Expressions of perinatal idioms of distress and ethnopsychology in Sierra Leone: implications for community-based interventions

Expressions of perinatal idioms of distress and ethnopsychology in Sierra Leone: implications for community-based interventions | Research Square Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Expressions of perinatal idioms of distress and ethnopsychology in Sierra Leone: implications for community-based interventions Abdulai Jawo Bah, Haja Ramatulai Wurie, Mohamed Samai, Rebecca Horn, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8813787/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Studies suggest high rates of ante- and post-natal depression in low- and middle-income countries (LMICs), yet relatively little scholarship addresses how perinatal women experience and express psychological distress in these low-resource settings. To address this gap, we conducted a rapid ethnographic study including 96 free list interviews with community members and 16 key informants (KI) pile sorts. Thematic analysis of data was supported by frequency analysis and multidimensional scaling. Participants included pregnant and new mothers, non-pregnant and non-lactating mothers, elderly women, and men in the community to gauge a diverse range of views. Twenty signs of distress were identified. The heart (at), mind (maynd), and body (bodi) comprised the self-concept and were related to sadness, stress, loneliness, anger, worry, and thinking too much. They used the heart and mind to describe problems associated with emotions and thoughts, respectively. Participants articulated several idioms of distress, including stres(stress), poil at (spoil heart), and ed nor de or e wan go off (pre-psychosis or crase), that occur within a context of poverty, marital disharmony or inter-partner conflict and gender inequality. These idioms of distress exist as discrete indicators with overlapping features, operating on a continuum of severity that could progress over time, both within and across idioms. These findings can inform mental health literacy and communications that are less stigmatizing, and the development of culturally salient screening tools and interventions that are locally appropriate. This could potentially increase uptake and engagement with services and enhance therapeutic outcomes for perinatal women with psychological distress. Psychiatry Perinatal women perinatal psychological distress idioms of distress and ethnopsychology Figures Figure 1 Introduction In a systematic review and meta-analysis examining the prevalence of common perinatal mental disorders in LMICs, it was found that approximately 15.6 % of pregnant women and 19.8 % of new mothers, equivalent to over 33 million pregnant women (Sedgh et al., 2014) and 24 million new mothers (Singh et al., 2013), may be affected by these conditions (Fisher et al., 2012). There is a lack of exploration into the various causes, manifestations, and localized interpretations of PPD across diverse contexts, despite the significance of these problems. Notwithstanding, the evidence suggests that the risk factors, symptoms, and classification of these problems are highly dependent on the specific cultural and social environments (Kieling et al., 2011; Thulin et al., 2020). Anthropologists have been interested in how culture and life experiences influence the way people interpret and communicate social and psychological distress (Kirmayer and Bhugra, 2009). However, there is still an ongoing debate regarding the extent to which culture affects the experience and expression of mental illness (Jenkins, 2015). The concept of "idioms of distress," introduced by (Nichter, 2010), has become a central aspect of study for researchers aiming to understand how the culture and life experience of individuals from diverse sociocultural backgrounds influence the way they interpret and communicate suffering, pain, or illness (Kirmayer and Swartz, 2013). Despite being included in the current Diagnostic and Statistical Manual (DSM-5) used in psychiatry (White et al., 2017), these idioms are seldom examined within the realm of biomedicine. One reason for this is that such expressions go beyond mere medical diagnoses, often revealing underlying "interpersonal, social, political, economic, and spiritual sources of distress" (Nichter, 2010, p. 402). The lack of assessment within biomedicine may also be attributed to the structural violence prevalent in clinical medicine, which hinders physicians from adequately addressing social suffering even if they have the intention to do so (Mendenhall et al., 2019). The interpretation of idioms of distress is rooted in ethnopsychology, which involves the anthropological study of concepts related to self, mind, body, and their interconnected processes (White et al., 2022). It is essential to consider idioms of distress within the broader cultural models of ethnopsychology to fully grasp their meaning and significance. Ethnopsychology helps ensure that these terms are understood in their appropriate cultural context, identifies overlaps and distinctions among them, and facilitates their integration into public health messaging and treatment approaches (Kohrt et al., 2014). As idioms of distress often involve a strong emphasis on somatization, exploring ethnophysiological models becomes valuable. These models focus on the culturally guided perception of the mind-body relationship rather than actual biological differences (Hinton et al., 2012). By combining ethnopsychology, ethnophysiology, and the perceived associations with psychiatric disorders, a more comprehensive understanding of idioms of distress can be constructed, enhancing culturally sensitive care provision. Enhancing our knowledge of perinatal psychological distress (PPD) in low-resource and post-conflict settings, including their perceptions, experiences, meaning-making, and expressions, is crucial for establishing an evidence-based foundation to guide culturally appropriate measures and interventions in such contexts (Kieling et al., 2011; Patel and Kim, 2007). How local PPD manifest and are interpreted can significantly impact rates of stigma, utilization of mental health services, and overall health-seeking behaviors (Cork et al., 2019). The aim of this study was to assess and document how PPD are experienced and expressed in Sierra Leone to inform. the development of culturally valid assessments and treatments for PPD in Sierra Leone (Thulin et al., 2020). Socio-cultural context Sierra Leone is a country located in West Africa, bordered by Guinea to the north and east, Liberia to the southeast, and the Atlantic Ocean to the west (Fyfe, 1963). Sierra Leone was established by the British as a sanctuary for liberated African slaves, known as Creoles who were originally from the Bahamas, the United States, Nova Scotia, and Great Britain. In 1787, British philanthropists founded the "Province of Freedom," which later evolved into Freetown, a British crown colony and the primary hub for suppressing the slave trade. By 1792, freed slaves from Nova Scotia joined the initial settlers, known as the Maroons, and were later joined by a group of slaves from Jamaica in 1800. Sierra Leone, at the time, held a unique colonial status referred to as a "multiple dependency," (Fyle, 2006) and became a crown colony in 1808. The capital and largest city is Freetown, which is located in the western part of the country and is home to around 1.2 million people (Leone, 2016). The official language is English, but Krio and various indigenous languages are also widely spoken. The population of Sierra Leone is around 7.9 million, with a growth rate of 2.5% (Leone, 2015). Sierra Leone has a diverse economy, with agriculture, mining, and fishing being the main sources of income (Bonuedi et al., 2022). Sierra Leone experienced eleven years civil war, during which all rebel groups, certain elements within the government army, and even peacekeepers deliberately targeted women and girls as sex slaves. They were subjected to systematic rape. Furthermore, the civil war exacerbated the already limited access to maternal and child healthcare services, exacerbating the vulnerabilities of pregnant women and new mothers. The extreme violence targeting women during the conflict has extended into the post-conflict period, with rape becoming alarmingly commonplace. In an effort to address domestic violence, provide support to victims, and raise awareness about the consequences of gender-based violence, Family Support Units (FSU) were established within police departments. However, there is limited evidence of their positive impact thus far. Upon marriage, women typically reside in their husband's community, and children are considered to "belong" to the