Chesmal Siriwardhana

A systematic review of resilience and mental health outcomes of conflict-driven adult forced migrants.

BackgroundThe rising global burden of forced migration due to armed conflict is increasingly recognised as an important issue in global health. Forced migrants are at a greater risk of developing mental disorders. However, resilience, defined as the ability of a person to successfully adapt to or recover from stressful and traumatic experiences, has been highlighted as a key potential protective factor. This study aimed to review systematically the global literature on the impact of resilience on the mental health of adult conflict-driven forced migrants.MethodologyBoth quantitative and qualitative studies that reported resilience and mental health outcomes among forcibly displaced persons (aged 18+) by way of exploring associations, links, pathways and causative mechanisms were included. Fourteen bibliographic databases and seven humanitarian study databases/websites were searched and a four stage screening process was followed.ResultsTwenty three studies were included in the final review. Ten qualitative studies identified highlighted family and community cohesion, family and community support, individual personal qualities, collective identity, supportive primary relationships and religion. Thirteen quantitative studies were identified, but only two attempted to link resilience with mental disorders, and three used a specific resilience measure. Over-reliance on cross-sectional designs was noted. Resilience was generally shown to be associated with better mental health in displaced populations, but the evidence on this and underlying mechanisms was limited.DiscussionThe review highlights the need for more epidemiological and qualitative evidence on resilience in forcibly displaced persons as a potential avenue for intervention development, particularly in resource-poor settings.

Prolonged internal displacement and common mental disorders in Sri Lanka: the COMRAID study.

Background Evidence is lacking on the mental health issues of internally displaced persons, particularly where displacement is prolonged. The COMRAID study was carried out in year 2011 as a comprehensive evaluation of Muslims in North-Western Sri Lanka who had been displaced since 1990 due to conflict, to investigate the prevalence and correlates of common mental disorders. Methods A cross-sectional survey was carried out among a randomly selected sample of internally displaced people who had migrated within last 20 years or were born in displacement. The total sample consisted of 450 adults aged 18–65 years selected from 141 settlements. Common mental disorders (CMDs) and post-traumatic stress disorder (PTSD) prevalences were measured using the Patient Health Questionnaire and CIDI sub-scale respectively. Results The prevalence of any CMD was 18.8%, and prevalence for subtypes was as follows: somatoform disorder 14.0%, anxiety disorder 1.3%, major depression 5.1%, other depressive syndromes 7.3%. PTSD prevalence was 2.4%. The following factors were significantly associated with CMDs: unemployment (odds ratio 2.8, 95% confidence interval 1.6–4.9), widowed or divorced status (4.9, 2.3–10.1) and food insecurity (1.7, 1.0–2.9). Conclusions This is the first study investigating the mental health impact of prolonged forced displacement in post-conflict Sri Lanka. Findings add new insight in to mental health issues faced by internally displaced persons in Sri Lanka and globally, highlighting the need to explore broader mental health issues of vulnerable populations affected by forced displacement.

Forced migration and mental health: prolonged internal displacement, return migration and resilience.

Forced internal displacement has been rising steadily, mainly due to conflict. Many internally displaced people (IDP) experience prolonged displacement. Global research evidence suggests that many of these IDP are at high risk for developing mental disorders, adding weight to the global burden of disease. However, individual and community resilience may act as protective factors. Return migration may be an option for some IDP populations, especially when conflicts end, although return migration may itself be associated with worse mental health. Limited evidence is available on effects of resettlement or return migration following prolonged forced internal displacement on mental health. Also, the role of resilience factors remains to be clarified following situations of prolonged displacement. The public health impact of internal displacement is not clearly understood. Epidemiological and interventional research in IDP mental health needs to look beyond medicalised models and encompass broader social and cultural aspects. The resilience factor should be integrated and explored more in mental health research among IDP and a clearly focused multidisciplinary approach is advocated.

Reducing the scarcity in mental health research from low and middle income countries: A success story from Sri Lanka

There is an enormous inequity in global health as well as research. Less than 10% of research funds are spent on the diseases that account for 90% of the global disease burden. This case study of north–south, south–south collaborations in Sri Lanka is a classic example of the issues faced by mental health researchers in low and middle income countries (LMICs). In this paper, work carried out by the Institute of Psychiatry (IoP), Kings College London and the Institute for Research and Development (IRD) partnership since 1997 in Sri Lanka is presented to show an example of a successful private research institution based in a LMIC as a product of south–south and north–south collaboration in mental health research. The evidence of scarcity of mental health research and resources is overwhelmingly abundant in the context of Sri Lanka. IRD-IoP partnership showcases a successful north–south partnership with equality and efficiency. It has moved beyond start-up phase and has become a sustainable initiative in terms of funding, collaboration, research output and policy impact. International funding agencies, academics, and other bodies need to address sustaining such initiatives as priorities in reducing scarcity and inequity in mental health research in developing countries.

