Conflict, forced displacement and health in Sri Lanka: a review of the research landscape

Spatial spillovers of violent conflict amplify the impacts of climate variability on malaria risk in sub-Saharan Africa

Africa carries a disproportionately high share of the global malaria burden, accounting for 94% of malaria cases and deaths worldwide in 2019. It is also a politically unstable region and the most vulnerable continent to climate change in recent decades. Knowledge about the modifying impacts of violent conflict on climate-malaria relationships remains limited. Here, we quantify the associations between violent conflict, climate variability, and malaria risk in sub-Saharan Africa using health surveys from 128,326 individuals, historical climate data, and 17,429 recorded violent conflicts from 2006 to 2017. We observe that spatial spillovers of violent conflict (SSVCs) have spatially distant effects on malaria risk. Malaria risk induced by SSVCs within 50 to 100 km from the households gradually increases from 0.1% (not significant, P>0.05) to 6.5% (95% CI: 0 to 13.0%). SSVCs significantly promote malaria risk within the average 20.1 to 26.9 °C range. At the 12-mo mean temperature of 22.5 °C, conflict deaths have the largest impact on malaria risk, with an approximately 5.8% increase (95% CI: 1.0 to 11.0%). Additionally, a pronounced association between SSVCs and malaria risk exists in the regions with 9.2 wet days per month. The results reveal that SSVCs increase population exposure to harsh environments, amplifying the effect of warm temperature and persistent precipitation on malaria transmission. Violent conflict therefore poses a substantial barrier to mosquito control and malaria elimination efforts in sub-Saharan Africa. Our findings support effective targeting of treatment programs and vector control activities in conflict-affected regions with a high malaria risk.

Determinants of early cessation of exclusive breastfeeding practices among rural mothers from Jaffna District of Sri Lanka

BACKGROUND

Sri Lanka is an upper-middle-income country with excellent health statistics. However, 2016 Demographic and Health Survey data have shown 82% and 64% of mothers exclusively breastfed infants aged 0-6 months and 4-5 months, respectively. The short duration of exclusive breastfeeding (EBF) has an impact on the growth and development of babies. Since no studies have been reported on EBF practices of the rural mothers in Jaffna District, an administrative district among 25 districts of Sri Lanka, this study aimed to assess the factors influencing the early cessation of EBF.

METHODS

For this community-based cross-sectional study, 338 mother-child pairs were selected from 2013-14. EBF was defined as children not receiving any food or drink, including complementary foods, formula milk or milk products except for medicines and vitamins or mineral drops, other than breast milk since birth. Socio-economic and demographic factors, the influence of the mode of delivery, and knowledge on EBF were obtained using an interviewer-administered questionnaire. The details of EBF and reasons for the cessation of breastfeeding before six months were obtained from a subgroup of mothers (n = 208). Multivariate analysis was performed to explore the correlates of breastfeeding.

RESULTS

In this study, 71.2% (95% CI 64.5, 77.2) had practiced EBF for six months. Early discontinuation of EBF was practiced by employed mothers (AOR 4.3; 95% CI 1.3, 13.9), mothers of low birth weight babies (AOR 3.6; 95% CI 1.6, 8.2) and those who experienced Cesarean section birth (AOR 2.9; 95% CI 1.2, 6.9). The EBF practiced by mothers of rural Jaffna was not associated with the gender of the babies, type of family, number of children in a family, religion of the household, knowledge on EBF, or family income.

CONCLUSION

The prevalence of EBF up to six months was low in rural Jaffna, and it was influenced by employment, birthweight of the babies, and the mode of delivery. To enhance EBF, the Regional Directorate of Health Service, Jaffna, should take necessary action with policymakers to increase maternity leave for at least six months, reduce the Cesarean section rate, and provide nutritional support to pregnant mothers.

Displacement and degradation: Impediments to agricultural livelihoods among ethnic minority farmers in post-war Sri Lanka

Our understandings of the effects of war on land and resource access following armed conflicts are often shaped (and limited) by a reliance upon remotely sensed data. Here, we analyze household-level survey and community-level focus group data collected in Sri Lanka following the end of the nation's ethno-religiously rooted civil war (1983-2009) to determine if and how the war differently affected the nation's rice farmers. Our synthetic analyses revealed geographic variation in agricultural livelihood viability in post-war Sri Lanka, demonstrating how the protracted effects of war are exacerbating the vulnerability of rural Sri Lanka's ethno-religious minority (Tamil and Moor) populations by (re-)shaping access to critical natural resources, including both land and irrigation water.

Burden of congenital and hereditary anomalies in the war-affected territory at Pakistan-Afghanistan border

Background

Pashtun populations of Pakistan are the victim of long-lasting military combats, rendering 1.9 million inhabitants internally displaced. Studies highlighting congenital and hereditary anomalies in these populations are deficient.

Objectives

To elucidate the spectrum anomalies in the north-western war-affected territories of Pakistan.

Methods

A cross-sectional study was carried out from 2017 to 2019 and individuals or families with anomalies were ascertained through convenience and cluster random sampling. Phenotypic and pedigree data and information on bio-demographic variables were collected. Descriptive statistics were applied.