father. The absence of strong lineage connections serves as a major source of insecurity, vulnerability, and poverty among women, especially rural women from disadvantaged families who experience heightened effects of these challenges (Richards, 2005). A common practice in Sierra Leone is the payment of bride price, which involves offering property or other valuables or services to the parents of a woman in exchange for the right to marry her. Anthropological analysis often perceives women as commodities of exchange in the context of marriage and bride wealth. However, John Ogbu argues that bride price is not "purchase money" but rather a legitimization of marriage, asserting that it enhances, rather than diminishes, the status of African women (Ogbu, 1978). The findings of the Truth and Reconciliation Report (2004) reveal that the payment of bride price in Sierra Leone grants the husband complete control over his wife as her trustee, guardian, and protector, effectively placing the wife in a subordinate position within the home (Dougherty, 2004). According to customary law, the wife is treated on par with a minor, with ‘widow inheritance’ and structural gender discrimination still a common practice. In Sierra Leone, women and girls have historically faced significant challenges related to gender inequality. The major issues faced by women and girls in Sierra Leone include lack of education, healthcare, economic opportunities, and violence against women (Fitzgerald et al., 2016). Following the conclusion of the civil war, the Sierra Leone government launched a series of women's rights measures, which coincided with a global drive for gender parity (Borishansky 2018). A UN resolution 1325 on "Women, Peace, and Security" was developed as a commitment to dealing with gender-based and sexual violence in Sierra Leone. According to Josephine Beoku-Betts, the resolution will have limited impact because it fails to address the social and institutional features that permit the act of sexual violence in the absence of conflict, though it calls for the strengthening of the legal rights of women and supports local peacebuilding efforts (55, p. 654). Methodology This project was part of a larger ongoing sequential, mixed-method study focused on pregnant women, lactating mothers, elderly women and men in the community. Data collection occurred between 2019 and 2021 in urban and rural settings across the country's four districts ¾Western Area, Bo, Bombali, and Kono. This study employed a combination of rapid ethnographic approaches to explore local understandings of distress based on work from previous studies (Betancourt et al., 2009; Bolton et al., 2004; Keys et al., 2012; Rasmussen et al., 2011). The research methodology included free listing interviews (Miller et al., 2006), pile sort exercises (analysed using multi-dimensional scaling, MDS) and key informant interviews (Horn et al., 2020). When studying idioms of distress in Sierra Leone, there are linguistic factors to consider. Sierra Leone is predominantly a monolingual society where the majority of the population speaks the native language, Krio (aka pidgin English) (Fyfe, 1963). However, due to the historical influence of British colonialism and the spread of the English language through globalization, English has become significantly integrated into spoken discourse. Code-switching and code-mixing (Wahid et al., 2022), involving the use of English words or phrases within Krio sentences or vice versa, are common and accepted forms of communication across all social strata in Sierra Leone. The research team consisted of a doctoral candidate (AJB) specializing in global mental health and experienced in qualitative research and four research assistants fluent in the Krio language, and either recent university graduates or in the final phase of their studies. They represented various ethnic groups and were proficient in languages such as Mende, Temne, and Fullah, in addition to being fluent in Krio and English. These research assistants were trained by a researcher from Queen Margaret university who is an expert in global mental health research (RH) in a previous study and received a refresher training from the first author (AJB). All of the research assistants had prior experience working on similar research projects, making them familiar with the methodologies used. All of the research assistants remained involved throughout the project, including data analysis. Sampling and recruitments of participants The study recruited participants through a convenience sampling method from rural and urban areas in Kono, Bo, Bombali, and Western Area. Adult participants included community members aged 18 and above engaged in various forms of community work, such as house wives, petty traders, and farmers. Collaborating with the community mobiliser at the District Health Management Team (DHMT), specific locations within each district were chosen to ensure diversity based on factors such as religion, ethnicity, socio-economic status, and primary livelihood. The field researchers purposively selected participants to achieve representativeness across different age groups. Participants received monetary compensation for their time in the study, monetary incentives ($1 equivalent). Free list interviews A total of 96 free list interviews were conducted, with 24 participants from each of the districts in the four geopolitical regions. These included 32 lactating mothers, 37 pregnant women, 12 elderly women and 15 men in the communities across these districts to have a range of perspectives. The age of the respondents ranged from 18 to 69 years, with an average age of 38 years. The free list interviews were conducted between 2019 and 2021 in urban and rural settings across the country's four districts Western Area, Bo, Bombali, and Kono. The free list exercises were conducted individually in a private location to ensure the privacy of the respondents. Research assistants were trained to ask participants, "What are the problems faced by women in this community?" They prompted the respondents until they had provided all the information they could. The research assistants documented the problems identified by the participants, referred to as "primaries," and asked for detailed descriptions of each primary mentioned. If new primaries arose during the discussion of an existing primary, the research assistant noted them down and requested additional descriptions. This process continued until the participant began repeating responses or indicated they had no further contributions. Interviews were conducted in the preferred language of the respondents, primarily in Krio. For non-Krio interviews, translators hired by the field researchers were used to facilitate communication with the local participants. Each interview lasted approximately 45 minutes, during which handwritten notes were taken. Free list interview analysis Initially, the primary terms and their associated descriptors were carefully examined to identify any responses that conveyed the same concepts. Overlapping primaries were merged to create more cohesive categories. After reviewing and organizing all the primaries, they were ranked based on the number of respondents who mentioned them, resulting in a hierarchy of problem terms. To analyze the data from the free list interviews, thematic content analysis was used to evaluate the primary terms (Smith, 1992). The research team identified terms associated with emotional, cognitive, or behavioural problems experienced by perinatal women in Sierra Leone. These relevant terms were then grouped into themes by the research team using an iterative process. The most commonly reported or most meaningful term, as determined by the research team, was selected as the cover term (see supplementary table). The cover terms derived from the free list exercise served as a foundation for exploring clusters of mental health-related issues through the pile sorting exercise. Pile sort exercises with key informants Following the analysis of the free list study data, pile sort exercises were conducted with key informants (KIs) in Western Area and Bombali district. A total of 16 key informants (KIs) completed the pile sort exercise, and the characteristics of the respondents are detailed in Table 1. The interviewers worked in teams of two, forming two teams in total. Each team conducted one pile sort exercise on the first day in each district, followed by in-depth interviews in the subsequent sessions. In the free list phase of the study, respondents were asked to provide names and contact information of individuals in their community whom perinatal women consult when they have concerns related to. their thoughts, feelings, or behaviour. These identified