Authors: Budosan B., Jones, L.,Wickramasinghe,W.A.L., Farook, A.L., Edirisooriya, V., Abeywardena, G. & Nowfel, M. J.
Mental Health in Developing Countries
Some 450 million people worldwide currently suffer from some form of mental disease or brain condition, but almost half the countries in the world have no explicit mental health policy and nearly one-third have no program for coping with the rising tide of brain-related disabilities.  There is also a severe lack of mental health personnel and facilities throughout the developing world.  One of the ten recommendations in the World Health Report 2001 on how to approach this shortage of mental health professionals and improve mental health services stresses treating common mental disorders in a primary health care (PHC) context.  A mental health system of primary health care providers, traditional healers, and relief workers, if properly trained and supported, can provide cost-effective, good mental health care.  The basic component of integrating mental health into primary health care is the training of primary health care workers in the recognition and management of a range of mental disorders.  In member countries of the World Health Organization (WHO) South East Asia Region (SEAR) there is also an increasing awareness that mental health services should be integrated into the overall primary health care system.  Capacity building of mental health workers has been recognized as one of the most important steps in the development of mental health services in South Asia. [14, 18]
Mental Health in Emergencies
There is a growing evidence base on the implementation of mental health programs in developing countries, and manmade and/or natural disasters often provide opportunities to develop mental health services. [8, 9, 15, 16, 17, 19] Mental health needs arising from a disaster are best addressed by accessing the existing mental health services, and by capacity building initiatives that improve and extend these, rather than by setting up separate services for disaster survivors. [11, 12, 23] The emphasis must lie on the use of already existing services and manpower by allocating mental health issues into appropriate segments of the health sector.  Primary care is particularly appropriate because the primary care clinic is easily accessible and provides a non-stigmatizing environment for the treatment of mental disorders. [11,12]
Sri Lanka: Mental Health Needs and Services
Sri Lanka is a developing country with a severe shortage of mental health professionals.  According to the newly developed national mental health policy for Sri Lanka, the most common mental health problems in Sri Lanka can and should be managed in primary care.  In the preamble of the policy, the government of Sri Lanka acknowledges that the country has one of the highest suicide rates of any country in the world and that an estimated 2% of the population suffers from serious mental illness. 
Of the many countries hit by the tsunami in the Indian Ocean, Sri Lanka was also one of the worst affected.  Forty-thousand people were killed, many were severely injured, and approximately one in every thirty Sri Lankans lost their homes.  After the tsunami, mental health needs in Sri Lanka increased due to: a) exposure to extreme stressors and b) increased poverty.  Exposure to extreme stressors and increased poverty after mass disasters are risk factors for social and mental health problems, including common mental health disorders. [2, 11, 21] WHO predicts that 5-10% of people affected by disasters could develop a recognizable mental disorder, such as depressive and anxiety disorders, somatisation disorders, and acute stress disorder.  The 12-month prevalence of severe mental disorders before a disaster is estimated by the WHO at 2-3%; this rate may increase to 3-4% after a disaster.  Similarly, the 12-month prevalence of mild or moderate mental disorders may double after a disaster, from an estimated 10% to 20%.  After the tsunami, WHO Sri Lanka advised incoming international non-governmental organizations (NGOs) of mental health priorities including the development of community based mental health services, and in response to this and the direct request of medical officers in the area, one such INGO, International Medical Corps (IMC), chose to develop mental health services in Kalmunai, Ampara District. 
