This study evaluated the effectiveness of two mental health training programs for primary healthcare staff in Sri Lanka following a tsunami. One program provided PHC doctors with both theoretical training and supervised on-the-job training by psychiatrists, while the other provided mid-level PHC staff only brief theoretical training. Both groups improved their mental health knowledge, but PHC doctors improved more and were better able to identify mental disorders in patients. The longer, more comprehensive training combining theory and supervision was more effective at improving skills and care.

1. Evaluation of effectiveness of mental health training
program for primary health care staff in Hambantota
District, Sri Lanka post-tsunami
By Boris Budosan and Lynne Jones
Published May 1st, 2009
Keywords: education, emergency, mental health, primary health care, program
development, Sri Lanka, staff development, supervisions
Introduction
As a result of a humanitarian disaster, about 30-50% affected people develop signs of
either moderate or severe psychological distress. This group would benefit from a range
of social and basic psychological interventions that are considered helpful to reduce
distress (World Health Organization, 2005a). According to the same source, in
emergencies the population rates of mild and moderate mental disorders (mood and
anxiety disorders) are expected to increase by about 5-10% and the rate of severe mental
disorders may be expected to go up by 1-2% This group would need access to mental
health care, which should be provided through general health services or through
community mental health services within the health sector. Primary care is particularly
appropriate because the primary clinic is easily accessible and provides a non-
stigmatizing environment for the treatment of mental disorders (Ommeren at al., 2005).
Mental Health and Psychosocial Support (MHPSS) is reflected within a standard on
mental and social aspects of health in the 2004 Sphere Handbook, which in general
covers standards and indicators for the acute emergency phase of a humanitarian crisis
(Sphere Handbook). According to the Sphere Handbook, care for urgent psychiatric
complaints should be available through the primary health care system. Mental health
training and supervision of available primary health care (PHC) staff is a key action of
the minimum humanitarian response necessary to care for mental disorders in
emergencies (Inter-Agency Standing Committee, 2007). According to Inter-Agency
Standing Committee (IASC) guidelines, training should involve both theory and practice.
It can begin at the outset of emergency (Budosan et al., 2007; Mahoney et al., 2006;
Jones et al., 2007), and it should continue beyond the emergency as a part of a more
comprehensive response (Ommeren et al., 2005; Inter-Agency Standing Committee,
2007).
Evidence suggests that in low and middle income (LAMI) countries, support for primary
health care services with training, assistance and supervision by available specialist
mental health staff, is also the best way to extend mental care to the population (Saxena
et al., 2007). According to Lancet Global Mental Health Group (2007), good-quality

2. mental health training in primary-care settings is one of the strategies to scale up services
for people with mental disorders.
Appropriate training needs to be combined with continued supervision and support to
achieve effective mental health care in primary-care settings (World Health Organization,
2008). According to Siddiqi et al. (2005), the effectiveness of interventions to change
health professionals’ behavior and practices should be a priority area for researchers and
international agencies supporting health system development in developing countries.
The great majority of studies that evaluated the effectiveness of mental health training for
various groups of beneficiaries (residents, general practitioners, nurses) have been
conducted in developed countries ( Hodges et al., 2001; Hodgins et al., 2007; Kroenke
et al., 2000 ). The effectiveness of mental health training for PHC staff has also been
tested in some developing countries (AbuZeid et al., 1998; Amira et al., 1996; Cohen,
2001; Harding et al.,1983; Lum et al., 2008), but very few have examined the issue in
emergency settings. According to Patel and al. (2007), evidence for mental health
interventions for people who are exposed to conflict and other disasters is still weak.
The mental health training program described here was initiated by International Medical
Corps (IMC), an international non-governmental organization (INGO) working towards
the integration of mental health into primary care in developing countries. A year after
piloting its post-tsunami mental health program in Kalmunai in the North-East of Sri
Lanka (Budosan et al., 2007), IMC took the same mental health training model per
government request to the southern district of Hambantota, also hit hard by Tsunami.
The design of the capacity building programs were dictated to some degree by available
national staff training time. This provided the opportunity to contrast the effectiveness of
a less intense but longer mental health training intervention combined with on the job
supervised work to a shorter but more intense theoretical training intervention only. The
hypothesis was that longer and supervised training spread over time would be more
effective and result in changing clinical practices of PHC workers.
Methods
Setting
The mental health training program was conducted in the district of Hambantota in the
Southern province of Sri Lanka. The estimated population of 525,370 (World Health
Organization, 2005) consists mainly of Singhalese (97%) and the remaining 3% is
divided amongst Moors, Malays, Tamils and Burgers. It is estimated that between one-
quarter to one-third of the population in the Southern province lived below the poverty
line before the tsunami, with the numbers climbing exponentially after the disaster. Given
their relative poverty, Hambantota residents were particularly vulnerable to the economic
and psychological shock of the tsunami. The level of infrastructure in Hambantota is also
below national standards. The Sri Lankan 2001 census classified 38% of all dwellings in