individuals were approached in each district and were further asked to recommend other knowledgeable individuals who are not professionals in dealing with such problems but possess insights into local community and cultural perspectives (Betancourt et al., 2011; Lee et al., 2018). Professionals were excluded to ensure a focus on local knowledge and experience rather than Biomedical responses. All pile sort exercises were conducted in Krio to ensure clear understanding of the signs of distress by the key informants. On average, the pile sort exercises took 45 minutes. Pile sorting process and analysis The 20 identified signs of distress from the free list study interviews were written on cards with Krio on the front and English at the back. Pile sorts were conducted for individual key informants (KIs). They were asked to sort the cards into three piles representing signs of distress they commonly observed in their community, those they encountered occasionally, and those they rarely encountered. Eight pile sorts of this nature were conducted. Following the pile sort, the interviewer randomly selected a sign of distress from the "often" pile and asked the KI to identify other accompanying signs that they commonly observed in individuals displaying that specific sign of distress. This process aimed to determine which signs were frequently present together in the same person. The KIs were then asked to name the grouping of signs. This grouping task was repeated up to three times for each KI. The KIs had the flexibility to select from all the signs of distress, allowing certain signs to appear in multiple categories (Rasmussen et al., 2011). Through the pile sorting exercise, potential clustering of signs was explored as participants physically grouped items and explained the relationships among them (Keys et al., 2012). For each district, the data from the clustering pile sort exercises were entered into a matrix that examined item-by-item relationships. The percentages of pile sorts in which two items were placed in the same pile were computed and used to generate a two-dimensional map using multi-dimensional scaling (MDS). This map illustrated the overall patterns of items in each district (see Figure 1). Groupings of items that indicated potential thematic clusters were identified. Ethical approval This study was conducted following the principles outlined in the Declaration of Helsinki. This study was given ethical approval by Queen Margaret University Edinburgh Research Ethics Committee and the Sierra Leone Ethics and Scientific Review Committee, Ministry of Health and Sanitation. All methods were carried out in accordance with relevant guidelines and regulations. Respondents were read an information sheet about the study and gave verbal informed consent to be interviewed, which was documented by the research assistants. Results Three themes were identified. The first theme, "Idioms of distress and ethnopsychology," examined the salient social and cultural means by which perinatal women express their distress, which was reflected in the field notes. It reveals the intersection between culture and psychology. Three sub-themes emerged: "heart," "mind," and "body," which correspond to the concepts of the self and personhood. The second theme, "clusters of idioms of distress," showed how clusters of signs are used to identify perinatal women in distress, stress, poil at and ed nor de or e wan go off” . The third theme was "comparing our locally identified idioms with the DSM-5 and ICD-10," which compares the idioms of distress and the Western diagnostic constructs to understand the similarities and the salient local construct specific to the Sierra Leone context. This section is organized by describing the socio-demographic characteristics of the participants and then presenting the three themes that emerged in this study highlighted above. Demographic characteristics of participants In all, 96 respondents (age range 18–68 years) volunteered for the free listing interviews: 32 new mothers, 37 pregnant women, 12 non-lactating and non-pregnant women, and 15 male partners. We also recruited 16 women (aged 30-59 years) for the pile sort exercise; all were non-pregnant and non-lactating community women (see Table 1). Table 1: Demographic characteristics of participants in the study District N Lactating mothers Pregnant women Non-lactating and non-pregnant women Men Age   of participants Free listing 27 ± 6 Range=18-41 26 ± 5 Range=18-40 45 ± 6 Range=40-69 39 ± 13 Range=28-68 Free list interviews Western Area 24 9 7 4 4 Bombali 24 8 11 2 3 Bo 24 7 10 3 4 Kono 24 8 9 3 4 Pile sorting Western Area 8 - - 8 - Bombali 8 - - 8 - Culturally grounded idioms of perinatal distress Participants described a wide range of emotional, cognitive, behavioural, and social signs of perinatal distress during the free-list interviews, articulated in Krio and illustrated with verbatim quotes. Commonly reported manifestations included stress, loneliness, excessive rumination (“thinking too much”), irritability, sadness, sleep disturbances, and social withdrawal. Interpersonal conflict, feelings of neglect or abandonment, shame, and reduced appetite were also frequently mentioned. More severe expressions included harmful thoughts, feelings of worthlessness, neglect of infants, and suicidal ideation or attempts. These findings highlight locally recognised expressions of perinatal psychological distress and provide insight into the ethnopsychological understanding of distress within this sociocultural context (Table 2). Table 2: Signs of distress identified during the free list interviews # Signs of perinatal distress Krio Selected quotes 1 Stressed Stres “The in-laws putting unnecessary stress on the pregnant woman, blaming her for stopping the man from helping them” 2 Isolation Kip to iysef “Not mingling due to the stress, she has” 3 Loneliness De fil lonlie “She sits quietly and has less to do with people” 4 Thinking too much De tink tu mos “Whether they will deliver safely or not” 5 Easily get angry De vex quick wan “Even when someone is joking with me” 6 Feeling sad and unhappy De fil sad/ nor gladi “Some nurses don’t know how to talk to new mothers. This makes us angry” 7 Use of abusive language/quarrel De kos boku n yuz hash wod dem “When the woman advises him to stop polygamy, he become angry and they quarrel” 8 Feeling neglected/abandoned /disappointed Fil lek nobody no kya bot am “The men are fine with their partner until they become pregnant, they abandon them they show less concern and caring” 9 Insomnia No ebul fo slip “The pregnant woman will short of blood, because she does not sleep, when she develops jealousy in her mind”. 0 Regret for not aborting the baby Regret we I no pul di bele “She was having the thought of doing abortion because her partner was not treating her well”. Confused/poor concentration Konfyuz “Confused of what to do or food for the baby” “She does not concentrate on things she’s doing” 2 Jealous Jelos “They think the man is going after other women, now they are pregnant” 3 Harmful thoughts Think for du bad “Think bewitching the man through a native doctor and making them mad” 4 Feeling worthless Fil lek iy noto bete posin “She asked her friends what is wrong with her, and start thinking that she’s not good enough and felt sad, when her husband abandoned her”. 5 Loss of appetite Nor de fil fo it bete “She cooks but does not have appetite to eat” “Some can’t eat even when they want to” 6 Talking to oneself Tok to iysef “She will be focusing in one direction for a while and talking to herself unconsciously”. 7 Women abandoned their babies Uman we no kya bot iy pikin “When the woman is not ready to have a baby, she regrets, will not take care of the baby and abandons the baby”. 8 Feeling shamed Fil shame “The husband denied the pregnancy, she felt that shame and discouraged” 9 Crying De kray kray “She cried a lot and was finding it difficult to sleep after her partner left her for another woman” 20 Attempted suicide Try fo kil iysef “Take to mind, thought of killing herself by drinking soda” Concepts of Self and Corresponding Idioms of Distress The participants frequently employed a combination of English and Krio words and phrases to articulate their understanding of the concept of the self and related idioms of distress.   They used metaphors that goes beyond mere linguistic expressions that actually reveal how abstract ideas are connected to more tangible, physically experienced concepts. Various aspects of the self were discussed, including the "at" (heart), as in "warm at" (temperament), “poil at" (depression), “at nor sweet” (sadness); "mind" (the head, mind or brain), which symbolizes the integration of mental aspects within the physical dimension, and "bodi" (physical body). It is important to note that these terms should not be considered as distinct and separate categories, as there was considerable overlap in their conceptual and linguistic usage. The term "at" was often combined with "mind" to convey the seamless connection between the mind and emotion. A list of these idioms of distress associated with these constructs is provided in Table 3. 