Ethical challenges in mental health research among internally displaced people: ethical theory and research implementation

Millions of people undergo displacement in the world. Internally displaced people (IDP) are especially vulnerable as they are not protected by special legislation in contrast to other migrants. Research conducted among IDPs must be correspondingly sensitive in dealing with ethical issues that may arise. Muslim IDPs in Puttalam district in the North-Western province of Sri Lanka were initially displaced from Northern Sri Lanka due to the conflict in 1991. In the backdrop of a study exploring the prevalence of common mental disorders among the IDPs, researchers encountered various ethical challenges. These included inter-related issues of autonomy, non-maleficence, beneficence, confidentiality and informed consent, and how these were tailored in a culture-specific way to a population that has increased vulnerability. This paper analyses how these ethical issues were perceived, detected and managed by the researchers, and the role of ethics review committees in mental health research concerning IDPs. The relevance of guidelines and methodologies in the context of an atypical study population and the benefit versus risk potential of research for IDPs are also discussed. The limitations that were encountered while dealing with ethical challenges during the study are discussed. The concept of post-research ethical conduct audit is suggested to be considered as a potential step to minimize the exploitation of vulnerable populations such as IDPs in mental health research.

Social networks, social support and psychiatric symptoms: social determinants and associations within a multicultural community population

PurposeLittle is known about how social networks and social support are distributed within diverse communities and how different types of each are associated with a range of psychiatric symptoms. This study aims to address such shortcomings by: (1) describing the demographic and socioeconomic characteristics of social networks and social support in a multicultural population and (2) examining how each is associated with multiple mental health outcomes.MethodsData is drawn from the South East London Community Health Study; a cross-sectional study of 1,698 adults conducted between 2008 and 2010.ResultsThe findings demonstrate variation in social networks and social support by socio-demographic factors. Ethnic minority groups reported larger family networks but less perceived instrumental support. Older individuals and migrant groups reported lower levels of particular network and support types. Individuals from lower socioeconomic groups tended to report less social networks and support across the indicators measured. Perceived emotional and instrumental support, family and friend network size emerged as protective factors for common mental disorder, personality dysfunction and psychotic experiences. In contrast, both social networks and social support appear less relevant for hazardous alcohol use.ConclusionsThe findings both confirm established knowledge that social networks and social support exert differential effects on mental health and furthermore suggest that the particular type of social support may be important. In contrast, different types of social network appear to impact upon poor mental health in a more uniform way. Future psychosocial strategies promoting mental health should consider which social groups are vulnerable to reduced social networks and poor social support and which diagnostic groups may benefit most.

Risk of mental health and nutritional problems for left-behind children of international labor migrants

BackgroundOne-in-ten Sri Lankans are employed abroad as International Labor Migrants (ILM), mainly as domestic maids or low-skilled laborers. Little is known about the impact their migration has on the health status of the children they ‘leave behind’. This national study explored associations between the health status of ‘left-behind’ children of ILM’s with those from comparative non-migrant families.MethodsA cross-sectional study design with multi-stage random sampling was used to survey a total of 820 children matched for both age and sex. Socio-demographic and health status data were derived using standardized pre-validated instruments. Univariate and multivariate analyses were used to estimate the differences in mental health outcomes between children of migrant vs. non-migrant families.ResultsTwo in every five left-behind children were shown to have mental disorders [95%CI: 37.4-49.2, p < 0.05], suggesting that socio-emotional maladjustment and behavioural problems may occur in absence of a parent in left-behind children. Male left-behind children were more vulnerable to psychopathology. In the adjusted analyses, significant associations between child psychopathological outcomes, child gender and parent’s mental health status were observed. Over a quarter (30%) of the left-behind children aged 6–59 months were ‘underweight or severely underweight’ compared to 17.7% of non-migrant children.ConclusionsFindings provide evidence on health consequences for children of migrant worker families in a country experiencing heavy out-migration of labour, where remittances from ILM’s remain as the single highest contributor to the economy. These findings may be relevant for other labour ‘sending countries’ in Asia relying on contractual labor migration for economic gain. Further studies are needed to assess longitudinal health impacts on the children left-behind.