3. the district as “temporary”, based on the use of non-durable construction materials- 11%
higher than the national average. Anecdotal reports from PHC doctors interviewed in
Hambantota reported that pre-tsunami, Hambantota presented the highest suicide and
alcohol consumption rates on the island. According to the initial assessment through
focus groups and in-depth interviews conducted at the outset of the training program,
three most prevalent mental health problems in Hambantota were alcohol consumption,
unexplained physical symptoms and depression.
At the time of the study, mental health services in Hambantota district were regularly
provided only by two PHC physicians with some additional training in mental health.
They were operating four outpatient mental clinics under the bi-weekly supervision of a
consultant psychiatrist based in Colombo. Less than half of Hambantota’s population had
local access to mental health services.
Study design
A longitudinal observational study design was used to contrast the effectiveness of two
mental health training interventions for PHC staff.
Study population
The population of PHC doctors received less intense but longer mental health training
combined with on the job supervised work from psychiatrists, while the population of
mid-level public PHC staff received shorter, but more intense theoretical training only,
from 10 trained PHC doctors. Altogether, 38 PHC doctors (27.14 % of all PHC doctors in
Hambantota), and 499 mid-level public PHC staff (almost 100% of mid-level public PHC
workforce in Hambantota) received some form of training intervention from July 2006 to
January 2007. All PHC staff involved in training were responsible for provision of
primary health care to Hambantota population.
Measures
The theoretical mental health knowledge was measured with multiple-choice tests before
and after the training intervention, in both groups of trainees. The test for PHC doctors
contained 30, and the test for mid-level public PHC staff 15 questions. The statistical
index Cronbach alfa was used to measure the degree of internal consistency of
knowledge tests (Wells & Wollack, 2003), and it was .84. Practical performance of PHC
doctors was observed by psychiatrists and measured by using Mental Health On-the-job
training Competency Checklist and Goal Setting Form. The detection rate of mental
health problems was evaluated by reviewing data collection sheets and mental health
assessment forms which also helped development of the case registry of mental health
patients in Hambantota. These two measures were used only for PHC doctors. Socio-
demographic and process variables, e.g. training attendance were noted. Performance of
trainers was observed and evaluated by using scale with 9 tasks measuring the quality of
presentation, presentation techniques, and participants’ satisfaction with presentation with

4. a minimum of zero and a maximum of 9. Years of education and experience of trainers
were evaluated on a point-scale, where one point was given for each year of trainer’s
education and work experience.
The construct validity of all study instruments was determined by: a) the professional
judgment of local experts, b) the available evidence on the use of similar instruments in
similar situations, and c) general recommendations in the literature on questionnaire
design. (Fathala, 2004).
Intervention
The design of the mental health training program for Hambantota’s PHC workers
followed IMC mental health training model already implemented in other parts of Sri
Lanka (Budosan et al., 2007). The theoretical and on-the-job training of PHC doctors by
psychiatrists was followed by the theoretical training of mid-level public PHC staff. A
training of trainers (ToT) model was used in which the PHC doctors trained the mid-
level staff. In a coordination with the local health authorities, a workshop model was
selected as the best mode to deliver theoretical portion of the mental health training.
Two-day workshops were the most feasible and realistic option for the majority of
Hambantota PHC doctors, and one-day workshops for the majority of Hambantota mid-
level public PHC staff. The best model for the mental health on-the-job training of PHC
doctors was that they join the already existing mental health clinic closest to their work
post. Altogether, 70 hours of theoretical training, and on average 7.7 on-the-job training
sessions per participant were delivered to PHC doctors. 12 hours of intense theoretical
training were delivered to mid-level public PHC staff.
The role of health workers within the existing primary health care system and their
interest in mental health were the two most important conditions for the selection of
training participants. Consequently, PHC doctors and mid-level public PHC staff
employed within the primary health care system in Hambantota with a keen interest both
to join the training and to implement newly acquired mental health knowledge/skills in
their everyday practice were automatically selected. The training materials produced
incorporated tasks of increasing recognition of the condition, confirming the diagnosis,
and responding to the mental health problem (Murthy & Narendra, 1983). The mental
health curriculum 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 (Wein,
S. & al., 2002).
Training staff resources for the training of PHC doctors included one international and
three local psychiatrists. 10 local PHC doctors trained in mental health conducted the
training of mid-level public PHC staff.