Mental Health Needs and Services in Kalmunai, Ampara District
In the aftermath of the tsunami, it became clear that Kalmunai, a coastal region with a population of 401,534,  was one of the hardest hit areas in Sri Lanka.  Although no pre-tsunami epidemiological data on the prevalence rates of mental disorders were available for Ampara District and Kalmunai specifically, [3, 24] it was assumed that rates generally ranged from about 10% to 25% in the community, and from 15% to 30% among primary health care patients.  Before the tsunami, mental health services in Kalmunai were provided by two Medical Officers of Mental Health (MOMH),  who were basically general physicians with three months of training in mental health.  No psychiatrist was permanently based in Kalmunai or Ampara. The nearest psychiatrist was located in the neighboring district of Batticaloa, serving the population of all three North-Eastern Sri Lankan districts (Trincomalee, Batticaloa, and Ampara) with a total population of 1.5 million people.  The primary health care staff in Kalmunai did not practice mental health at all. For these reasons, IMC decided to launch a pilot program to integrate mental health services into primary health care in Kalmunai by specifically targeting primary health care doctors. These doctors, known as Divisional Medical Officers of Health (DMOH), are the physicians responsible for preventative primary health care services within the Sri Lankan medical system. Each of them is in charge of his/her health division, which in Kalmunai is an administrative unit covering an average population of around 50,000.  IMC piloted its program in collaboration with the Sri Lankan Ministry of Health, WHO Sri Lanka, local psychiatric colleagues, and local health authorities in the Kalmunai Deputy Provincial Directorate of Health Services (DPDHS).
IMC’s Mental Health Model versus Other Psychosocial Interventions
In the immediate aftermath of the tsunami, many agencies arrived offering psychosocial support in the affected districts, including Kalmunai. Many different kinds of interventions were offered, most focusing on the short term. Activities included counseling within the camps; critical incident stress management; family support; training-of-trainers programs; short term training of counselors, teachers, and health workers; screening and diagnostic tools; support to affected health workers; family tracing within Sri Lanka and internationally (ICRC); support services for women and children; specific services for orphans; and community development.
International Medical Corps’ model for training primary health care professionals in mental health care service delivery has at its core the existing health care structure of the host country, meaning this is not a traditional approach typified by short-term counseling and discrete training programs, but rather a long-term, comprehensive training program conducted in a primary care setting. This model focuses on partnerships with key local and international health players, and was developed in line with Inter-Agency Standing Committee (IASC) guidelines on mental health and psychosocial support in emergency settings.  IMC piloted this training program after consultations with local health professionals, and in response to their call for help. The training concept was discussed with the WHO and approved by the Ministry of Health in Colombo, and was designed to be in keeping with and promote: 1) the mental health policy for Sri Lanka created by the Sri Lankan Ministry of Health;  2) the WHO’s existing health systems in tsunami-affected areas in Sri Lanka;  and 3) the WHO’s five-year mental health plan for Northeast Sri Lanka  which, among other things, advocated the integration of mental health into primary health care services and the training of primary health care staff. IMC’s plan was to pilot a mental health training program in Kalmunai, Ampara and later to expand services to the neighboring districts of Batticaloa and Hambantota, which were also hit hard by the tsunami.
Program Goal and Objective
The overall goal of IMC’s mental health training program in Kalmunai was to improve the emotional and psychological health status of tsunami-affected communities. The objective was to increase the mental health capacity of Kalmunai Divisional Medical Officers of Health and to enable them to become trainers of their mid-level PHC health care staff (public health midwives and public health inspectors), so that all were able to deliver clinical services.
Selection of Training Participants
The following criteria were applied for the selection of training participants: 1) role within the existing primary health care system in Kalmunai, 2) keen interest in mental health, 3) readiness to implement newly acquired mental health knowledge/skills, and 3) administrative health division. Namely, Kalmunai District had been divided into 10 smaller Medical Officer of Health divisions, and each of these had to be represented in the training. There were no selection tests, admission interviews, and/or objective evaluations of participant motivation for the training. However, focus groups with Kalmunai Divisional Medical Officers of Health, and in-depth interviews with key mental health players in Kalmunai (DPDHS Kalmunai) and Sri Lanka (Ministry of Health, WHO Sri Lanka, local psychiatrists) were used at the beginning of the project to assess: a) mental health needs in Kalmunai, b) need for mental health training in Kalmunai, and c) verbal motivation and commitment of Divisional Medical Officers of Health to attend one such training. A social and demographic inventory of study areas was made (including health facilities and personnel).
