The aftermath of war; mental health, substance use and their correlates with social support and resilience among adolescents in a post-conflict region of Sri Lanka

The study addresses adolescent mental health in a post-conflict setting, focusing on Vavuniya district in Northern Sri Lanka, which experienced intense civil war, repeated displacement, damaged infrastructure, poverty, and under-functioning education and healthcare systems. Adolescents in conflict-affected regions face risks including displacement, bereavement, exposure to violence, and school disruption, which can contribute to common mental disorders and related behaviors (e.g., absenteeism, aggression, substance use). Global estimates suggest that about 22% of people exposed to conflict in the prior decade experience mental disorders. Despite Sri Lanka’s primary care strengths, a treatment gap and stigma persist in post-conflict areas. The research aimed to estimate the prevalence of common mental disorders, suicidal ideation (initial aim), substance use (alcohol, tobacco, illicit drugs), and examine their associations with perceived social support and resilience among adolescents aged 12–19 years residing in Vavuniya.

Background literature highlights that exposure to armed conflict is associated with elevated risks of depression, anxiety, PTSD, and other mental disorders. The WHO estimates a 22% prevalence of mental disorders among populations exposed to conflict in the past decade. Prior work in Sri Lanka documents significant mental health impacts on children and adolescents in conflict-affected northern and eastern provinces, compounded by stigma and health system gaps. The four “P” framework (predisposing, precipitating, perpetuating, protective) is used to conceptualize factors influencing adolescent mental health. Existing studies from other conflict settings (e.g., Uganda, Ukraine) report increased depression and anxiety symptoms and their association with risk behaviors, emphasizing the importance of protective factors such as social support and resilience.

Design: Population-based cross-sectional study conducted in Vavuniya district, Sri Lanka, July 2019–October 2020. Setting: Multi-ethnic, predominantly Sri Lankan Tamil district with rural majority; four Divisional Secretariat Divisions (DSDs) and 102 Grama Niladhari Divisions (GNDs). Population: Adolescents aged 12–19 years, residing in Vavuniya ≥5 years, speaking Tamil, Sinhala, or English. Exclusions: Severe hearing/speech problems, autism/significant intellectual disability, severe chronic diseases, non-household living (e.g., orphanages), inability to consent/assent or comprehend questionnaires. Sample size: Based on adolescent population and estimated 50% prevalence; using OpenEpi with 95% precision, design effect 1.5; initial n=570, inflated to 700 for 20% non-response. Sampling: Modified Expanded Program on Immunization (EPI) cluster sampling. Sample drawn from 29 GNDs (24 participants from 28 GNDs; 48 from one GND). If multiple eligible adolescents in a household, the eldest was selected. Instruments: Socio-demographic questionnaire; Youth Quality of Life Questionnaire; Child and Youth Resilience Measure (CYRM); Multidimensional Scale of Perceived Social Support (MSPSS); Patient Health Questionnaire (PHQ-9/PHQ-A); Brief Questionnaire on War; Beck Hopelessness Scale (BHS); adapted comprehensive substance use questionnaire based on UNODC tool. Cultural adaptation: English instruments translated to Tamil and Sinhala using a combined qualitative/quantitative consensus approach with bilingual Community Involvement and Engagement (CIE) group to ensure cultural and dialectal appropriateness; sensitive questionnaires (notably suicidal ideation) were removed following ERC and CIE guidance. Ethics and data collection: ERC recommended excluding suicidal ideation questions and increasing minimum age to 12 years; written parental permission and adolescent assent/consent obtained. Trained research assistants conducted interviews in private, open areas near homes; mixed interviewer- and self-administered formats used, with sensitive items self-completed. Statistical analysis: SPSS v23; two-sided tests (p<0.05). Chi-square for associations; Spearman correlations for depression, hopelessness, QoL, social support, and resilience; linear regression to assess independent effects and variance explained (e.g., resilience and QoL predicted by perceived social support). COVID-19 curtailed data collection in October 2020, yielding a final sample of 585.