Results

A total of 361 independent individuals or families with anomalies were recruited. The anomalies were grouped into 8 major and 72 minor entities. Among major categories, neurological disorders had the highest representation (n = 100; proportion: 0.277; 95% CI: 0.231-0.323), followed by sensorineural defects (n = 70; prop.: 0.194), limb defects (n = 60; prop.: 0.166), visual impairments (n = 55; prop.: 0.152), and musculoskeletal defects (n = 37; prop.: 0.102). Among the neurological disorders, intellectual disability had the highest occurrence (58%), whereas talipes and limb amputations were the most prominent in limb defects (22% and 20%, respectively). The anomalies had sporadic and isolated presentations most often (76% each), while parental consanguinity was observed in 34% of index cases.

Conclusions

The high incidence of neurological, sensorineural, and limb defects, the preponderance of sporadic cases, and low level of parental consanguinity may indicate a potentially high contribution of nongenetic factors in the etiology of anomalies. The majority of anomalies are the cause of severe disability.

Depression, Disability, and Cognitive Impairment Among Elders With Medical Illnesses Attending Follow-Up Clinics at a Tertiary Care Hospital in Northern Sri Lanka

INTRODUCTION

The rising proportion of the elderly is increasingly affected by non-communicable diseases. Despite an abundance of literature suggesting that elders with medical conditions are more vulnerable to depression, disability, and cognitive impairment, these tend to go unnoticed and unaddressed. This study describes the prevalence and correlates of depression, disability, and cognitive impairment among elders with medical illnesses attending follow-up clinics in a tertiary care hospital in northern Sri Lanka.

METHODS

This descriptive cross-sectional study was carried out among 122 elders (≥60 years) attending medical clinics at Teaching Hospital Jaffna. Depression, disability, and cognitive impairment were assessed by the 15-item Geriatric Depression Scale, 12-item World Health Organization Disability Assessment Schedule 2.0, and Montreal Cognitive Assessment, respectively. Student's T-Test, ANOVA, and correlation coefficient were used in analyzing data using Statistical Package for Social Sciences 25 (SPSS-v25) (IBM, New York, United States).

RESULTS

The mean age of the participants was 68.3 years (SD=5.70); 58 (47.5%) were males and 64 (52.5%) were females. Prevalence of depression was 44.3% (95% CI=35.5-53.1), while disability was 95.9% (95% CI=92.4-99.4) and cognitive impairment was 80.3% (95% CI=73.2-87.4). Depression was significantly associated with gender (p=0.013), marital status (p=0.019), and living arrangement (p<0.001). Cognitive impairment was significantly associated with education level (p=0.045), and disability was associated with education level (p=0.008) and marital status (p=0.027). Among the study participants, only 12 (9.8%) had previously sought professional help for depression, disability, or cognitive impairment.

CONCLUSION

Depression, disability, and cognitive impairment are common among the elderly attending medical clinics in Teaching Hospital Jaffna, and are, in most cases, unaddressed.

Putative juvenile terrorists: the relationship between multiple traumatization, mental health, and expectations for reintegration among Islamic State recruited adolescent and young adult fighters

Background

In several conflicts worldwide children are recruited as fighters in irregular forces. These children need to be reintegrated into the society after the conflict. However, concurrent to various reservations in the communities, the reintegration of former child soldiers is challenged by the fact that many of the affected children were indoctrinated by the armed group and traumatized through war events. Even several years after the defeat of the terrorist organization ISIS in Iraq, systematic efforts towards the reintegration of children who had been recruited by ISIS are notably absent.

Methods

we conducted clinical interviews with a sample of N = 59 adolescents and young adults who were incarcerated for terrorism in the prisons of the Kurdistan Region of Iraq to assess levels and types of trauma exposure, PTSD, depression, readiness to reintegrate and ongoing identification with ISIS.

Results

We found high levels of PTSD and depression that were associated with trauma exposure. The subjective readiness to reintegrate into the communities was associated with trauma exposure and was mediated by depression, even after controlling for the influence of ongoing identification with the armed group.

Conclusion

The study indicates that trauma-related mental ill-health should be considered in efforts to reintegrate young former terrorists.

Promotion of Resilience in Migrants: A Systematic Review of Study and Psychosocial Intervention

This systematic review aimed to contribute to a better and more focused understanding of the link between the concept of resilience and psychosocial interventions in the migrant population. The research questions concerned the type of population involved, definition of resilience, methodological choices and which intervention programmes were targeted at migrants. In the 90 articles included, an heterogeneity in defining resilience or not well specified definition resulted. Different migratory experiences were not adequately considered in the selection of participants. Few resilience interventions on migrants were resulted. A lack of procedure's descriptions that keep in account specific migrants' life-experiences and efficacy's measures were highlighted.

Establishing the Domains of a Hospital Disaster Preparedness Evaluation Tool: A Systematic Review

Introduction:

Recent disasters emphasize the need for disaster risk mitigation in the health sector. A lack of standardized tools to assess hospital disaster preparedness hinders the improvement of emergency/disaster preparedness in hospitals. There is very limited research on evaluation of hospital disaster preparedness tools.

