We first discuss how health providers perceive mental health issues and factors contributing to their onset as well as associated health seeking. Throughout, we compare providers accounts with those of community members, presented in a separate publication (10). Further, we discuss the dynamics of the health system itself and challenges to MHPSS service delivery as perceived by health providers, highlighting challenges in the delivery of person-focused care as per Star field (27).
Provider perceptions on factors affecting the onset of mental health conditions
In response to prompts on factors affecting the onset of stress and mental health issues, providers described complex and dynamic interactions, relating primarily to the populations’ (both Lebanese and Syrian) exposure to war and political instability, a tense community and family environment, and precarious financial conditions within Lebanon. Figure 1 presents a CLD illustrating a consolidated account of the factors precipitating compromised wellbeing and MH condition onset, and associated health seeking.
Overall, we identify three main feedback loops from provider’s accounts. Loop L1 (see left of diagram, Figure 1), outlines how the level of resources available at family levels directly links to a persons’ ability to secure and take care of their physical health, and over time, their ability to therefore secure employment and contribute to their family’s resources. Providers noted that particularly in the Beqaa, where there were limited employment opportunities and where tensions between local host and Syrian refugee communities were high, resources at household levels were scarce and over time physical health suffered. Health providers linked the availability of employment opportunities further to the political instability in Lebanon and the wars witnessed in the region, noting these factors were main causes for the impairment of economic growth. The financial constraints in the country left people unable to secure their livelihood and afford to meet family needs such as school tuition fees and accessing healthcare services.
“Pressure mainly stems from the situation in the country. Schools are expensive, there is no work, and hospitals are expensive and inaccessible. If a person gets sick, he has to pay huge sums of money for hospitalization if he does not have insurance or social security.” A nurse living in Beirut
Moreover, providers talked about poverty and limited employment as major challenges in the country and a main contributor to mental health issues.
“Poverty is a big issue that carries with it depression.” A HCP from Beirut
Further, providers also linked exposure to wars and displacement to the health of families and communities as well as physical health issues. Providers noted that potential trauma or high levels of distress due to the loss of loved ones could directly compromise a person’s health or their ability to look after their health, or over time may lead to epigenetic changes impacting the health of future generations (see Loop 2, center of Figure 1).
“In refugee communities, due to the war, some people face psychological shocks that cause imbalance.”HCP from Beqaa
Providers also noted that displacement itself often prompts the emergence of strained community relationships. Clashes between diverse cultures, for example, may compromise community mental health.
“People who immigrated because of the war might have experienced a change in culture and traditions which affected their mental health.”HCP from Beqaa
Additionally, HCPs from the Beqaa region specifically highlighted how community relations and strained relationships could lead to violence occurring at community and family levels (see Loop 3, lower left Figure 1). Participants from this group spoke about how the cultural norms and patriarchal system in the Beqaa region shaped both ableist norms and masculinity identities within which able bodied individuals are advantaged and within which men need to hold power and dominate in roles within the family and the community. When such roles are threatened interpersonal violence often ensues, and providers noted that exposure to violence over time may also lead to intergenerational trauma taking root, thus affecting family wellbeing further, and leading to the onset of chronic stress and mental health issues for whole families. Such accounts are very similar to those noted by community members (7), particularly within the Beqaa.
Accounts of what prompts the onset of chronic stress and mental health conditions were largely consistent across providers from the Beqaa and Beirut areas. The main differences highlighted relate to increased tensions between communities in the Beqaa and providers impressions of increased interpersonal violence and intergenerational trauma within this region.
As outlined above, the information provided by health care providers was overarchingly consistent with that of community members (10). However, in contrast to communities, providers reflected more on how genetic predisposition and the ability of persons to actively care for one’s physical health can affect stress and wellbeing levels (see Loops L2).
Provider perceptions of community health seeking behaviours
Providers in both settings reflected on factors that shape community level health seeking behaviours (see centre of Figure 1, utilization rate variable referring to utilization of formal health services). Social stigma was noted as the main barrier to access and utilization of mental health services. Participants noted that stigma affects both the acceptance of mental health conditions and willingness of the affected person or patient to seek or continue seeking treatment for improvement. Stigma was noted to be fueled by lack of knowledge and limited awareness of mental health as well as myths and traditional beliefs as influenced by religion (see Loop L4, right top hand side of Figure 1).
Healthcare providers clarified that stigma was present in communities and in the health system itself as well; patients for example may fear the judgmental attitudes of providers towards mental health and therefore not seek care. Perceptions of communities, as related to trust in providers and expectations of providers keeping problems confidential, and perceptions on the structural quality of care offered at health facilities, were noted to affect health seeking. (see right hand side of Figure 1).
