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

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.

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.

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.

The impact of forced migration on the mental health of the elderly: a scoping review.

BACKGROUND: The worldwide elderly population fraction is increasing, with the greatest rise in developing countries. Older adults affected by conflict and forced migration mainly taking place in developing countries may be particularly vulnerable to poor mental health due to other age-specific risk factors. This review aims to explore global evidence on the effect of conflict-induced forced migration on the mental health of older adults. METHODS: Seven bibliographic databases were searched. The title and abstract of 797 results were reviewed for qualitative and quantitative studies meeting inclusion and exclusion criteria. RESULTS: Six studies were selected for the in-depth review. Five papers assessed mental health in older adult populations displaced as refugees. One paper assessed mental health of older adults with varying immigration status. CONCLUSIONS: This review highlights the dearth of evidence about the impact of forced migration on the mental health of older adults. Further research is needed to explore the risk factors and processes that contribute to adverse mental health outcomes among older adult populations. This is essential to the development of interventions for this vulnerable and at-risk population, particularly in resource-poor settings.

Integrated care systems in England: the significance of collaborative community assets in promoting and sustaining health and wellbeing.

Until recently the healthcare system in England was based on a commissioning/provider model. However, this has been replaced with an Integrated Care Systems (ICSs) approach, aimed at improving health and wellbeing and reducing inequalities through local collaborative partnerships with public sector organizations, community groups, social enterprise organizations and other local agencies. Part of this new approach is an emphasis on the role of community assets (i.e., local resources), that are considered integral to promoting positive health and wellbeing outcomes. This paper presents research from a series of three research studies on "community assets" conducted in the East of England within a newly established ICS. Based on analysis of qualitative data highlighting the lived experience of community asset members, this paper shows the positive wellbeing impact on vulnerable community members that assets provide. Further insight on the local impact and the collaborative nature of the research is provided suggesting that new asset-based approaches recognize the social determinants of health. This presents a shift away from positivistic linear approaches to population health and wellbeing to a new non-linear collaborative approach to addressing health inequalities and promoting wellbeing. The authors suggest that exploring this through a complexity theory lens could illuminate this further. Finally, the authors warn that while community assets have an important role to play in empowering citizens and providing much needed support to vulnerable and disadvantaged communities, they are not a substitute for functioning funded public sector services that are currently being undermined by ongoing local governments funding cuts. As such, while community assets can help ameliorate some of the negative effects people experience due to economic, structural and health disadvantages, only a more fair and more equal distribution of resources can address growing health inequalities.

The impact of engaging with community groups: asset-based approaches and the lived experience of socially vulnerable populations in the UK.

Introduction: Asset-based approaches to improve citizen wellbeing and address inequalities are now being adopted by public health practitioners. There is some evidence that participatory approaches and the promotion of community assets have the capacity to mitigate against the social determinants that generate health disparities. However, questions remain about how they work in practice. This paper reports on research carried out to provide insight into how a diverse range of community assets support (or not) the wellbeing of vulnerable citizens and to provide an improved understanding of people's lived experiences including the challenges of citizens who belong to community assets face. Two subsequent studies were undertaken in a region of England comprising of two neighboring municipalities where health inequalities are stark. Both municipalities contain within them areas of social deprivation. The initial study was completed in March 2020, 1 week before England's first COVID-19 lockdown restrictions were introduced and the subsequent study was conducted to explore the impact of social restrictions on the community assets forum members. Methods: A combined phenomenological and ethnographic methodological approach was adopted for both studies. For the initial study ethnographic methods were used including 42 qualitative face-to-face interviews focusing on the lived experience of participants. Observations, informal conversations, photographs, and field notes were also carried out to allow researchers to become familiar with the setting, to build rapport and trust provide a contextual understanding of the relationship between the activity or place and participants' experiences of wellbeing. For the subsequent study thirty-six interviews (including interviews with community assets leaders) were conducted online or by phone due to COVID-19 social restrictions. Results and discussion: The studies' findings support the supposition that these groups are community assets which help ameliorate against the social detriments of health and wellbeing that have led to widening health inequalities in the region. The findings from both studies clearly illustrate the importance of sociality for wellbeing, and that participation in these groups are an important determinant of wellbeing. The data demonstrates how social capital is generated within a range of community groups and spaces. It also conveys the needs and deficits existing within groups highlighting the need to provide more assistance to vulnerable citizens. While most themes were common to all community forums, there were some noticeable place-based differences.