Objective:

This study aimed to determine the presence and availability of hospital preparedness tools across the world, and to identify the important components of those study instruments.

Method:

A systematic review was performed using three databases, namely Ovid Medline, Embase, and CINAHL, as well as available grey literature sourced by Google, relevant websites, and also from the reference lists of selected articles. The studies published on hospital disaster preparedness across the world from 2011-2020, written in English language, were selected by two independent reviewers. The global distribution of studies was analyzed according to the World Health Organization’s (WHO) six geographical regions, and also according to the four categories of the United Nations Human Development Index (UNHDI). The preparedness themes were identified and categorized according to the 4S conceptual framework: space, stuff, staff, and systems.

Result:

From a total of 1,568 articles, 53 met inclusion criteria and were selected for data extraction and synthesis. Few published studies had used a study instrument to assess hospital disaster preparedness. The Eastern Mediterranean region recorded the highest number of such publications. The countries with a low UNHDI were found to have a smaller number of publications. Developing countries had more focus on preparedness for natural disasters and less focus on chemical, biological, radiological, and nuclear (CBRN) preparedness. Infrastructure, logistics, capacity building, and communication were the priority themes under the space, stuff, staff, and system domains of the 4S framework, respectively. The majority of studies had neglected some crucial aspects of hospital disaster preparedness, such as transport, back-up power, morgue facilities and dead body handling, vaccination, rewards/incentive, and volunteers.

Conclusion:

Important preparedness themes were identified under each domain of the 4S framework. The neglected aspects should be properly addressed in order to ensure adequate preparedness of hospitals. The results of this review can be used for planning a comprehensive disaster preparedness tool.

Implementation of a non-randomized controlled trial of yoga-based intervention to reduce behavioural issues in early adolescent school-going children in Sri Lanka

Background

Adolescence can be difficult to navigate and the post-conflict environment in Jaffna Province, Sri Lanka compounds existing issues for adolescents. Conduct problems, hyperactivity along with emotional problems are challenges faced by adolescents, particularly in fragile, post-conflict settings. This study was a non-randomized controlled trial carried out in 4 educational zones over 6 months. The study implemented a yoga-based intervention package: two types of slow breathing for 5-6 min, Surya-namaskaram for 6-8 min, and mindfulness meditation for 5-6 min. Pre/post quantitative assessments were conducted with intervention and control groups. A focus group was conducted with the intervention group. The aim was to evaluate. Effectiveness of implementing a yoga-based intervention package in grade 8 school children (early adolescents) to address behavioural problems.

Results

Paired t-test and independent t-tests were completed for both arms using statistical product and service solutions (SPSS21). Parents’ assessments of emotional issues reduced for the intervention group (n = 584) [t(584) = 11.41, p = 0.001] along with reduction of the total difficulty score [t(584) = 28.12, p = 0.001]. Teachers’ assessments indicated prosocial scores improved in the intervention group [t(584) = − 28.5, p = 0.001]. Students’ self-assessments in the intervention group indicate a reduction in emotional problems [t(584) = 6.4, p = 0.001], and reduction in problems with peers [t(584) = 14.4, p = 0.001]. Within the control group (n = 499), teachers’ assessments indicated emotional problems increased [t(499) = − 9.5, p = 0.001] and prosocial scores reduced [t(499) = 13.5, p = 0.001]. Students’ self-assessments in the control group indicated emotional problems increased [t(499) = − 27.1, p = 0.001]. A comparison of post-test scores revealed a statistically significant difference between groups. Focus group results indicate students felt the intervention had an overall positive effect on school achievements, family dynamics and individual health.

Conclusions

This yoga-based intervention package appeared to be effective in reducing both externalizing and internalizing symptoms in adolescents. Practicing Surya-namaskaram, breathing control techniques and mindfulness meditation significantly reduced both externalizing symptoms (conduct problems and hyperactivity) as well as internalizing symptom (emotional problem and peer problems). It is recommended this intervention be scaled up across Sri Lanka and other similar post-conflict regions.

Mental health among displaced and non-displaced populations in Valledupar, Colombia: do inequalities continue?

During the long-lasting civil war in Colombia, thousands of people were displaced mainly from rural to urban areas, causing social disruption and prolonged poverty. This study aimed at analyzing the traumatic experience many years ago on the current psycho-emotional status of displaced families as well as the ongoing inequalities regarding displaced and non-displaced communities in one of the most affected areas by the armed conflict. An interview survey was conducted among 211 displaced families and 181 non-displaced families in 2 adjacent compounds in Valledupar, Colombia. The questionnaire used questions from the validated national survey and was revised and applied by staff members of the departmental secretary of health who conducted additional in-depth interviews. The study showed that the living conditions of the displaced community were precarious. The past traumatic events many years ago and the current difficult living conditions are associated with psychological problems being more frequent among the displaced people. The displaced people had experienced more violent acts and subsequently had a larger number of emotional symptoms (fright, headache, nervousness, depression, and sleeplessness). Other stress factors like economic problems, severe disease or death of family members and unemployment prevailed among displaced persons. The non-displaced lived in a more protected environment with less exposure to violence and stress, although belonging to a similarly low socio-economic stratum. It is recommended to take measures for a better protection of the displaced community, improve their access to the job market, offer different leisure activities and facilitate public transport.

