. This could be attributed to the lack of a dental home. A pediatrician's role is crucial in initiating the process of acquiring a dental home for this special population.

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.

Non-communicable diseases research output in the Eastern Mediterranean region: an overview of systematic reviews.

BACKGROUND: Rates of non-communicable diseases (NCDs) are rapidly rising in the Eastern Mediterranean Region (EMR). Systematic reviews satisfy the demand from practitioners and policy makers for prompt comprehensive evidence. The aim of this study is to review trends in NCD systematic reviews research output and quality by time and place, describe design and focus, and examine gaps in knowledge produced. METHODS: Using the Montori et al. systematic reviews filter, MeSH and keywords were applied to search Medline Ovid, Cochrane Central and Epistemonikos for publications from 1996 until 2015 in the 22 countries of the EMR. The 'Measurement Tool to Assess Systematic Reviews', AMSTAR, was used to assess the methodological quality of the papers. RESULTS: Our search yielded 2439 papers for abstract and title screening, and 89 papers for full text screening. A total of 39 (43.8%) studies included meta-analysis. Most of the papers were judged as being of low AMSTAR quality (83.2%), and only one paper was judged as being of high AMSTAR quality. Whilst annual number of papers increased over the years, the growth was mainly attributed to an increase in low-quality publications approaching in 2015 over four times the number of medium-quality publications. Reviews were significantly more likely to be characterized by higher AMSTAR scores (±SD) when meta-analysis was performed compared to when meta-analysis was not performed (3.4 ± 1.5 vs 2.6 ± 2.0; p-value = 0.034); and when critical appraisal of the included studies was conducted (4.3 ± 2.3 vs 2.5 ± 1.5; p-value = 0.004). Most of the reviews focused on cancer and diabetes as an outcome (25.8% and 24.7%, respectively), and on smoking, dietary habits and physical activity as exposures (15.7%, 12.4%, 9.0%, respectively). There was a blatant deficit in reviews examining associations between behaviors and physiologic factors, notably metabolic conditions. CONCLUSIONS: Systematic reviews research in the EMR region are overwhelmingly of low quality, with gaps in the literature for studies on cardiovascular disease and on associations between behavioral factors and intermediary physiologic parameters. This study raises awareness of the need for high-quality evidence guided by locally driven research agenda responsive to emerging needs in countries of the EMR.

Characteristics of Breast Cancer Metastasizing to Bone in a Mediterranean Population.

AIM: This study examines clinicopathological, molecular, and radiological characteristics of breast cancer metastasizing to the bone in a Mediterranean population. METHODS: Cases of breast cancer with metastasis to bone were retrieved from the pathology department archives. Descriptive statistics and bivariate inferential statistics of retrieved clinical (demographic, focality, laterality, axillary lymph node status, and metastasis-free interval), radiological (skeletal site of bone metastasis, type of bone lesion), and microscopic (grade, subtype of breast cancer, lymphovascular status, perineural status, lymph node involvement, nodal extracapsular extension, molecular subtype) data were conducted. RESULTS: Out of 123 cases analyzed, 93.5% were ductal, 90% had axillary lymph node metastasis, 60.5% were luminal A, 59.6% were osteolytic, and 54.4% had grade III. Discordance in the status of ER, PR, and HER2 between the primary breast tumor and the corresponding bone metastases was noted, with the highest rate of change reported for PR (35.7%). Significance was detected at the level of difference between the subtype of breast cancer with regards to the radiologic features where the ductal subtype was found to be mostly osteolytic while the lobular subtype was mostly either osteoblastic or mixed (p-value=0.05). The metastasis-free interval was significantly associated with the number of metastatic bone lesions (P=0.001). CONCLUSION: The significant association between metastasis-free interval and the number of metastatic bone lesions suggests that a higher interval allows more time for tumors to manifest multiple lesions. The high rate of discordance in the status of PR, ER, and HER2 was congruent with the literature highlighting the need to further investigate underlying mechanisms.

Correction to: Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

[This corrects the article DOI: 10.1186/s13031-019-0224-y.].

Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

BACKGROUND: Syrian healthcare workers (HCWs) are among those who fled the Syrian conflict only to face further social and economic challenges in host countries. In Lebanon, this population group cannot formally practice, yet many are believed to be operating informally. These activities remain poorly documented and misunderstood by the academic, policy and humanitarian communities. This study aims to understand mechanisms of informal provision of services, the facilitators and barriers for such practices and to present policy recommendations for building on this adaptive mechanism. METHOD: A qualitative descriptive study based on an in-depth interview approach with a sample of Syrian informal healthcare workers (IHCWs) residing in Lebanon was adopted. Known sponsor networks followed by snowball sampling approaches were used to recruit participants. Data collection occurred between September and December 2017. All interviews were audio-recorded, transcribed and translated into English. An inductive thematic analysis was used. RESULTS: Twenty-two participants were recruited. Motivational factors that led HCWs to practice informally were personal (e.g. source of income/livelihood), societal (cultural competency), and need to fulfill a gap in the formal health service sector. Being connected to a network of IHCWs facilitated initiation of the informal practice until eventually becoming part of a community of informal practice. The central challenge was the informal nature of their practice and its negative consequences. Most IHCWs were afraid of arrest by the government upon identification. Most interviewees indicated being discriminated against by host communities in the form of differential wages and tense interpersonal relationships. Almost all recommended a change in policy allowing them to practice formally under a temporary registration until their return to Syria. CONCLUSION: Our study confirmed the presence of IHCWs operating in Lebanon. Despite its informal nature, participants perceived that this practice was filling a gap in the formal health system and was helping to alleviate the burden of IHCWs and refugee health needs. In line with interviewees' views, we recommend that policy decision makers within humanitarian agencies and the Government of Lebanon explore the possibilities for allowing temporary registration of displaced Syrian IHCW to benefit local host communities and refugee populations.

Prevalence, Awareness, and Control of Hypertension in Greater Beirut Area, Lebanon.

BACKGROUND: Hypertension (HTN) has been identified as the leading risk factor for mortality and the third cause of disability worldwide. Lebanon has witnessed a threefold increase in the prevalence of HTN in the past decade. The timely exploration and detection of the factors contributing to a higher prevalence of the disease among the Lebanese population is fundamental. The objectives of this study were to assess the prevalence, awareness, and control rates of HTN in Greater Beirut Area in Lebanon and to identify their respective predictors. METHODS: A representative sample of 501 participants aged 18-79 years residing in Greater Beirut Area was examined. Data collection form was filled up, through interviews, physical exams, and lab tests. The analysis was done for three defined outcomes: blood pressure status (normotensive, prehypertension, and hypertension), unaware HTN, and uncontrolled HTN. These were compared for the various associated predictors. RESULTS: The sample consisted of 64.3% women and mean age 45.4 ± 15 years and the subjects were predominantly from low educational income levels. The results showed that 36.4% of the study participants were hypertensive, 25.3% were prehypertensive, and 38.2% had optimal blood pressure, while the awareness rate was 65.4% and control rate was 61%. The independent predictors of HTN were age, gender, marital status, T2D, body fat, triglyceride (positive correlates), and income level (negative correlate). Moreover, unawareness of HTN was common among older age, men, single participants, and the obese. We could not identify any factor related to uncontrolled HTN. CONCLUSION: The trend in the prevalence of HTN in Greater Beirut Area is found to be consistent and relatively high, yet there was an observed improvement in the awareness and control of the disease. Public health measures on a national level are urgently needed to curb the increasing prevalence of HTN, achieve primary prevention, and better control the disease.