Health and behavioural consequences of the civil war in Sri Lanka

• A case of war-affected women heading households in Mullaitivu

By Dr. Thulitha Wickrama, 

Dr. K.A.S. Wickrama, Sivaguru Thanigaseelan, Wijaya Wickramaratne and 

Dr. Darshan Perera

Thousands of people including civilians, military and paramilitary were killed and millions more affected due to the ethnic conflict in Sri Lanka (LLRC, 2011). It is widely understood that all Sri Lankan citizens were affected as a result of the conflict (Ministry of Resettlement, 2012). 

The present study was conducted by the National Human Resource Development Council of Sri Lanka, Ministry of Public Administration, in the Mullaitivu District, one of the worst affected areas by the war. The objective of the present study were to gain a thorough understanding of the mental, physical, and behavioural health of women heading households, the key socioeconomic unit of vulnerable families, to recommend policies and programs that would enhance their human resource potential through educational, training, employment, and quality of life interventions. 

Individuals residing in this area witnessed traumatic deaths of loved ones, injuries, abductions, kidnappings, hijackings, displacement through refugee experiences, economic, educational, infrastructure, and health neglect, and social isolation. 

Traumatised refugees who belong to ethnic minorities as those from Mullaitivu District have less access to education. Female gender, lack of social support, and lower education are the main predisposing factors of mental illness including PTSD. Moreover, experience of stressful events and daily strains give rise to mental illnesses, such as PTSD, depression and anxiety disorders. 

Thus, the current study documents the disaster experiences, psychological resources, Government assistance, and mental, physical, and behavioural health of war-affected women in Mullaitivu District, an area worst affected by the concluded civil war in Sri Lanka.

Significance of the study

Mental and physical health problems and unhealthy behaviours are common reactions among individuals who have been subjected to military conflicts over a lengthy period of time. Among these conditions, mental illnesses are most prevalent and persistent for decades. Mental illnesses such as PTSD and depression make an individual’s life dysfunctional.  Previous studies have shown that most often war victims present poor mental health including depressive symptoms, somatisation and substance use, as reactions towards traumatic events. These mental health problems also arise due to the family strains such as family economic hardship brought on by experiences of war. 

Greater experiences with war damages and loss have shown depressive symptoms and lower overall health rating of individuals. Behavioural health or specifically healthy eating behaviour is also a significant problem among individuals of war-affected communities due to family economic strains, community poverty and dangers, unavailability of healthy food. 

Moreover, adding to the complexity is the culture specific nature of health symptoms. Non-Western cultures additionally express psychological distress through somatic symptoms. Thus war-related physical injuries and psychological distress-induced physical expressions, directly and indirectly through family and community strains, may both be reported among individuals as physical illnesses. These health and behavioural consequences may be more pronounced in war-affected women.

The theoretical framework

Research has established the links between war-exposed community context and decreased health of residents. Literature has also shown the increased financial strain and greater community dangers in war-affected communities. However, little is known about the mediating processes that link war exposure as measured by perceived war danger and economic adversity caused by the war and health outcomes of war victims, particularly war exposed household heading women. 

War is more consequential for women in traditional societies due to their greater commitment to child rearing and family economic managements. Government assistance would directly counteract mental and physical health risk of war exposure. 

Furthermore, consistent with positive psychological literature, we posit that optimism may play an important mediating effect on the association between war experiences and health outcomes. Thus, we hypothesised that optimism and Government assistance will operate as mediating mechanisms linking war related experiences (economic cutbacks and perceived danger) and health outcomes (mental, physical, behavioural, and maternal). 

In addition, we also hypothesised in the present study that there will be greater mental and physical illness and decreased behavioural health among women reporting greater family economic problems and perceived dangers of the 

environment.

Sample, sampling, and data collection

The sample came from the District of Mullaitivu in north east Sri Lanka. It is one of the most heavily-devastated regions of the country from the recently concluded three decades old civil war. The primary occupation in the region is fishing and farming. The study sample consisted of war-affected women heading households who were the sole breadwinners for their families (Women Heading Households), living in the Mullaitivu District of Sri Lanka. 

A sample of 4,459 women heading households were randomly selected from Government records at the Mullaitivu District Administrative Head Office’s Statistics Department. Data was collected through face-to-face interviews by trained interviewers with an educational background in the psychosocial subjects and employed in the Divisional Secretariat offices in the sub administrative regions of Mullaitivu District.

Supporting our hypotheses, the results show that increases in family economic cutbacks directly increases poor health outcomes, poor mental health, poor physical health, and poor maternal health, while increase in community safety directly decreases poor health outcomes. 

Moreover, supporting our mediating hypotheses, healthy eating behaviour, optimism, and Government service plays a significant mediating role between family economic cutbacks, community safety, and health outcomes. Increase in community dangers significantly increased all three constructs; healthy eating behaviour, optimism, and Government service, while increased family economic cutbacks significantly decrease healthy eating behaviour. 

From among the mediating variables, increase in healthy eating behaviour significantly decreased both poor mental and physical health. Increase in optimism significantly decreased poor physical health while increase in Government service significantly decreased poor maternal health. Showing important linking mechanism, increase in Government service significantly increased optimism while increase in optimism significantly increased healthy heating behaviour. 

Discussion and conclusions

The present study contributes to the literature by broadening our understanding of the mediating effects of psychological resources such as optimism and Government assistance on the association between contextual dangers and family economic problems among mental, physical, and behavioural health among individuals exposed to disasters. Particularly, the findings underscore the mediating role of optimism among war-affected victims. 

These findings are immensely useful for the formulation of programs and intervention for war-affected individuals. These programmes should specifically focus on the development of resilience factors such as optimism among individuals of war-affected areas. 

The findings also highlight the importance of improving Government services to significantly mediate in their impact on health outcomes. In addition, the direct and indict overall influence of community safety and family financial strain on health emphasise the need for directly compensating these factors in war-affected regions. 

Giving further importance to the findings is the vulnerable population of interest in the study; that is, this being a study of ethnic minority Tamil women heading households. Better understanding of the psychosocially significant mediating variables can be used to bring greater relief to these most strained individuals of a 

community.

[Dr. Thulitha Wickrama is Dean of Research, Colombo Institute of Research and Psychology; Dr. K.A.S. Wickrama is Georgia Athletic Association Endowed Professor, Department of Human Development and Family Science, University of Georgia, USA; Sivaguru Thanigaseelan is Assistant Director, NHRDC, Ministry of Public Administration and Home Affairs; Wijaya Wickramaratne, former Chairman, National Human Resource Development Council of Sri Lanka (NHRDC); and Dr. Darshan Perera is Chairman, Colombo International Institute of Research and Psychology.]