Innovation summary

During 26 years of protracted war in Sri Lanka, more than 100,000 people of all ethnicities are estimated to have died, and hundreds of thousands have been injured1,2, with substantial internal and external displacement from conflict compounded by the 2004 tsunami3. The existing approach to providing mental health care to the conflict-affected population in Sri Lanka is through limited Medical Officers of Mental Health (MOMH; numbering 1 MOMH to 30 villages or more), alongside mental health units at regional hospitals and a psychiatric unit at the Jaffna Teaching Hospital. These resources are insufficient to meet the population needs, especially due to the severity of trauma, difficulties experienced in displacement, and return migration.

The goal of this study is to integrate mental health into primary care by providing training to Primary Care Practitioners (PCP) and Public Health Personnel (PHP) serving conflict-affected populations in resource-poor, primary care settings in the Northern Province via a scaled-up training intervention based on the World Health Organization mental health gap action programme (WHO mhGAP 2.0). The study also aims to enhance community awareness, reduce stigma, and improve psychosocial well-being of local communities by including community representatives (CR). A 3-day (24 hour) training intervention will be delivered to PCP/PHP in selected primary care facilities located across the Northern Province. CR from the community of the facility catchment area will be provided with a separate, tailored 1-day training intervention.  

Impact summary

The following outcomes are expected:
  • At least 40% of PCP, 40% of PHP, and 30% of CR trained on mhGAP, and a 40% increase in concurrence between PCP and psychiatrist evaluations
  • 20% reduction in symptoms among patients, and 50% reduction in stigma among CR
  • Completion of an economic evaluation to understand financial implications

Innovation details

Background
 
Since the end of conflict in 2009, Northern Sri Lanka has an increased need to rebuild the health system. Currently, there is a lack of human resources, as the amount of new healthcare professionals being trained is below that of the growing need in the region. The relative political, social, and economic stability in the region is favourable to training new healthcare workers and increasing the capacity of existing health work force. This project aims to improve the skills of existing primary care health work force by adding mental health care into primary care services (first port of call) across all districts of the province.
 
Content of the innovation
 
A cross-sectional study was completed at primary care level in 2016 to understand the prevalence and burden of mental health disorders in the Northern region of Sri Lanka. Here, the evidence gathered in the pilot is combined with locally created videos and training materials to adapt the mhGAP 2.0 intervention programme to ensure it is locally relevant. 
 
25 primary care facilities will receive training over the course of one week, in which primary care practitioners (PCP) and public health professionals (PHP) attend a three-day training involving role-plays, videos, and seminars using material developed by the World Health Organization. Once trained, they will be asked to use their training to diagnose, treat, and refer patients with possible mental health problems, and patients visit a psychiatrist to confirm their diagnosis and receive treatment as required. Additionally, community representatives (CR) such as religious leaders, traditional healers, and Ayurvedic practitioners from the areas near each primary care facility will be provided with a tailored version of the training intervention, and afterwards asked to help raise awareness, find local resources, and organise mental health promotional activities in their communities. PHP will be asked to engage in activities such as stigma reduction, enabling referrals, and supporting CR-led community engagement activities. There will be two refresher courses for PCP, PHP, and CR 3 and 6 months after the first training course. A psychiatrist will provide feedback to each facility to enhance the quality of clinical assessment.
 
Long-term aims of the innovation
 
It is envisaged that the training intervention using mhGAP-IG will increase rates of correct identification, treatment/management, and specialist referral rates by PCP. It is also envisaged that extending this training intervention to involve PHP in the region will improve the delivery of psycho-education and monitoring of mental health care delivery, and will increase referrals.  In addition, the study explores the task-shifting of mental health care provision from health services to the community.
 
In the long-term, it is hoped that these trained PCP, PHP and CR will aid to: 
  • Reduce acute and long-term disease burden and service-provision costs
  • Provide effective/accessible mental health care
  • Help reduce mental health related stigma
  • Enhance community awareness
  • Support the improvement of psychosocial well-being among vulnerable/traumatized post-conflict populations in the area4

 

Key drivers

Critical involvement of a key stakeholder
We have partnered with the Northern Ministry of Health in Sri Lanka who are interested in including the COMGAP-S training programme into their strategic 5-year plan for the region. This partnership will ensure not only successful implementation but also sustainability over time.

