No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Mental Health of Expatriate and Kosovar Albanian Humanitarian Aid Workers
Abstract
The mental health consequences of exposure to traumatic events and the risk factors for psychological morbidity among expatriate and Kosovar Albanian humanitarian aid workers have not been well studied. In June 2000, we used standardised screening tools to survey 285 (69.5%) of 410 expatriate aid workers and 325 (75.8%) of 429 Kosovar Albanian aid workers from 22 humanitarian organizations that were implementing health programmes in Kosovo. The mean number of trauma events experienced by expatriates was 2.8 (standard deviation: 2.7) and by Kosovar staff 3.2 (standard deviation: 2.8). Although only 1.1% of expatriate and 6.2% of Kosovar aid workers reported symptoms consistent with the diagnosis for post-traumatic stress disorder, 17.2% and 16.9%, respectively, reported symptoms satisfying the definition of depression. Regression analysis demonstrated that the number of trauma events experienced was significantly associated with depression for the two sets of workers. Organisational support services may be an important mediating factor and should be targeted at both groups.
... The finding that trauma exposure and associated symptomology (i.e., CPTSD) was associated with increased risk-taking is consistent with a vast body of literature citing that trauma exposure causes elevated risk-taking behaviours [47] and suggests that risk-taking behaviour might signal a need for mental health support among humanitarian workers. Specifically, alcohol use as a form of risktaking behaviour, particularly among international staff [48], is consistent with previous research noting high levels of alcohol use among humanitarian workers even in instances where, overall, humanitarian aid workers were found to experience no change in negative mental health outcomes post-assignment [8,11,13,44]. ...
... That said, there were large differences in the proportion of (predominantly Iranian) national staff endorsing alcohol consumption compared to international staff (12 % vs. 88 %), which, and consistent with previous findings [48], highlights a need to consider possible sociocultural differences in risk-taking behaviours. Similarly, and given that acts of suicide are forbidden in Islamic cultures [49], observed differences between national and international staff on measures of suicidality in the current study may also be explained by socio-cultural differences present in the current sample. ...
... Inconsistent with previous findings [12,48], perceived social support among humanitarian workers was not found to account for risk-taking and suicidality in the current sample. While an unexpected finding given the previously reported role of social support in mitigating the risk of psychological distress among disaster responders [34], a 2021 metaanalysis conducted by Zalta et al. suggests a more complex relationship between social support and trauma-related symptomology, whereby social support may, in part, depend on the nature of the traumatic event [52]. ...
... It is well recognised that exposure to stressors (acute and chronic) negatively affect humanitarian aid workers' mental health and can lead to short and/or long term adverse mental health [5,10,[12][13][14][15][16][17][18]. Individual studies have described that different types of humanitarian aid workers are at increased risk of developing depression [12,13,15,19], anxiety [12,13,15,19], burnout [12,13,15] and post-traumatic stress disorder (PTSD) [12][13][14]19], in addition to hazardous alcohol consumption as a coping mechanism [19,20]. ...
... Five studies surveyed international humanitarian aid workers only [28,[30][31][32][33] and four studies assessed both national and international aid workers [19][20][21]34]. The most common term used to describe the participants was 'humanitarian aid worker'. ...
... Other terms included: 'relief force worker', 'aid worker' and 'humanitarian worker'. Six studies provided details of the job roles of the humanitarian aid workers who participated [19,20,28,30,31,33]. The most ...
Background
Humanitarian crises and disasters affect millions of people worldwide. Humanitarian aid workers are civilians or professionals who respond to disasters and provide humanitarian assistance. In doing so, they face several stressors and traumatic exposures. Humanitarian aid workers also face unique challenges associated with working in unfamiliar settings.
Objective
To determine the occurrence of and factors associated with mental ill-health among humanitarian aid workers.
Search strategy
CINAHL plus, Cochrane library, Global Health, Medline, PubMed, Web of Science were searched from 2005–2020. Grey literature was searched on Google Scholar.
Selection criteria
PRISMA guidelines were followed and after double screening, studies reporting occurrence of mental ill-health were included. Individual narratives and case studies were excluded, as were studies that reported outcomes in non-humanitarian aid workers.
Data analysis
Data on occurrence of mental ill-health and associated factors were independently extracted and combined in a narrative summary. A random effects logistic regression model was used for the meta-analysis.
Main results
Nine studies were included with a total of 3619 participants, reporting on five types of mental ill-health (% occurrence) including psychological distress (6.5%-52.8%); burnout (8.5%-32%); anxiety (3.8%-38.5%); depression (10.4%-39.0%) and post-traumatic stress disorder (0% to 25%). Hazardous drinking of alcohol ranged from 16.2%-50.0%. Meta-analysis reporting OR (95% CI) among humanitarian aid workers, for psychological distress was 0.45 (0.12–1.64); burnout 0.34 (0.27–0.44); anxiety 0.22 (0.10–0.51); depression 0.32 (0.18–0.57) and PTSD 0.11 (0.03–0.39). Associated factors included young age, being female and pre-existing mental ill-health.
