背景:证据表明,各国在提供精神卫生保健方面存在很大差异。经历脆弱性相关风险的国家承受着严重的精神病患者健康负担,此外,由于财政和人力资源短缺,扩大精神卫生服务的能力有限。将精神卫生服务纳入常规初级保健是提高服务可用性的一个潜在策略,然而,对于目前活跃的卫生保健提供者在初级保健层面参与心理健康和社会心理支持服务(MHPSS)提供的经验知之甚少.本研究旨在确定在黎巴嫩初级保健水平上提供MHPSS服务的医疗保健提供者如何看待心理健康和卫生系统应对不断增加的精神疾病负担的能力,以期确定加强MHPSS服务实施的机会,以综合人员为中心的护理模式。
方法:采用了定性研究设计,包括15次半结构化访谈和2次参与小组模型构建研讨会,其中包括参与初级保健水平的精神卫生保健提供的卫生保健提供者(HCP)。参与者来自两个截然不同的脆弱性背景(贝鲁特和贝卡)。研讨会期间,因果循环图描绘了对导致压力和精神疾病健康的因素的共同理解,相关的寻求健康的行为,并引发了卫生系统内的挑战和障碍。这项研究是一项更大的研究的一部分,该研究的重点是了解居住在黎巴嫩的社区成员中塑造心理健康观念和寻求健康行为的动态。
结果:研究结果是围绕一个因果循环图组织的,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,参与者将家庭层面的财政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。在第二个动态中,参与者将暴露与战争联系起来,冲突和流离失所,导致创伤事件的发生和高度痛苦以及紧张的家庭和社区关系。最后,与会者描述了将文化规范和父权制与黎巴嫩人口中的暴力和代际创伤联系起来的第三种动态。在描述寻求帮助的途径时,参与者注意到社会污名在社区和卫生专业人员中的强烈影响;后者被注意到对患者-提供者关系产生负面影响.与会者还谈到了提供精神卫生服务的困难,并将其与卫生系统本身的设计联系起来,注意到当前的系统面向以患者为中心的护理,只关注患者的疾病经历,而不是以个人为中心的护理,因为提供者和患者承认对健康的更广泛的结构和社会影响,并共同努力达成解决健康和其他社会需求的适当决定。提供以人为本的护理的障碍包括缺乏连贯的心理健康信息系统,在我们的研究背景下,初级卫生保健人员提供MHPSS服务的能力有限,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准备好并愿意参与以个人为中心的综合护理模式。
结论:精神疾病是一个主要的公共卫生问题,对个人健康和福祉有影响;在黎巴嫩等脆弱的背景下,预计精神病患者的健康负担将上升,这对现有的卫生系统构成了实质性挑战。需要具体的多部门努力和投资,以(1)减少耻辱,改善公众对精神疾病健康和相关护理需求的看法,(2)促进实施以个人为中心的综合护理,以解决精神健康问题。
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.