[Prishtina-E] JAMA: Mental Health, Social Functioning, and Attitudes of Kosovar Albanians Following the War in Kosovo (Vol. 284 No. 5, August 2, 2000)

[Leze Theresa Zagreda]

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Subject: JAMA: Mental Health, Social Functioning, and Attitudes of Kosovar 
Albanians Following the War in Kosovo (Vol. 284 No. 5, August 2, 2000)
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>JAMA - Journal of the American Medical Association
>Vol. 284 No. 5, August 2, 2000
>
>Mental Health, Social Functioning, and Attitudes of Kosovar Albanians
>Following the War in Kosovo
>
>Barbara Lopes Cardozo, MD, MPH; Alfredo Vergara, PhD; Ferid Agani, MD;
>Carol A. Gotway, PhD
>
>Context
>The 1998-1999 war in Kosovo had a direct impact on large numbers of
>civilians. The mental health consequences of the conflict are not known.
>
>Objectives
>To establish the prevalence of psychiatric morbidity associated with the
>war in Kosovo, to assess social functioning, and to identify vulnerable
>populations among ethnic Albanians in Kosovo.
>
>Design, Setting, and Participants
>Cross-sectional cluster sample survey conducted from August to October
>1999 among 1358 Kosovar Albanians aged 15 years or older in 558 randomly
>selected households across Kosovo.
>
>Main Outcome Measures
>Nonspecific psychiatric morbidity, posttraumatic stress disorder (PTSD)
>symptoms, and social functioning using the General Health Questionnaire
>28 (GHQ-28), Harvard Trauma Questionnaire, and the Medical Outcomes
>Study Short-Form 20 (MOS-20), respectively; feelings of hatred and a
>desire for revenge among persons surveyed as addressed by additional
>questions.
>
>Results
>Of the respondents, 17.1% (95% confidence interval [CI], 13.2%-21.0%)
>reported symptoms that met Diagnostic and Statistical Manual of Mental
>Disorders, Fourth Edition criteria for PTSD; total mean score on the
>GHQ-28 was 11.1 (95% CI, 9.9-12.4). Respondents reported a high
>prevalence of traumatic events. There was a significant linear decrease
>in mental health status and social functioning with increasing amount of
>traumatic events (P.02 for all 3 survey tools). Populations at increased
>risk for psychiatric morbidity as measured by GHQ-28 scores were those
>aged 65 years or older (P = .006), those with previous psychiatric
>illnesses or chronic health conditions (P<.001 for both), and those who
>had been internally displaced (P = .009). Populations at risk for poorer
>social functioning were living in rural areas (P = .001), were
>unemployed (P = .046) or had a chronic illness (P = .01). Respondents
>scored highest on the physical functioning and role functioning
>subscales of the MOS-20 and lowest on the mental health and social
>functioning subscales. Eighty-nine percent of men and 90% of women
>reported having strong feelings of hatred toward Serbs. Fifty-one
>percent of men and 43% of women reported strong feelings of revenge; 44%
>of men and 33% of women stated that they would act on these feelings.
>
>Conclusions
>Mental health problems and impaired social functioning related to the
>recent war are important issues that need to be addressed to return the
>Kosovo region to a stable and productive environment.
>
>JAMA. 2000;284:569-577
>
>
>In late February 1998, clashes in Kosovo between Serbian police forces
>and members of the Kosovo Liberation Army intensified.1 Serbian forces
>burned homes and killed dozens of ethnic Albanians in these raids. As a
>result of the fighting, thousands of ethnic Albanians were displaced
>from their homes in Kosovo; many took refuge with host families, while a
>smaller proportion (several thousands) fled to the hills and forests.1
>By the time North Atlantic Treaty Organization (NATO) operations began
>against Serbia on March 24, 1999, about 260,000 people had been
>displaced within Kosovo and 199,000 had fled to other countries.2 It is
>estimated that as result of this conflict, more than 800,000 people
>became refugees in neighboring countries (mainly Albania, Montenegro,
>and the former Yugoslav Republic of Macedonia), as well as secondary
>countries of asylum in Europe, the United States, and elsewhere. On June
>9, 1999, an agreement between NATO and Serbia was reached, and the
>following day NATO halted its bombing campaign.