5. Active participatory approaches, didactic teaching and on-the-job training were equally
used as teaching methods in the training of PHC doctors, while a didactic teaching
method prevailed in the training of mid-level public PHC staff. On-the-job training was
observed and supervised by local and international psychiatrists.
Important characteristics of two training interventions are summarized in Table 1.
Outcomes
The primary outcome measures were changes in test scores and practical performance
after training interventions. The secondary outcome measure was a change in the
detection rate of mental disorders among PHC doctors; in all measures higher scores
indicate improvement compared to baseline measurements. All sets of ratings (baseline
and end-point) were completed by an experienced psychiatrist, who was actively
involved as a trainer in the training program.

6. Process indicators
Training attendance was coded as either complete for those participants who completed at
least 70% or more training, or incomplete for those who completed less than 70%
training.
Analyses
The mean values of knowledge pre and post- tests were compared separately for both
trainings with matched pairs t-test (p=.05) to show any improvement after each training
intervention. The eventual difference between the group of PHC doctors and mid-level
public PHC staff who passed the post-test was tested for statistical significance with the
chi-square test (p=.05). 6
One-way analysis of covariance – ANCOVA (p = .05) was used to compare post-test
results of two groups after removing the effect of their pre-tests. A stepwise approach
was used to determine socio-demographic and process variables significantly associated
with the outcome on the knowledge test. Those variables found by chi-square and Fischer
exact test (p =.05) to be associated with the outcome were included in a binary logistic
regression analysis (p = .05), to determine the impact of independent variables on the
outcome.
The performance of trainers in both trainings were compared, and tested for statistical
significance with t-test for two independent samples (p = .05). Correlation factor (r) was
calculated for the relationship between trainers’ performance and their years of
education/experience. The monthly average number of detected mental disorders post-
intervention was compared with the monthly average number of detected mental
disorders during the training and pre-intervention. The difference between groups was
tested for statistical significance with one-way ANOVA test (p=0.05). The statistical tests
were done by Sigma XL 5.3.4 package.
Results
Sample
20 PHC doctors and 120 mid-level public PHC staff were randomly selected as a sample
for this study. There was a significant difference in the number of female participants,
years of work experience and the location of workplace between these two groups (see
Table 2).

8. Comparison of outcomes
PHC doctors achieved a significant improvement ( t =10.88, p < .05 ) in the results of
post-tests ( µ=24.25, SD=2.75 ) compared to pre-tests ( µ=19.30, SD= 4 ). Also, post-test
results of mid-level public PHC staff ( µ =9.95, SD=1.83 ) were significantly better (t =
17.2, p < .05) than the results of their pre-tests ( µ = 8.62, SD = 1.69 ).The difference in
the post-tests results of two groups persisted after adjustment for the results of their pre-
tests [ F ( 1, 137) = 140.65, p < .001 , ANCOVA].
If pass/fail criteria were used with the cut-off point of 75% correct answers (Public
Service Commission of Canada, 2006), there was a significant difference in the
percentages of PHC doctors (85%) and mid-level public PHC staff (50%) who passed the
test (χ2
(1) = 8.48, p < .01 ).
On-the-job training improved the practical skills of the PHC doctors, which were
virtually non-existent before the training intervention. After the training, 85% of them
were able to make correct diagnosis and take appropriate decisions regarding medication
and the treatment of mental problems, 92.3 % were able to give correct information and
advice about the drug, if prescribing, and all of them were able to provide clear
instructions and explanations for the patient about his or her problem.
Age category, work experience and baseline test knowledge were associated with the
outcome of post-test for PHC doctors in bivariate analysis (see Table 3), but not in
multivariate analysis; age category (p = .83), work experience (p = .82) and baseline test
knowledge (p = .24).

