1. Rachel Burns London School of Hygiene and Tropical Medicine
Health status of returning refugees, internally displaced persons, and the host community in a post-conflict district in Northern Sri Lanka: A cross-sectional survey
Rachel Burns
London School of Hygiene and Tropical Medicine

2. Background Adverse impacts of conflict-driven displacement on health
Less is known about the health effects of prolonged conflict
Sri Lankan Context
30 years of protracted internal conflict until 2009
At peak of conflict, almost 1 million people displaced
Displacement associated with conflict is increasingly recognised as an important issue in global health.
Evidence shows that conflict-driven displacement has profound impacts on both the physical and mental health of those displaced.
While both groups may flee for similar root causes, their experiences with displacement and subsequent health needs are heterogeneous and multidimensional.
Understanding the unique health status and associated risk factors for sub-populations with distinct displacement profiles is vital for effective and equitable humanitarian service delivery
How does displacement status and other risk factors affect the health of men and women in Vavuniya, Sri Lanka?

3. Methods Analysis of a cross-sectional survey carried out in 2011
Primary exposure: Displacement status of each household
Inclusion criteria: Returning refugees (RET); Internally Displaced Persons (IDP); Host Community (HOC) ~ 190 each
Outcomes: (1) 36-item Short Form Questionnaire (SF-36); (2) 9-item Patient Health Questionnaire (PHQ-9); (3) Chronic disease status
Other exposure variables analyzed according to a hierarchical conceptual framework
Returning Refugees (RET): any household containing refugees who had returned to Vavuniya district from 1st January 2010 to 30th March 2011;
Internally Displaced Persons (IDP): displaced in the most recent civil conflict (ending in June 2009) and living in Cheddikulum IDP camp, Vavuniya District at the time of the survey;
Host Community (HOC): never displaced internally and never sought asylum as refugee at any time over the past 10 years
at least one of the following: hypertension, angina, heart attack, congestive heart disease, diabetes, lung diseases, cancer, mental health disorders, or chronic renal disease

4. Conceptual framework showing the hierarchical relationship between the different levels of risk factors and the measured health outcomes
Univariable associations of displacement status and potential risk factors with each outcome were observed.
Multivariable logistic regressions were performed for mental health status and chronic disease status. A generalised linear regression with a Gaussian distribution and identity link function was employed for SF-36 total score, and effect sizes were reported as the β coefficient
For the multivariable analysis, the base model included the outcome, displacement status and a priori sex and age
Starting with the first domain, we adopted a forward modelling approach using likelihood ratio tests to determine inclusion into the model
The final model constructed was then used as the base model in the second domain and the process was continued until the last domain and final model was found.

5. Results: displacement status
Mild Depression (PHQ-9)
5.8% HOC
10.5% IDP
3.2% RET
IDP: 1.1 (0.5, 2.5); p=0.791
RET: 0.6 (0.2, 1.7); p=0.320
* Adjusting for sex, age, and employment
Quality of Life (SF-36)
84 (71-90) HOC
66 (47-85) IDP
85 (71-90) RET
IDP: -6.7 (-11.4, -2.0); p=0.006**
RET: 4.0 (-1.0, 89); p=0.114
* Adjusting for sex, age, education level, income level, employment status, debt, dietary intake, number of displacements, measles vaccination, awareness of alcohol, number of people in the home
Chronic Disease Status
24.7% HOC
26.3% IDP
24.2% RET
IDP: 1.3 (0.4, 4.4); p=0.63
RET: 0.5 (0.2, 1.1); p=0.103
* Adjusting for sex, age, dietary intake, aware of alcoholism, attempted suicide, aware of violence against children

6. Results: risk factor analysis
Mild Depression (PHQ-9)
Age >=60: 14.9 (3.1, 71.9); p=0.001
Quality of Life (SF-36)
Female: -3.6 (-7.1,-0.1); p=0.042
Age >=60: (-23.1,-13.3); p=0.001
In debt: -5.6 (-8.5, -2.7); p=0.001
Less than 3 fruit & veg: -5.1 (-7.6,-2.5); p=0.001
Chronic Disease Status
Age >=60: 23.0 (8.8,59.9); p=0.001
Greater than 3 fruit & veg: 2.1 (1.3, 3.2); p=0.001
Aware of alcoholism: 2 (1.2, 3.2); p=0.005

7. Discussion
IDPs showed strong evidence of a lower quality of life compared to the HOC and RET
Mild depression: Age and effect of prolonged exposure to trauma and conflict
At least one chronic disease: Expected linear trend with age; higher diet diversity as a proxy for eating more fat and salt
Lower quality of life: women and older adults; uncertainty associated with limited income, debt and food insecurity; trauma-associated with experiencing repeated episodes of displacement

8. Conclusions Limitations Small sample size
Cannot fully infer causal associations of cross-sectional data
Recall bias, self-reporting of chronic disease status
Findings suggest:
Unique health needs of different migrant sub-groups
Need for mental health care services in post-conflict settings
NCDs are a growing challenge in displaced populations

9. Acknowledgements
Thank you to the co-authors: Kolitha Wickramage, Anwar Musah, Chesmal Siriwardhana, and Francesco Checchi
And
Dr Sharika, Dr Thulasi and Dr Sanjeeva from IOM Sri Lanka Health team and Dr R.Surenthirakumaran of Faculty of Medicine, University of Jaffna for technical guidance in training the field team; the field team comprised of enumerators who collected the data; and, the government representatives across IDP camp, District and National levels that assisted in providing access and clearance to undertake study.