An administrative committee comprised of two Sri Lankan psychiatrists, two Kalmunai Divisional Medical Officers of Health, the Kalmunai DPDHS director, and IMC’s Mental Health Coordinator. The role of the committee was to devise a preliminary training program for DMOHs with a view to their becoming trainers of PHC staff, monitoring and evaluating program implementation, and helping develop mental health curriculum. Training data were collected using both quantitative and qualitative data collection methods, including: a) focus groups, b) in-depth interviews, c) mental health assessments of patients, d) observation of the practical skills of trainees, e) surveys of training participants, f) testing the mental health knowledge of trainees, and g) collection of general data from the patients.
The following instruments were used for monitoring and evaluation purposes: a) a form with structured focus group questions, b) an open-ended questionnaire for in-depth interviews, c) a mental health assessment form, d) a mental health on-the-job training competency checklist and goal setting form, e) a public health questionnaire f) a training evaluation form, g) a multiple-choice knowledge test, and h) a data collection form. The construct validity of these instruments was determined by: a) the professional judgment of local and international experts, b) the available evidence on the use of similar instruments in similar situations, and c) general recommendations in the literature on questionnaire design. 
Semi-structured in-depth interviews with key mental health personnel followed by focus groups and survey of primary care professionals were used during the initial assessment and also served as periodic monitoring tools. The form for the evaluation of mental health training was used to monitor participants’ satisfaction with the training, and the mental health knowledge test was administered to test their mental health knowledge at the beginning and at the end of the training program. Data on the diagnostic specificity of medical officers in training were collected by observation during their on-the-job training. Observers were local and international psychiatrists who also actively participated in the design, implementation, and evaluation of the whole project. The mental health assessment form was used to help structure the clinical interview. The data collection sheet was used to collect patients information for the development of the case registry of mental health patients in Kalmunai. These last two forms were created by IMC Mental Health Technical Advisor Dr. Lynne Jones and had been used previously in similar mental health programs in other countries. Data on openings of new mental health clinics were collected directly from the local health authorities (DPDHS Kalmunai).
Theoretical Training (mental health workshops)
A combination of theoretical and practical training was identified as the best model for upgrading the mental health knowledge and skills of Kalmunai Divisional Medical Officers of Health. Once monthly theoretical workshops of two-day duration were considered the most realistic option for delivering the theoretical portion of the training. An active learning and participatory approach was adopted in preference to didactic teaching methods. Case studies and small discussion groups enhanced critical thinking and problem solving skills among the participants. The discussion of mental health problems encountered by workshop participants in the field was especially useful. During the workshops, Divisional Medical Officers of Health were also given ideas and skills on how to proceed with the training of their mid-level PHC staff (public health midwives and public health inspectors).
On-the-job training was widely accepted as the best mode for delivering the practical portion of the training; however, ensuring it occurred posed some difficulties. Firstly, Divisional Medical Officers of Health were not used to seeing mental health patients and found the reorganization of clinical time a challenge, particularly in light of their many other duties and responsibilities. Secondly, mental health patients were unaccustomed to going to DMOHs first for their problems. Thirdly, Kalmunai and Ampara lacked a permanent local psychiatrist who could properly organize and supervise such mental health trainings.