9. Age category was the only variable associated with the outcome of post- test for mid-
level public PHC staff in bivariate analysis (see Table 4), but not in multivariate analysis
(p = .35)

11. The performance of the psychiatrists as trainers of PHC doctors (µ = 8.25, SD=.96) was
significantly better (t =2.8, p = .02) than the performance of GPs as trainers for mid-level
public PHC staff ( µ = 6.5, SD = 1.08). Better educated and more experienced trainers
performed better in training (r = .91 ).
PHC doctors in Hambantota showed a significant improvement in the detection rate of
mental disorders after the training intervention (F = 10.14, p = .003). (See chart 1).
After the training program, the number of registered mental health patients increased in
all health administrative areas of Hambantota district (see Chart 2).

12. Discussion
The whole training program in Hambantota proved acceptable to the local community as
indicated by the high level of engagement of PHC professionals over 6-month period of
the program. Both training interventions took place in a primary care setting, but the
differences in their implementation included both the duration and the
comprehensiveness of the intervention, as well as trainers’ characteristics
(education/experience) and performance in training. The training for PHC doctors was
longer and more comprehensive. It included both theoretical and on-the-job training
component and was conducted by specialists. According to Hodges et al. (2001), the
duration of the intervention, the degree of active participation of the learners, and the
degree of integration of new learning into the learners’ clinical context are the three most
important variables that determine the effectiveness of an educational intervention.

13. Hodgins et al. (2007) also argue that local “context-driven” training should lead to
increased knowledge and reported change in practices by PHC doctors with mental health
patients. According to Joukamaa et al. (1995), the ability among primary health care
practitioners to detect mental disorders is associated with the quality and
comprehensiveness of their mental health training.
The characteristics of trainers in terms of their years of experience in training and
fieldwork is directly related to improving the outcome of the training process ( AbuZeid
et al, 1998).
This study of the effectiveness of a mental health training program for PHC staff in one
district of Sri Lanka supports these findings and adds to the limited evidence base on
innovative strategies for delivering training as a part of a humanitarian assistance in post
disaster and resource-poor settings in developing countries. It also adds to the evidence
that a comprehensive mental health training intervention for PHC professionals is
feasible in a challenging area, such as this part of Sri Lanka, and provides a template that
can be replicated and adopted for use in similar settings.
According to the Lancet Global Mental Health Group (2007), innovative models of
providing mental health services in primary health care need to be implemented in many
LAMI countries. In these settings, there are usually insufficient trained mental health
professionals, and building the mental health capacity of PHC staff through various
training interventions is often the only effective way of providing mental health services
to a large population. Such ToT model is often advocated as an appropriate method of
disseminating training widely (World Health Organization, 2008).
The change in mental health knowledge of both categories of PHC workers and change in
practical skills of PHC doctors after trainings in Hambantota were within the range of
achieved improvements after similar trainings described in the literature (Budosan et al.,
2007; Harding et al.,1983; Kroenke et al., 2000). The principal finding of this study is
that the training of longer duration for PHC doctors spread out over time and combined
with supervision provided by psychiatrists was effective not just in increasing mental
health knowledge / skills, but also in changing mental health practices. The brief and
intense theoretical training for mid-level public PHC staff delivered on its own by the
trained PHC trainers did increase their knowledge, but not to the same degree as the
combined training provided by mental health practitioners. This suggests that future
trainings using a ToT model should ensure that such trainings incorporate practical
components and that the skill set of the trainers is of a sufficiently high standard.
IMC mental health strategy advocates a comprehensive and longer training intervention
combined with supervised on-the-job training targeting all health workers involved in the
provision of primary health care in their communities. However, circumstances on the
ground often force the use of different training approaches with different groups which
allows for the comparison of different training interventions.