Self-reported diseases and their associated risk factors among camp-dwelling conflict-affected internally displaced populations in Nigeria

Background Conflict in Nigeria displaced millions of people, and some settled in camp-like locations within the country. Evidence on the association between living conditions and health outcomes among these populations are limited. This study investigated the risk factors associated with illnesses among camp-dwelling internally displaced persons (IDPs) in northern Nigeria. Methods A cross-sectional study was conducted in nine camps in 2016. Self-reported data on socio-demography, resource utilization and disease outcomes were collected. Association between health conditions and various factors, including sanitation and healthcare access, was investigated. Results Data from 2253 IDPs showed 81.1% (CI = 79.5-82.7) experienced one or more health conditions; however, over 20% did not access healthcare services. Most common diseases were malaria, fever, typhoid and diarrhoea. Multivariable logistic regression presented as adjusted odds ratios(aOR) and 95% confidence intervals(CIs) showed factors significantly associated with increased likelihood of illnesses included being female (aOR = 1.53;CI = 1.19-1.96), overcrowding (aOR = 1.07;CI = 1.00-1.36), long-term conditions (aOR = 2.72;CI = 1.88-3.94), outdoor defecation (aOR = 2.37;CI = 1.14-4.94) and presence of disease-causing vectors (aOR = 3.71;CI = 1.60-8.60). Conclusion Most diseases in the camps were communicable. Modifiable risk factors such as overcrowding and poor toilet facilities were associated with increased poor health outcomes. This evidence highlights areas of high priority when planning humanitarian public health interventions.

A Cross-Sectional Analysis of the Prevalence and Determinants of Mental Distress Among Ethiopian Returnees

BACKGROUND

Returning internally displaced persons (IDPs) to their homes can be a difficult and traumatic experience, particularly after a long period of displacement. Furthermore, traumatic experiences encountered during displacement during the flight process may be replayed in the minds of IDP returnees when they return to their original locations, raising the risk of re-traumatization. This could have a detrimental impact on the mental health of returning IDPs. Despite this, the mental health of returnee IDPs in Ethiopia has received less consideration. As a result, the aim of this study was to determine the prevalence and determinants of mental distress among Ethiopian returnees.

METHOD AND PARTICIPANTS

A community-based cross-sectional study with 623 participants was conducted from January 1 to 30, 2021, using a systematic sampling technique. The Kessler psychological distress scale was used to assess mental distress (K-10). Bivariable and multivariable binary logistic regression is used to investigate the relationship between variables. Statistical significance was described as a P-value of less than 0.05 with a 95% confidence interval.

RESULTS

The total number of people interviewed was 623, with a 100% response rate. With a 95% confidence interval of 47 to 51.9, the prevalence of psychological distress was 49.4%. Unemployment (AOR=2.1, 95% CI 1.38 to 3.40), inadequate social support (AOR=1.92, 95% CI 1.53 to 2.56), having little knowledge of post-returnee life (AOR=2.17, 95% CI 1.23 to 3.37), and the number of traumatic events (AOR=1.92, 95% CI 1.53 to 2.56) were all found to be significant in the multivariate logistic regression.

CONCLUSION

Returnee IDPs have a high prevalence of psychological distress, according to this report. It is suggested that knowledge of how to adapt to a new life after returning to the original land be given, as well as consistent psychosocial help.

Entamoeba histolytica and amoebic liver abscess in northern Sri Lanka: a public health problem

Entamoeba histolytica (E. histolytica) is a facultative protozoan parasite implicated in amoebic liver abscesses (ALA), the most common extraintestinal manifestation of this infection. E. histolytica is endemic to sub-tropical and tropical countries and has been a major public health concern in northern Sri Lanka (SLK) for the last three decades. This has been attributed to a multitude of factors such as poor sanitation, hygiene, male sex, middle age, overcrowding, unsanitary practices in the production of indigenous alcoholic beverages, and alcohol consumption. Additionally, while rates of E. histolytica have declined substantially throughout the rest of the island, largely due to better infrastructure, it remains pervasive in the northern peninsula, which is generally less developed. Infection arises primarily from fecal-oral transmission through the consumption of contaminated drinking water containing cysts. Upon ingestion, cysts multiply into trophozoites and colonize the host colonic mucosa using lectin and cysteine proteases as virulence factors, leading to host invasion. Symptoms occur along a spectrum, from asymptomatology, to pyrexia, abdominal cramping, and amoebic dysentery. Colonization of the colon results in the formation of distinct flask-shaped ulcers along the epithelium, and eventual penetration of the lamina propria via the production of matrix metalloproteinases. ALA then develops through trophozoite migration via the mesenteric hepatic portal circulation, where microabscesses coalesce to form a single, large right-lobe abscess, commonly on the posterior aspect. The progression of infection to invasive disease is contingent on the unique interplay between host and pathogen factors, such as the strength of host-immunity to overcome infection and inherent pathogenicity of the Entamoeba species. As a preventable illness, E. histolytica complications such as ALA impose a significant burden on the healthcare system. This mini-review highlights epidemiological trends, risk factors, diagnostic modalities, treatment approaches, and opportunities for prevention of E. histolytica-induced ALA, to help address this endemic problem on the island of SLK.