Thus several preliminary steps had to be taken to ensure on-the-job training could be incorporated into the program. These steps were: 1) the prior refreshment of the mental health knowledge and skills of Divisional Medical Officers of Health during the theoretical portion of the training program, 2) the identification of a certain number of mental health patients in different health administrative areas in Kalmunai, 3) the establishment of a system of mobile clinics (and later a system of mental health clinics) in different areas of Kalmunai, and 4) the creation of a supervision timetable. Supervision was conducted by psychiatrists and senior residents in psychiatry, who had to travel a considerable distance from Kandy and other districts, and by the IMC Coordinator. A manual entitled “Mental Health Curriculum for Divisional Medical Officers of Health” was produced. Local psychiatrists as well as Kalmunai Divisional Medical Officers of Health actively participated in the creation of this manual. The most important mental health topics covered in five two-day workshops from April to August 2005 were included in the manual. Finally, 28 on-the-job training sessions were conducted during a three-month period (July, August, and September 2005).  Sessions were delivered through mobile clinics in camps for internally displaced persons (IDPs) and through mental health clinics held in primary care offices staffed by DMOHs. During on-the-job training, 51 mental health patients were seen by different Kalmunai DMOHs, 60% of DMOHs attended 80% or more of the theoretical part of the training (workshops), and 90% of them attended one or more on-the-job training session (see Table 1).
Table 1. Training attendance by Divisional Medical Officers of Health (DMOHs)
In certain cases the same patients were seen by more than one DMOH.
Whenever a patient was seen by a new DMOH, he/she was considered as a new patient for this particular DMOH. Also, more than one DMOH was allowed to participate in each on-the-job training session.
Most of the participants were satisfied with the different aspects of mental health training (see Table 2).
Table 2. Satisfaction of Divisional Medical Officers of Health with the training (N=10)
Different skills of trainees were monitored by their supervisors during the on-the-job part of the training (see Table 3).
Table 3. On-the-job training competency checklist
A case registry of mental health patients in Kalmunai was formed for different health divisions (see Table 4).
Table 4: Breakdown of mental health cases by health division (MOH area)
After they finished the training, DMOHs were actively involved in the training of their mid-level PHC staff (public health midwives and public health inspectors). 158 mid-level PHC staff in Kalmunai completed the training, which was 100% of the mid-level health force under the direct supervision of DMOHs . As a result of IMC’s training efforts thirteen mental clinics were opened in Kalmunai health division (see Table 5). Availability, affordability, and access to mental health services was improved for the whole population of Kalmunai.
Table 5. Mental clinics in Kalmunai health division
Selection of Training Participants
The key decision that needs to be made when embarking on mental health capacity building in primary health care is who and how to train. Different health systems in different countries have different kinds of workers as the main providers of primary health care—these are paraprofessionals in some countries, midwives or general practitioners in others. One of the problems post-disaster is that external agencies intent on training will overload the same unfortunate worker with numerous trainings (e.g. HIV, malaria, trauma) with the result that time is taken out of his/her work, while at the same time no thought is given to how he/she will sustain or deliver on all his/her new sets of skills, or how multiple new skills can be integrated. A second problem is the failure to provide follow-up and supervision after short courses, so that trainees are left floundering when seeing actual cases.
IMC attempted to address these problems through collaboration with other agencies, which was essential to avoid duplication of effort and overloading the same staff with multiple trainings. Thorough decision-making at all levels of the health system resulted in the choice to train DMOHs as the best way of integrating mental health services into primary health care. Significant factors in this choice included the DMOHs direct request for this training, the fact that DMOHs had already been treating mental health issues without support, and the DMOHs’ desire to train their own staff.
The Effectiveness of the Training Intervention
This program was implemented with a long-term view. IMC arranged repeated regular meetings that maximized and coordinated the effects of a combined regimen of theoretical training and practical supervision by local and international experts. According to the available literature,  IMC met the three important requirements for the effectiveness of an educational intervention: 1) duration of the intervention (IMC’s intervention was ongoing longitudinal educational intervention), 2) the degree of active participation of the learners (IMC’s intervention was interactive), and 3) the degree of integration of new learning into the learner’s clinical context (the location of IMC’s intervention was a preexisting primary care setting).
