When the war was over, little changed: women's posttraumatic suffering after the war in Mozambique

Mediators of Ethnic Differences in Dropout Rates From a Randomized Controlled Treatment Trial Among Latinx and Non-Latinx White Primary Care Patients With Anxiety Disorders

ABSTRACT

Disparities in treatment engagement and adherence based on ethnicity have been widely recognized but are inadequately understood. Few studies have examined treatment dropout among Latinx and non-Latinx White (NLW) individuals. Using Andersen's Behavioral Model of Health Service Use (A behavioral model of families' use of health services. 1968; J Health Soc Behav. 1995; 36:1-10) as a framework, we examine whether pretreatment variables (categorized as predisposing, enabling, and need factors) mediate the relationship between ethnicity and premature dropout in a sample of Latinx and NLW primary care patients with anxiety disorders who participated in a randomized controlled trial (RCT) of cognitive behavioral therapy. Data from a total of 353 primary care patients were examined; 96 Latinx and 257 NLW patients participated. Results indicated that Latinx patients dropped out of treatment more often than NLW patients, resulting in roughly 58% of Latinx patients failing to complete treatment compared with 42% of NLW, and approximately 29% of Latinx patients dropping out before engaging in modules related to cognitive restructuring or exposure, relative to 11% of NLW patients. Mediation analyses suggest that social support and somatization partially explained the relationship between ethnicity and treatment dropout, highlighting the importance of these variables in understanding treatment disparities.

Ghost Encounters Among Traumatized Cambodian Refugees: Severity, Relationship to PTSD, and Phenomenology

Ghost encounters were found to be a key part of the trauma ontology among Cambodian refugees at a psychiatric clinic, a key idiom of distress. Fifty-four percent of patients had been bothered by ghost encounters in the last month. The severity of being bothered by ghosts in the last month was highly correlated to PTSD severity (r = .8), and among patients bothered by ghosts in the last month, 85.2% had PTSD, versus among those not so bothered, 15.4%, odds ratio of 31.8 (95% confidence level 11.3-89.3), Chi square = 55.0, p < .001. Ghost visitations occurred in multiple experiential modalities that could be classified into three states of consciousness: full sleep (viz., in dream), hypnagogia, that is, upon falling asleep or awakening (viz., in sleep paralysis [SP] and in non-SP hallucinations), and full waking (viz., in hallucinations, visual aura, somatic sensations [chills or goosebumps], and leg cramps). These ghost visitations gave rise to multiple concerns-for example, of being frightened to death or of having the soul called away-as part of an elaborate cosmology. Several heuristic models are presented including a biocultural model of the interaction of trauma and ghost visitation. An extended case illustrates the article's findings.

Chronic pain and associated factors in Maputo, Mozambique: a pilot study

Introduction

Studies estimate that 20% of adults suffer from chronic pain. A meta-analysis in low- and middle-income countries (LMICs) found 34% had chronic pain. There are few studies on pain prevalence gathered in Africa. This study surveyed the capital city of Mozambique.

Methods

This was a cross-sectional study employed in a community setting. The Vanderbilt Global Pain Survey comprised questions on the behaviour and attitudes of respondents regarding pain, including previously validated metrics: the Pain Catastrophizing Scale, the World Health Organization Disability Assessment Schedule, the Brief Pain Inventory, Widespread Pain Index and Symptom Severity Score, and the Michigan Body Map.

Results

Ninety-seven surveys were completed out of 100. Pain every day lasting for more than 6 months in their lifetime was reported as 39.2% (CI: 29.4-49.6), and 52% of respondents had pain the day of the interview. However, the pain resulted in little difficulty with activities of daily living and maintaining relationships (61%-89%). Although none reported mental health disorders, 53.6% had experienced a traumatic event in their life, with 45.2% having related nightmares, anxiety, or fear. Most respondents (99%) would take oral medication if it helped their pain, with a large proportion willing to spend significant money for these (49% would pay >US$40) and willing to travel long distances to get help (55.2% would travel >40 kilometer).

Conclusion

The prevalence of chronic pain in Maputo, Mozambique is similar to the average for LMICs. Trends in high-income countries suggest that multimodal pain management and multidisciplinary treatments may improve optimal pain control in LMICs.