Additionally, providers noted that it may be unclear where exactly in the health system community members should seek help for mental health conditions. Providers noted that general practitioners were generally approached for physical symptoms, however the latter may turn out to be related to psychological challenges.
Similar to community member accounts (7), providers mentioned that people usually seek support from their friends, families, and religious figures prior to seeking support from the health system.
“HP: Most people first seek friends, people they rely on or trust. The second step when they don’t have much awareness about mental health, they might seek GPs because the symptoms are portrayed physically. It could be a stomach pain or headache. Your mental health issues might have been around for so long that they have compromised your immune system.” HCP from Beirut
“In simple cases like anxiety and depression, they might resort to their family.“ HCP from Beqaa
“HP: Many people who suffer from bipolar disorder and schizophrenia are taken to religious figures instead especially the Syrians coming from traditional villages.” HCP from Beqaa
Providers clarified that the community view utilization of formal mental health services as the last resort, and further highlighted the limited availability and affordability, as well as perceptions of low service quality, as main barriers of access to mental health services. These accounts were consistent with those of community members, across both the Greater Beirut area and the Beqaa(10).
Systems barriers to person focused care
Barrier 1: Lack of cohesive and coordinated health management information system compromises quality of care
Providers mentioned that no harmonized filing or health information system exists within the current Lebanese system. Thus, the full medical or psychological history of persons needs to be elicited at each patient encounter, potentially compromising the wellbeing of the patient further or sparking anger, particularly in case of mental health conditions.
“The administrative process and structure plays a role. The patient repeats the things to the nurse, then GP, then they have to go to different floors. We should be aware of these things to facilitate the process for the patient. The easier, the better. What if the patient has no energy to repeat the same story again?” HCP from Beirut
Providers reflected that the system is currently not built for mental health conditions and that lack of a cohesive and coordinated system, across diverse providers, severely limits file sharing and also referral and follow-up.
“Our problem is with harmonizing files of patients and data management. This is our biggest problem, and we brought it up with the Ministry. We cannot solve it now. Its solution is a bit far. We are five NGOs. Each has its system and tools. The data is not harmonized. We don’t even have online data.” HCP from Beirut
Barrier 2: Limited human resource capacity for mental health due to limited training and scarce resources
Providers mentioned that the shortage in human resources specialized in mental health is a major challenge, especially in the Beqaa area. Specialized cadres are scarce within the country, and when available largely focused around the capital.
“Another thing is that there should be an analysis to find out which areas in Lebanon lack psychotherapists. As I mentioned before, the further you go outside Beirut, the less psychotherapists you’ll find. So, there should be a needs analysis to know in which regions we should hire more psychotherapists.” HCP from Beqaa
Providers noted that among generalist staff, limited training on mental health and psychosocial support had been provided, and where training had been provided – as for example was the case with MhGAP training during 2015-2016, this was largely around how to screen, manage and refer cases when needed, with limited refresher or follow-up programs further taking place. Participants related the lack of training to general funding limitations experienced by the Ministry.
“Lack of training also related to the lack of funding to the ministry. GPs were trained to screen for mental health issues and refer to mental health specialist when necessary. Yet refresher training are no longer being done “. HCP from Beqaa
Participants explained that given the limited training on case management, health providers lack the skills and confidence needed to admit and treat severe cases. In the Beqaa area, admission of severe cases may be refused given lack of capacity.
“In the Bekaa for example, if someone needs hospitalization, we do not have the hospitals that would accept these cases. Even if the mental health patient gets admitted to a hospital, there is concern about some extreme cases. Sometimes the hospital would refuse a patient because they are scared the patient might jump out of the window for example or hurt himself. They are not trained to accept these cases.” HCP from Beqaa
Participants also noted that training for staff should be comprehensive, and additionally tackle the high levels of stigma prevalent even within the health service. Some providers for example consider mental health issues as a taboo.
“Staff inside the hospital have a stigma and say this is a ward for crazy people. We received this feedback, and we immediately launched a sensitization plan. Mental health staff carry out sensitization sessions rather than trainings to sensitize the hospital staff and front liners about the definition of mental health and the Community Mental Health Center and it services” HCP from Beqaa
Barrier 3: Limited service integration and coordination compromises the systems’ ability to address the mental health burden
Providers acknowledged multi-factorial determinants of mental health issues and described the need for interventions that aim for prevention rather than management. The health system relies on general practitioners referring patients to mental health specialists, however ambiguity in case management remain, with limited clarity over focal points for specific cases.