• Sample: N=585; mean age 15.02±2.13 years; 50.4% female. School dropout: 8.9% (n=52). War exposure: 15.6% (n=91) exposed to ≥1 war-related event; 93.4% (n=85) of exposed reported internal displacement; 87.9% (n=80) reported family loss of property/belongings. - Substance use (lifetime): 7.0% (n=41) reported any alcohol, tobacco, or illicit substance use; most were males aged 15–19. Among users, 80.5% used tobacco products; first substance used: Bidi 34.21%, Betel quid 23.7%, Beer 15.8%, others (cigarettes, spirits, wine, Babul, Mawa) 26.29%. Reasons: curiosity 80%, friends’ use 72.5%, easy access 70%, feeling unhappy/lonely 27.5%. - Mental health: Moderate–severe depression prevalence 3.9% (n=23). Moderate–severe hopelessness 5.2% (n=8) among participants aged ≥17 years (hopelessness assessed in n=155). - Psychosocial measures: Perceived social support mean 6.24±0.80 (max 7). Youth QoL mean 88.4±8.73 (max 100). Resilience mean 54.10±5.15 (max 60). - Associations: Depression associated with hopelessness, age, dropping out of school, and perceived social support (chi-square p≤0.01). Hopelessness associated with perceived social support (p=0.01). Crude ORs: depression-to-hopelessness OR 9.20 (95% CI 1.89–44.77); high perceived social support associated with lower odds of depression OR 0.21 (95% CI 0.08–0.57) and hopelessness OR 0.13 (95% CI 0.03–0.55). - Correlations (Spearman): Social support with depression r=−0.20 (p<0.01) and with hopelessness r=−0.40 (p=0.000). QoL with depression r=−0.28 (p=0.000) and with hopelessness r=−0.40 (p<0.01); QoL with social support r=0.50 (p=0.000). Resilience with hopelessness r=−0.49 (p<0.01), with depression r=−0.14 (p<0.01), and with social support r=0.60 (p<0.01). - Regression: Perceived social support explained 40% of variance in resilience (R²=0.40); β=4.04 (95% CI 3.55–4.533). Perceived social support explained 22% of variance in QoL (R²=0.22); β=5.6 (95% CI 4.650–6.627). - Additional observations: Depression, substance use, and school dropout were more prevalent among ages 15–19. Adolescents who dropped out of school were more likely to report depression and lifetime substance use than those who remained in school.

Findings suggest notably low prevalence of depression (3.9%) and moderate–severe hopelessness (5.2% among ≥17 years) a decade after the end of Sri Lanka’s civil war, possibly reflecting recovery over time and strong protective factors. High perceived social support and resilience scores, alongside strong negative correlations between social support/resilience and depression/hopelessness, indicate that family, peer, and community support, and cultural cohesion may buffer against mental health problems in conflict-affected adolescents. Despite community concerns about substance use, lifetime self-reported use was low (7.0%), likely under-reported due to social desirability and sensitivity of the topic, a known issue in adolescent surveys. School dropout was associated with higher depression and substance use, aligning with literature that links socioeconomic adversity to educational disengagement and worse mental health outcomes. Overall, the results emphasize the protective role of social support and resilience in post-conflict adolescent mental health, while highlighting areas of vulnerability (older adolescents, school dropouts) that may benefit from targeted interventions.

Adolescents in Vavuniya exhibited low prevalence of depression and hopelessness and reported high perceived social support and resilience. Negative associations between depression/hopelessness and social support/resilience suggest these are important protective factors. Given the observed school dropout prevalence and its association with adverse outcomes, enhancing academic support and educational attainment should be a priority in this conflict-affected region. The study underscores the value of strengthening social support systems and resilience-building in adolescent mental health strategies in post-conflict settings.

• Data collection was curtailed by COVID-19 restrictions, yielding a final sample of 585 versus the planned 700. - Sensitive measures were modified: questions on suicidal ideation were excluded; hopelessness was assessed only among participants aged ≥17 years (n=155), limiting generalizability of hopelessness findings. - Potential under-reporting of substance use due to self-report bias and sensitivity, despite privacy safeguards. - Exclusion of adolescents in non-household settings (e.g., orphanages) and those with severe disabilities or severe chronic illnesses may limit generalizability. - Five-year residency requirement may exclude more recently resettled adolescents who could differ in exposures and outcomes.