'We just been forced to do it': exploring victimization and agency among internally displaced young mothers in Bogotá

Background

Armed conflict in Colombia has a history of 50 years that continues to this day. According to the Victims Record of Colombia, from 1985 to 2013 2.683.335 women have been victims of the armed conflict. Women have been described as the main victims of the armed conflict, especially in the Colombian cultural context that in some regions is still considered to be a ‘machista’ and patriarchal one. In contrast, some authors have explicitly stressed Colombian women’s agency instead of positioning them only as victims. Some of them are described as ‘survivors’ of the war, emphasizing their impressive resistance to the outcomes of war and forced displacement. In contrast to the background of these scholarly discussions, our study focused on how displaced women living in Bogotá themselves articulate their experiences of agency and victimization. This paper will therefore explore how women, in reconstructing their life stories, expressed the tussles between victimization and agency.

Methods

We used qualitative methods conducted within an ethnographic approach. Based on ten years of experience in the neighborhood and one year of fieldwork, we collected the life stories of twenty internally displaced mothers, and ran eight workshops with them. We analyzed the narratives with a specific focus on how women expressed victimization and agency in four important periods in their life that related to the process of displacement: when they left home, when they became pregnant, when they were forced to leave their towns, and when they arrived in Bogotá.

Results

Participants’ life stories showed how they struggled with agency during their lives. They were victims of abuse and violence during childhood and finally decided to leave their homes. They decided to have their babies despite the fact that they were abandoned by their partners and families, and after doubts about and attempts to have an abortion. Throughout the process of displacement the participants had been engaged in ambiguous relationships with armed groups. Finally they arrived in Bogotá and faced adverse circumstances but were looking for better opportunities for them and their children.

Conclusion

The analysis of how internally displaced women narrated their life stories showed us that the concepts that dominate scholarly debates about agency, victimization and survivorship do not do justice to the life stories of the participants in our study. These stories show that changes with a major impact were loaded with ambiguity and were characterized by helplessness, lack of control and agency simultaneously. The reconstruction of these life stories goes beyond the stereotype of displaced women as only ‘victims’, but points also to their agency and courageous decisions they made in contexts that were not controlled by them and where support was often lacking. Instead of label them, it is important to understand the complexity of the life experiences of IDW, in order to build policies that offer them aids as victims, but also build policies and intervention programs that empower them as agents in order to support them during resettlement.

Prevalence of mental disorders and epidemiological associations in post-conflict primary care attendees: a cross-sectional study in the Northern Province of Sri Lanka

BACKGROUND

Experiencing conflict and displacement can have a negative impact on an individual's mental health. Currently, prevalence of mental health disorders (MHDs) at the primary care level in post-conflict areas within the Northern Province of Sri Lanka is unknown. We aimed to explore this prevalence in conflict-affected populations attending primary care, using a structured package of validated screening tools for MHDs.

METHODS

This cross-sectional study aimed to determine factors related to mental health disorders at the primary care level in Northern Province, Sri Lanka. A structured interview was conducted with internally displaced adults attending 25 randomly selected primary care facilities across all districts of Northern Sri Lanka (Jaffna, Mannar, Mullaitivu, Vavuniya). Participants were screened for depression, anxiety, psychosis, PTSD, and somatoform symptoms.

RESULTS

Among 533 female and 482 male participants (mean age 53.2 years), the prevalence rate for any MHD was 58.8% (95% CI, 53.8-61.4), with 42.4% screening positive for two or more disorders (95% CI, 38.6-46.1). Anxiety prevalence was reported at 46.7% (95% CI, 41.9-51.5), depression at 41.1% (95% CI, 38.7-44.5), PTSD at 13.7% (95% CI, 10.6-16.8), somatoform symptoms at 27.6% (95% CI, 23.6-31.5), and psychosis with hypomania at 17.6% (95% CI, 13.3-21.9).

CONCLUSION

This is the first study at the primary care level to investigate prevalence of MHDs among conflict-affected populations in the Northern Province, Sri Lanka. Results highlight unmet mental health needs in the region. Training intervention to integrate mental health services into primary care is planned.

Health status of returning refugees, internally displaced persons, and the host community in a post-conflict district in northern Sri Lanka: a cross-sectional survey

Background

Although the adverse impacts of conflict-driven displacement on health are well-documented, less is known about how health status and associated risk factors differ according to displacement experience. This study quantifies health status and quality of life among returning refugees, internally displaced persons, and the host community in a post-conflict district in Northern Sri Lanka, and explores associated risk factors.

Methods

We analysed data collected through a household survey (n = 570) in Vavuniya district, Sri Lanka. The effect of displacement status and other risk factors on perceived quality of life as estimated from the 36-item Short Form Questionnaire, mental health status from 9-item Patient Health Questionnaire, and self-reported chronic disease status were examined using univariable analyses and multivariable regressions.