Understanding the Effects of Mental Health on Reproductive Health Service Use: A Mixed Methods Approach

Appropriate and woman-led health care for displaced women is essential to respecting basic human rights. In this article, we describe the results of an analysis of the association between mental health and reproductive health service use from a sample of Congolese refugee women residing in short- and long-term camps in Rwanda, with a post-hoc qualitative potion added to expand upon the data-based results. Our findings suggest that structural factors including health policy initiatives affect or even inhibit individual care choices.

Forced migration: health and human rights issues among refugee populations

Undocumented migration is a global phenomenon that is manifest in diverse contexts. In this article, we examine the situations that precipitate the movement of large numbers of people across several African countries, producing a unique type of undocumented migrant--the refugee. These refugee movements impact already fragile African health care systems and often involve human rights violations that are of particular concern, such as gender-based violence and child soldiers. We use examples from several countries in sub-Saharan Africa, including the Democratic Republic of the Congo, Rwanda, Liberia, Sierra Leone, and Mozambique. Drawing on key documents from the United Nations High Commissioner for Refugees, current research, and our personal international experiences, we provide an overview of forced migration and discuss implications and opportunities for nurses to impact research, practice, and policy related to refugee health.

Unravelling the spirits' message: a study of help-seeking steps and explanatory models among patients suffering from spirit possession in Uganda

As in many cultures, also in Uganda spirit possession is a common idiom of distress associated with traumatic experiences. In the DSM-IV and -5, possession trance disorders can be classified as dissociative disorders. Dissociation in Western countries is associated with complicated, time-consuming and costly therapies. Patients with spirit possession in SW Uganda, however, often report partial or full recovery after treatment by traditional healers.

The aim of this study is to explore how the development of symptoms concomitant help-seeking steps, and explanatory models (EM) eventually contributed to healing of patients with spirit possession in SW Uganda. Illness narratives of 119 patients with spirit possession referred by traditional healers were analysed using a mixed-method approach.

Treatments of two-thirds of the patients were unsuccessful when first seeking help in the medical sector. Their initially physical symptoms subsequently developed into dissociative possession symptoms. After an average of two help-seeking steps, patients reached a healing place where 99% of them found satisfactory EM and effective healing. During healing sessions, possessing agents were summoned to identify themselves and underlying problems were addressed. Often-mentioned explanations were the following: neglect of rituals and of responsibilities towards relatives and inheritance, the call to become a healer, witchcraft, grief, and land conflicts.

The results demonstrate that traditional healing processes of spirit possession can play a role in restoring connections with the supra-, inter-, intra-, and extra-human worlds. It does not always seem necessary to address individual traumatic experiences per se, which is in line with other research in this field. The study leads to additional perspectives on treatment of trauma-related dissociation in Western countries and on developing effective mental health services in low -and middle-income countries.

Risk for family rejection and associated mental health outcomes among conflict-affected adult women living in rural eastern Democratic Republic of the Congo

Stigma due to sexual violence includes family rejection, a complex outcome including economic, behavioral, and physical components. We explored the relationship among conflict-related trauma, family rejection, and mental health in adult women living in rural eastern Democratic Republic of the Congo, who participate in a livestock-based microfinance program, Pigs for Peace. Exposure to multiple and different types of conflict-related trauma, including sexual assault, was associated with increased likelihood of family rejection, which in turn was associated with poorer mental health outcomes. Design of appropriate and effective interventions will require understanding family relationships and exposure to different types of trauma in postconflict environments.

The association between post-traumatic stress-related symptoms, resilience, current stress and past exposure to violence: a cross sectional study of the survival of Quechua women in the aftermath of the Peruvian armed conflict

BACKGROUND

The long lasting resilience of individuals and communities affected by mass violence has not been given equal prominence as their suffering. This has often led to psychosocial interventions in post-conflict zones being unresponsive to local realities and ill-equipped to foster local strengths. Responding to the renewed interest in resilience in the field of violence and health, this study examines the resilience and post-traumatic responses of Indigenous Quechua women in the aftermath of the political violence in Peru (1980-2000).

METHODS

A cross-sectional study examined the relationship between resilience, post-traumatic responses, exposure to violence during the conflict and current life stress on 151 Quechua women participants. Purposive and convenience sampling strategies were used for recruitment in Ayacucho, the area most exposed to violence. The study instruments were translated to Quechua and Spanish and cross-culturally validated. Data was analyzed using hierarchical regression analysis. A locally informed trauma questionnaire of local idioms of distress was also included in the analysis.