1. “At” (heart) was used by respondents most predominantly to denote aspect of the heart, which is a concept historically rooted in the Krio language and was referred to by respondents as the seat of emotions. ‘At’ was often used with adjectives of temperature (e.g., warm), taste (e.g., not sweet), weight (heavy), as a metaphorical source to describe emotions. For instance, ‘nor swit’ (not sweet) may symbolize an unhappy feeling, evident in phrases like "at no swit". Furthermore, this was also seen in ‘at warm’ (temperament) which describes anger, ‘at heavy’ (heart heavy) which denotes grief. This often result in a cascade of physical and psychological symptoms, which manifests as weight loss and heightened stress levels, preventing them from finding peace and hindering their ability to engage in income-generating activities. The mother does not have rest heart and can’t do business to get money. Because the heart of the woman will not be at peace. This makes them to lose weight. It will also make them to become stress (18, LM, WAR). Inter-partner conflicts contribute significantly to emotional distress, particularly when husbands engage with other women. This situation elicits pain, fear of STIs, and a complex emotional state characterized by sadness and anger. This is often compounded by fear for the baby's health for suckling mothers whose husbands lack employment or engage in business, resulting in persistent worries, loss of appetite, and an inability to remain in one place. When my husband goes around with other women, I feel pain in my heart and fear of him becoming infected with HIV and infect me. I feel sad and angry (20, PW, WAU) ………...because the suckling mothers have poil heart for sick babies, their husbands do not have jobs or they do not do business to get money. I am fearful for the baby’s health, worried, lose appetite, and I cannot steady at one place (38, LM, Kono). Another woman experienced "Pwel heart," as a consequence of the negative relationship with her father due to pregnancy out of wedlock. The emotional state of pregnant women is further complicated when their husbands do not spend time with them and provide them emotional support, leading to feelings of discouragement, and unhappiness Depression (pwel heart): I feel this way because I am not in good terms with my father because of the pregnancy (18, PW, WAR) Neglect by a partner, evidenced by a lack of interest in the woman, engenders pain in her heart, leading to frustration, sadness, and disrupted sleep patterns. The overall emotional state of pregnant and lactating women is characterized by feelings of being unwell, resulting in hearts that are not 'sweet.' when a man doesn’t want to know about the woman, it will cause pain in her heart. She will become frustrated, sad and will not be able to sleep at night (28, LM, Bo) …………...because the pregnant woman and lactating mothers are not feeling good, their hearts are not sweet. Feel bad and sit alone reflecting of the pain and burn heart (28, NPNL, Kono) Disappointment, another emotional state labeled as "pwel heart," arises when the man responsible denies the pregnancy, potentially leading to abortion and endangering the life of the pregnant woman. Post-birth, the emotional distress continues in the form of "burn at" or distress, particularly when women witness their partners with other women, which worsen their emotional pain. The persistent pain in the hearts of women is heightened when partners neglect their responsibilities towards them and their children. when the man who impregnated the woman disappears, the woman would be stressed and sometimes meet out this anger of the children… (30, M, Koinadugu) …. the woman felt disappointed (poil at), and she misbehaves (25, PW, Bo). Tragically, some pregnant women experience miscarriages, resulting in profound heartbreak. For young mothers, encountering the individuals involved with their partners elicits sadness and intensifies the pain in their hearts As soon as the woman become pregnant, the man takes the woman to their parents and marry another woman. This makes the woman felt bad (34, LM, Bombali) ……this affect both pregnant women and lactating mothers because they will think that they are not good enough for the man (40, PW, Kono). 2. ‘Maynd’ (mind or head): Respondents used ‘mind’ to communicate the integrated physical and mental aspect of the brain. They used these idioms of distress to describe a state of burnout or cognitive overload (see Table 3). The ‘mind’ was also described as not sweet (‘maynd no swit’) or not steady (‘maynd no stedi’) to denote distress and stress, respectively. The ‘mind’ was referred in some cases to denoting severe effects of mental distress (e.g., ‘take to maynd’). The emotional experiences of pregnant and young mothers are multifaceted and profoundly impact their mental well-being. Frustration and withdrawal contribute to feelings of sadness, unhappiness, and discouragement, especially when there is a lack of intimate connection with their spouses. This emotional distress not only affects the woman's mental state but also has the potential to lead to mental health issues. Women experience frustration or take to mind. They feel sad, unhappy and discouraged. This happens when men do not make time for their partners (pregnant or new mothers), their mind is not steady, they worry and vex easily, which leads to mental health problems (29, NPNL, Kono) Financial constraints exacerbate the emotional burden, as the inability to provide for basic needs results in extreme difficulty for the woman. The inability to attend to basic needs, such as caring for their babies or seeking medical attention, is a consequence of the women's minds being preoccupied, leading to loss of hope and confrontations with their partners. Insecurities about self-worth and comparisons with other women contribute to a deep sense of inadequacy and mental anguish. She has pain in her mind, because when she is not having money to take care of the baby and herself. The suckling mother felt pain in her mind because the husband does not give her money and don not spend time with her. The woman feels jealous, sad, use abusive language on the husband and sometimes fight him. (20, LM, Bombali). New mothers deprived of financial support and companionship face pain in their minds, making them unable to interact with others, further intensifying their unhappiness. The lack of support from partners may even drive some women to contemplate suicide, highlighting the critical role of emotional and financial support during pregnancy and lactation. When men don’t support pregnant women or lactating mothers…………when the perinatal woman separate with the man that impregnate them, it leads to frustration, sleepless night and increase blood pressure, due to the lack of support and shame. They take to mind and attempt to kill themselves (32, M, WAU…) 3. ‘Bodi’ (physical body): Respondents most commonly spoke of ‘pen’ (pain) of the ‘bodi’ or ‘wikness’ (weakness) as corporeal idioms of distress. These socio-somatic symptoms (somatization), which they expressed as degeneration of the ‘bodi’ was often described as an effect of mental distress. This is when she feels pain in her head. This makes them unable to breastfeed (FLI_19) Because of the pressure from husband and in-law will make blood pressure rise and worries a lot, fear for safe delivery (FLI_30) Clusters of idioms of distress Respondents described three dominant clusters of idioms of distress (see fig 1) that operated on an increasing continuum of severity, both across and within idioms. As detailed above, the social suffering experienced by perinatal women can present either in externalizing (stress) or internalizing (poil at) forms of psychological distress, and the levels of distress that they produce, initiates the sequence. Over time, this can progress on a continuum of stress, stress bad, stress bad bad wan (increase in the degree of stress from mild, moderate to severe).  