Results

We found strong evidence that perceived quality of life was significantly lower for internally displaced persons than for the host community and returning refugees, after adjusting for covariates. Both mental health status and chronic disease status did not vary remarkably among the groups, suggesting that other risk factors might be more important determinants of these outcomes.

Conclusions

Our study provides important insights into the overall health and well-being of the different displaced sub-populations in a post-conflict setting. Findings reinforce existing evidence on the relationship between displacement and health but also highlight gaps in research on the long-term health effects of prolonged displacement. Understanding the heterogeneity of conflict-affected populations has important implications for effective and equitable humanitarian service delivery in a post-conflict setting.

Iron status and anaemia in Sri Lankan secondary school children: A cross-sectional survey

BACKGROUND

Iron deficiency, the most common micronutrient disorder and cause of anaemia globally, impairs growth, cognition, behaviour and resistance to infection.

METHODS/RESULTS

As part of a national survey of inherited haemoglobin variants in 7526 students from 72 secondary schools purposefully selected from the 25 districts of Sri Lanka, we studied 5912 students with a normal haemoglobin genotype. Median age was 16.0 (IQR 15.0-17.0) years and 3189 (53.9%) students were males. Most students were Sinhalese (65.7%), with fewer Tamils (23.1%) and Muslims (11.2%). Anaemia occurred in 470 students and was more common in females (11.1%) than males (5.6%). Haemoglobin, serum ferritin, transferrin receptor and iron were determined in 1196 students with low red cell indices and a structured sample of those with normal red cell indices (n = 513). The findings were weighted to estimate the frequencies of iron deficiency and iron deficiency anaemia classified according to WHO criteria. Iron depletion (serum ferritin <15ug/ml) occurred in 19.2% and cellular iron deficiency (low serum ferritin and transferrin receptor >28.1 nmol/l) in 11.6% students. Iron deficiency anaemia (cellular iron deficiency with low haemoglobin) occurred in only 130/2794 (4.6%) females and 28/2789 (1.0%) males. Iron biomarkers were normal in 83/470 (14.6%) students with anaemia. In multiple regression analysis, the odds for iron depletion and cellular iron deficiency were about one-third in males compared with females, and the odds for iron deficiency anaemia were about one fifth in males compared to females. Tamil ethnicity and age <16 years increased the risk of all three stages of iron deficiency and living at high altitude significantly reduced the risk of iron depletion.

CONCLUSIONS

Low iron status and anaemia remain common problems in Sri Lankan secondary school students especially females, younger students and the socioeconomically disadvantaged Tamil population. More research is needed to identify factors other than low iron status that contribute to anaemia in adolescents.

Rapidly Increasing Trend of Recorded Alcohol Consumption Since the End of the Armed Conflict in Sri Lanka

Aim

To evaluate temporal changes in recorded alcohol consumption in Sri Lanka during and after the armed conflict 1998-2013.

Methods

District level alcohol sales, and mid-year population data for the whole study period (1998-2013) were consistently available from the Department of Excise and the Department of Census and Statistics for 18 of 25 districts. These data were used to estimate the recorded per capita consumption for the areas that were not directly exposed to the armed conflict. An interrupted time series design was employed to estimate the impact of the end of the armed conflict on recorded adult per capita alcohol consumption of population lived in the 18 districts.

Results

Adult per capita recorded alcohol consumption among Sri Lankans living in the 18 districts was 1.59 l of pure alcohol in 1998. This increased up to 2.07 l in 2009 and 2.55 l in 2013. Prior to the end of the conflict in 2009 adult per capita recorded consumption increased by 0.051 l of pure alcohol per year (95% CI: 0.029-0.074, P < 0.001); after 2009 this was 0.166 l per year (95% CI: 0.095-0.236, P < 0.001). Beer consumption showed the highest per capita growth compared with other beverages.

Conclusions

Adult per capita recorded alcohol consumption among Sri Lankans living in areas that were not directly exposed to the conflict increased markedly after the end of the conflict. Rapid socio-economic development, alcohol industry penetration and lack of alcohol control strategies during the post-conflict period may have driven this increase.

Short summary

Adult per capita recorded alcohol consumption among Sri Lankans living in 18 districts that were not directly exposed to the armed conflict increased markedly after the end of the conflict in 2009, with a dramatic acceleration in the trend of per capita beer consumption.

Psychosocial wellbeing and physical health among Tamil schoolchildren in northern Sri Lanka

BACKGROUND

Mental disorders contribute to the global disease burden and have an increased prevalence among children in emergency settings. Good physical health is crucial for mental well-being, although physical health is multifactorial and the nature of this relationship is not fully understood. Using Sri Lanka as a case study, we assessed the baseline levels of, and the association between, mental health and physical health in Tamil school children.

METHODS

We conducted a cross sectional study of mental and physical health in 10 schools in Kilinochchi town in northern Sri Lanka. All Grade 8 children attending selected schools were eligible to participate in the study. Mental health was assessed using the Sri Lankan Index for Psychosocial Stress - Child Version. Physical health was assessed using Body Mass Index for age, height for age Z scores and the Multi-stage Fitness Test. Association between physical and mental health variables was assessed using scatterplots and correlation was assessed using Pearson's R.