Workplace coaching: a meta-analysis and recommendations for advancing the science of coaching.

Workplace coaching has experienced a dramatic rise in popularity over the past decade and is one of the fastest growing performance-enhancing interventions used by modern organizations. Yet, despite its popularity, workplace coaching has not been the subject of much empirical research and a true science of coaching has yet to be developed. The purpose of this research was to update prior meta-analyzes that investigated the impact of coaching on organizational outcomes and to provide recommendations for how the field needs to evolve. Results indicated that, consistent with prior meta-analyzes, workplace coaching is effective in achieving positive organizational outcomes. The effects of several moderators were also investigated. Finally, we discuss the results in terms of recommendations for future directions that we believe will establish and advance the science of coaching.

Protocol of a randomised clinical trial to integrate mental health services into primary care for postconflict populations in Northern Sri Lanka (COMGAP-S).

INTRODUCTION: Sri Lanka has a long history of armed conflict and natural disasters increasing the risk of mental health disorders in the population. Due to a lack of specialist services, there is a treatment gap between those seeking and those able to access mental health services. The aim of this research programme is to integrate mental health services into primary care to meet the needs of this postconflict population. METHODS AND ANALYSIS: This is a stepped wedge cluster design randomised clinical trial of the WHO mental health Gap Action Programme primary care mental health training intervention. We will provide a 10-day training to primary care practitioners of 23 randomly selected primary care facilities aimed at increasing their ability to identify, treat and manage common mental health disorders. Public health professionals and community representatives will receive a tailored training intervention to increase mental health awareness. Refresher courses will occur at 3 and 6 months post training. Supervision and monitoring will occur for 1 month pre and post training. Target sample sizes have been calculated separately for each group of participants and for each outcome. ETHICS AND DISSEMINATION: This trial has received ethical approval from the Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, UK (SC/jc/FMFREP/16/17 076) and from the Faculty of Medicine, University of Jaffna, Sri Lanka (J/ERC/17/81/NDR/0170) and non-engagement approval has been received from the funding body, the Centers for Disease Control and Prevention (2018-015). All participants gave written consent. Dissemination of study results will be completed through publication of academic articles, conference presentations, town hall meetings, written pamphlets in plain language, reports to Ministry of Health and other government organisations and through social media outlets. TRIAL REGISTRATION NUMBERS: ISRCTN registry: ISRCTN62598070. SLCTR registration number: SLCTR/2018/008.

Examining post-conflict stressors in northern Sri Lanka: A qualitative study.

Forcibly displaced individuals typically encounter daily stressors, which can negatively impact mental health above and beyond direct exposure to war-related violence, trauma and loss. Understanding the perspectives of war affected communities regarding daily stressors can enhance the integration of mental health into local primary care. The aim of the current study was to explore how daily stressors are conceptualized in a post-conflict setting. Data collection was completed with 53 adult participants who were recruited from primary healthcare clinics in Northern Province, Sri Lanka. Individual interviews were conducted in Tamil, audio-recorded, translated from Tamil to English, and transcribed. Themes emerging from the data were organized into an analytical framework based on iterative coding and grounded in the daily stressors framework. Stressors were conceptualized as chronic stressors and systemic stressors. Findings indicate that chronic stressors, such as loss of property, permeate daily life and have a profound impact on psychological wellbeing. Interviewees additionally reported that systemic stressors stemmed from unresolved grief for missing family members and limited support from institutions. The results of the current study complement existing literature, suggesting the value of multipronged approaches which identify and address symptoms of complicated bereavement while simultaneously alleviating financial hardship. An understanding of stressors experienced by conflict-affected populations in times of chronic adversity can be informative for the design and implementation of culturally-tailored interventions.

Characteristics and Influencing Factors of Healthcare Utilization in Post-conflict Primary Care Attendees in Northern Sri Lanka.