14. Limitations
The study was not a randomized controlled trial, but was the most feasible design in the
setting of an actual health service innovation in a resource-poor area. There were no
comparison cohorts of PHC doctors and mid-level public PHC staff who received no
training intervention.
This is because mental health was not practiced by PHC workers in Hambantota before
the training intervention, and it was logical to assume that the changes in knowledge
/skills and mental health practices would occur only by those PHC workers who
completed the training. Another important limitation of the study is that the evaluation of
the effectiveness of the training intervention was done by trainers, which introduces the
possibility of bias in their reporting. The outcome measures used in this study focused on
the results of mental health training. Therefore, although the study confirmed positive
changes in clinical practices of PHC doctors, it was still unable to answer the important
question as to whether their improved practices improved patients’ outcomes. Finally, the
findings of this study are nested in the particular social and cultural milieu of one Sri
Lankan district after the major disaster; the unique challenges and opportunities for the
program may not necessarily generalize to other settings and other circumstances easily.
Strengths of the study and mental health training
program
The study attempted to contrast two different training approaches with two different
groups of PHC workers, and to compare their outcomes. To the best of our knowledge,
this is the first study to examine the comparative outcomes of two different mental health
training interventions for PHC staff delivered as components of a humanitarian assistance
in a low-income setting after a major disaster.
The whole training program in Hambantota increased the overall mental health
knowledge of Hambantota PHC professionals, and it was effective in changing the
mental health practices of PHC doctors. It also confirmed the hypothesis that longer
mental health training of PHC workers spread out over time and combined with
supervision would result in change of their clinical practices. The strength of the training
program was a result of several factors combined together: a) the change in Sri Lankan
policy promoting integration of mental health into primary health care ( Democratic
Socialist Republic of Sri Lanka, 2005), b) commitment of PHC professionals to
implement the results of the policy, c) professionally designed mental health training in
tune with the IASC guidelines being developed at that time ( Inter-Agency Standing
Committee, 2007), d) timing of the program (after the major disaster), and e) cohesive
work of all major stakeholders (government, WHO, local health authorities, local and
international mental health professionals and Hambantota PHC staff).

15. Implications for future research
When evidence from randomized trials is not available, or is difficult to generalize,
observational and interventional studies like this one provide useful information, but must
be carefully interpreted (Buerkens et al., 2004). Nevertheless, both observational and
intervention research is possible, and careful evaluation of ongoing practice and the
lessons learned is valuable (Banatala & Zwi, 2000). Future randomized controlled trials
(RCT) of both training for PHC doctors and mid-level public PHC staff should address
the point made here for generating more scientifically credible evidence of the
effectiveness of mental health training for PHC workers we have described in this paper.
In recognition of the limitations of study reported here, we would recommend further
studies of training interventions for PHC workers in other settings, and another follow-up
study of outcomes of patients who were detected as a result of mental health training of
PHC workers in Hambantota.
Future research could also address the issue of sustainability of mental health training
intervention in Hambantota. It would be important to know if the positive trend in the
detection rate of mental disorders by PHC doctors in Hambantota is sustained in the long
term. Developing countries have limited resources, so it is particularly important to invest
in health care that works and is sustainable in a long-term (Garner et al., 1998).
One other possibility for further research is to see how opportunities initially provided by
post-tsunami relief efforts in Hambantota were used to develop mental health services in
this Tsunami-affected district. According to Saraceno et al. (2007), professional
understanding of effects of disasters, paired with post-emergency mental health interest,
can provide enormous opportunities for mental health system development. Furthermore,
mental health investments in primary care are important but are unlikely to be sustained
unless they are preceded and/or accompanied by the development of community mental
health services.
This study can also help stimulate further research in the field of mental health
interventions in emergency settings. According to IASC Guidelines (2007), scientific
evidence regarding the mental health and psychosocial support that prove most effective
in emergency settings is still thin. Future studies could address the indications of the
relative success of specific interventions for specific mental health conditions, for
example interventions for depression delivered in primary care.

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©2009 The author(s)
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Humanitarian Assistance, its editors and staff, the Feinstein International Center, or Tufts
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