Skip to main content
SpringerLink
Log in

Changes in mental health stigma among healthcare professionals and community representatives in Northern Sri Lanka during an mhGAP intervention study

  • Research
  • Published:
Social Psychiatry and Psychiatric Epidemiology Aims and scope Submit manuscript

Abstract

Purpose

Research indicates that exposure to conflict, natural disasters, and internal displacement can increase mental health conditions. Since the end of the civil conflict within Sri Lanka, the country has worked to increase access to mental health services to meet the needs of conflict-affected populations, however, gaps remain. To address this, integration of mental health services into primary care can reduce the strain on growing specialized care. As part of a larger study primary care practitioners (doctors), public health professionals (nurses, midwives), and community representatives (teachers, social workers) were trained to deliver mental health services in primary care across the heavily impacted Northern Province. The aim was to reduce mental health stigma among enrolled healthcare workers and community representatives by 50%.

Methods

Stigma was measured across all participant groups at six time points: pre- and post- initial training at baseline, pre- and post- refresher training 3-months after initial training, and pre- and post- refresher training 6-months after initial training.

Results

Results indicate a small improvement in average stigma scores at the 6-month refresher point for primary care practitioners, and no meaningful difference in average scores across time points for public health professionals or community representatives.

Conclusion

World Health Organization mhGAP training appears to reduce stigma among primary care practitioners and could be an effective strategy to counteract mental health stigma in low resource settings. Future research should investigate underlying mechanisms of stigma reduction to improve delivery of mental health services in primary care and community settings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Doherty S, Hulland E, Lopes-Cardozo B, Sivalingam K, Surenthirakumaran R, Cookson S, Siriwardhana C (2019) Prevalence of mental disorders and epidemiological associations in post-conflict primary care attendees: a cross-sectional study in the Northern Province of Sri Lanka. BMC Psych 19:83

    Article  Google Scholar 

  2. Doherty S, Dass G, Edward A, Stewart R, Roberts B, Abas M (2022) Protocol of a randomized facility trial to integrate mental health services into primary care for postconflict populations in Northern Sri Lanka (COMGAP-S). BMJ Open 12(1):e051441. https://doi.org/10.1136/bmjopen-2021-051441

    Article  PubMed  PubMed Central  Google Scholar 

  3. Porter M, Haslam N (2005) Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA 294:5

    Article  Google Scholar 

  4. Steel Z, Chey T, Silove D, Marnane C, Bryant R, Van Ommeren M (2009) Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA 302(5):537–549

    Article  CAS  PubMed  Google Scholar 

  5. Kathriarachchi S, Seneviratne L, Amarakoon L (2019) Development of mental health care in Sri Lanka: Lessons learned Taiwanese. J Psych 33(2):55

    Google Scholar 

  6. Patel V (2012) Global mental health: from science to action. Har Rev Psych 20(1):6–12

    Article  Google Scholar 

  7. Keynejad R, Spagnolo J, Thornicroft G (2021) WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact. EBMH 24(3):124–130

    Google Scholar 

  8. Siriwardhana C, Adikari A, Jayaweera K, Abeyrathna B, Sumathipala A (2016) Integrating mental health into primary care for post-conflict populations: a pilot study. Int J Mental Health Sys 10(1):1–12

    Google Scholar 

  9. Doherty S, Kianian B, Couture A, Dass G, Edward A, Hulland E, Manolova G, Sivayokan S, Solomon M, Stewart R, Surenthirakumaran R, Lopes-Cardozo B (2022) Integrating mental health into primary care for conflict-affected populations: Implementing mhGAP in Northern Sri Lanka In progress. Ment Health Fam Med 9(1):15–24

    Google Scholar 

  10. Fernando S, Deane F, McLeod H (2010) Sri Lankan doctors’ and medical undergraduates’ attitudes towards mental illness. Soc Psych and Psych Epi 45(7):733–739

    Article  Google Scholar 

  11. Henderson C, Noblett J, Parke H, Clement S, Caffrey A, Gale-Grant O, Schulze B, Druss B, Thornicroft G (2014) Mental health-related stigma in health care and mental health-care settings. Lancet Psych 1(6):467–482

    Article  Google Scholar 

  12. Sickel A, Seacat J (2014) Nabors N Mental health stigma update: A review of consequences. Adv Mental Health 12(3):202–215