Sri Lanka's healthcare systems attempts to provides access to universal healthcare services for all citizens and is designed to be free of out-of-pocket payments. Despite a 30-year civil conflict, natural disasters, and COVID-19, the healthcare system within the country remains robust and strong. However, due to a lack of formalized pathways and centralized record keeping, the pattern of service utilization is still relatively unknown, which raises concerns regarding effective allocation of scarce resources and efficiency of referral pathways. To address this gap in knowledge, part of the parent study (COMGAP-S), consisted of a survey on healthcare service use conducted among adults attending primary care facilities. The results from this quantitative data analysis indicate the majority of people seeking care originate from rural areas, are older (50+), attend divisional hospitals, and report paying fees at point of contact. Our findings indicate a need for more efficient use of healthcare services, creation of referral routes to ensure limited healthcare resources are used effectively. Additionally, further investment in services is needed to ensure Sri Lanka's healthcare system meets the standard of universal healthcare as proposed by the World Health Organization. These findings address a gap in knowledge for national decision-makers within Sri Lanka along with other similar post-conflict healthcare settings across the globe.

Challenges and lessons learned in re-filming the WHO mhGAP training videos for Sri Lankan context - a qualitative study.

BACKGROUND: Understanding and addressing the unmet mental health needs burden in the Northern Province of Sri Lanka is the subject of the COMGAP-S two-phase study. Phase Two involves the implementation of the World Health Organization's mental health Gap Action Programme (mhGAP) in primary healthcare settings. As part of the contextual adaptation of mhGAP, eleven of the videos provided in the mhGAP training package have been re-filmed by a local team. We investigated the challenges, barriers and good practices of this adaptation effort from the point of view of team participants. METHODS: Twelve persons from the adaptation team, including students of medicine and drama, doctors, drama lecturers and professionals, consented to in-depth individual interviews following an open-ended topic guide with a member of the COMGAP-S study team. Interviews were recorded, transcribed, translated as necessary, and subjected to thematic analysis. RESULTS: The majority of participants perceived the process positively and had pride in their involvement. Expectations, opportunities, and exposure were discussed as stemming from the video production. The main challenges derived from the analysis were lack of discussion around budgeting, logistical difficulties, struggles with team cooperation, and creative differences. Issues around exact translation into the local Tamil dialect and modelling around mental health were emphasised by the majority of participants. Potential uses for the videos were identified beyond the current study and recommendations included setting out clear guidance around available funding and role allocation, and increasing the flexibility in adapting the material. CONCLUSIONS: This study illustrated details of the adaptation of existing video materials to facilitate locally-based training for non-specialists on mhGAP curricula. With this, we have added to the knowledge base on conducting cultural and language adaptations and our findings indicate participants felt adapting the mhGAP films to local context was vital to ensuring training materials were culturally appropriate and valid. TRIAL REGISTRATION: This project was nested within the larger COMGAP-S clinical trial. Ethics approval was granted from the Ethics Review Committee, Faculty of Medicine, University of Jaffna (J/ERC/17/81/NDR/0170) and the Faculty Research Ethics Panel, Faculty of Medical Science, Anglia Ruskin University (SC/jc/FMSFREP/16/17076). The project is registered with the Sri Lankan Clinical Trial Registry (SLCTR/2018/008) and listed on the ISRCTN registry (trial ID ISRCTN62598070).

Discordance of high PD-L1 expression in primary and metastatic urothelial carcinoma lesions.

Immune checkpoint inhibitors (ICI) targeting PD-(L)1 are effective in select patients with advanced urothelial carcinoma (UC). High PD-L1 expression enriches for response to ICIs; however, the predictive value of PD-L1 expression is limited, which may be due in part to dynamic expression of PD-L1 in the tumor environment. We sought to characterize PD-L1 expression in primary UC and paired metastatic lesions to gain insight into the potential discordance of tumor PD-L1 expression during the metastatic process. MATERIALS AND METHODS: Immunohistochemical staining for PD-L1 using the SP-142 antibody was performed on primary tumors and matched metastatic specimens in 77 evaluable subjects with advanced UC. Immunohistochemical staining was scored for the percentage of cells positive (<5%, ≥5%) in tumor cell (TC) and immune cell (IC) compartments. Correlation of PD-L1 expression in TCs and ICs was estimated using Spearman's correlation coefficients (rho, ρ). Cohen's kappa statistics (κ) were utilized to assess the agreement in PD-L1 expression between groups. RESULTS: High (≥5%) PD-L1 expression in primary and metastatic biopsies, respectively, was observed in 6.0% and 7.7% of TCs and in 14.5% and 11.5% of ICs. IC PD-L1 expression in primary tumors was not correlated with IC PD-L1 expression in paired metastatic lesions (ρ = 0.05, P = 0.67) and there was poor agreement in high expression rates between primary and metastatic lesions in the IC compartment (κ= 0.086). CONCLUSION: High PD-L1 IC expression is temporally and spatially discordant between primary and metastatic UC lesions. Future studies of PD-(L)1 targeted therapies in patients with metastatic UC may benefit from use of fresh biopsies of metastatic lesions to define PD-L1 expression when feasible.

