Mental health disorders are a crucial contributor to disability and mortality, as
well as to accidental and non-accidental injuries globally 1]. Armed conflict and the ensuing conditions are risk factors for poor mental and physical
health in adolescents and children 2]–5]; in fact, the prevalence of mental disorder tends to double in emergency and post-conflict
settings 6]. Conflict not only exposes adolescents to violent and traumatic events which are
known to increase mental health problems, but can also radically change the social
and economic environment which can catalyse the emergence of psychiatric disorders
7], 8].
Recent cross sectional research indicates that the causal relationship between trauma
and child and adolescent mental health is not simple; family functioning and other
adversities may also independently impair mental health. Previous studies in Sri Lanka
have identified high levels of exposure to war-related events and concurrent mental
disorder in children 9], 10]. In addition, several studies support the notion that multiple traumatic exposures
compound to produce a higher likelihood of mental disorder 11], 12]. Importantly, experience of traumatic events and mental health disorders are associated
with cognitive impairment and school absenteeism 13]. Studies suggest, however, that everyday stressors may partially mediate the relationship
between war-related exposures and mental health outcomes, and that exposure to mass
trauma and experiences of family violence are independently associated with mental
health problems in children 14]–16].
The inclusion of secondary adversities as moderators in the trauma exposure and mental
health relationship may mistakenly downplay the importance of risk and protective
factors. It is not possible to infer levels of mental health and well-being based
on the presence or absence of risk and protective factors alone; two people exposed
to identical environmental conditions can display different mental health profiles
17]. Mental health is determined by a broad range of social, economic, and environmental
factors on an individual, community and social level; these factors work in manifold
interacting processes 18]. Identifying specific, changeable risk and protective factors may be crucial in addressing
mental health problems in children.
According to the UN Convention on the Rights of the Child 19], every child has the right to the best possible health and opportunity for developing
to their full potential, especially those affected by armed conflict. Good physical
health has been identified as a crucial factor for promoting mental health in LMIC
contexts 18], 20]. Physical health is a measure composed of multiple, interacting components and its
relationship with mental health is complex and multifaceted 21]. Many physical health conditions increase the risk for mental disorder, whilst mental
health conditions complicate health seeking behaviours, lifestyle behaviours and treatment
outcomes 21], 22]. In this particular study, we selected two indices of physical health that can be
reliably assessed in children in a post-conflict context, malnutrition and physical
fitness.
High prevalence of malnutrition is common in conflict and post-conflict situations
23]. Socio-economic status and living conditions are strongly correlated with mental
health in young people 3], 24]. Among children and adolescents, malnutrition, particularly thinness, is a feasible
proxy indicator of a difficult home life that lacks sufficient available food. We
identified no studies that assessed the association between adolescent malnutrition
and mental health in post-conflict states, despite its crucial role in adolescent
psychological development 25]. In the absence of evidence regarding malnutrition, research indicates that food
insecurity is associated with poor mental health outcomes; it is a predictor of depression,
suicidal ideation and low mood in adolescents 26].
Physical activity impacts mental health through a variety of mechanisms including
psychological, psychosocial, pharmacological and physiological 27]. Physical fitness is the physiological outcome of increased physical activity 28]. The promotion of physical activity and fitness may improve mental health in several
ways: through the promotion of self-esteem, increased resilience, improved self-worth
and image, and it has a protective effect against mental disorder, especially depressive
symptoms 29], 30]. Meta-analytic evidence from HICs suggests a positive impact of physical activity
interventions on self-esteem in young people 31]. RCT evidence indicates that physical activity significantly reduces depression,
anxiety and can increase self-esteem in young people 32]. Cross-sectional evidence supports the relationship between fitness, activity and
depression in HICs; a longitudinal study in adolescents identified a protective effect
of cardiorespiratory fitness against depression 33]. There is also emerging evidence of an association between physical fitness and mental
health in LMICs 34].