    Article  Google Scholar 

  13. Fernando S, Deane F, McLeod H (2017) The delaying effect of stigma on mental health help-seeking in Sri Lanka. Asia-Pacific Psych 9:1

    Google Scholar 

  14. Samarasekara N, Davies M, Siribaddana S (2012) The stigma of mental illness in Sri Lanka: the perspectives of community mental health workers. Stigma Res & Action 2(2):93–99

    Article  Google Scholar 

  15. World Health Organization (2018) mhGAP Operations Manual https://www.who.int/publications/i/item/mhgap-operations-manual

  16. Luty J, Fekadu D, Umoh O, Gallagher J (2006) Validation of a short instrument to measure stigmatised attitudes towards mental illness. Psych Bull 30(7):257–260

    Article  Google Scholar 

  17. Luty J, Rao H, Arokiadass S, Easow J, Sarkhel A (2008) The repentant sinner: methods to reduce stigmatised attitudes towards mental illness. Psych Bull 32(9):327–332

    Article  Google Scholar 

  18. Bland M, Altman D (1997) Statistics notes: Cronbach’s alpha. BMJ 314(7080):572

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Nickless A, Voysey M, Geddes J, Yu L, Fanshawe T (2018) Mixed effects approach to the analysis of the stepped wedge cluster randomised trial—Investigating the confounding effect of time through simulation. PLoS ONE 13(12):e0208876

    Article  PubMed  PubMed Central  Google Scholar 

  20. Li F, Hughes JP, Hemming K, Taljaard M, Melnick ER, Heagerty PJ (2021) Mixed-effects models for the design and analysis of stepped wedge cluster randomized trials: An overview. Stat Methods Med Res 30(2):612–639. https://doi.org/10.1177/0962280220932962

    Article  PubMed  Google Scholar 

  21. Agresti A (2018) An introduction to categorical data analysis. John Wiley & Sons, New York

    Google Scholar 

  22. R Core Team 2020 R: A language and environment for statistical computing https://www.R-project.org/

  23. Bates D, Martin M, Ben B, Walker S (2014) Fitting linear mixed effects models using lme4. J Stat Softw 67(1):48. https://doi.org/10.18637/jss.v067.i01

    Article  Google Scholar 

  24. Kuznetsova A, Brockhoff PB, Christensen RHB (2017) lmerTest package: tests in linear mixed effects models. J Stat Soft 82:1–26

    Article  Google Scholar 

  25. Elff M, Heisig J, Schaeffer M, Shikano S (2021) Multilevel analysis with few clusters: Improving likelihood-based methods to provide unbiased estimates and accurate inference. Brit J of Pol Sci 51(1):412–426

    Article  Google Scholar 

  26. Christensen RHB 2015 Ordinal—regression models for ordinal data R package version 28

  27. Stan Development Team, 2021 Stan modeling language users guide and reference manual, 2.28, https://mc-stan.org

  28. Goodrich B, Gabry J, Ali I, Brilleman S (2020) rstanarm: Bayesian applied regression modeling via Stan. R package version 2:1

    Google Scholar 

  29. Bürkner PC (2017) brms: An R package for Bayesian multilevel models using Stan. J of Stat Software 80:1–28

    Article  Google Scholar 

  30. Bürkner PC (2018) Advanced Bayesian multilevel modeling with the R package. The R Journal 1705:11123

    Google Scholar 

  31. Vehtari A, Gelman A, Gabry J (2017) Practical Bayesian model evaluation using leave-one-out cross-validation and WAIC. Stat & Comp 27(5):1413–1432

    Article  Google Scholar 

  32. Thornicroft G, Mehta N, Clement S, Evans-Lacko S, Doherty M, Rose D, Koschorke M, Shidhaye R, O’Reilly C, Henderson C (2016) Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet 387(10023):1123–1132

    Article  PubMed  Google Scholar 

  33. Simmons L, Jones T, Bradley E (2017) Reducing mental health stigma: the relationship between knowledge and attitude change. Eur J Ment Health 1(12):25–40

    Article  Google Scholar 

  34. Koschorke M, Oexle N, Ouali U, Cherian AV, Deepika V, Mendon GB, Gurung D, Kondratova L, Muller M, Lanfredi M, Lasalvia A (2021) Perspectives of healthcare providers, service users, and family members about mental illness stigma in primary care settings: A multi-site qualitative study of seven countries in Africa, Asia, and Europe. PLoS ONE 16(10):e0258729