RESULTS

There were 461 participants included in the study. Girls significantly outperformed boys in the MH testing t (459) = 2.201, p < 0.05. Boys had significantly lower average Body Mass Index for age and height for age Z scores than girls (BMI: t (459) = -4.74, p <0.001; Height: t (459) = -3.54, p < 0.001). When compared to global averages, both sexes underperformed in the Multi-Stage Fitness Test, and had a higher prevalence of thinness and stunting. We identified no meaningful association between the selected variables.

CONCLUSIONS

Our results do not support the supposition that the selected elements of physical health are related to mental health in post-conflict Sri Lanka. However, we identified a considerable physical health deficit in Tamil school children.

Exposure to conflict and disaster: A national survey on the prevalence of psychotic experiences in Sri Lanka

Recent research conducted in high-income countries suggests psychotic experiences are common in the general population, but evidence from low- and middle-income countries (LMIC) remains limited. Sri Lanka is a LMIC affected by three decades of civil conflict and, in 2004, a devastating tsunami. This study aimed to investigate the prevalence of psychotic experiences in a general population sample in Sri Lanka and associations with conflict- and tsunami-related trauma. This is a first National Mental Health Survey conducted in Sri Lanka. A cross-sectional, multi-stage, cluster sampling design was used to estimate the prevalence of psychotic symptoms. Data on socio-demographic characteristics, conflict- and tsunami-related trauma, and psychotic experiences were collected using culturally validated measures in a sample of 5927 participants. The weighted prevalence of psychotic symptoms was 9.7%. Exposure to one or more conflict-related events (adj. OR 1.79, 95% CI 1.40-2.31, p<0.001) and loss or injury of a family member or friend through conflict (adj. OR, 1.83, 95% CI 1.42-2.37, p<0.001) were associated with increased odds of reporting psychotic experiences. Psychotic experiences were more common in individuals directly exposed to tsunami disaster (adj. OR, 1.68, 95% CI 1.04-2.73, P=0.035) and in those who had a family member who died or was injured as result of tsunami (adj. OR, 1.42, 95% CI 1.04-1.94, p=0.029). Our findings suggest that psychotic experiences are common in the Sri Lankan population. Exposure to traumatic events in armed conflicts and natural disasters may be important socio-environmental factors in the development of psychotic experiences.

Integrating mental health into primary care for post-conflict populations: a pilot study

BACKGROUND

Mental health care in post-conflict settings is often not prioritized, despite its important public health role. There is a salient gap in integrating mental health into primary care, especially in post-conflict settings. In the post-conflict Northern province of Sri Lanka, a pilot study was conducted to explore the feasibility of integrating mental health into primary care through a mhGAP-based training intervention.

METHODS

Using the mhGAP training intervention modules, a 24 h training programme was held over 3 days for primary care practitioners serving post-conflict populations (including internally displaced people and returnees). mhGAP intervention guide and video material was used in the training. Pre/post knowledge increase was measured. A qualitative study was also nested within the training programme to explore views, attitudes and perceptions of primary care practitioners on integrating mental health into primary care in the region. In-depth interviews were conducted.

RESULTS

Twelve primary care practitioners participated. The average service duration of the group was 7.6 years. The mean pre- and post-test scores of the PCP group were 72.8 and 77.2 % respectively. All 12 took part in the qualitative component. Participants highlighted their experiences of conflict and displacement, discussed the health profiles/needs of post-conflict populations in the region and provided insight into mental health care and training needs at primary care level. Participants also provided feedback on the mhGAP-based training; the cultural and contextual relevance of training material and content.

CONCLUSION

This study was planned as a local demonstrative project to explore the feasibility of training primary care practitioners to promote the integration of mental health into primary care for post-conflict populations. To our knowledge, this is the first such attempt in Sri Lanka. Findings highlight the practical, operational and attitudinal barriers to integrate mental health into primary care, especially in resource-poor, post-conflict settings. Important feedback on mhGAP intervention guide, its implementation and training material was gained.

Associations of mental distress with residency in conflict zones, ethnic minority status, and potentially modifiable social factors following conflict in Sri Lanka: a nationwide cross-sectional study

BACKGROUND

The subject of post-conflict mental health lacks studies that are nationally representative or large enough to allow robust examination of levels of distress according to residency in geographical zones of conflict and ethnic minority status. We undertook a nationwide study in Sri Lanka to address these issues.

METHODS

We used tablet devices to survey 20,632 people across 18 of 25 districts in Sri Lanka, of which nine were purposefully selected and nine randomly selected districts. Based on their exposure to war and levels of population displacement, these districts were classified as being in the severe, moderate, or minimal conflict zones. Trained local fieldworkers did private interviews with the participants in the local language; responses were entered directly into the tablet devices. The questions assessed exposure to a wide range of stresses, including ongoing adversities, threat or protection issues, and service access factors, and respondents provided categorical responses (yes/no) to a list of items. We used the 25-item Hopkins Symptom Checklist to measure depression and anxiety in participants. We used multivariate analysis and calculated population-attributable fractions to estimate potential improvement in mental distress if modifiable factors were addressed.