FINDINGS

Sixty percent of women (n = 91) were recruited from Ayacucho city and the rest from three rural villages; the mean age was 45 years old. Despite high levels of exposure to violence, only 9.3% of the sample presented a level of symptoms that indicated possible PTSD. Resilience did not contribute to the overall variance of post-traumatic stress related symptoms, which was predicted by past exposure to violence, current life stress, age, and schooling (R2 = .421). Resilience contributed instead to the variance of avoidance symptoms (Stand β = -.198, t = -2.595, p = 0.010) while not for re-experiencing or arousal symptoms.

CONCLUSIONS

These findings identified some of the pathways in which resilience and post-traumatic responses interrelate in the aftermath of violence; yet, they also point to the complexity of their relationship, which is not fully explained by linear associations, requiring further examination. Age and gender-sensitive health care is considered critical almost fifteen years after the end of the conflict. The notable resilience of Quechua women-despite exposure to a continuum of violence and social inequalities-also calls for enhanced recognition of women not only as victims of violence but also as complex social actors in the reconstruction of post-conflict societies.

Experiences of female survivors of sexual violence in eastern Democratic Republic of the Congo: a mixed-methods study

BACKGROUND

The conflict in eastern Democratic Republic of the Congo (DRC) is the deadliest since World War II. Over a decade of fighting amongst an array of armed groups has resulted in extensive human rights abuses, particularly the widespread use of sexual violence against women.

METHODS

Using a mixed-methods approach, we surveyed a non-random sample of 255 women attending a referral hospital and two local non-governmental organizations to characterize their experiences of sexual and gender-based violence (SGBV). We then conducted focus groups of 48 women survivors of SGBV to elaborate on survey findings. Quantitative and qualitative data underwent thematic and statistical analysis respectively.

FINDINGS

Of the women surveyed, 193 (75.7%) experienced rape. Twenty-nine percent of raped women were rejected by their families and 6% by their communities. Thirteen percent of women had a child from rape. Widowhood, husband abandonment, gang rape, and having a child from rape were significant risk factors for social rejection. Mixed methods findings show rape survivors were seen as "contaminated" with HIV, contributing to their isolation and over 95% could not access prophylactic care in time. Receiving support from their husbands after rape was protective against survivors' feelings of shame and social isolation.

INTERPRETATION

Rape results not only in physical and psychological trauma, but can destroy family and community structures. Women face significant obstacles in seeking services after rape. Interventions offering long-term solutions for hyper-vulnerable women are vital, but lacking; reintegration programs on SGBV for women, men, and communities are also needed.

The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5

BACKGROUND

There is considerable debate about the cross-cultural applicability of the posttraumatic stress disorder (PTSD) category as currently specified. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds. This review examines various types of cross-cultural validity of the PTSD criteria as defined in DSM-IV-TR, and presents options and preliminary recommendations to be considered for DSM-5.

METHODS

Searches were conducted of the mental health literature, particularly since 1994, regarding cultural-, race-, or ethnicity-related factors that might limit the universal applicability of the diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria for DSM-5.

RESULTS

Substantial evidence of the cross-cultural validity of PTSD was found. However, evidence of cross-cultural variability in certain areas suggests the need for further research: the relative salience of avoidance/numbing symptoms, the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms. This review also indicates the need to modify certain criteria, such as the items on distressing dreams and on foreshortened future, to increase their cross-cultural applicability. Text additions are suggested to increase the applicability of the manual across cultural contexts: specifying that cultural syndromes-such as those indicated in the DSM-IV-TR Glossary-may be a prominent part of the trauma response in certain cultures, and that those syndromes may influence PTSD symptom salience and comorbidity.

CONCLUSIONS

The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

The epidemiology of spirit possession in the aftermath of mass political violence in Mozambique

In this article we assess the prevalence rates of harmful spirit possession, different features of the spirits and of their hosts, the correlates of the spirit possession experience, health patterns and the sources of health care consulted by possessed individuals in a population sample of 941 adults (255 men, 686 women) in post-civil war Mozambique in 2003-2004. A combined quantitative-qualitative research design was used for data collection. A major study outcome is that the prevalence rates vary according to the severity of the possession as measured by the number of harmful spirits involved in the affliction. The prevalence rate of participants suffering from at least one spirit was 18.6 percent; among those individuals, 5.6 percent were suffering from possession by two or more spirits. A comparison between possessed and non-possessed individuals shows that certain types of spirit possession are a major cause of health impairment. We propose that knowledge of both local understandings of harmful spirit possession and the community prevalence of this kind of possession is a precondition for designing public health interventions that sensitively respond to the health needs of people afflicted by spirits.