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Kaur A, Kallakuri S, Kohrt BA, Heim E, Gronholm PC, Thornicroft G, Maulik PK (2021) Systematic review of interventions to reduce mental health stigma in India. Asian J Psych 55:102466

    Article  Google Scholar 

  36. Corrigan PW, Mittal D, Reaves CM, Haynes TF, Han X, Morris S, Sullivan G (2014) Mental health stigma and primary health care decisions. Psych Res 218(1–2):35–38

    Article  Google Scholar 

  37. Mutiso VN, Pike K, Musyimi CW, Rebello TJ, Tele A, Gitonga I, Thornicroft G, Ndetei DM (2019) Feasibility of WHO mhGAP-intervention guide in reducing experienced discrimination in people with mental disorders: a pilot study in a rural Kenyan setting. Epi and Psych Sci 28:2

    Google Scholar 

  38. Kaur A, Kallakuri S, Daniel M, Yatirajula SK, Devarapalli S, Maulik PK (2021) Directly engaging with people with lived experiences of mental illness from the communities in India. SSM-Mental Health 1:100024

    Article  Google Scholar 

  39. Thornicroft G, Sunkel C, Aliev AA, Baker S, Brohan E, El Chammay R, Davies K, Demissie M, Duncan J, Fekadu W, Gronholm PC (2022) The Lancet Commission on ending stigma and discrimination in mental health. The Lancet 400:10361

    Article  Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge Dr Chesmal Siriwardhana (1978–2017) who was the original Principal Investigator and sadly passed away before the completion of the project.

Funding

This publication was supported by the Cooperative Agreement Number GH001654, funded by the U.S. Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Centers for Disease Control and Prevention or the Department of Health and Human Services. This project was also supported by the Northern Ministry of Health, Sri Lanka, and the University of Jaffna, Sri Lanka. The Funding organization was involved in consultations regarding the scientific validity of the design, analysis of the data, preparation and review of the manuscript for publication. The Northern Ministry of Health, Sri Lanka was involved in data collection management. The University of Jaffna, Sri Lanka was involved in consultations on the design of the study, collection and interpretation of data, preparation and review of the manuscript for publication.

Author information

Authors and Affiliations

  1. Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, CM1 1SQ, UK

    Shannon Doherty

  2. U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA, 30329, USA

    Behzad Kianian, Ahoua Kone & Barbara Lopes-Cardozo

  3. THEME Institute, 50/13, Old Kesbawa Road, Boralesgamuwa, Sri Lanka

    Giselle Dass, Anne Edward & Madonna Solomon

  4. World Health Organization, Av. Appia 20, 1211, Geneva, Switzerland

    Gergana Manolova

  5. Department of Community and Family Medicine, University of Jaffna, Ramanathan Road, PO Box 57, Thirunelvely, Jaffna, Sri Lanka

    Sambasivamoorthy Sivayokan & Rajendra Surenthirakumaran

Authors
  1. Shannon Doherty
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Behzad Kianian
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giselle Dass
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Anne Edward
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ahoua Kone
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Gergana Manolova
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sambasivamoorthy Sivayokan
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Madonna Solomon
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Rajendra Surenthirakumaran
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Barbara Lopes-Cardozo
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SD wrote the first draft of the manuscript. BK carried out the statistical analysis. GD, AE, AK, GM, SS, MS, RS, and BLC contributed to the concept and design. All authors carried out interpretation of data, critical review of the manuscript for intellectual content, as well as administrative, technical, or material support. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Shannon Doherty.

Ethics declarations

Conflict of interests

The authors declare no competing interests.

Ethics approval

Ethics approvals were obtained from the Faculty of Medical Science Research Ethics Panel (FMSFREP 16/17 076) and the University of Jaffna Faculty of Medicine Ethics Review Committee (J/ERC/17/81/NDR/0170).

Consent to participate

Written informed consent was received from all participants prior to enrollment in the clinical trial after presentation of the information sheet. All materials were presented in the language of choice of the participant: English, Tamil, or Sinhalese.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 260 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Doherty, S., Kianian, B., Dass, G. et al. Changes in mental health stigma among healthcare professionals and community representatives in Northern Sri Lanka during an mhGAP intervention study. Soc Psychiatry Psychiatr Epidemiol (2024). https://doi.org/10.1007/s00127-024-02684-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00127-024-02684-4

Keywords

Search

Navigation