Conducting a cross-sectional study examining prevalence of mental health issues in conflict-affected adults attending primary care in Northern Sri Lanka: Challenges and lessons-learned

The country of Sri Lanka underwent a Civil War from 1983-2009 which resulted in approximately half a million people displaced from their homes. The Northern Province of the country was particularly affected by the conflict. Research suggests that the experience of living in a conflict setting can affect people’s mental health resulting in depression, anxiety and post-traumatic stress disorder, among other issues. Treatment of these mental health disorders is then made more difficult in low-resource settings where there is a lack of specialised care available, such as psychiatrists and psychologists. Before this study, the prevalence of mental health disorders in post-conflict Northern Province was unknown and therefore it was unclear how many people required help. As the Northern Province has a strong primary care system, we decided to explore if people went to their GP to seek help for mental health disorders. To accomplish this, we decided to use a cross-sectional survey to take a snapshot of how many people attended primary care facilities with potential mental health disorders. We included both males and females over the age of 18 who were displaced during the conflict. We found high rates of anxiety, depression, post-traumatic stress disorder, somatoform symptoms, and psychosis with hypomania among our participants. These results indicate that there are many people attending primary care facilities who require treatment. Our findings are being used to train GPs in the region to identify and manage mental health disorders to ensure people who need help are able to access it

Challenges and lessons learned in re-filming the WHO mhGAP training videos for Sri Lankan context - a qualitative study

Background : Understanding and addressing the unmet mental health needs burden in the Northern Province of Sri Lanka is the subject of the COMGAP-S two-phase study. Phase Two involves the implementation of the World Health Organization's mental health Gap Action Programme (mhGAP) in primary healthcare settings. As part of the contextual adaptation of mhGAP, eleven of the videos provided in the mhGAP training package have been re-filmed by a local team. We investigated the challenges, barriers and good practices of this adaptation effort from the point of view of team participants. Methods: 12 persons from the adaptation team, including students of medicine and drama, doctors, drama lecturers and professionals, consented to in-depth individual interviews following an open-ended topic guide with a member of the COMGAP-S study team. Interviews were recorded, transcribed, translated as necessary, and subjected to thematic analysis. Results: The majority of participants perceived the process positively and had pride in their involvement. Expectations, opportunities, and exposure were discussed as stemming from the video production. The main challenges derived from the analysis were lack of discussion around budgeting, logistical difficulties, struggles with team cooperation, and creative differences. Issues around exact translation into the local Tamil dialect and modelling around mental health were emphasised by the majority of participants. Potential uses for the videos were identified beyond the current study and recommendations included setting out clear guidance around available funding and role allocation, and increasing the flexibility in adapting the material. Conclusions: This study illustrated details of the adaptation of existing video materials to facilitate locally-based training for non-specialists on mhGAP curricula. With this, we have added to the knowledge base on conducting cultural and language adaptations and our findings indicate participants felt adapting the mhGAP films to local context was vital to ensuring training materials were culturally appropriate and valid

Protocol of a randomized clinical trial to integrate mental health services into primary care for post-conflict populations in Northern Sri Lanka (COMGAP-S)

Introduction- Sri Lanka has a long history of armed conflict and natural disasters increasing the risk of mental health disorders in the population. Due to a lack of specialist services, there is a treatment gap between those seeking and those able to access mental health services. The aim of this research programme is to integrate mental health services into primary care to meet the needs of this postconflict population. Methods and analysis- This is a stepped wedge cluster design randomised clinical trial of the WHO mental health Gap Action Programme primary care mental health training intervention. We will provide a 10-day training to primary care practitioners of 23 randomly selected primary care facilities aimed at increasing their ability to identify, treat and manage common mental health disorders. Public health professionals and community representatives will receive a tailored training intervention to increase mental health awareness. Refresher courses will occur at 3 and 6 months post training. Supervision and monitoring will occur for 1 month pre and post training. Target sample sizes have been calculated separately for each group of participants and for each outcome. Ethics and dissemination- This trial has received ethical approval from the Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, UK (SC/jc/FMFREP/16/17 076) and from the Faculty of Medicine, University of Jaffna, Sri Lanka (J/ERC/17/81/NDR/0170) and non-engagement approval has been received from the funding body, the Centers for Disease Control and Prevention (2018-015). All participants gave written consent. Dissemination of study results will be completed through publication of academic articles, conference presentations, town hall meetings, written pamphlets in plain language, reports to Ministry of Health and other government organisations and through social media outlets. Trial registration numbers- ISRCTN registry: ISRCTN62598070. SLCTR registration number: SLCTR/2018/008

Displacement-Related Stressors in a Sri Lankan War-Affected Community: Identifying the Impact of War Exposure and Ongoing Stressors on Trauma Symptom Severity

In recent years, there has been a shift in the literature towards identifying how ongoing stress adversely affects mental health beyond the effect of direct exposure to war-related violence. The goal of the current study was to investigate the relationship between displacement-related stressors and trauma symptom severity. Participants (N = 1015) were recruited from primary healthcare clinics (PHCs) in Northern Sri Lanka and completed a demographic and displacement history questionnaire, the Stressful Life Events Checklist, and the Harvard Trauma Questionnaire. Four latent stressor constructs were identified through exploratory and confirmatory factor analyses: 1) personal safety concerns; 2) war-related loss; 3) material loss, and 4) personal hardships. Structural equation modeling was used to examine the relationship between stressors and trauma symptom severity. In the final structural equation model, war-related loss and material loss were positively related to symptom severity whereas psychosocial hardship was found to be negatively related to symptom severity. Results highlight how an integrated model of mental health can more fully inform the needs stemming from displacement-related stressors