This also occurs for poil at, which can progress from at poil, at poil bad to at poil bad bad wan (mild, moderate and severe forms of poil at). Continued experiences with stress and poi at and worry can eventually culminate in ed nor de or wan go off (pre-psychosis or crase). There was some overlap between these categories as well, indicating the interconnectedness of how respondents experienced distress. We discuss each of these clusters below: 1. Stress The "English word stress" is frequently incorporated into Krio dialogue, reflecting one of many words adopted from biomedicine I n everyday conversation. Nonetheless, everyone generally perceives "stress" as a commonplace expression and utilize it to denote a specific type of socio-emotional experience. The distress concept stress had six discrete indicators and two indicators overlap with another concept poil at (2 out of 6) (see fig 1). According to our study, perinatal women that are stressed tend to be sad or unhappy, abusive, aggressive, confused and overthinking without a solution ……they quarrel and fight with their partners. Community members described perinatal women suffering from stress as being worried, easily get angry, lack encouragement, feeling unloved and confused.  They also explained that stressed perinatal women were sometimes viewed as bringing shame to the family by their relatives and as a bad example by the community, especially for teenage mothers. This is worrying to the family and some community members who view stressed perinatal women to be “trauma” and unafraid of harming their babies. Respondents attributed stress among pregnant women and new mothers to men denying paternity, having problems with in-laws, experiencing marital disharmony and poverty.  Several other participants noted that perinatal women who were prone to be aggressive and using abusive languages in responds to the lack of faithfulness of their partners were often called "jealous woman" within the community and suffer domestic abuse from them.  Probing further, one participants contextualized the beating of these pregnant women and new mothers by their partners as normative, given the community socio-cultural and patriarchal norms and beliefs….. . “Some men beat their lactating mothers in this community and even cause bodily harm, when this is done the women are ashamed to go out”. …..[ ]……. “some husbands will even go to the house of their in-laws and beat these women”. 2. Poil at The distress concept poil at had the largest number of distress indicators at eight and the largest percentage of indicators overlap with other concepts (4 out of 8, two with stress, two with ed nor de or wan go off) (see fig 1). A perinatal woman with poil at was described as sad or prone to sitting quietly isolate themselves. Of the eight indicators of poil at, the four unique to poil at were: loneliness, crying, feeling worthless and feeling ashamed. The reported causes of poil at were varied, but were often linked to maltreatment from partner, neglect, lack of emotional support and the associated loss of financial support from the partner. Citing a case of poil at regarding a new mother, one lactating mother attributed her symptoms – talking to herself, loneliness, crying, feeling worthless, feeling ashamed and having harmful thoughts —to her husband not engaged in any income generating activity like job and their inability to buy food, clothes and medicine for their babies when they get sick.  According to this respondent, being a new mother made her more at risk of poil at. 3. Ed nor de or wan go off (pre- psychosis or crase) The cultural concept of Ed nor de or wan go off had three discrete indicators and two indicators overlap with poil at (2 out of 5). Of the five indicators of ed nor de or wan go off, the three unique to ed nor de or wan go off were: “feeling sad, use of abusive language and regret for not aborting the baby” (see fig 1). These women often shout and use abusive words, do not talk politely and easily get angry with their partners, family or community members. They can be described as having ‘warm at’ and ‘hot temper' and may feel neglected, lack focus and think of dying. One respondent described a stressed pregnant woman as “contemplating on harming her partner, the woman her partner was cheating with and abort the baby”. A perinatal woman exhibiting signs of ed nor de or wan go off were described as extremely frustrated and torment and mentally “not at peace”. Loss of appetite and talking to oneself is shared with poil at. One respondent emphatically stated that “this was specifically due to loss of appetite and not the lack of food”, which is in contrast to the persistent problem of hunger reported by the perinatal women in these settings. … “loss appetite due to treatment from husband and too much thinking” …... [ ] “the person will not feel to eat at all even though the food is available due to stress”. One respondent reported that a new mother woman with signs of wan go off will often look afar, busy talking to oneself, always alert, which is due to lack of money, poor health condition and lack of a place to stay with the baby. This is made worse when the baby is sick, “the mother does not have rest heart, do not steady at one place and can’t do business to get money”. These new mothers do not often wash and take care of their baby. Comparing the locally generated symptoms of perinatal psychological distress with DSM 5 and ICD 10 The third theme was "comparing the locally generated signs with DSM-5 and ICD-10," which compares the idioms of distress and signs with Western diagnostic nosology to understand the similarities and the salient features specific to the Sierra Leone context. The study found 20 signs of psychological distress symptoms from the participants' interviews, summarised in Table 4. It also includes all the significant symptoms from DSM-5 and ICD-10 for depression diagnosis. The participants described all nine DSM-5 and ten ICD-10 criteria for major depression, with some signs of anxiety, stress, and somatisation, with differences in wording. The comparison showed that the critical symptoms for depression diagnosis, according to the DSM-5 and ICD-10, are sadness, loss of interest and pleasure, and decreased energy, resulting in tiredness and decreased activity. Of the 20 signs identified by participants, four are not included in the primary criteria of the DSM-5 or ICD-10: stress, headaches and body pain, and anger Table 4: Symptoms of perinatal psychological distress compared to DSM-5 and ICD-10 symptoms Symptoms of depression described Quotes DSM - 5 symptoms* ICD - 10 symptoms* Withdrawal and not wanting to talk “Feel sad and sit alone thinking of the pain and burn heart and just want to be left to themselves” Markedly diminished interest or pleasure in all, or almost all activities. Fatigue or loss of energy nearly every Loss of interest and enjoyment Reduced energy, increased fatigability and diminished activity. Crying or sadness “Anytime the lactating mother see the woman her partner is having an affair with, she become sad and the pain in her heart increases” Depressed mood most of the day, nearly every day (e.g., feels sad, empty, hopeless) Depressed mood.    Loss of interest and enjoyment Poor concentration “The woman will be seated and start thinking deeply that when you call her, she would not hear you because she is lost in thought” Diminished ability to think or concentrate or indecisiveness, nearly every day. Psychomotor agitation or retardation nearly everyday (a) Reduced concentration and attention Thinking too much “Sit lonely, thinking too much of the maltreatment from family and the husband relatives. I often think of aborting the pregnancy” Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick. [The sense of worthlessness or guilt associated with a major depressive episode may include unrealistic negative evaluations of one's worth or guilty preoccupations or ruminations over minor past failings] Fear and worry** “Because of the pressure from husband and in-law will make blood pressure rise and worries a lot, fear for safe delivery” Thought of harming partner** “Because this can lead to the woman poisoning, stabbing or using abusive language on the man or consulting a witch doctor” Stress** “Because of the pressure from husband and in-laws will make the blood pressure rise and worries a lot for safe delivery” Sleep problems “Some women become unable to sleep even when they try, whether during the day or at night, due to the stress” Insomnia or hypersomnia nearly everyday Disturbed sleep Easily get angry** “When their mind is sick and they do not feel good they vex easily and sometime fight with their husband” Talk to oneself** “She’s going crase (mad), talk to herself, poor health condition, emaciated and filthy” Don't care “Don't have sex with the man, stop cooking, laundry and talking to the man” Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly everyday Loss of interest and enjoyment Suicidal thoughts “When men don't support pregnant women or lactating mothers, neglect and cheat on them, they will take to mind and attempt to kill themselves” Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicidal attempt or a specific plan to commit suicide Ideas of self-harm or suicide Loss of appetite “They don't feel like eating even when the food is available” Significant weight loss when not dieting or weight gain Diminished appetite Anger** “Some nurses don't know how to talk to the lactating mothers. This makes us angry easily.” Shame** “She stays indoors all day and only come out after everyone has gone to their farms because of the shame” Regret** “They don’t go to hospital for check-ups because they might not even have good clothes. This makes them feel regret and lose weight. They stop doing their small businesses. They stop taking part in community activities like cleaning.” Hopelessness “Men are in the habit of leaving their pregnant women at home. They don’t go out with their women; hence they are pregnant. This makes these women to think that they are not good enough” Depressed mood most of the day or nearly every day. (e.g., feels sad, empty, hopeless). Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick. (1) Depressed mood (c) Ideas of guilt and unworthiness. (d) Bleak and pessimistic views of the future. (b) Reduced self-esteem and self-confidence. (c) Ideas of guilt and unworthiness Self-blame/guilt “If the lady was going it school before she gets pregnant, she will hide from her school firmed out of shame and worry that they might laugh anther” Feelings of worthless or excessive or inappropriate guilt (which maybe delusional) nearly every day (not merely self-reproach or guilt about being sick). *Number/letter on the DSM-5 or ICD-10 scales in parenthesis.     **Symptoms not listed as key identifiers on the DSM-5 orICD-10 scales. (However, some are included in the DSM-5 "Associated Features Supporting Diagnosis". "(Pregnant women and new mothers often present with tearfulness, irritability, brooding, obsessive rumination, anxiety, excessive worry over physical health, and complaints of pain [e.g., headaches, abdominal or generalized body pain) (America Psychiatric association, 2013, Section II, p.27). Discussion This study identified 20 idioms of distress in Sierra Leonean perinatal ethnopsychology related to emotional, cognitive, and psychosocial distress. These idioms provide a first step towards understanding the complex use, meaning, and interpretations of idioms of distress that are culturally and linguistically intelligible. Sierra Leonean ethnopsychology is unique in its collectivist view of what it means to be a person and the somatisation of psychological distress. The majority of the idioms refer to the heart and the brain, and other studies have found that heart- and brain-related terms are central to communicating emotional distress, as reported in previous studies (Fabian et al., 2018; Keys et al., 2012; Lasater et al., 2018). In our study, more perinatal women reported heart-related idioms than mind-related ones, and Fabian et al. (2018) reported similar findings in Liberia. This could be because heart-related symptoms are not associated with mental health problems and thus are not stigmatising, or it could be because these women find the heart more accessible to conceptualise than the mind, as reported in Nepal, where heart-mind problems were found (Clarke et al., 2014). The rest of the idioms were about somatisation and related signs and symptoms; vaginal discharge, weakness, pain, tiredness, and high blood pressure. In our study, 'stress' was the most common idiom. The term 'stress' refers to a persistent emotional state that results from other signs of distress and is more of a state of being than a passing emotion. It can progress along a continuum to severe stress and, if not treated, can lead to 'thinking too much' (Lasater et al., 2018). The term stress is embedded in Krio conversations and is borrowed from biomedicine. It is commonly understood as a discrete form of socio-emotional experience. It is considered a normal part of life's challenges, including financial insecurity, emotions (worry, anger, and torment), excessive thinking, mental disturbance, relationship issues, and physical symptoms like headaches and pain. Several models have emerged linking idioms of mental distress to other pathologies that are not necessarily linked to mental distress in biomedical nosology. The participants linked overthinking to 'crase' (psychosis), and this corroborated similar studies in different settings such as China, South Africa, Peru, and Haiti (den Hertog et al., 2016; Nisar et al., 2020). Unlike the DSM-5 and ICD-10, excessive rumination (thinking too much) in this ethnopsychology model is thought to progress to psychosis through interaction with other mind-related pathophysiologic pathways via a network model (Keys et al., 2012; Patel, 1995). Network analysis sees psychological distress as clustered and interconnected rather than a measurable latent category (Borsboom and Cramer, 2013). This makes it possible to treat these or groups of symptoms and shifts the focus to holistic and community-based treatments that are not based on Western frameworks and conceptual models. Heart idioms were also referred to as antecedents for disease, though they were more frequently related to physical illness. The idiom "pressure" is a critical expression associated with heart symptoms such as heart jogs (palpitations) and may represent the evolution of stress idioms over time. Similar findings were reported in a previous study in India, where the idiom tension was related to hypertension and diabetes (Atal and Foster, 2021). This implies that the idiom 'pressure' may signify both a mental illness and a physical symptom (Weaver, 2017). These findings can be applied to improve common perinatal mental disorder screening, diagnosis, and treatment in Sierra Leone. Psychoeducation and public health approaches should pay more attention to what might happen when the head and heart are mentioned (Kohrt and Hruschka, 2010). Perinatal women with complaints of heart pain need to be helped holistically with their somatic complaints. A holistic approach to somatic complaints should consider metaphor, idioms, ethnopsychology, trauma memory, and stress biology (Hinton and Otto, 2006). This method will help find and treat physical problems causing mental, emotional, and physical complaints. This study sheds light on the dynamics between Western biomedicine and Sierra Leonean medico-religious healing, a relationship that traces its lineage to Sierra Leone's colonial past. How clinical and traditional care providers, their patients, and family members in Sierra Leone use and interpret emotional and physical signs of distress may show how Western-style clinical care models confirm, debate, or discard Sierra Leonean ethnomedical concepts (Keys et al., 2012). This study adds to a lexicon that can be used to teach health professionals how to screen, diagnose, and treat mental health in primary care settings. However, important linguistic and cultural meanings that are part of lay discourse may have needed to be recovered in translation. The study identified 20 categories of symptoms and descriptions of common perinatal mental disorders from the participants' interviews, summarised in Table 4. For a comprehensive comparison, the table also presents all the crucial DSM-5 and ICD-10 symptoms necessary for classifying a major depressive episode. All nine DSM-5 criteria (designated 19) and all ten ICD-10 criteria (labelled 1-3 and A) were reported by the women, though with varying explanations (Davies et al., 2016). The symptoms and experiences recorded were compared against the international diagnostic standards of the DSM-5 and ICD-10 scales. The comparison showed that the critical criteria for diagnosing depression in both diagnostic systems were reflected in the women's descriptions and expressions. On both scales, these criteria include a low mood that lasts for a long time, a loss of interest and pleasure, and less energy, which leads to more tiredness and less activity (Clarke et al., 2013). The results indicate that among Sierra Leonean perinatal women in the four districts, their experiences or symptoms of common perinatal mental disorders resemble those listed in the DSM-5 and ICD-10 scales. However, they also presented with signs of stress and anxiety. This backs up the results of earlier studies (Green et al., 2018; Snodgrass et al., 2018) that found that psychological distress looked and felt the same compared to international norms. Of the 20 symptoms reported by the participants, six are not included in the primary diagnostic criteria of the DSM-5 or ICD-10 scales. These are regret, stress, quickly getting angry, talking to oneself, and feeling ashamed.  