FINDINGS

Our results showed a stepwise increase in symptoms of depression (10%, 33%, 40%) and anxiety (13%, 23%, 23%) across minimal, moderate, and severe conflict zones, respectively. Membership of an ethnic minority group was associated with depression (Tamil odds ratio [OR] 2·4 [95% CI 1·8-3·1], other ethnic minority OR 2·7 [2·1-3·6]) and anxiety (Tamil OR 1·5 [1·1-2·0], other ethnic minority OR 1·5 [1·2-1·8]). Other fixed characteristics associated with depression and anxiety were older age (both depression and anxiety; OR 2·7 [95% CI 2·0-3·7] for anxiety and 2·3 [1·7-3·0] for depression), being married (anxiety only; OR 1·5 [95% CI 1·1-2·1]), and time spent in camps for internally displaced people (anxiety only; OR 1·4 [95% CI 1·0-1·9]). Modifiable characteristics were threat or protection issues (depression OR 1·8 [95% CI 1·2-2·8], anxiety OR 1·8 [1·3-2·6]) and scarcity of food (depression OR 1·4 [1·2-1·6], anxiety OR 1·4 [1·2-2·7]), loss of job (OR 1·2 [95% CI 1·2-1·4] for anxiety), and proximity to army camps (OR 1·6 [95% CI 1·2-2·2] for depression). Allaying of safety concerns had the potential to reduce depression by 53% and anxiety by 57%, with other factors (removal of army camps from proximity and addressing food scarcity, loss of jobs and threat/protection issues) making smaller contributions to a reduction in depression and anxiety.

INTERPRETATION

Our findings offer a basis for detecting high-risk groups and provide directions in devising policies and programmes aimed at alleviating psychological distress in Sri Lanka. Restoration of safety seems to be crucial to mental health recovery.

FUNDING

Australian National University-Department of Immigration Border Protection Collaborative Research Program.

Militarization, human rights violations and community responses as determinants of health in southeastern Myanmar: results of a cluster survey

Background

The Myanmar army and ethnic armed groups agreed to a preliminary ceasefire in 2012, but a heavy military presence remains in southeastern Myanmar. Qualitative data suggested this militarization can result in human rights abuses in the absence of armed engagements between the parties, and that rural ethnic civilians use a variety of self-protection strategies to avoid these abuses or reduce their negative impacts. We used data from a household survey to determine prevalence of select self-protection activities and to examine exposure to armed groups, human rights violations and self-protection activities as determinants of health in southeastern Myanmar.

Methods and findings

Data collected from 463 households via a two-stage cluster survey of conflict-affected areas in eastern Myanmar in January 2012, were analyzed using logistic regression models to identify associations between exposure to state and non-state armed groups, village self-protection, human rights abuses and health outcomes. Close proximity to a military base was associated with human rights abuses (PRR 1.30, 95 % CI: 1.14-1.48), inadequate food production (PRR 1.08, 95 % CI: 1.03-1.13), inability to access health care (PRR 1.29, 95 % CI: 1.04-1.60) and diarrhea (PRR 1.15, 95 % CI: 1.05-1.27. Direct exposure to armed groups was associated with household hunger (PRR1.71, 95 % CI: 1.30-2.23). Among households that reported no human rights abuses, risk of household hunger (PRR 5.64, 95 % CI: 1.88-16.91), inadequate food production (PRR 1.95, 95 % CI: 1.11-3.41) and diarrhea (PRR 2.53, 95 % CI: 1.45-4.42) increased when neighbors’ households reported experiencing human rights abuses. Households in villages that reported negotiating with the Myanmar army had lower risk of human rights violations (PRR 0.91, 95 % CI: 0.85-0.98), household hunger (PRR 0.85, 95 % CI: 0.74-0.96), inadequate food production (PRR 0.93, 95 % CI:0.89-0.98) and diarrhea (PRR 0.89, 95 % CI:0.82-0.97). Stratified analysis suggests that self-protection strategies may modify the effect of exposure to armed groups on risk of human rights violations and some health outcomes.

Conclusion

Militarization may negatively affect health in southeastern Myanmar, and village self-protection activities may reduce these impacts. As southeastern Myanmar opens to international health and development interventions, implementing agencies should consider militarization as a determinant of health and design interventions that can mediate its effects. Such interventions should take into account existing self-protection strategies, seek to provide support where possible and, at all times, take care not to unintentionally undermine them.

Electronic supplementary material

The online version of this article (doi:10.1186/s13031-015-0059-0) contains supplementary material, which is available to authorized users.

Mental health of displaced and returnee populations: Insight from the Sri Lankan post-conflict experience

The month of May 2015 marked the sixth year since the end of conflict in Sri Lanka. The cause of death, destruction and displacement, three decades of conflict has had a major impact on health, especially on mental health of those affected by forced displacement. Post-conflict regions of Sri Lanka has seen improvements in many areas, including resettlement of displaced populations and rebuilding of health-related infrastructure. However, substantial gaps exist around the management of health needs among returnee populations, especially in the area of psychosocial health. Long-term mental health and resilience trajectories of those affected by prolonged displacement and experiencing return migration during post-conflict periods remain important, yet critically understudied areas.