Implementing a pharmacist-led, individualized medication assessment and planning (iMAP) intervention to reduce medication related problems among older adults with cancer.

OBJECTIVES: Medication-related problems (MRP) affecting older adults are a significant healthcare concern and account for billions in medication-related morbidity. Cancer therapies can increase the prevalence of MRP. The objective of this study was to test the feasibility and effectiveness of implementing a pharmacist-led individualized medication assessment and planning (iMAP) intervention on the number and prevalence of MRP. MATERIALS AND METHODS: This prospective pilot study enrolled oncology outpatients aged ≥65years. Intervention feasibility encompassed recommendation acceptance rate and intervention delivery time. The intervention was facilitated by pharmacists where patients received comprehensive medication management at baseline and at the 30- and 60-day follow-up. RESULTS: Forty-eight eligible patients enrolled and 41 patients (85.4%) were included in the analysis. Mean age was 79.1years [range 65-101]; 66% women, 83% Caucasian, mean comorbidity count was 7.76. Forty-six percent of the pharmacist recommendations were accepted and the prevalence of MRP at baseline versus 60-day follow-up decreased by 20.5%. The average time to conduct the initial session was 22min versus 15min for the follow-up sessions. Resources needed included a tracking system for scheduling follow-up calls and a database for tracking acceptance of recommendations. A total of 123 MRP were identified in 95% of patients (N=39) with a mean of 3 MRP per patient. The mean reduction in number of MRP (3 at baseline versus 1.6 at 60-day follow-up) was 45.5%. CONCLUSIONS: The pharmacist-led iMAP intervention was feasible and effective at reducing MRP. Additional inter-professional medication safety based interventions measuring patient-reported outcomes are still needed.

Programmed evolution for optimization of orthogonal metabolic output in bacteria.

Current use of microbes for metabolic engineering suffers from loss of metabolic output due to natural selection. Rather than combat the evolution of bacterial populations, we chose to embrace what makes biological engineering unique among engineering fields - evolving materials. We harnessed bacteria to compute solutions to the biological problem of metabolic pathway optimization. Our approach is called Programmed Evolution to capture two concepts. First, a population of cells is programmed with DNA code to enable it to compute solutions to a chosen optimization problem. As analog computers, bacteria process known and unknown inputs and direct the output of their biochemical hardware. Second, the system employs the evolution of bacteria toward an optimal metabolic solution by imposing fitness defined by metabolic output. The current study is a proof-of-concept for Programmed Evolution applied to the optimization of a metabolic pathway for the conversion of caffeine to theophylline in E. coli. Introduced genotype variations included strength of the promoter and ribosome binding site, plasmid copy number, and chaperone proteins. We constructed 24 strains using all combinations of the genetic variables. We used a theophylline riboswitch and a tetracycline resistance gene to link theophylline production to fitness. After subjecting the mixed population to selection, we measured a change in the distribution of genotypes in the population and an increased conversion of caffeine to theophylline among the most fit strains, demonstrating Programmed Evolution. Programmed Evolution inverts the standard paradigm in metabolic engineering by harnessing evolution instead of fighting it. Our modular system enables researchers to program bacteria and use evolution to determine the combination of genetic control elements that optimizes catabolic or anabolic output and to maintain it in a population of cells. Programmed Evolution could be used for applications in energy, pharmaceuticals, chemical commodities, biomining, and bioremediation.