However, anger is part of other depression diagnostic scales, such as the Hamilton Rating Scale for Depression (Davies et al., 2016). The DSM-5 and the ICD-10, the most widely used and globally accepted measurement tools, are considered the gold standard, which might miss out on salient aspects of common perinatal mental disorders that are local context-specific (Patel and Hall, 2021). Though the core symptoms are universal (Kirmayer and Bhugra, 2009), some are exotic due to cultural influences, with clinical and public health implications. Even though they often overlap with Western psychiatric nosology, they are not synonymous (match in a one-to-one relationship). Therefore, locally developed context-specific screening tools may capture heterogeneity beyond the standard DSM-5 and ICD-10 and are often symptoms of more than one disorder (Cork et al., 2019). Limitations This study has several limitations that should be considered when interpreting its findings. As a rapid ethnographic study, the time-limited data collection may not fully capture the diversity and depth of idioms of distress among perinatal women or other community subgroups. While we engaged a wide range of participants to ensure breadth, the sample was not statistically representative, and findings may not generalize beyond the specific cultural and geographic setting studied. Additionally, the relationship between culture and language is dynamic and constantly evolving. Perinatal women’s everyday conversations may carry layered cultural and linguistic meanings that are not easily translatable, raising the possibility that some nuances of distress expression were lost during data collection or interpretation. Furthermore, although pile sorts with key informants enabled the identification of culturally salient idioms, interpretation across dialects or communities may vary, which could limit the transferability of findings within and beyond Sierra Leone. The reliance on self-report data also introduces the possibility of social desirability bias, particularly in contexts where mental health stigma is pervasive. Finally, while the study provides insight into locally relevant expressions of psychological distress, it does not establish the diagnostic validity or clinical utility of the identified idioms. Future research should explore their application in clinical settings, examine their correspondence with standardized measures, and assess their potential to inform culturally appropriate interventions. Conclusion This study offers important insights into how perinatal psychological distress is understood, experienced, and communicated in a low-resource, post-conflict setting. By identifying twenty signs of distress and examining the interplay between the heart, mind, and body within local conceptualizations of the self, the findings illuminate culturally embedded expressions of emotional suffering. The use of idioms such as stres, poil at, and ed nor de or e wan go off reflects a nuanced continuum of distress that emerges in response to structural and interpersonal stressors, including poverty, marital conflict, and gender inequality. These idioms provide a culturally resonant framework for recognizing psychological distress among perinatal women and could serve as a foundation for developing stigma-reducing mental health literacy, locally tailored screening tools, and contextually appropriate interventions. In recognizing the embeddedness of these expressions within sociocultural contexts, the study underscores the importance of integrating local knowledge into mental health systems. Doing so can improve engagement with services, promote early identification of distress, and ultimately enhance therapeutic outcomes for women during the perinatal period. However, as culture and language evolve, sustained ethnographic engagement and participatory approaches are necessary to ensure that mental health strategies remain relevant and effective. This research contributes to the growing body of literature advocating for culturally grounded global mental health approaches and reinforces the critical need to center women’s voices and lived experiences in the design of services in resource-limited settings. Declarations Competing interests The authors declare no competing interests Funding declaration This research was funded by the National Institute for Health Research (NIHR) Global Health Research programme 16/136/100. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the UK Department of Health and Social Care. Data availability The data used in this study are available from the corresponding author upon reasonable request. Author contribution and declaration Abdulai Jawo Bah: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Haja Ramatulai Wurie: Writing – review & editing, Methodology. Mohamed Samai: Writing – review & editing, Methodology. Rebecca Horn: Writing – review & editing, Supervision, Methodology, Conceptualization. Alastair Ager: Writing – review & editing, Validation, Supervision, Resources, Methodology, Funding acquisition, Conceptualization. Acknowledgements We acknowledge the contribution of the research assistants, who demonstrated high levels of commitment and professionalism throughout the data collection process, including Ajaratu Kamara, Mamadu Jalloh, Sinava B. Lamin, Simeon S. Sesay, Joan B. Lavally, and Malik Sulaiman Daewood. We extend our heartfelt gratitude to the chiefs, mammy queens, pregnant women, new mothers, men and elderly women in the communities we conducted this study for their cooperation and unwavering support throughout the study. References Atal, S., Foster, J., 2021. “A woman’s life is tension”: A gendered analysis of women’s distress in poor urban India. Transcultural Psychiatry 58, 404–413. https://doi.org/10.1177/1363461520947836 Betancourt, T.S., Speelman, L., Onyango, G., Bolton, P., 2009. A Qualitative Study of Mental Health Problems among Children Displaced by War in Northern Uganda. Transcult Psychiatry 46, 238–256. https://doi.org/10.1177/1363461509105815 Bolton, P., Wilk, C.M., Ndogoni, L., 2004. Assessment of depression prevalence in rural Uganda using symptom and function criteria. Soc Psychiatry Psychiatr Epidemiol 39, 442–447. https://doi.org/10.1007/s00127-004-0763-3 Bonuedi, I., Kornher, L., Gerber, N., 2022. Agricultural seasonality, market access, and food security in Sierra Leone. Food Sec. 14, 471–494. https://doi.org/10.1007/s12571-021-01242-z Borsboom, D., Cramer, A.O.J., 2013. Network Analysis: An Integrative Approach to the Structure of Psychopathology. Annu. Rev. Clin. Psychol. 9, 91–121. https://doi.org/10.1146/annurev-clinpsy-050212-185608 Clarke, K., King, M., Prost, A., 2013. Psychosocial Interventions for Perinatal Common Mental Disorders Delivered by Providers Who Are Not Mental Health Specialists in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. PLOS Medicine 10, e1001541. https://doi.org/10.1371/journal.pmed.1001541 Clarke, K., Saville, N., Shrestha, B., Costello, A., King, M., Manandhar, D., Osrin, D., Prost, A., 2014. Predictors of psychological distress among postnatal mothers in rural Nepal: A cross-sectional community-based study. Journal of Affective Disorders 156, 76–86. https://doi.org/10.1016/j.jad.2013.11.018 Cork, C., Kaiser, B.N., White, R.G., 2019. The integration of idioms of distress into mental health assessments and interventions: a systematic review. Global Mental Health 6. https://doi.org/10.1017/gmh.2019.5 Davies, T., Schneider, M., Nyatsanza, M., Lund, C., 2016. “The sun has set even though it is morning”: Experiences and explanations of perinatal depression in an urban township, Cape Town. Transcult Psychiatry 53, 286–312. https://doi.org/10.1177/1363461516632389 den Hertog, T.N., de Jong, M., van der Ham, A.J., Hinton, D., Reis, R., 2016. “Thinking a Lot” Among the Khwe of South Africa: A Key Idiom of Personal and Interpersonal Distress. Cult Med Psychiatry 40, 383–403. https://doi.org/10.1007/s11013-015-9475-2 Dougherty, B.K., 2004. Searching for Answers: Sierra Leone’s Truth & Reconciliation Commission 8. https://journals.flvc.org/ASQ/article/view/136349 Fabian, K., Fannoh, J., Washington, G.G., Geninyan, W.B., Nyachienga, B., Cyrus, G., Hallowanger, J.N., Beste, J., Rao, D., Wagenaar, B.H., 2018. “My Heart Die in Me”: Idioms of Distress and the Development of a Screening Tool for Mental Suffering in Southeast Liberia. Cult Med Psychiatry 42, 684–703. https://doi.org/10.1007/s11013-018-9581-z Fisher, J., Cabral de Mello, M., Patel, V., Rahman, A., Tran, T., Holton, S., Holmes, W., 2012. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ 90, 139-149H. https://doi.org/10.2471/BLT.11.091850 Fitzgerald, F., Naveed, A., Wing, K., Gbessay, M., Ross, J.C.G., Checchi, F., Youkee, D., Jalloh, M.B., Baion, D., Mustapha, A., 2016. Ebola virus disease in children, Sierra Leone, 2014–2015. Emerging infectious diseases 22, 1769. https://doi.org/10.3201/eid2210.160579 Fyfe, C., 1963. A history of Sierra Leone. CUP Archive. https://books.google.com/books/about/A_History_of_Sierra_Leone.html?id=HJaRAAAAIAAJ Fyle, M.C., 2006. Historical Dictionary of Sierra Leone. Scarecrow Press. https://search.worldcat.org/title/60500176 Green, E.P., Tuli, H., Kwobah, E., Menya, D., Chesire, I., Schmidt, C., 2018. Developing and validating a perinatal depression screening tool in Kenya blending Western criteria with local idioms: A mixed methods study. J Affect Disord 228, 49–59. https://doi.org/10.1016/j.jad.2017.11.027 Hinton, D.E., Kredlow, M.A., Bui, E., Pollack, M.H., Hofmann, S.G., 2012. Treatment change of somatic symptoms and cultural syndromes among Cambodian refugees with PTSD. Depress Anxiety 29, 147–154. https://doi.org/10.1002/da.20905 Hinton, D.E., Otto, M.W., 2006. Symptom Presentation and Symptom Meaning Among Traumatized Cambodian Refugees: Relevance to a Somatically Focused Cognitive-Behavior Therapy. Cognitive and Behavioral Practice 13, 249–260. https://doi.org/10.1016/j.cbpra.2006.04.006 Horn, R., Sesay, S.S., Jalloh, M., Bayoh, A., Lavally, J.B., Ager, A., 2020. Expressions of psychological distress in Sierra Leone: implications for community-based prevention and response. Glob Ment Health (Camb) 7, e19. https://doi.org/10.1017/gmh.2020.12 Jenkins, J.H., 2018. Anthropology and psychiatry: the contemporary convergence. Textbook of Cultural Psychiatry 20–32. https://anthropology.ucsd.edu/_files/Faculty%20Files/Jenkins/Anthropology%20and%20Psychiatry%20A%20Contemporary%20Convergence%20for%20Global%20Mental%20Health.pdf Keys, H.M., Kaiser, B.N., Kohrt, B.A., Khoury, N.M., Brewster, A.-R.T., 2012. Idioms of distress, ethnopsychology, and the clinical encounter in Haiti’s Central Plateau. Social Science & Medicine 75, 555–564. https://doi.org/10.1016/j.socscimed.2012.03.040 Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., Rohde, L.A., Srinath, S., Ulkuer, N., Rahman, A., 2011. Child and adolescent mental health worldwide: evidence for action. The Lancet 378, 1515–1525. https://doi.org/10.1016/S0140-6736(11)60827-1 Kirmayer, L.J., Bhugra, D., 2009. Culture and Mental Illness: Social Context and Explanatory Models, in: Salloum, I.M., Mezzich, J.E. (Eds.), Psychiatric Diagnosis. John Wiley & Sons, Ltd, Chichester, UK, pp. 29–40. https://doi.org/10.1002/9780470743485.ch3 Kirmayer, L.J., Swartz, L., 2013. Culture and global mental health. Global mental health: Principles and practice 41–62. https://books.google.com/books?hl=en&lr=&id=vMI8BAAAQBAJ&oi=fnd&pg=PA41&dq=Kirmayer,+L.J.,+Swartz,+L.,+2013.+Culture+and+global+mental+health.+Global+mental+health:+Principles+and+practice+41–62.&ots=kXQebDBu24&sig=ATdbmJ8A7s_weshu9HicHdd9wsQ - v=onepage&q&f=false Kohrt, B.A., Hruschka, D.J., 2010. Nepali Concepts of Psychological Trauma: The Role of Idioms of Distress, Ethnopsychology, and Ethnophysiology in Alleviating Suffering and Preventing Stigma. Cult Med Psychiatry 34, 10.1007/s11013-010-9170–2. https://doi.org/10.1007/s11013-010-9170-2 Kohrt, B.A., Rasmussen, A., Kaiser, B.N., Haroz, E.E., Maharjan, S.M., Mutamba, B.B., de Jong, J.T., Hinton, D.E., 2014. Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology. International Journal of Epidemiology 43, 365–406. https://doi.org/10.1093/ije/dyt227 Lasater, M.E., Beebe, M., Warren, N.E., Souko, F., Keita, M., Murray, S.M., Bass, J.K., Surkan, P.J., Winch, P.J., 2018. Dusukasi—The Heart That Cries: An Idiom of Mental Distress Among Perinatal Women in Rural Mali. Cult Med Psychiatry 42, 930–945. https://doi.org/10.1007/s11013-018-9579-6 Stats SL., 2016. Sierra Leone 2015 population and housing census. Provisional Results. Freetown Sierra Leone: Statistics Sierra Leone. https://www.scirp.org/reference/referencespapers?referenceid=2941744 Stats SL., 2015. population and housing census, 2015. Freetown: Government of Sierra Leone. https://sierraleone.unfpa.org/sites/default/files/pub-pdf/Census%20Agriculture%20Report.pdf Mendenhall, E., Rinehart, R., Musyimi, C., Bosire, E., Ndetei, D., Mutiso, V., 2019. An ethnopsychology of idioms of distress in urban Kenya. Transcultural Psychiatry 56, 620–642. https://doi.org/10.1177/1363461518824431 Miller, K.E., Omidian, P., Quraishy, A.S., Quraishy, N., Nasiry, M.N., Nasiry, S., Karyar, N.M., Yaqubi, A.A., 2006. The Afghan Symptom Checklist: A Culturally Grounded Approach to Mental Health Assessment in a Conflict Zone. American Journal of Orthopsychiatry 76, 423–433. https://doi.org/10.1037/0002-9432.76.4.423 Nichter, M., 2010. Idioms of Distress Revisited. Cult Med Psychiatry 34, 401–416. https://doi.org/10.1007/s11013-010-9179-6 Nisar, A., Yin, J., Yiping, N., Lanting, H., Zhang, J., Wang, D., Rahman, A., Li, X., 2020. Making therapies culturally relevant: translation, cultural adaptation and field-testing of the Thinking Healthy Programme for perinatal depression in China. BMC Pregnancy and Childbirth 20, 368. https://doi.org/10.1186/s12884-020-03044-1 Ogbu, J.U., 1978. African bridewealth and women’s status. American Ethnologist 5, 241–262. https://doi.org/10.1525/ae.1978.5.2.02a00040 Patel, A.R., Hall, B.J., 2021. Beyond the DSM-5 Diagnoses: A Cross-Cultural Approach to Assessing Trauma Reactions. Focus (Am Psychiatr Publ) 19, 197–203. https://doi.org/10.1176/appi.focus.20200049 Patel, V., 1995. Explanatory models of mental illness in sub-Saharan Africa. Social science & medicine 40, 1291–1298. https://doi.org/10.1016/0277-9536(94)00231-H Patel, V., Kim, Y.-R., 2007. Contribution of low-and middle-income countries to research published in leading general psychiatry journals, 2002–2004. The British Journal of Psychiatry 190, 77–78. https://doi.org/10.1192/bjp.bp.106.025692 Rasmussen, A., Katoni, B., Keller, A.S., Wilkinson, J., 2011. Posttraumatic idioms of distress among Darfur refugees: Hozun and Majnun. Transcultural psychiatry 48, 392–415. https://doi.org/10.1177/1363461511409283 Richards, P., 2005. To fight or to farm? Agrarian dimensions of the Mano River conflicts (Liberia and Sierra Leone). African affairs 104, 571–590. https://doi.org/10.1093/afraf/adi068 Sedgh, G., Singh, S., Hussain, R., 2014. Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends. Stud Fam Plann 45, 301–314. https://doi.org/10.1111/j.1728-4465.2014.00393.x Singh, S., Darroch, J.E., Ashford, L.S., 2013. Adding It Up: The Need for and Cost of Maternal and Newborn Care–Estimates for 2012. https://www.guttmacher.org/report/adding-it-need-and-cost-maternal-and-newborn-care-estimates-2012 Snodgrass, J.G., Zhao, W., Lacy, M.G., Zhang, S., Tate, R., 2018. The cross-cultural expression of internet gaming distress in North America, Europe, and China. Addict Behav Rep 9, 100146. https://doi.org/10.1016/j.abrep.2018.100146 Thulin, E.J., McLean, K.E., Sevalie, S., Akinsulure-Smith, A.M., Betancourt, T.S., 2020. Mental health problems among children in Sierra Leone: Assessing cultural concepts of distress. Transcult Psychiatry 136346152091669. https://doi.org/10.1177/1363461520916695 Wahid, S.S., Sarker, M., Arafat, A.S.M.E., Apu, A.R., Kohrt, B.A., 2022. Tension and Other Idioms of Distress Among Slum Dwelling Young Men: A Qualitative Study of Depression in Urban Bangladesh. Cult Med Psychiatry 46, 531–563. https://doi.org/10.1007/s11013-021-09735-4 Weaver, L.J., 2017. Tension Among Women in North India: An Idiom of Distress and a Cultural Syndrome. Cult Med Psychiatry 41, 35–55. https://doi.org/10.1007/s11013-016-9516-5 White, R.G., Fay, R., Chiumento, A., Giurgi-Oncu, C., Phipps, A., 2022. Communication about distress and well-being: Epistemic and ethical considerations. Transcult Psychiatry 13634615221082795. https://doi.org/10.1177/13634615221082795 White, R.G., Jain, S., Orr, D.M.R., Read, U.M. (Eds.), 2017. The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health. Palgrave Macmillan UK, London. https://doi.org/10.1057/978-1-137-39510-8 Additional Declarations The authors declare no competing interests. Supplementary Files Extractfromthefreelistdataanalysis.docx Extract from the free list data analysis Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information

Related documents

• Strengthening Women's Agency During Pregnancy#891265
• Existing practices, gaps and strategies to promote perinatal mental health in Ghana.#439287
• Language attrition and semi-lingualism among Liberian and Sierra Leonean refugee children: A sociolinguistic-psychological dynamic of trauma and mental health in stateless refugees in Oru, Nigeria#29718
• Unseen and underserved: A scoping review of perinatal mental health interventions in Sub-Saharan Africa.#1167126
• An institutional ethnography of development-induced displaced mothers#373256