Impact of Ebola experiences and risk perceptions on mental health in Sierra Leone, July 2015

Jalloh, Mohamed F; Li, Wenshu; Bunnell, Rebecca E; Ethier, Kathleen A; O’Leary, Ann; Hageman, Kathy M; Sengeh, Paul; Jalloh, Mohammad B; Morgan, Oliver; Hersey, Sara; Marston, Barbara J; Dafae, Foday; Redd, John T

In a systematic review, adverse mental health impact has been documented among conflict-affected persons. 24 In Sierra Leone, during protracted civil conflict, exposure to traumatic events was associated with non-specific physical ailments. 46 High prevalence of traumatic experiences and psychiatric sequelae has also been documented among Sierra Leonean refugees. 25 Among war affected youth in Sierra Leone, social disorder and perceived stigma contributed to both externalising and internalising problems. 47 Former child soldiers in Sierra Leone saw reliable improvement in PTSD symptoms over time, suggesting that a supportive environment may encourage resilience. 48 A key recommendation in previous studies and WHO guidance is to integrate mental health into primary healthcare services. 49 One study found global return on investments for scaling up treatment for depression and anxiety. 50 An example of such effort is in progress in Sierra Leone wherein public health nurses are trained to screen patients for possible mental health needs. 51 The WHO Mental Health Gap Action Programme emphasises that scaling up mental health services is a joint responsibility that requires collaboration from governments, health professionals, donors, civil society, communities and families. 52 limitations Although a random national sample was obtained, our sample is not necessarily nationally representative. The sample had a higher proportion of respondents with any education compared with the general population. 53 However, we did not find any association between education level and mental health symptoms, suggesting that this may not have influenced our findings. We acknowledge the necessity of validating survey instruments before using them in a new cultural context. Although PHQ-4 and IES-r have been widely used globally, 31-37 54 neither has been validated nor used in Sierra Leone prior to this study. We therefore do not know the validity of clinical cut-off scores for our sample. To the best of our knowledge, PHQ-4 and IES-r (or the shortened form in this assessment) have not been used to measure population-level symptoms of mental health in any similar setting; making it impossible to compare our results to similar populations elsewhere. However, we found both had acceptable internal reliability and factorial validity. In the current survey, the PHQ-4 instrument demonstrated acceptable internal reliability (Cronbach's α=0.78) and good factorial validity (GFI=0.999, CFI=0.999, RMSEA=0·030). The shortened IES-6 scale used in the present study demonstrated acceptable internal reliability (Cronbach's α=0.78) and good factorial validity (GFI=0·998, CFI=0·998, RMSEA=0.023). In addition, the national sample was not designed to produce specific estimates for directly affected persons such as Ebola survivors, families of Ebola victims and quarantined persons. Moreover, there are no baseline/historical data available for comparisons. We also did not measure the effects of exposure to Sierra Leone's civil conflict on long-term PTSD outcomes on the population prior to Ebola.