Conclusions
Mental ill-health is common among humanitarian aid workers, has a negative impact on personal well-being, and on a larger scale reduces the efficacy of humanitarian organisations with delivery of aid and retention of staff. It is imperative that mental ill-health is screened for, detected and treated in humanitarian aid workers, before, during and after their placements. It is essential to implement psychologically protective measures for individuals working in stressful and traumatic crises.
... Working to alleviate suffering associated with conflict, poverty, disease, and natural disasters, aid workers face complex and challenging situations that are mentally and physically taxing (Jachens, 2019). They suffer elevated rates of mental health symptoms and diagnoses compared with general populations, including posttraumatic stress disorder (PTSD), depression, anxiety, burnout, and heavy alcohol consumption (Connorton et al., 2012;Garbern et al., 2016;Jachens et al., 2016;Lopes Cardozo et al., 2005Putman et al., 2009). Given their crucial role in responding to situations of global instability, and the notable toll it can take, it is of vital public health importance to increase access to, engagement with, and the effectiveness of resources and services that support the mental health and resilience of aid workers. ...
... Factors such as heavy workloads, long hours, unsupportive managers, stressful team environments, and unrealistic expectations for productivity are commonly reported by aid workers as major stressors (Curling & Simmons, 2010;Jachens et al., 2018;Strohmeier & Scholte, 2015;Young et al., 2018), and are also associated with increased risk of poor mental health (Brooks et al., 2015). Poor organizational support was also significantly associated with increased depression after deployment for international aid workers (Brooks et al., 2015;Lopes Cardozo et al., 2005). In addition, female aid workers report further challenges related to security, harassment at work, and balancing work and family responsibilities (Gritti, 2015;Strohmeier & Panter-Brick, 2020). ...
... Previous research has found that expatriates experience higher levels of burnout than locally employed aid workers and that being an expatriate aid worker is a risk for poor mental health (Young & Pakenham, 2021). Research has also demonstrated that rates of depression were related to number of deployments for international aid workers, with high rates of depression after the first deployment and a peak at five deployments (Lopes Cardozo et al., 2005). ...
International aid workers provide critical services to millions of people around the world who are facing conflict, poverty, disease, and natural disasters. As such, aid workers routinely encounter danger and adversity, and endure negative mental health sequelae, including traumatic stress. While aid organizations have begun to provide psychosocial support services to their employees, the barriers and facilitators impacting aid workers’ access to mental health resources and services are understudied, and it is unclear how organizational actions facilitate or impede aid worker utilization of these services. Fourteen international aid workers participated in 90-min semistructured interviews and reflexive thematic analysis was used to identify key themes from the interviews. Workplace barriers to access and utilization of psychosocial services included expectations of workplace productivity, unsupportive management, fear of negative career consequences, lack of organizational recognition of mental health symptoms, services that do not meet aid workers' needs, and limited resources. Facilitators included positive messaging from employers around mental health, referrals to specific providers experienced in serving aid workers, and training managers about mental health and trauma. Future directions and implications are discussed.
... This can evoke moral dilemmas and feelings of helplessness among iHAWs (Eriksson et al., 2009). Organisational stressors such as high deployment frequency, work conflicts, poor management, a lack of management support, a lack of reciprocity, perceived inequity at work, and heavy workload are likely more important causes of stress for iHAWs (Cardozo et al., 2005;Dubravka et al., 2016;Eriksson et al., 2009). ...
... AUD is associated with increased mortality rates and burden of illness (Carvalho et al., 2019). Our results are supported by previous findings of increased levels of alcohol use among iHAWs (Cardozo et al., 2005;Dubravka et al., 2016). Higher alcohol consumption may be part of an international humanitarian lifestyle. ...
... We did not study national staff. This group runs a greater risk to be killed, wounded or kidnapped (Stoddard et al., 2020), and reported greater psychological distress compared to iHAWs (Cardozo et al., 2005). Considering that national staff makes up for 90 % of the aid workers (Stoddard et al., 2009), further investigation into the distinction between international and national staff is warranted (Shevchenko and Fox, 2008). ...
Research findings show humanitarian work impacts one's health. We conducted a prospective observational study among 618 international humanitarian aid workers (iHAWs)’ recruited from 76 countries to investigate health changes and ill-health risk factors after mostly short-term (<1 year) medical emergency assignments. The aid workers were assigned to 27 countries. Data collected between 2017 and 2020.
