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Kim Y, Rimal D, K C A, Shrestha S, Luitel NP, Prigerson HG, Tol WA, Surkan PJ. Understanding Nepali widows' experiences for the adaptation of an instrument to assess Prolonged Grief Disorder. Transcult Psychiatry 2023; 60:891-904. [PMID: 33351725 DOI: 10.1177/1363461520949005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The experience of grief varies across different cultures and contexts. Women in Nepal who lose their husbands confront discrimination, social isolation, and abuse that influence their experience of grief. Through eight focus group discussions with Nepali widows, we elicited socially sanctioned grief reactions and local idioms used to describe common cognitive, behavioral, and emotional symptoms of grief. Accordingly, modifications to an existing instrument for Prolonged Grief Disorder, the PG-13, are suggested to capture grief symptoms as experienced by Nepali widows. Items in the PG-13 were translated to colloquial Nepali and adapted to maintain comprehensibility, acceptability, relevance, and completeness. Based on the grief-related issues reported in the focus group discussions, the addition of five new items and a new criterion to capture symptoms related to social discrimination are proposed. Widows perceived elevated symptoms one year after the loss to be problematic. It is thus recommended that the duration criterion in the original PG-13 be adjusted from at least six months to at least one year after the loss. These proposed modifications to the instrument should be validated through future psychometric testing.
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Affiliation(s)
- Yoona Kim
- Bloomberg School of Public Health, Johns Hopkins University
| | | | - Angela K C
- Bloomberg School of Public Health, Johns Hopkins University
| | | | | | | | - Wietse A Tol
- Section of Global Health, Department of Public Health, University of Copenhagen
- Peter C. Alderman Program for Global Mental Health at HealthRight International
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Mezzanotte KS, Bhardwaj A, Kim Y, Rimal D, Lee JK, Shrestha A, Tol WA, Luitel NP, Surkan PJ. Social determinants of impaired functioning among Nepali widows: A mixed methods study. Glob Public Health 2022; 17:3853-3868. [PMID: 36065622 DOI: 10.1080/17441692.2022.2118346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite considerable stigmatisation of widows in Nepal, little is known about factors affecting their ability to function in society. Using mixed methods, we studied psychosocial factors associated with impaired functioning among Nepali widows. For the qualitative analysis, we analysed 3 focus groups, 25 in-depth interviews, and 12 key-informant interviews. The quantitative analysis was based on data from 204 widows. Odds ratios were calculated linking psychosocial exposures to impaired functioning using adjusted logistic regression models. Low social support (aOR = 2.35, 95% CI: 1.2, 4.6, generally; aOR = 3.3, 95% CI: 1.7, 6.42, specifically from family members), experiences of discrimination (aOR = 2.97, 95% CI: 1.43, 6.14), and low life control (aOR = 4.3, 95% CI: 1.86, 10.1) were risk factors for impaired functioning. Qualitative findings suggested how discrimination and lack of control contribute to impaired functioning. Support from the husband's family appeared to be more important to a widow's functioning, compared to from her own parents. Knowledge about risk factors for impaired functioning can help inform interventions for Nepali widows.
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Affiliation(s)
- Kathryne S Mezzanotte
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anvita Bhardwaj
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yoona Kim
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Damodar Rimal
- Transcultural Psychosocial Organization Nepal (TPO), Kathmandu, Nepal
| | - Jane K Lee
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Abina Shrestha
- Women for Human Rights, Single Women Group, Kathmandu, Nepal.,Humanities Department, Bagiswori College, Tribhuvan University, Bhaktapur, Nepal
| | - Wietse A Tol
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nagendra P Luitel
- Transcultural Psychosocial Organization Nepal (TPO), Kathmandu, Nepal
| | - Pamela J Surkan
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Isolation and Its Impact on Widows: Insights from Low-Resourced Communities in Binga District, Zimbabwe. SOCIAL SCIENCES-BASEL 2022. [DOI: 10.3390/socsci11070298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The lives of women change immediately after the death of their husbands. After the death of their husbands, they experience extraordinary isolation which excludes them from important socioeconomic decisions. This paper discusses how widows are isolated and excluded in pertinent socioeconomic spheres and decisions that impact negatively on their lives including the lives of their children in low resourced communities of Binga District in Zimbabwe. Twenty-four widows were participants in this study, which used a qualitative research approach, a phenomenological research design and purposive sampling strategy. Ten widows participated in individual interviews whilst fourteen widows participated in two separate focus group interviews comprising seven widows each to provide insights on how they were isolated after the death of their husbands. Germain to isolation, thematic data analysis findings revealed that, upon the death of their husbands, widows are vulnerable to exclusion from critical decisions on accrued wealth, socioeconomic amenities and activities needed for their optimal well-being and the welfare of their children. The findings show the need for negotiated professional and community social interventions that are organised and integrated.