Impact of Economic Labour Migration: A Qualitative Exploration of Left-Behind Family Member Perspectives in Sri Lanka

Abstract Sri Lanka is a major labour sending country in Asia, with a high proportion of female labour migrants employed as domestic housemaids in the Middle East with increasing remittances. Despite such financial gains for families and national economy, health and social effects on the left-behind families have had limited exploration. This qualitative study was carried out across five districts with high labour migration rates in Sri Lanka. Twenty in-depth interviews were conducted with participants recruited through purposive sampling. Data was analysed using content and thematic analysis and emerging themes were mapped. Pre-migration socio-economic situation, economic difficulties and higher earning possibilities abroad were considered to be the major push and pull factors for labour migration. Post-migration periods were shown to be of mixed benefit to left-behind families and children suffer the negative effects of parental absence. The absence of support mechanisms for dealing with adverse events such as serious injury, death, abuse or imprisonment were cited as major concerns. Post-migration periods affect the health, well-being and family structures of left-behind families. Promoting economic prosperity while ensuring health and social protection is a formidable policy challenge for ‘labour sending’ countries such as Sri Lanka.

An intervention to improve mental health care for conflict-affected forced migrants in low-resource primary care settings: a WHO MhGAP-based pilot study in Sri Lanka (COM-GAP study)

BackgroundInadequacy in mental health care in low and middle income countries has been an important contributor to the rising global burden of disease. The treatment gap is salient in resource-poor settings, especially when providing care for conflict-affected forced migrant populations. Primary care is often the only available service option for the majority of forced migrants, and integration of mental health into primary care is a difficult task. The proposed pilot study aims to explore the feasibility of integrating mental health care into primary care by providing training to primary care practitioners serving displaced populations, in order to improve identification, treatment, and referral of patients with common mental disorders via the World Health Organization Mental Health Gap Action Programme (mhGAP).Methods/DesignThis pilot randomized controlled trial will recruit 86 primary care practitioners (PCP) serving in the Puttalam and Mannar districts of Sri Lanka (with displaced and returning conflict-affected populations). The intervention arm will receive a structured training program based on the mhGAP intervention guide. Primary outcomes will be rates of correct identification, adequate management based on set criteria, and correct referrals of common mental disorders. A qualitative study exploring the attitudes, views, and perspectives of PCP on integrating mental health and primary care will be nested within the pilot study. An economic evaluation will be carried out by gathering service utilization information.DiscussionIn post-conflict Sri Lanka, an important need exists to provide adequate mental health care to conflict-affected internally displaced persons who are returning to their areas of origin after prolonged displacement. The proposed study will act as a local demonstration project, exploring the feasibility of formulating a larger-scale intervention study in the future, and is envisaged to provide information on engaging PCP, and data on training and evaluation including economic costs, patient recruitment, and acceptance and follow-up rates. The study should provide important information on the WHO mhGAP intervention guide to add to the growing evidence base of its implementation.Trial registrationSLCTR/2013/025.

Impact of exposure to conflict, tsunami and mental disorders on school absenteeism: findings from a national sample of Sri Lankan children aged 12--17 years

BackgroundArmed conflicts and natural disasters are common. Millions of people, including children are killed, injured, disabled and displaced as a result. The effects of conflict and natural disaster on mental health, especially of children are well established but effects on education have received less attention. This study investigated associations between conflict and/or tsunami exposure in Sri Lanka and their associations with absenteeism in a national sample of school children.MethodsA cross-sectional survey was conducted in 2006–7 among 1,505 randomly selected school children aged 12–17 years attending government schools in 17 districts. The hypotheses were that absenteeism would be more common in children previously affected by conflict or the 2004 tsunami and that at least part of this effect would be accounted for by mental disorders. Survey information included socio-demographic, conflict and tsunami exposure, mental health status (Strengths and Difficulties Questionnaire) and information on absenteeism (defined as 20% or greater non-attendance over one year).ResultsThe total sample of consisted of 1,505 students aged 12–17 years with a mean age of 13.7 years. 120 children reported at least one conflict exposure and 65 reported at least one tsunami exposure while only 15 reported exposure to both conflict and tsunami. Prevalence of emotional disorder caseness was 2.7%, conduct disorder caseness 5.8%, hyperactivity disorder caseness 0.6%, and 8.5% were identified as having any psychiatric disorder. Absenteeism was present in 26.8%. Overall, previous exposure to tsunami (OR 2.29 95% CI 1.36-3.84) was significantly associated with absenteeism whereas exposure to conflict was not (OR 1.32 95% CI 0.88-1.97), although some specific conflict-related exposures were significant risk factors. Mental disorder was strongly associated with absenteeism but did not account for its association with tsunami or conflict exposure.ConclusionsExposure to traumatic events may have a detrimental effect on subsequent school attendance. This may give rise to perpetuating socioeconomic inequality and needs further research to inform policy and intervention.