We also compared a gold-standard clinical interview with self-report questionnaires to assess whether self-report scores overestimate the prevalence of clinical anxiety, depression and PTSD. Analyses consisted of repeated measures ANOVAs and adjusted odds ratios, using pre-assignment (T1), post-assignment (T2) and two-month follow-up data (T3). Humanitarian workers experienced on average, 2.6 experienced and witnessed potential traumatic events, and 4.8 male and 5.6 female assignment-related stressors. Self-report health indicators demonstrated a significant increase in emotional exhaustion, loss of vitality, decreased social functioning and emotional well-being between T1 and T2, all of which improved between T2 and T3. PTSD, depression, experienced role limitations, physical functioning, pain, and general health – remained stable. Anxiety levels decreased significantly between T1 and T2. The presence of DSM-5 disorders anxiety (6.6 %), depression (1.3 %) and PTSD (0.3 %) was low compared to norm populations, except for alcohol-use disorder (13 %). None of the reported T2 risk factors was significant at T3. Compared to the clinical interview, self-report cut-off thresholds inflated the presence of a potential anxiety disorder (3×), PTSD (8×) and depression (25×). Humanitarian work is highly stressful but most iHAWs remained healthy. Looking into how iHAWs stay healthy may be a more useful way forward.
... those hired outside of the country of mission). Despite an arguably greater need for psychological support among national staff however, extant studies on traumatic exposure and mental health among humanitarian aid workers have overwhelmingly focused on expatriate or international staff (3,4). There has been considerably less focus given to national staff and volunteers, the latter of which represent a significant proportion of the humanitarian workforce, and many of whom are at an early stage of their career (under 25 years). ...
... This protects individuals' dignity, reduces exposure of members to secondary trauma, and ensures needs-matched care. (1,3,5,8,10,12,15,17) Facilitators should be accessible for continuation of care through further informal, interpersonal discussions (particularly in low-resource settings) and/or linking to ongoing support where available. It is also important that the facilitator is relatable to the members, particularly for youth, though again is context specific. ...
... This can lead to improved healthy coping strategies, self-awareness, and the management or prevention of distress escalation or re-escalation. (1)(2)(3)(4)(5)(6)(7)(8)(9)(10) The nature of humanitarian work often results in workers and volunteers prioritising others' well-being before their own. The group format of GPFA may encourage this workforce to attend to support their peers, and through this they may also receive benefits. ...
This report forms part of Wellcome’s 2020 Workplace Mental Health Commission. The aim of the commission was to understand the existing evidence behind a sample of approaches for supporting anxiety and depression in the workplace, with a focus on younger workers. This report is about the use of Group Psychological First Aid for supporting humanitarian workers and volunteers, aged 14-24.
... In a review of trauma-related mental health problems in national staff from various disaster and conflict-affected countries, Strohmeier and Scholte (2015) reported that many studies found that national staff experienced a large number of traumatic events, with a study in Northern Uganda reporting that more than 50% of national workers had experienced five or more PTEs (Ager et al., 2012). International and Kosovar Albanian national HAWs who were exposed to a higher number of traumatic events were also more likely to be at an increased risk of PTSD and depression at post-deployment (Lopes Cardozo et al., 2005Cardozo et al., , 2012. However, these research findings from the trauma exposure paradigm face critical methodological issues that limit our ability to draw strong conclusions. ...
... National staff face the dual challenge of working to support their communities while also being subjected to the same extreme stressors and traumatic experiences related to the humanitarian emergencies in their countries Lopes Cardozo et al., 2005). Especially in post-conflict settings and diverse international organizations, national staff survivors may work alongside colleagues whose nationality, ethnicity, tribe, or religion is that of the perpetrator group, thus putting national staff at risk for PTSD symptoms and distress Tay, 2020, personal communication). ...
... Similarly, in organizations in South Sudan, a higher although not statistically significant proportion of international staff compared to national staff reported EE (29% vs. 19%) and DP (23% vs. 18) . These findings together point to the possibility that despite the higher number of psychosocial stressors faced (Table 21.1), national staff may be better able to mitigate these risks with more available social support, which has been consistently found to be a strong protective factor against burnout and other mental health outcomes in this group (Ager et al., 2012;Eriksson et al., 2009;Lopes Cardozo et al., 2005). ...
The growing number, demands, and scale of humanitarian emergencies substantially tax the mental health and psychosocial well-being of humanitarian aid workers (HAWs). Recent research found that organizational aspects of humanitarian aid work, rather than incidents of trauma, are perceived as the primary sources of stress and are stronger predictors of adverse psychological health outcomes among HAWs. This chapter will provide a review and synthesis of the contemporary scientific knowledge on the organizational and psychosocial factors influencing mental health and well-being of national and international HAWs. The last section summarizes recommendations for intervention strategies for the pre-, during, and post-deployment phases of humanitarian operations, informed by existing guidelines and the current evidence base. National and international staff’s different needs and priorities for organizational support are distinguished.