IMC’s mental health training also followed consensus-based guidelines for international training in mental health, as established by the task force of the International Society for Traumatic Stress Studies.  The training was grounded in respect for the concerns of individuals, their families, and the communities involved in the training. Moreover, an open dialogue was promoted among trainers, training participants, and other key mental health players, e.g. the Ministry of Health, the WHO, and other INGOs working in Sri Lanka, which helped to integrate different perspectives and positions on mental health trauma. Trainings were culturally-sensitive and appropriate for the context, which was specially important for on-the-job trainings involving mental health patients. The confidentiality of patients data was of utmost importance; data were shared only with mental health professionals directly involved in training. The patients’ wishes as to whether to give or not to give certain information were respected.
The mental health curriculum for Divisional Medical Officers of Health included several core elements that should shape the development and implementation of training curricula:  1) competence in listening and other communication skills, 2) training in properly recognizing mental health problems in a community, 3) teaching established mental health interventions, 4) providing strategies for problem-solving, 5) training in the treatment of medically unexplained somatic pain, and 6) learning to collaborate with existing local resources, e.g. indigenous healers.
Monitoring and Evaluation
The training was monitored and evaluated through individual interviews, focus groups, and participant-observation. On average more than 70% of training participants were satisfied with different elements of the training such as: 1) organization of the lectures, 2) active participation, 3) quality of lectures, 4) timeliness, and 5) training facilities. The effectiveness of the mental health training was evaluated by pre- and post-training knowledge tests and by the observation of trainee clinical skills. Unfortunately, not enough pre-tests and post-tests were returned to the trainers to make any definitive conclusions about the theoretical mental health knowledge of Kalmunai DMOHs. The testing failed mostly because it has not been accepted by the DMOHs as a knowledge-evaluation method. However, during the observation of their practical performance in the field, all the DMOHs demonstrated good communication skills, respect for the patients, and a good working knowledge of referral procedures. The majority of medical officers provided clear instructions and explanations to the patient, were able to make correct psychiatric diagnosis, and took appropriate decisions regarding medication and treatment. Their performance regarding taking relevant medical history, performing appropriate mental health examinations, and keeping complete mental health records proved only partially satisfactory and requires further work. Time constraints and patient workload were the main reasons why trainees usually did not have sufficient time to spend with each patient. Overall, the competence of DMOHs was high enough for seven Kalmunai trainees to be recommended by consultant psychiatrists from Kandy for the position of Medical Officers of Mental Health (MOMHs) in the future. This recommendation is in tune with the mental health policy for Sri Lanka. The long term plan is to appoint one MOMH for every Ministry of Health district by 2010 and is seen as achievable. 
At the outset disagreements over the best approach for a national strategy for mental health took some time to resolve. However, the discussions were very productive and resulted in Sri Lanka being one of the first tsunami-affected countries to produce a national mental health strategy—endorsed by its parliament—that firmly states that mental health services should be provided at the community level. The most serious constraints encountered were logistical and bureaucratic, combined with the shortage of psychiatrists in the rural most disaster affected areas of the country. The distance between Ampara and Kandy is a minimum of six hours’ hard driving, which was a challenge for local supervisors. The layered nature of the public health system and the dispersal of the key players meant that it took a considerable time to reach consensus on whom and how to train.
The main problems in on-the-job training were shortages of appropriate psychiatric medications in the field, and lack of time on the part of Divisional Medical Officers of Health. This often prevented DMOHs from spending enough time with mental health patients to take an appropriate mental health history and do the proper mental health assessment. Over time, especially with their recognition as having a specialization, this may change.
Another challenge was the cultural style of “Western” NGOs. Patience, endurance, and self-control are highly appreciated personal qualities in Sri Lanka. They are also extremely important personal qualities for anybody who wants to successfully communicate with Sri Lankan people. The goal-orientation of international NGOs with tight deadlines and funding constraints sometimes led to clashes and frustration in implementation. Western workers benefited from learning the importance of the above mentioned personal qualities as a necessary prerequisite to implementing successful programs in Sri Lanka.
