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. 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. 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. 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.

中文翻译：

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准备好在脆弱的情况下提供以人为本的护理：黎巴嫩精神卫生服务案例


有证据表明，各国提供的精神保健服务存在很大差异。经历脆弱性相关风险的国家承受着沉重的精神疾病健康负担，而且由于财政和人力资源短缺，扩大精神卫生服务的能力有限。将心理健康服务纳入常规初级保健是提高服务可用性的一项潜在策略，但目前对初级保健层面参与心理健康和社会心理支持服务（MHPSS）提供的积极卫生保健提供者的经验知之甚少。本研究旨在确定在黎巴嫩初级保健层面提供 MHPSS 服务的医疗保健提供者如何看待心理健康以及卫生系统解决日益增加的精神疾病负担的能力，以期找到加强以人为本的 MHPSS 服务实施的机会护理模式。采用定性研究设计，包括 15 次半结构化访谈和 2 次参与式小组模型构建研讨会，参与者包括参与初级保健水平精神保健服务的医疗保健提供者 (HCP)。参与者是从两个截然不同的脆弱环境（贝鲁特和贝卡）招募的。在研讨会期间，得出了因果循环图，描绘了对导致压力和精神疾病的因素、相关的健康寻求行为以及卫生系统内的挑战和障碍的共同理解。这项研究是一项更大规模研究的一部分，该研究的重点是了解影响黎巴嫩社区成员心理健康认知和寻求健康行为的动态。 调查结果围绕因果循环图进行组织，该因果循环图描绘了研讨会参与者所描述的三个中心动态。首先，与会者将家庭层面的财务限制和无法保障生计与背景社会政治压力因素联系起来，主要指收容社区和叙利亚难民之间的融合挑战。在第二种动态中，参与者将战争、冲突和流离失所的经历与创伤事件和高度痛苦以及紧张的家庭和社区关系的发生联系起来。最后，与会者描述了第三种动态，将文化规范和父权制度与黎巴嫩民众遭受暴力和代际创伤联系起来。在描述寻求帮助的途径时，参与者指出了社区内和卫生专业人员之间的社会耻辱的强烈影响；据指出，后者会对医患关系产生负面影响。参与者还谈到了提供精神卫生服务方面的困难，并将其与卫生系统本身的设计联系起来，指出当前的系统面向以患者为中心的护理，仅关注患者的疾病经历，而不是以人为中心医疗服务提供者和患者承认对健康更广泛的结构和社会影响，并共同努力做出适当的决定来解决健康和其他社会需求。提供以人为本的护理的障碍包括缺乏连贯的精神卫生信息系统、在初级卫生保健人员中提供 MHPSS 服务的人员能力有限以及在我们的研究背景下许多精神卫生服务提供者之间的服务整合和协调不足。 然而，至关重要的是，提供者账户表明卫生专业人员愿意并愿意参与以人为本的综合护理模式。精神疾病是一个重大的公共卫生问题，对个人健康和福祉产生影响；在黎巴嫩这样的脆弱环境中，精神疾病的负担预计将会上升，这对现有卫生系统提出了实质性挑战。需要具体的多部门努力和投资，以（1）减少耻辱并改善公众对精神疾病和相关寻求护理需求的看法；（2）促进实施以个人为中心的综合护理，以解决心理健康问题。