... Further differentiating between expatriate (i.e., those hired outside of the country of mission) and national staff (i.e., those hired within the country of mission), Lopes Cardozo et al. [4] found that national staff reported more exposure to traumatic events as well as greater anxiety, depression, and PTSD symptoms, compared to expatriate staff. Similar findings were reported by Musa and Hamid in Darfur [5]. ...
... Similar findings were reported by Musa and Hamid in Darfur [5]. Having shared experiences and cultures, national staff often identify more closely with the victims than their expatriate counterparts [4][5][6]. Despite an arguably greater need for psychological support among national staff due to increased exposure and adverse symptoms, however, extant studies on traumatic exposure and mental health among humanitarian aid workers have overwhelmingly focused on expatriate or international staff [4,7]. ...
... Having shared experiences and cultures, national staff often identify more closely with the victims than their expatriate counterparts [4][5][6]. Despite an arguably greater need for psychological support among national staff due to increased exposure and adverse symptoms, however, extant studies on traumatic exposure and mental health among humanitarian aid workers have overwhelmingly focused on expatriate or international staff [4,7]. Consequently, there has been considerably less focus given to national staff and volunteers, the latter of which represent a significant proportion of the humanitarian workforce. ...
Humanitarian workers are at an elevated risk of occupational trauma exposure and its associated psychological consequences, and experience increased levels of anxiety, depression, and post-traumatic stress disorder (PTSD) compared to the general population. Psychological first aid (PFA) aims to prevent acute distress reactions from developing into long-term distress by instilling feelings of safety, calmness, self- and community efficacy, connectedness and hope. Group PFA (GPFA) delivers PFA in a group or team setting. This research sought to understand ‘What works, for whom, in what context, and why for group psychological first aid for humanitarian workers, including volunteers?’ A rapid realist review (RRR) was conducted. Initial theories were generated to answer the question and were subsequently refined based on 15 documents identified through a systematic search of databases and grey literature, in addition to the inputs from a core reference panel and two external experts in GPFA. The findings generated seven programme theories that addressed the research question and offered consideration for the implementation of GPFA for the humanitarian workforce across contexts and age groups. GPFA enables individuals to understand their natural reactions, develop adaptive coping strategies, and build social connections that promote a sense of belonging and security. The integrated design of GPFA ensures that individuals are linked to additional supports and have their basic needs addressed. While the evidence is sparce on GPFA, its ability to provide support to humanitarian workers is promising.
... Over the last 10 years, humanitarian settings have become increasingly violent and risky places to work in. Direct attacks on aid workers have increased, and deaths among humanitarian workers have reached record highs (Cardozo et al., 2005;Hoelscher et al., 2015;Sheik et al., 2000;Stoddard et al., 2009). Despite the growing risks faced in the field, in the past decade, the number of people working for humanitarian aid agencies around the world nearly doubled from just over 200,000 in 2009 to more than 450,000 in 2015 (Stoddard et al., 2015). ...
... To date, studies of mental health in humanitarian aid workers have been limited in both number and design Cardozo et al., 2005;Eriksson et al., 2001;Eriksson et al., 2013Eriksson et al., , 2015Holtz et al., 2002;Jones et al., 2006;Lopes Cardozo et al., 2012;Shah et al., 2007). Most studies were cross-sectional and so unable to look at patterns of traumatic stress response over time. ...
... The instrument for assessing chronic stressors was modified from one used in previous studies and included items on living, security concerns, heavy workload and nongovernmental organization's lack of recognition for accomplishments, and lack of communication (Eriksson et al., 2003). The measure assessing trauma experiences included exposure to serious threatening events such as unwanted sexual contact, threats of physical harm, kidnapping, murder of a colleague or family member, or intentional destruction of home or office and was adapted to fit the specific context of international humanitarian aid workers (Cardozo et al., 2005). ...
Most studies of mental health in humanitarian aid workers have found low levels of posttraumatic stress disorder, making it hard to disaggregate and look at differences between subgroups. This study sought to identify the risk and protective factors associated with resistant, resilient, and nonresilient trajectories of stress response over time that could be used to inform more targeted training and organizational support programs for aid workers. Aid workers from 19 qualifying humanitarian organizations who aged ≥18 years and were to deploy for 3 to 12 months completed questionnaires at 3 time points (pre, post, and follow-up). We identified 3 unique groups (nonresilient, resistant, and resilient) using latent class growth analysis and identified predictors of subgroup classification using multivariate logistic regression. Single individuals were less likely to be in the resilient group than in the resistant group compared to coupled individuals. Individuals with one prior deployment were three times more likely to be nonresilient than resistant compared to individuals with no previous deployments. There was no significant difference in resistant, resilient, and nonresilient classification for individuals with >2 deployments. Findings suggest a need for supplemental training and psychosocial support post the first deployment as well as resources focused on potential this should be cumulative rather than accumulative effects of stress and trauma exposure for more seasoned deployers.