“Focal points are not clear, within the components we tackled. The communication path between all components should be clear to facilitate the pathway for the patient. If somebody is absent, who is the replacement? All these are important matters. If the case manager is absent and the patient comes, and I have no clue about the patient’s file, how can I help them?” HCP from Beirut
Further, particularly where mental and physical health issues cannot be easily disentangled, responsibilities for care and service coordination and integration remain a challenge.
“I think it is important for each hospital to have a mental health department, especially in the Bekaa hospitals or remote areas. Sometimes, for instance, in cases of bedwetting among children, we need to know if the case is medical or if the child is being harassed. If I refer a child who is being harassed to a pediatrician who is not aware of harassment and mental health issues, he might not be able to help the child and might drag him into a spiral of medication and examinations.” HCP from Beqaa
Despite the above-mentioned, participant accounts also clearly highlight the readiness of health providers to engage more fully with the delivery of person-focused and integrated mental health services.
Facilitator 1: Providers perceive mental and physical health as interrelated phenomena to be treated coherently and in conjunction with each other
Providers acknowledged that communities and other providers with limited mental health training often focus on physical symptoms and illness, but in our accounts, providers reflected on these being interrelated phenomena. They clarified that physicians are trained to take into consideration mental health issues when there is no clinical reason for the physical pain of the patient.
“HP: I can imagine that screening is very essential for GPs. After GPs run their tests, and they notice there is no physical cause, the GP would know that there is a mental health issue” HCP from Beqaa
Participants further reflected that mental health issues are due to multiple factors that are related to socioeconomics, family and social relations, genetics and adopted lifestyles (as mentioned in the previous section on factors leading to the onset of mental health issues)
Facilitator 2: Providers are ready to build trusting and open relationships with patients
HCPs talked about the importance of their role in building trust with the patient and helping them to be open about his/ her mental health issues in a secure and safe environment. Providers emphasised that patients still view mental health issues as a taboo, which is why continued open communication is important.
The trust building process is key because for some patients it is taboo, they don’t like to talk about it” HCP Beirut
“The first thing we used to work on is discussing their needs and building trust. Then, we would get to the phase where they would set targets they want to improve.” HP Beqaa
However, providers acknowledged that building trust remains a challenge given both high workloads and ambiguity around care coordination. Additionally, HCPs mentioned that most patients still consider mental health as a taboo and that physicians themselves may find it difficult to open up the topic with the patient for the first time.
Facilitator 3: Providers are concerned with the evolution of people’s experienced health problems
Providers noted that working with other professionals to tackle not just health issues but wider social issues leading to the emergence or exacerbation of mental health issues is crucial. For example, they clarified that social workers may be more experienced in building trust with communities and helping them open up and communicate about their mental health concerns.
Providers also mentioned the need to organize outreach campaigns in cooperation with different civil organizations and primary healthcare centers as well as the need to seek support of the social media to spread awareness among the community. They noted that the challenge with current outreach activities is that they are targeted primarily at Syrian refugees, leaving a gap for Lebanese persons who prefer seeking care from private clinics.
“There is a lot more we could do. We could run outreach campaigns in cooperation with different civil organizations and we could have better presence on social media.” HCP from Beirut
“The outreach affects Syrians more than the Lebanese. As for the Lebanese, we usually reach them through healthcare centers, but it is not effective since the Lebanese tend to go to a doctor or a private clinic instead.” HCP from Beqaa
Points of fragility and Suggested Interventions
GMB participants across the Beqaa and Beirut were asked to reflect on the causal loop diagram they developed (Figure 1 and Appendix 1) and to vote for the top weaknesses and issues affecting mental health service utilization and delivery in Lebanon. HCPs across both settings identified the issue of stigma which is fueled by lack of awareness to MH among the population including the potentially stigmatizing attitudes of the HCPs themselves towards mental health. Additionally, HCPs reflected on the limited availability of services due to the limited funds and human resources within the country, which affects the continuous training and education of the providers and even availability of medications. HCPs from the Beqaa additionally noted the issue of violence at the family and community levels as a major factor leading to mental health issues among the population in Beqaa.
At the end workshops, HCPs were given the chance to suggest potential interventions to improve the situation of mental health service delivery in Lebanon (see Table 2). Across accounts, we note staff focusing on factors which may undermine wellbeing and/or undermine the health systems’ ability to deliver care. Conducting awareness campaigns was a common suggestion to fight stigma, stop inter-personal violence and help people seek mental health care. Providers from the Beqaa recommended the need for multisectoral coordination and collaboration among the different ministries, taskforces and field practitioners, including the need to secure funds and financial resources for this care delivery. Beirut HCPs instead suggested the need for more research that assess the burden of mental-ill health, current awareness levels and gaps in service provision; they noted this could be used for advocacy purposes to support raising funds (Table 2).