Although there is now a growing body of evidence for the various positive impacts
of physical activity on the physical, mental and social wellbeing of young people,
including those ‘at-risk’ in developed, peaceful settings 30], 31], 35]–38]; the relationship between physical activity and mental health in post-conflict settings
remains unclear 39], 40]. It is not clear whether the associations identified in HIC settings are externally
valid and relevant for adolescents living in post-conflict conditions.
Increasingly, physical activity and exercise-based interventions are incorporated
into assistance for conflict-affected populations; the evidence base for these interventions
is scant 41]. Several publications support the notion that physical activity can act as a buffer
in the relationship between stressors and mental illness 42], 43].
In the post-conflict context, the promotion of fitness through physical activity and
sport might represent a potential intervention lever, it may alleviate stress and
assist with reducing the symptoms of mental disorder 44]. It is essential to test these assumptions prior to the use of physical activity
to promote positive mental health among young people in post-conflict contexts. Coordinating
an appropriate response to the challenges that mental disorders present requires an
understanding of risk and protective factors for poor mental health 45].
In this study we assessed psychological distress and physical health in Grade 8 students
in Killinochchi, using a locally validated measure of mental health. Secondary aims
were to explore the associations between both physical fitness and malnutrition and
mental health. In 2009, Sri Lanka emerged from a prolonged civil conflict between
Government forces and the Liberation Tigers of Tamil Eelam (LTTE). During the conflict
thousands of people died, were injured, or went missing; many more were displaced,
often multiple times 46]. Previous research in adult and adolescent populations has identified variable levels
of common and severe mental disorders dependent, in part, on exposure to traumatic
events and current life situation 46]–54].
We predict a high prevalence of stunting and malnutrition among young adolescents
in Kilinochchi as a result of the high exposure to adverse conditions. Previous studies
of BMI in Sri Lanka have identified geographic variation. “Jayatissa and Randbanda
55] conducted a large scale, representative study of BMI for age and height for age in
Sri Lanka. Prevalence of underweight (defined in the study as 5th percentile of BMI)
in 13 year-old boys and girls was 66.5 and 26.4 % respectively; prevalence of stunting
(3rd percentile) was 41.3 and 40.1 % 55]. Further, a cross-sectional study in Mullaitivu identified a large proportion of
underweight (-2 standard deviations (SD) weight-for-age in this study), 34 %, in 6-18
year olds 56].”
We predict that young adolescents who are malnourished will have worse mental health
than healthy weight adolescents in the target population. Food insecurity and malnutrition
are positively correlated in Sri Lanka 57]. Previous research in among displaced populations in Sri Lanka identified an association
between food insecurity and common mental health disorders in adults, notably depression,
and this association persisted in return migrants one year later 49], 50]. Wickramage et al. 58] assessed the prevalence of malnutrition and mental disorder in children left behind
by international labour migrants. Children from migrant families exhibited significantly
higher prevalence of emotional problems and hyperactivity disorders than comparative
families, although the study did not assess the relationship between malnutrition
and mental health. We identified no studies that assess the relationship between malnutrition
and poor mental health in young adolescents, despite evidence from Sri Lanka and developed
settings suggesting the two may well be associated.
A review of physical activity prevalence in South Asian children and adolescents identified
regional decreases in average activity, although only one publication from Sri Lanka
was included 59], 60]. The study relied on parent-reported data and identified ‘satisfactory levels’ of
physical activity in children aged 8–12 in Colombo. We identified no studies of fitness
in Sri Lankan children and adolescents. Further, we identified no studies that assess
the relationship between mental health and physical activity, or fitness, in Sri Lanka.
In the absence of fitness or activity data we cannot comment on the potential of physical
activity for mental health promotion in this context. Based on regional data we predict
a low level of fitness in the target group, due to decreasing levels of physical activity
in the South Asian region. Further, we predict an association between physical fitness
and mental health in the target population, as current research indicates a positive
association between physical activity and positive aspects of mental health.