... However, there are mixed results around the effects of trauma in aid workers. Studies with humanitarian workers have found that exposure to life-threatening traumatic events is associated with depression and PTSD (Cardozo et al., 2005;Jones, Müller, and Maercker, 2006). But other research with humanitarian workers has indicated that exposure to traumatic events does not uniquely predict depressive symptoms, anxiety or burnout (Ager et al., 2012), that trauma is not a key stressor identified by aid workers themselves (Young et al., 2018) and that organisational stressors predict negative mental health outcomes when controlling for trauma (Jachens et al., 2019). ...
... Existing studies indicate national workers have greater psychological distress than internationals and receive less support and are likely to have lived through traumas due to the circumstances that necessitated the aid work (Ager et al., 2012;Cardozo et al., 2005;Connorton et al., 2012;Mercado, 2017). On the other hand, international workers can be affected by a lack of local support network, separation from family, difficulty repatriating home and higher risks for heavy drinking (Connorton et al., 2012;Ehrenreich and Elliott, 2004;Jachens et al., 2016;Porter and Emmens, 2009). ...
... Younger age has been established as a risk factor for burnout and distress in aid workers (Cardozo et al., 2005;Eriksson et al., 2009;Musa and Hamid, 2008). This finding is consistent with research in other sectors where young workers in service fields face a higher risk of burnout (Maslach, Schaufeli, and Leiter, 2001). ...
This study examines fifteen possible risk and protective factors for aid worker mental health under the categories of job context, work conditions and demographics. Many of these factors have not been examined previously. We use a cross‐sectional survey with 369 participants in 77 countries. Results indicate job context risk factors include emergency postings and being an international worker. There were no significant differences between humanitarian and development workers, none between organisation types, and the number of past traumas was not associated with negative mental health outcomes. Protective work conditions included higher income, long‐term contracts, past‐psycho‐social trainings and voluntary postings. Demographic protective factors included older age, more work experience, and higher religiosity and spirituality, while female gender was a risk factor. This study provides a more nuanced understanding of mental health in the sector, which can inform the development of more targeted supports for the mental health of aid workers.
This article is protected by copyright. All rights reserved
... The challenging and complex environments within which humanitarians operate increase their risk for developing negative mental health outcomes (Cardozo & Salama, 2002;Cardozo et al., 2005;Cardozo et al., 2012;Chan & Huak, 2004;Ehring, Razik, & Emmelkamp, 2011;Eriksson et al., 2001Eriksson, Kemp, Gorsuch, Hoke, & Foy, 2001McFarlane, 2004;Musa & Hamid, 2008;Ursano, Fullerton, Vance, & Kao, 1999;Welton-Mitchell, 2013). Humanitarians are civilians and professionals who voluntarily respond to the 'human costs of disasters such as wars, floods, earthquakes, famines, or refugee crises, or respond to longer term issues such as poverty, hunger, and disease' (Antares Foundation, 2012, p. 7). ...
... To grasp the critical role of intimate partner social support, and the detrimental impact of its unavailability, it is important to understand the humanitarian context and existing data on humanitarian well-being. An expanding body of research demonstrates how the humanitarian context can lead to negative mental health outcomes including depression, anxiety, post-traumatic stress disorder (PTSD), decreased life satisfaction, substance abuse, and burnout (Cardozo & Salama, 2002;Cardozo et al., 2005;Cardozo et al., 2012;Connorton, Perry, Hemenway, & Miller, 2011;Curling & Simmons, 2010;Ditzler, Hoeh, & Hastings, 2015;Eriksson et al., 2001). ...
... In a study of former humanitarians, 15% had clinically significant levels of depression and 15% struggled with alcohol abuse (Cardozo & Salama, 2002). Cardozo et al. (2005) found that 1.1% of expatriate and 6.2% of national staff working in Kosovo met diagnostic criteria for PTSD, but that 17.2 and 16.9% respectively could be diagnosed as depressed. Regarding Cardozo et al.'s study (2005), Musa and Hamid (2008) comment that the authors used significantly higher cut-off scores (eight and nine) on the General Health Questionnaire than the usual cut-off score of four. ...
Humanitarians are critical players in alleviating suffering worldwide. As a result of their willingness to put themselves in challenging, often dangerous environments, humanitarians are at high risk for negative mental health outcomes. Addressing humanitarian mental health effectively must consider the well-being of the intimate partner. The paper reviews the literature on humanitarian mental health, the protective nature of social support, the relevance of the intimate partner as a provider of social support, and outcome research on interventions that increase social support through the inclusion of the intimate partner. This paper draws comparisons between military and humanitarian intimate partners and provides information on the military’s research and programming as a model for humanitarian organisations to consider. One of the most effective ways to improve humanitarian mental health is to increase the well-being of the intimate partner and intimate relationship.
