Mental health prevalence, healthcare use and access between 2018 and 2022 in Sri Lanka: an analysis of survey data
Authors: Deivanayagam Thilagawathi Abi , Ní Chobhthaigh Sorcha , Devakumar Delan , Patel Kishan , Rannan-Eliya Ravindra Prasan 
Published: October 2023

Background
Sri Lanka has suffered four decades of violent conflict, a tsunami, terrorist attacks and an economic crisis, with unknown mental health consequences. People living with mental health difficulties may experience individual, interpersonal, social or structural barriers to help-seeking. These may include stigma, lack of knowledge, denial, fear of societal repercussions, language, acceptability/appropriateness of care, lack of family support, availability of medication, lack of transport and financial barriers. It is possible that several of these factors may have manifested during the challenging time period for Sri Lankans at which this study took place.

Methods
Using a sample of 4030 respondents from two waves of a nationally representative survey, this study assessed the changes in the prevalence of mental health conditions, and subsequent changes in rates of healthcare usage and access, among adults in Sri Lanka between 2018 and 2022. This spanned a period of crisis and unrest, inclusive of the Easter Sunday attacks in 2019, anti-Muslim riots, the coronavirus disease 2019 pandemic and lockdown measures, as well as the current economic crisis that started in late 2021. Descriptive analyses were conducted to assess the demographic and socioeconomic characteristics of the cohort, and to quantify the prevalence of mental health difficulties within the cohort at each wave. Regression analyses examined the changes in prevalence of mental health difficulties over time. Cross-sectional descriptive analyses examined rates of healthcare use and access among those experiencing mental health difficulties, and regression analyses compared use and access for those experiencing different levels of mental health difficulties, adjusting for age, sex, education, socioeconomic status, ethnicity, religion, region and language.

Results
We found that 2.9% of Sri Lankans experienced high mental health difficulties during 2018–9 and 6.1% in 2021–2. There was a statistically significant increase in prevalence between 2018–9 and 2021–2 (β = 0.23, 95% confidence interval 0.20 to 0.26; p < 0.05). This rise was disproportionately higher amongst older adults, those in the lowest socioeconomic classes, and those not from a minority ethnic group. The gap between inpatient use for those living with the highest and lowest levels of mental health difficulties widened across the study period, though the outpatient use gap remained stable. Finally, while those with high mental health difficulties reported high levels of unmet need for health care, when compared to those with the lowest levels of mental health difficulty, the difference was not found to be significant, likely due to a restricted sample size.

Future work and limitations
It would be beneficial for future studies to investigate issues with measuring mental health, applicability and the cultural safety of mental health measures.

Conclusions
We explored mental health in Sri Lankans during critical time periods when the country experienced various traumatic events. The lessons learnt from how mental health and healthcare access and use were measured in this study allows us to strengthen methods for future studies, allowing for robust longitudinal analyses of healthcare use and access for those experiencing common mental health difficulties.

Funding
This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Global Health Research programme as award number 17/63/47.
A plain language summary of this article is available on the NIHR Journals Library website https://doi.org/10.3310/HJWA5078.