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A Conceptual Review of Loneliness in Adults: Qualitative Evidence Synthesis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111522. [PMID: 34770035 PMCID: PMC8582800 DOI: 10.3390/ijerph182111522] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 12/17/2022]
Abstract
The paper reports an evidence synthesis of how loneliness is conceptualised in qualitative studies in adults. Using PRISMA guidelines, our review evaluated exposure to or experiences of loneliness by adults (aged 16+) in any setting as outcomes, processes, or both. Our initial review included any qualitative or mixed-methods study, published or unpublished, in English, from 1945 to 2018, if it employed an identified theory or concept for understanding loneliness. The review was updated to include publications up to November 2020. We used a PEEST (Participants, Exposure, Evaluation, Study Design, Theory) inclusion criteria. Data extraction and quality assessment (CASP) were completed and cross-checked by a second reviewer. The Evidence of Reviews of Qualitative Research (CERQual) was used to evaluate confidence in the findings. We undertook a thematic synthesis using inductive methods for peer-reviewed papers. The evidence identified three types of distinct but overlapping conceptualisations of loneliness: social, emotional, and existential. We have high confidence in the evidence conceptualising social loneliness and moderate confidence in the evidence on emotional and existential loneliness. Our findings provide a more nuanced understanding of these diverse conceptualisations to inform more effective decision-making and intervention development to address the negative wellbeing impacts of loneliness.
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Surkan PJ, Garrison-Desany HM, Rimal D, Luitel NP, Kim Y, Prigerson HG, Shrestha S, Tol W, Murray SM. Adaptation and psychometric validation of the Prolonged Grief Disorder scale among widows in central Nepal. J Affect Disord 2021; 281:397-405. [PMID: 33352410 DOI: 10.1016/j.jad.2020.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 11/10/2020] [Accepted: 12/05/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Symptoms of grief vary by culture and societal reactions to death may be gender specific. We aimed to validate a Nepali language version of the Prolonged Grief-13 item scale (PG-13) among widows. METHODS We tested two adapted versions of a Prolonged Grief Disorder (PGD) instrument with 204 Nepali-speaking widows: one was a Nepali translation of the original PG-13 items, while the other contained five additional items derived from qualitative research. We evaluated internal consistency, factor structure, and construct and criterion validity. RESULTS Participants were on average 44 years old (SD=9.3), completed 6.7 years of school (SD=3.3) and had survived their husbands by 10 years (SD=8.1). Thirteen percent met global criteria for PGD. The removal of one original PG-13 item (felt emotionally numb) from both versions due to poor discriminant validity resulted in 12- and 17-item versions. Exploratory factor analysis supported a one-factor structure for the PG-12 and PG-17. Both versions of the scale exhibited high internal consistency (0.89 and 0.93 respectively). Confirmatory factor analysis suggested that symptoms of PGD were distinct from post-traumatic stress disorder (PTSD), anxiety and depressive symptoms. The PG-12 had lower sensitivity (74.1%) but higher specificity (83.6%) compared to the PG-17 (81.5% and 73.5% respectively). LIMITATIONS Psychosocial counselors' clinical interview global ratings were used as the standard for comparison in criterion validity analyses. Generalizability to other socio-cultural (e.g. non-widowed, low-caste) populations and men in Nepal cannot be assumed. CONCLUSIONS Results indicate satisfactory psychometric properties and validity of both versions of the PG instruments, supporting their use with Nepali speaking widows.
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Affiliation(s)
- Pamela J Surkan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Henri M Garrison-Desany
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Damodar Rimal
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Baluwatar, Kathmandu, Nepal, GPO Box 8974/CPC Box 612
| | - Nagendra P Luitel
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Baluwatar, Kathmandu, Nepal, GPO Box 8974/CPC Box 612
| | - Yoona Kim
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medical College, New York, NY, USA
| | - Sumeera Shrestha
- Women for Human Rights, single women's group, P.O. Box 8973 NPC 427, Baluwatar, Kathmandu, Nepal
| | - Wietse Tol
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA; Section of Global Health, Department of Public Health, University of Copenhagen
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Garrison-Desany HM, Lasater ME, Luitel NP, Rimal D, Pun D, Shrestha S, Tol W, Surkan PJ. Suicidal ideation among Nepali widows: an exploratory study of risk factors and comorbid psychosocial problems. Soc Psychiatry Psychiatr Epidemiol 2020; 55:1535-1545. [PMID: 32794027 DOI: 10.1007/s00127-020-01932-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 08/07/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Suicide is a leading cause of death among Nepali women of reproductive age. Suicidal ideation has known associations with stressful life events, which Nepali widows disproportionately experience. We aimed to identify risk and protective factors that could lead to effective interventions for this population. METHODS To study suicidal ideation in Nepali widows, we collected data from 204 women in urban, semi-urban, and rural areas whose husbands died at least one year prior. The questionnaire included sociodemographic information, the Hopkins Symptom Checklist-25, PTSD Checklist-Civilian Version, Somatic Symptom Scale-8, and the Multidimensional Scale of Perceived Social Support. Overall severity of prolonged grief was assessed by a counselor after completing a structured clinical interview. Using multivariate regression models, we assessed associations of sociodemographic and psychosocial indicators with past-year suicidal ideation. Latent profile analysis was also performed to estimate profiles of comorbidities. RESULTS Past-year suicidality was high, with 16.2% (N = 33). Each year increase since husband's death was protective and reduced odds of ideation 8% (95% CI 0.85-0.98) and being educated and of older age also reduced the odds of ideation by 0.21 (95% CI 0.06-0.70), and 0.09 (95% CI 0.01-0.64), respectively. Depression (OR = 6.37, 95% CI 2.78-14.59), PTSD (OR = 3.84, 95% CI 2.15-6.86), prolonged grief (OR = 6.04, 95% CI 3.04-12.00) and anxiety (OR = 6.52, 95% CI 2.96-14.38) were highly associated with suicidality, and mapped onto the three profiles of increasing mental distress severity. CONCLUSION Suicide remains a major issue among Nepali widows, showing high comorbidity with other mental disorders. Screening for depression, anxiety, and prolonged grief, may aid in identifying widows at increased risk of suicidal ideation.