Key implications for practice The humanitarian context can lead to high levels of poor mental health outcomes. Humanitarian distress and attrition has a negative impact on an organization′s mission effectiveness and bottom-line. One of the most effective ways to improve humanitarian mental health is to increase the well-being of the intimate partner and intimate relationship.
... Research on stress and mental health problems suffered by aid workers in their efforts to help traumatized individuals in prolonged complex emergency situations is scarce and still a new field (Adams, Boscarion, & Figley, 2006). The bulk of research has focused on the wellbeing of peacekeepers and armed personnel and traumatic events facing them (Cardozo et al., 2005). Aid workers operating in war zones encounter situations that are likely to generate more distress than would normal, everyday situations (Salama, 2007). ...
... There are some findings suggesting burnout is prevalent among aid workers in complex emergency situations (Cardozo et al., 2005). Burnout is a state of physical, mental and emotional exhaustion resulting from prolonged demanding and stressful situations (Pines, Aronson, & Kafry, 1981). ...
... The authors concluded that compassion satisfaction might alleviate the effects of burnout. Cardozo et al. (2005) conducted a study with 285 expatriate aid workers and 325 Kosovar Albanian aid workers from 22 humanitarian organizations carrying out health projects in Kosovo. The study was concerned with mental health problems related to exposure to traumatic events. ...
... Other studies have suggested that older and more experienced workers exhibit lower levels of distress and CF, possibly due to their adoption of coping strategies or the quitting of individuals already experiencing significant distress. (Eriksson et al., 2009;Lopes Cardozo et al., 2005) Noticeably, some studies conducted on internal and external displaced refugees from Syria have indicated that men are often exposed to more traumatic events and are at a greater risk of developing PTSD (Tekeli-Yesil et al., 2018). This may imply differing gender roles in non-Western contexts, leading to variable exposures to traumatic experiences. ...
... This is considered a form of passive coping. The low prevalence of substance use, such as alcohol use, among HAWs can be attributed to cultural beliefs (Lopes Cardozo et al., 2005). ...
Introduction
Forced displacement constitutes a global crisis impacting millions of people especially in the Middle East, leaving them impacted by traumatic history. Humanitarian aid workers (HAWs) who support displaced individuals are exposed to high risk of burnout and secondary traumatic stress (STS).
Methods
This study aimed to identify the prevalence of compassion satisfaction (CS) and compassion fatigue (CF), referring to burnout and STS, respectively, using the Professional Quality of Life Scale (ProQOL). The study explored the relationships between these factors and personal variables that are related to shared trauma, as well as coping mechanisms assessed using the Brief-COPE questionnaire among Middle Eastern HAWs working with displaced individuals.
Results
The study involved 78 HAWs supporting displaced individuals in the Middle East. The mean age was 25.81 years (SD = ± 5.54); 55% were females, and the majority (88%) were Syrians. Approximately 90% of participants were engaged in Turkey and Syria. The most prevalent coping mechanisms were religion and planning. Being a graduate predicted burnout, whereas older age, previous mental diagnosis, and shared trauma predicted higher STS levels. Compassion satisfaction was predicted by active coping, and compassion fatigue was predicted by negative coping.
Conclusion
HAWs require education to recognize CF signs and psychological training to promote effective coping mechanisms, mitigate CF, and enhance higher levels of CS. More research is needed on the psychology of HAWs and the role of shared trauma and coping mechanisms.
... The same pattern was identified in a study focusing on 446 HAWs from China, where 30% developed PTSD [11]. Other symptoms related to trauma were found in various studies, such as burnout among 40% of HAWs from 44 different countries [12], and alcohol abuse was found among 16.2% of HAWs in Kosovo [13]. ...
... Risk factors for such stress responses include exposure to extremely stressful events such as dealing with dead bodies [14], previous exposure to disaster [10], length of mission [15], and low socio-economic status [16], among other factors. Protective factors, on the other hand, included early experience and training [17], perceived organizational support [18], tolerance for ambiguity [19], coping strategies, emotional intelligence [20], and serving as non-local staff [13]. ...
Background: Humanitarian aid workers (HAWs) are indirectly exposed to atrocities relating to people of concern (POC). This may result in a risk of secondary traumatization demonstrated by post-traumatic stress symptoms (PTSSs). Previous studies have demonstrated that hemispheric lateralization (HL) moderates the relationship between threat exposure and post-traumatic stress symptoms (PTSSs). Aims: We hypothesized that indirect exposure to atrocities (IETA) would be positively correlated with PTSSs among HAWs with right and not left HL. Method: Fifty-four HAWs from several countries that provided humanitarian support in Greece and Colombia participated in this correlational and cross-sectional observation study. They completed scales relating to IETA, PTSSs were assessed using a brief, valid scale, and HL was measured. Results: IETA was positively and significantly related to PTSSs (r = 0.39, p < 0.005). Considering HL, IETA was unrelated to PTSSs among people with right HL (r = 0.29, p = 0.14), while IETA was related to PTSSs among people with left HL (r = 0.52, p = 0.008). Right HL emerged as a protective factor in the relationship between IETA and PTSS. Conclusions: An assessment of dominant HL can serve as one consideration among others when deploying HAWs in specific locations and roles, vis à vis IETA. Moreover, those found to have a higher risk for PTSSs based on their HL could be monitored more closely to prevent adverse reactions to IETA.