>      As the Serbian troops began to pull out of Kosovo, the nearly
>750,000 Albanians from Kosovo who had been living in refugee camps in
>Albania, Macedonia, and Montenegro began to return to Kosovo.2 On their
>return, the displaced Albanians had to come to terms with the
>destruction of their homes and property, missing family members, and the
>traumatic experiences of violence, rape, and persecution. The full
>psychological impact of such emergency situations is a neglected issue.3
>However, recent epidemiological studies in Bosnia4 and studies among
>Cambodian refugees living on the Thai border5 and in the United States
>have shown that psychiatric morbidity is much higher in populations that
>have experienced war, persecution, and mass violence.6, 7
>      To estimate the prevalence of psychiatric morbidity and to identify
>specific vulnerable populations, the Centers for Disease Control and
>Prevention (CDC) and the Institute of Mental Health and Recovery in
>Kosovo, in collaboration with Doctors of the World, conducted a mental
>health survey among ethnic Albanians in Kosovo from August 20 to October
>7, 1999. The survey focused on the period of August 1998 through August
>1999, when most of the intense violence took place.
>
>
>METHODS
>
>Survey Design
>
>Assuming a true prevalence of 20% of mental health-related problems8 and
>a cluster sample design effect of 2, we estimated that a minimum of 1135
>adults aged 15 years or older would be required for a 95% confidence
>interval (CI) to detect a prevalence between 15% and 25%. On the basis
>of available household size and age distribution, we estimated that a
>minimum of 504 households would need to be surveyed. The number of
>households targeted was increased to 600 to compensate for refusals and
>absent adults and to obtain estimates for various subgroups of the
>population.
>      We conducted a 2-stage, 30-cluster sample survey using the 1991
>Kosovo census as a primary sampling frame. Because these data did not
>reflect population movements before and during the ethnic conflict,
>additional data sources were used to adjust the 1991 population figures.
>These sources were village surveys from the United Nations High
>Commissioner for Refugees and food distribution population estimates
>from Action Against Hunger (a nongovernmental organization), both
>reflecting information collected during the weeks before our survey. The
>primary sampling frame consisted of all villages and cities listed in
>the 1991 census, excluding those that were predominantly populated by
>Serbs (70% Serb population) and those that had a population of less than
>100 Albanian inhabitants. The sampling frame was stratified into urban
>(cities with a population >10,000) and rural areas. Using this sampling
>frame, we estimated the total ethnic Albanian population in Kosovo to be
>1.6 million. With probability proportional to population size, we
>selected 15 clusters from the rural and 15 from the urban frame in the
>first sampling stage. In the second stage of sampling, 20 households
>were randomly selected within each chosen cluster (20 households from
>each of 30 clusters for a total of 600 households) using an appropriate
>method designed for the Expanded Programme on Immunization and adapted
>to the particular field conditions.9
>      Identification of cluster samples differed for urban centers and
>rural villages. No maps were available for the villages, and many
>villages were spread out over a large geographic area. We drew maps of
>each cluster, which were then divided into segments of approximately
>equal populations. We then randomly chose a single segment by first
>numbering all segments and then blindly drawing a segment number from a
>bag containing all numbers. In the cities, Kosovo Force (KFOR) offices
>usually had aerial or other maps available. In these cases, we
>superimposed a grid to partition the map into neighborhoods. The
>neighborhoods were numbered, and then a number was blindly chosen to
>randomly select a neighborhood for our survey.
>      After a segment or neighborhood was chosen, the first household to
>be surveyed was chosen randomly as follows. Households were mapped and
>numbered in a random direction from the center to the edge of the
>segment, chosen by spinning a bottle. The first household was chosen by
>blindly drawing a number from a bag using the same method described
>above. The next house was selected to be the closest house to the left,
>as the interviewer exited the house just surveyed. This process was
>repeated until 20 households were surveyed, or until the team leader
>decided it was time to leave for security reasons.