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Affiliation(s)
- H M Garrison-Desany
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - M E Lasater
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - N P Luitel
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - D Rimal
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
| | - D Pun
- Women for Human Rights, Single Women's Group, Kathmandu, Nepal
| | - S Shrestha
- Women for Human Rights, Single Women's Group, Kathmandu, Nepal
| | - W Tol
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - P J Surkan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Ghaith SM, AL-Baddareen GS, Al Ali TM, Akour MM. Perceived social support among widowed women in Jordan: An exploratory study. WOMENS STUDIES INTERNATIONAL FORUM 2020. [DOI: 10.1016/j.wsif.2020.102364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hendrickson ZM, Kim J, Tol WA, Shrestha A, Kafle HM, Luitel NP, Thapa L, Surkan PJ. Resilience Among Nepali Widows After the Death of a Spouse: "That Was My Past and Now I Have to See My Present". QUALITATIVE HEALTH RESEARCH 2018; 28:466-478. [PMID: 29110564 DOI: 10.1177/1049732317739265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Responses to the death of a spouse vary; although some are at increased risk of poorer physical and mental health outcomes, others have more resilient responses. In light of the limited scope of research on widows' experiences in Nepal, a setting where widows are often marginalized, we explore themes of resilience in Nepali widows' lives. Drawing from a larger qualitative study of grief and widowhood, a thematic narrative analysis was performed on narratives from four widows that reflected resilient outcomes. Individual assets and social resources contributed to these widows' resilient outcomes. Forgetting, acceptance, and moving forward were complemented by confidence and strength. Social support and social participation were key to widows' resilient outcomes. These four narratives reflect the sociocultural context that shape widows' resilient outcomes in Nepal. Future studies on the emergent themes from this exploratory study will help identify how best to encourage resilient outcomes among widows.
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Affiliation(s)
- Zoé M Hendrickson
- 1 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jane Kim
- 1 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Wietse A Tol
- 1 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abina Shrestha
- 2 Women for Human Rights, Single Women Group, Kathmandu, Nepal
| | - Hari Maya Kafle
- 2 Women for Human Rights, Single Women Group, Kathmandu, Nepal
| | | | - Lily Thapa
- 2 Women for Human Rights, Single Women Group, Kathmandu, Nepal
| | - Pamela J Surkan
- 1 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Kim J, Tol WA, Shrestha A, Kafle HM, Rayamajhi R, Luitel NP, Thapa L, Surkan PJ. Persistent Complex Bereavement Disorder and Culture: Early and Prolonged Grief in Nepali Widows. Psychiatry 2017; 80:1-16. [PMID: 28409713 DOI: 10.1080/00332747.2016.1213560] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Persistent complex bereavement disorder (PCBD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has not been well studied in socioculturally diverse populations. Thus, this qualitative study examined (a) how widows in Nepal understand grief, (b) whether a local construct of PCBD exists, and (c) its comparability with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), terminology. METHODS Using an adapted Explanatory Model Interview Catalogue (EMIC) framework, semistructured interviews with 25 widows and 12 key informants, as well as three focus-group discussions (n = 20), were conducted between October 2014 and April 2015. Through an inductive grounded theory-based approach, we used the constant comparative method, iteratively coding transcripts to identify themes and patterns in the data. Also, we created two lists of grief responses, one of early reactions and another all reactions to grief, based on the frequency of mention. RESULTS No single term for grief was reported. Widows reported a local construct of PCBD, which was broadly compatible with DSM-5 terminology but with important variation reflecting societal influence. Surviving torture during conflict, economic and family stressors, and discrimination were mentioned as important determinants that prolong and complicate grief. Suicidal ideation was common, with about 31% and 62% of widows reporting past-year and lifetime suicidality, respectively. Findings may not be generalizable to all Nepali widows; participants were recruited from a non-governmental organization, from Kathmandu and its neighboring districts, and were primarily of reproductive age. CONCLUSIONS While PCBD symptoms proposed in DSM-5 were mentioned as relevant by study participants, some components may need adaptation for use in non-Western settings, such as Nepal.
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