... Similar results also brought Budosan (2020), Hunt (2009), andJoseph (2013). Studies also suggest that insufficient support within the organization (Cardozo et al., 2005) and poor supervisory and team members (Aldamman et al., 2019) negatively affect the mental health of humanitarian workers. Regarding support of the current organization and superior, respondents of this study have a very "I sometimes feel like I need to make sense of catastrophic events around me." Strongly agree -5 (5.6) -3 (3.4) 2 (2.3) 3 (3.4) 2 (2.3) -Agree 10 (11.2) 22 (24.7) ...
... This shows how vital role organizational factors may play, being a protective factor for humanitarian workers (Rizkalla & Segal, 2019). Inadequate social support (Eriksson et al., 2001) and poor communication with friends and family (Cardozo et al., 2005;Lopes Cardozo et al., 2013) are among the factors with the negative effect on mental well-being as well. In total, 50.5% of logisticians feel that the people they talk to understand their experience from the field. ...
Aid workers have to deal with an environment where safety is often compromised, which also applies to humanitarian logisticians. With growing numbers of both emergencies and attacks on humanitarian workers, this environment is becoming even more challenging. The presented study focuses on trauma exposure of humanitarian logisticians. It answers two research questions. First, if these logisticians are exposed to traumatic events, and second, whether they voluntarily seek psychological support. Data were collected through a semistructured questionnaire distributed to various organizations and agencies. In total, 89 logisticians participated in this study. The results demonstrate that almost 89% of respondents often heard about trauma events, and around 50% of respondents have been directly exposed to some. Humanitarian logisticians name these trauma events as rebel attacks, shootings, or earthquakes. In total, 23 logisticians had voluntarily sought psychological counseling, and 11 logisticians have considered doing so. This study offers the first evidence of humanitarian logisticians’ mental health and trauma exposure. All humanitarian workers should be monitored for psychological distress. Adequate support should be provided to these people regardless of whether they are national or international workers or their job placement.
... In fact, at any given time, between 6.2 and 43.0% of aid workers reported clinical levels of PTSD (median prevalence in two reviews were of 17.0 and 19.1%; Connorton et al., 2012;Strohmeier and Scholte, 2015), and between 4.0 and 58.0% of clinical depression (median prevalence in two reviews were 18.5 and 27.1%; Connorton et al., 2012;Strohmeier and Scholte, 2015). The significant variations in disorders' prevalence may be due to the homogeneous samples used in most studies on aid workers (e.g., aid workers only working in Kosovo; Holtz et al., 2002;Cardozo et al., 2005). Differences in the type of assignments or level of security in the geographic region may have contributed to important variations in prevalence (e.g., Solomon and Green, 1992). ...
... Therefore, it is possible that our high incidence of PMIE, especially of PMIE relating to others' actions (75.3%), could encompass different types of PMIE. Future studies of aid workers should investigate nuances in the types of PMIE, specifically those that could relate to having chosen to not act in a situation where they feel that they morally should have, having been constrained to not act in the face of wrongdoing or repeatedly witnessing human suffering toward which there is no immediate solution (e.g., Chaplo et al., 2019). Estimated model for the effect of PMIE on PTSD symptoms, depression symptoms, and posttraumatic growth, after accounting for PTE. ...
Introduction
Potentially morally injurious events (PMIE) are events that violate one’s deeply held moral values or beliefs, and that have the potential to create significant inner conflict and psychological distress. PMIE have been recognized as an important psychological risk factor in many high-risk occupational groups. However, no study to date has investigated how PMIE relate to the mental health of aid workers. Furthermore, little is known about the mechanisms by which PMIE might be associated with mental health indicators.
Methods
Participants were 243 aid workers (72% female; Mage = 39.31) who had completed at least one aid assignment (M = 8.17). They completed an online questionnaire about their PMIE, trauma history, and mental health. A structural equation model was constructed to examine the roles of negative cognitions and subsequent self-care behaviors in the relationship between PMIE and PTSD symptoms, depression symptoms, and posttraumatic growth, above and beyond the contribution of potentially traumatic events.
Results
Within the model, the indirect effect through negative cognitions fully accounted for the associations between PMIE and symptoms of PTSD and depression. For the association between PMIE and posttraumatic growth, two indirect effects emerged: the first through negative cognitions and subsequent self-care and, the second, through self-care alone.
