Since the end of conflict in 2009, Northern Sri Lanka is seeing a rapid rehabilitation and rebuilding process in health and other infrastructure. However, the need for human resources is the least being met, as the rate of capacity building and training new cadres are significantly below that of the growing need in the region.
The COMGAP-S project aims to improve the skills of existing primary care health work force in integrating mental health into primary care services in Northern Sri Lanka.
This project, already having being implemented in pilot form in the Northern Province, aims to improve the skills of existing primary care health work force in integrating mental health into primary care services across all districts of the Northern Province.
This project had two specific aims:
Cross-sectional Study (Phase 1)
A comprehensive cross-sectional study was completed in 2015-2016 to identify the mental disorder burden at primary care level in the region. The setting was all 5 districts in Northern Sri Lanka and focused on populations who are post-conflict internally displaced populations and returnees. Understanding mental health care burden and needs in the region informs the intervention development and delivery to adequately address the treatment gap at primary care level.
Findings from the cross-sectional study (open access publication), which was conducted with 1,015 adult participants in 25 primary care clinics across the Northern Province, showed that out of the patients visiting primary care, 59% could reasonably receive a diagnosis of any mental health disorder, while 42% of all patients could be diagnosed with two mental health disorders. These figures paint the stark picture of prevalence of mental health issues in the post-conflict population of Sri Lanka. 90% of the participants lived in the region during conflict, and 77.5% were displaced more than one.
Of the mental health issues taken into account in the cross-sectional study, the prevalence of anxiety was 47%. Depression – perhaps the most ubiquitous mental disorder in the world – ranked second most represented with 42%. Somatoform symptoms made for 28% of the mental health issues detected, and psychosis represented 18% of mental disorders. PTSD, which traces its origins to traumatic events in the life of individuals, stands at 14% of mental health issues. This was not a surprising finding in light of the fact that 37.8% lost at least one family member throughout the conflict, while 56.5% of the sample had family injured during the conflict.
Read more about the methodology and experiences in the cross-sectional study in our case publication by SAGE Research Methods.
mhGAP Training (Phase 2)
The second aim of the study utilised an adapted version of the World Health Organization mental health gap programme (WHO mhGAP) to train primary care practitioners to deliver mental health treatment within the primary care health system in Northern Sri Lanka. The COMGAP-S research team received training in mhGAP in August 2017 from Dr. Peter Hughes, psychiatrist at the London Springfield University Hospital and trainer in mhGAP with the World Health Organization. This study was a randomized clinical trial using a stepped wedge cluster design and is registered with the ISRCTN registry (ISRCTN62598070) and the SLCTR registry (registration number: SLCTR/2018/008).
23 healthcare facilities were recruited into the clinical trial in all 5 districts of Northern Province (Jaffna, Mannar, Vavuniya, Mullativu) from 2018-2021. Primary care practitioners at each facility were trained to identify and manage common mental health issues using the WHO mhGAP training manual. Training also included referral pathways to specialised care for complex cases. Public health practitioners (midwives, nurses) and community representatives (teachers, social workers) were trained in mental health awareness and referral processes so they are better able to provide support and direction to those around them suffering from mental health problems. All training materials were culturally adapted and training videos were re-filmed in Sri Lankan healthcare contexts to increase acceptability.
Our project also included an economic evaluation component to explore cost-effectiveness of integrating mental health into primary health care. Additionally, a process evaluation was conducted and included qualitative case studies with primary health care staff and research team members to understand how the programme was received and implemented.
This phase of the project is now complete (2015-2021) and results from Phase 2 will be published in Open Access journals by the end of December 2021.
This project hopes to:
Provide a comprehensive account of the prevalence of mental disorders at primary care level within post-conflict Northern Sri Lanka
Narrow the treatment gap
Improve patient outcomes by integrating mental health into the primary health care system
This is a five-year programme, funded by the Office of Global Health, Centers for Disease Control & Prevention (CDC) in the US and led by the Faculty of Medical Science at Anglia Ruskin University, UK. This project ran from 2015-2021 and has now concluded.
Centers for Disease Control and Prevention (CDC)
The THEME Institute, Sri Lanka
University of Jaffna, Sri Lanka
Institute of Psychiatry, Psychology & Neuroscience, King’s College London