Sexual violence legislation in sub-Saharan Africa: the need for strengthened medico-legal linkages

Six sub-Saharan African countries currently have laws on sexual violence, including Kenya, and eight others have provisions on sexual violence in other legislation. Effective legislation requires functioning medico-legal linkages to enable both justice to be done in cases of sexual violence and the provision of health services for survivors of sexual violence. The health sector also needs to provide post-rape care services and collect and deliver evidence to the criminal justice system. This paper reviews existing data on sexual violence in sub-Saharan Africa, and summarises the content of sexual violence legislation in the region and the strengths and weaknesses of existing medico-legal linkages, using Kenya as a case study. Many sub-Saharan African countries do not yet have comprehensive post-rape care services, nor substantial co-ordination between HIV and sexual and reproductive health services, the legal and judicial systems, and sexual violence legislation. These need to be integrated by cross-referrals, using standardised referral guidelines and pathways, treatment protocols, and medico-legal procedures. Common training approaches and harmonised information across sectors, and common indicators, would facilitate government accountability. Joint and collaborative planning and working at country level, through sharing of information and data between the different systems remain key to achieving this.

The application of mixed methods designs to trauma research

Despite the use of quantitative and qualitative data in trauma research and therapy, mixed methods studies in this field have not been analyzed to help researchers designing investigations. This discussion begins by reviewing four core characteristics of mixed methods research in the social and human sciences. Combining these characteristics, the authors focus on four select mixed methods designs that are applicable in trauma research. These designs are defined and their essential elements noted. Applying these designs to trauma research, a search was conducted to locate mixed methods trauma studies. From this search, one sample study was selected, and its characteristics of mixed methods procedures noted. Finally, drawing on other mixed methods designs available, several follow-up mixed methods studies were described for this sample study, enabling trauma researchers to view design options for applying mixed methods research in trauma investigations.

Dynamics of socioeconomic risk factors for neglected tropical diseases and malaria in an armed conflict

BACKGROUND

Armed conflict and war are among the leading causes of disability and premature death, and there is a growing share of civilians killed or injured during armed conflicts. A major part of the civilian suffering stems from indirect effects or collateral impact such as changing risk profiles for infectious diseases. We focused on rural communities in the western part of Côte d'Ivoire, where fighting took place during the Ivorian civil war in 2002/2003, and assessed the dynamics of socioeconomic risk factors for neglected tropical diseases (NTDs) and malaria.

METHODOLOGY

The same standardized and pre-tested questionnaires were administered to the heads of 182 randomly selected households in 25 villages in the region of Man, western Côte d'Ivoire, shortly before and after the 2002/2003 armed conflict.

PRINCIPAL FINDINGS

There was no difference in crowding as measured by the number of individuals per sleeping room, but the inadequate sanitation infrastructure prior to the conflict further worsened, and the availability and use of protective measures against mosquito bites and accessibility to health care infrastructure deteriorated. Although the direct causal chain between these findings and the conflict are incomplete, partially explained by the very nature of working in conflict areas, the timing and procedures of the survey, other sources and anecdotal evidence point toward a relationship between an increased risk of suffering from NTDs and malaria and armed conflict.

CONCLUSION

New research is needed to deepen our understanding of the often diffuse and neglected indirect effects of armed conflict and war, which may be worse than the more obvious, direct effects.

Orthostatic Panic as a Key Vietnamese Reaction to Traumatic Events: The Case of September 11, 2001

This article discusses a culturally specific response to traumatic events: orthostatic panic attacks among Vietnamese refugees. We compared the rate and severity of orthostatic panic as well as the rates and severity of associated flashbacks a month before and a month after September 11, 2001. After that date, the rate and severity of orthostatic panic greatly increased, as did the rate and severity of associated flashbacks. The central role of orthostatic panic as a response to traumatic events is illustrated through a patient's vignette. An explanation of why September 11 so profoundly influenced this population is adduced, including an explanation of why it resulted in considerable worsening of orthostatic panic.