>      We interviewed all adult members of the household present. To
>ensure as much privacy as possible, we encouraged people to complete the
>questionnaires in separate rooms, and men and women interviewers paired
>up with same-sex interviewees to help them complete the questionnaires.
>A security curfew at dusk imposed by KFOR prevented interview teams from
>coming back to survey adults not present during the day. Because of the
>ongoing threat of land mines, KFOR considered access to some remote
>houses unsafe. These homes had to be excluded from our sample and
>replaced by the closest accessible household.
>      Native Kosovar Albanian survey team members had 3 days of training
>on general survey objectives, safety precautions, procedures for proper
>household selection (including randomly selecting the first household
>and handling special situations), and interviewing techniques
>(understanding the questionnaires and addressing sensitive topics). All
>members of the survey team were closely supervised for the first 2 days,
>and they continued to receive daily supervision and instruction until
>the survey was completed. Interviewers were instructed to refer
>participants who appeared to be in obvious distress to community mental
>health services where available. A list of these services was procured
>from the nongovernmental organization coordinating office at the United
>Nations Mission in Kosovo.
>      The study protocol was reviewed by a CDC institutional review board
>representative and informed consent was obtained verbally from all
>participants (with communication occurring in the potential
>participant's native language). The study protocol was also reviewed by
>Doctors of the World for ethical considerations.
>
>Screening Tools
>
>All instruments used in this survey were designed as self-report
>questionnaires, but because of a high percentage of illiteracy,
>especially in rural areas, questionnaires frequently had to be read
>aloud. Because of the need for expediency in collecting data,
>interviewers were instructed to read the questionnaires only to those
>who were illiterate, and to provide assistance if needed to those who
>completed the questionnaire themselves. We used 3 screening tools to
>assess mental health problems and social dysfunction: the General Health
>Questionnaire-28 (GHQ-28),10, 11 the Harvard Trauma Questionnaire
>(HTQ),12 and the Medical Outcomes Study 20 (MOS-20).13 We chose these
>instruments to obtain information on common, nonspecific psychiatric
>problems, to gather information on specific psychiatric syndromes such
>as posttraumatic stress disorder (PTSD) and related traumatic events,
>and to get a broad understanding of the level of social functioning and
>disability in this population.
>      The GHQ-28 is used as a community screening tool and for the
>detection of nonspecific psychiatric disorders among individuals in
>primary care settings.11 A higher mean score on the GHQ-28 represents
>poorer mental health status (score range, 0-28). The GHQ-28 is composed
>of 4 subscales (score range, 1-7): somatization, anxiety, social
>dysfunction, and depression. The HTQ combines the measurement of trauma
>events (part I) and symptoms of PTSD (part II), selected from the
>Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).14 We
>defined the occurrence of PTSD symptoms according to a scoring algorithm
>proposed by the Harvard Refugee Trauma Group,4, 12 on the basis of
>DSM-IV diagnostic criteria. The MOS-20 consists of 20 items on 6
>different scales that assess physical functioning, bodily pain, role
>functioning, social functioning, mental health, and self-perceived
>general health status. We scored the MOS-20 as recommended in the user's
>manual; each raw score was transformed to fit a 0-to-100 scale using a
>standard formula,13, 15 with the higher scores on this scale
>representing better functioning. All 3 tools have been extensively
>validated in many countries and cultures and in many disease
>settings.16-18
>      To assess the effect of broadly defined demographic characteristics
>on mental health status, we collected demographic information including
>age, sex, education level, and marital status. We added additional
>questions specific to the Kosovar Albanian population on feelings of
>hatred and a desire for revenge. All questionnaires were translated into
>Albanian and back-translated to English to ensure cultural
>appropriateness of the instrument and accuracy of the translation. A
>team of Albanian translators including a psychiatrist, a psychologist,
>and a primary care physician from the Institute for Mental Health and
>Recovery did the translation and adaptation of the screening tools.
>
>Data Analysis
>
>We adjusted prevalence estimates and CIs for cluster sampling and
>stratification using Epi Info version 6.4.19 Regression analyses were
>performed using SUDAAN, release 7.5.2 (Research Triangle Institute,
>Research Triangle Par)

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