 

Challenges

Competing priorities
Primary care practitioners have current heavy workloads at primary care level and will require comprehensive training and on-going support. 

 

Continuation

The study will provide evidence to make necessary policy changes to implement the model not only in the conflict-affected regions, but also in other parts of Sri Lanka. Evidence also can be used to inform service provision model development for other South Asian countries affected by conflict/forced migration. 
 
This project is a scaled-up version of a pilot study conducted between 2013/2014 in the Northern districts of Mannar and Puttalam with PCP. The current study has scaled-up implementation to include all districts of the Northern region of Sri Lanka as well as to include both PCP and PHP at primary care level and CR in the surrounding catchment areas. If successful in increasing correct identification, treatment, management, and referral of people seeking treatment at primary care level, as well as increasing mental health awareness and decreasing stigma, this project will then look at options to implement the programme across the other regions of the country.

 

Evaluation methods

Primary care practitioners at all facilities will be monitored (to establish a baseline of current diagnosis, management, and referral practices) for one month before training according to a stepped wedge design. After the training intervention is delivered, each facility will be continuously monitored until a month after the last facility has received the intervention. Randomly selected groups of patients with mental health diagnoses will be recruited from each facility during the pre- and post-training monitoring periods, and a psychiatrist will verify the diagnoses and provide feedback. PHP will be monitored on the delivery of mhGAP IG programme and referrals during the post-training one-year period. 
 
Study team members will monitor CR activities for 1 month to confirm if and how they are carrying out recommended activities. A set of qualitative and quantitative measures will be used to assess CR activities including early detection.
 
Evaluation tools include:
  • PCP/PHP: socio-demographic questionnaire with a section of medical education and experience
  • PCP/PHP: knowledge assessment pre- and post-testing questionnaires from mhGAP training package prior to training and at 3 and 6 months refresher training
  • CR: qualitative and quantitative assessments of mental health stigma levels pre- and post-intervention training using Discrimination and Stigma Scale (DISC-12)
  • Patients: brief socio-demographic questionnaire at point of recruitment, Hopkins Symptom Checklist (HSCL), The Harvard Trauma Questionnaire (HTQ) at point of recruitment, 3 and 6 months follow-up

Cost of implementation

A cost ratio economic evaluation will be completed to evaluate the cost-effectiveness of the innovation. This component will evaluate the ratio between costs associated of training PCP and PHP to identify, treat, and refer mental health care patients compared to the costs of referral to and treatment from psychiatrists. These costs will be linked to the primary outcome measure in order to determine the extra cost of training incurred to detect one extra patient. Other service use data (primary care, secondary care, social care, input from families) will be recorded through the Client Service Receipt Inventory (CSRI) for patients identified with CMDs (selected and recruited sample of patients), and costs will be calculated using unit costs specific to Sri Lanka. These costs will be added to the intervention costs, and will be compared with information from other sources to understand the economic implications of service provision to conflict-affected populations5.

Impact details

We estimate we will achieve:
  • 30% increase in primary care attendees who are correctly identified, treated and referred (if required) to specialist care for common mental disorders
  • 20% reduction in positive screening for common mental disorder measured through HSCL and HTQ among patients at 6 months follow-up, compared to point of recruitment
  • At least 50% reduction of mental health stigma among community representatives measured using DISC-12

References

  1. Somasundaram D (2013) Recent disasters in Sri Lanka: lessons learned. Psychiatr clin N Am 36(3): 321-338
  2. Husain F, Anderson M, Cardozo BL, Becknell K, Blanton C, Araki D, Vithana EK (2011) Prevalence of war-related mental health conditions and association with displacement status in postwar Jaffna District, Sri Lanka. JAMA 306(5): 522-531
  3. Siriwardhana C (2010) Windows of opportunity after a disaster: the case of Sri Lanka. Special issue on disasters. Asian Bioethics Review 2(2): 148-151
  4. Somasundaram D, Sivayokan S (2005) Mental health in the Tamil community. Shanthiham
  5. Chisholm D et al. (2000). Integration of mental health care into primary care. Demonstration cost-outcome study in India and Pakistan. Br J Psychiatry 176: 581-8.
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Sri Lanka