The team of psychiatrists from Kandy has offered to provide continuing support to Kalmunai and Ampara in the future. Occasional supervisions by international psychiatrists continued even after the official end of IMC’s mental health program in Kalmunai in January 2006. For example, Oxford psychiatrist Dr. Nick Rose, came to Kalmunai as IMC’s Mental Health Consultant in May 2006 and supervised 21 mental clinic sessions from May to July 2006. With the further upgrading of a system of mental health clinics in Kalmunai and the planned promotion of Kalmunai Divisional Medical Officers of Health to Medical Officers of Mental Health, Kalmunai now has the essential basics for community-based mental health care. A national mental health curriculum for Divisional Medical Officers of Health, with active participation of Kalmunai Divisional Medical Officers of Health, has been developed. The Kalmunai Divisional Medical Officers of Health have increased their mental health knowledge/skills and have begun providing a much-needed service to the area. They were supported in doing this by all the other key mental health players in Sri Lanka, e.g. the WHO, the Ministry of Health, local psychiatrists, and international non-governmental organizations (INGO’s). In spite of all the difficulties and constraints at the beginning of the project, this approach is now widely accepted as useful and all project participants are keen for it to endure and to be repeated. The Ministry of Health in Colombo and WHO Sri Lanka now consider the IMC mental health project in Kalmunai as a pilot model for developing community mental health services in other parts of Sri Lanka. Although the security situation in the Northeast deteriorated in 2006, it did not affect the gains of the Kalmunai mental health program. Trained Divisional Medical Officers of Health from Kalmunai volunteered to help with the mental problems of new IDPs in the Northeast (mostly in Trincomalee and neighboring Batticaloa district).
The authors would like to acknowledge the support and assistance of the following: IMC Sri Lanka, and IMC Headquarters for administering the program; Dr. Nazeer and DPDHS Kalmunai, Dr. Hiranthe De Silva from the Ministry of Health of Sri Lanka, and Mr. John Mahoney from WHO Sri Lanka for guidance and support, Dr. Iyad Zaquot and Dr. Nick Rose for contributing to mental health supervision and training, Kalmunai Divisional Medical Officers of Health for their active participation in the program and the study, and Heidi Gillis for proof reading.
We are very grateful to Stichtung Vluchteling (Netherlands Refugee Foundation) for the financial support of the whole project.
About the Authors
The authors were both involved in the implementation and evaluation of the project; Boris Budosan, M.D., M.P.H., psychiatrist; IMC mental health coordinator Sri Lanka coordinated the project and analyzed the data; Lynne Jones, OBE, MRCPsych, PhD, Senior Advisor Mental Health, International Medical Corps designed the project; performed initial assessments, monitoring, and evaluation; and contributed to the project’s success through her constant supervision and guidance; Professor Dr. W.A.L. Wickramasinghe, consultant psychiatrist, Kandy Teaching Hospital, Sri Lanka was the main lecturer at the workshops and main evaluator of the practical performance of DMOHs in the field; Dr. Edirisooriya V. and Dr. Abeywardena G., Senior Residents in Psychiatry, Kandy Teaching Hospital, Sri Lanka delivered the lectures at the workshops and evaluated on-the-job performance of DMOHs; Farook, A.L., and Nowfel, M.J., Divisional Medical Officers of Health, Kalmunai Ampara district Sri Lanka actively participated in the whole training as well as in a training design, and collection and evaluation of field data.
For data collection instruments contact Mr. Adib Fletcher, M.P.H., IMC Mental Health Monitoring/Evaluation Specialist, IMC DC Office, 1313 L St., N.W. Suite 220, Washington D.C. 20005, USA. Tel: 1-202-828-5155.
or Dr. Boris Budosan, IMC Mental Health/Public Health Specialist at firstname.lastname@example.org
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