Discussion
This study highlighted PMIE as a novel psychological risk factor for aid workers and pointed to two possible mechanisms by which these events may lead to PTSD, depression, and posttraumatic growth. This study adds to the current understanding of how high-risk occupational groups adapt psychologically to PMIE.
... Having such options likely contributed to the finding that many resolved not to rely on family as a main help source from early stages in their career. This contrasts with reports of emergency service workers, who generally prefer seeking help from family and friends (Cardozo et al. 2005;Benkel et al. 2009). This disparate finding may reflect the different nature of humanitarian roles and exposures. ...
... This disparate finding may reflect the different nature of humanitarian roles and exposures. These include long periods of separation during deployments where communication with home may be both irregular and stressful (Cardozo et al. 2005;Hearns and Deeny 2007). These may result in distinctly different communications cycles and outlets. ...
Due to the nature of their work and operating environments, humanitarian aid workers experience higher rates of psychological distress, burnout and mental health conditions than other emergency service worker populations. Fourteen international humanitarian workers were interviewed to examine whether they seek help from others in the context of work-related distress, specifically, their attitudes and behaviors regarding personal help-seeking at such times, their preferred sources of support and factors that enable or constrain effective help-seeking. Thematic analysis of the data derived five superordinate themes: (1) cultural aspects of help-seeking; (2) risks with formal, internal support; (3) lack of shared understanding of humanitarian context; (4) self-censoring and withdrawal; and (5) role maturity. There is high, in principle, support for personal help-seeking but its use is highly selective. Work colleagues are regarded as the most trusted and effective source of help in high stress periods, while barriers that exist with family and friends mean they are rarely sought out at such times. Trust and confidentiality concerns limit the use of internal agency supports and psychosocial services. External psychological services are preferred but are often found to be unsatisfactory. These findings can support aid organisations to address stigma perceptions that are commonly associated with personal help-seeking, particularly among early career practitioners, and normalise its use as a form of occupational self-care.
... Therefore, it is important to understand how this work environment affects the people that are engaged in providing humanitarian aid. Humanitarian aid workers (HAWs) are frequently exposed to trauma [4,5] and, additionally, the work is often associated with stressful conditions, such as political instability, ambiguity and high urgency [6,7]. In relation to their work, HAWs experience several adverse mental and physical health outcomes. ...
... The experience of professional HAWs will not readily translate to volunteers, as the initial situation and working conditions differ. For example, frequently discussed stressors in the research among professional HAWs are job insecurity, limited career opportunities and salary [4,7,17,18]. As these topics are not relevant for volunteer workers, it highlights the importance of investigating this group separately. ...
A majority of the workforce in the humanitarian aid consists of volunteers who partly suffer from health problems related to their voluntary service. To date, only a fraction of the current research focuses on this population. The aim of this qualitative explorative study was to identify burdening and protective organisational factors for health and well-being among humanitarian aid volunteers in a Greek refugee camp. To this end, interviews with 22 volunteers were held on site and afterwards analysed by using qualitative content analysis. We focused on international volunteers working in Greece that worked in the provision of food, material goods, emotional support and recreational opportunities. We identified burdening factors, as well as protective factors, in the areas of work procedures, team interactions, organisational support and living arrangements. Gender-specific disadvantages contribute to burdening factors, while joyful experiences are only addressed as protective factors. Additionally, gender-specific aspects in the experience of team interactions and support systems were identified. According to our findings, several possibilities for organisations to protect health and well-being of their volunteers exist. Organisations could adapt organisational structures to the needs of their volunteers and consider gender-specific factors.
... 20,27,38 One study found an increase in depression cases associated with number of deployments. 40 Another study conducted among active duty and National Guard/reserve women found that the odds of PTSD, depression, and risky drinking increased with number of deployments. 13 Corroborating this argument, another study found lower odds of PTSD and risky drinking among active duty women with no previous deployment experience. ...
... Studies show worse impacts on mental health for first-time responders due to the novelty of the challenges experienced. 38,40 Postdeployment Life ...
Purpose
The purpose of this study is to identify key risk factors that could negatively affect public health emergency responders’ health and wellbeing. We seek to use this information to provide recommendations and strategies to mitigate such risks.
Design/Methodology/Approach
A narrative review of the peer-reviewed literature on wellbeing of military personnel and other responders was conducted. Data was grouped and categorized according to overarching domains.
Findings
Factors associated with wellbeing were categorized into 5 domains: (1) demographics; (2) mental health concerns; (3) social networks; (4) work environment; and (5) postdeployment life. The strategies identified to promote wellbeing included mental health assessments, preparedness trainings, debriefs in the field, postdeployment debriefs, resources in the field, and further postdeployment decompression strategies.
Originality/Value
This study provides a unique understanding of the risk factors associated with poor health and wellbeing outcomes in public health emergency response work by extending the body of knowledge that focuses on other types of emergency and military response.
... The items are rated on a 4-point Likert scale. The HSCL-25 has been translated into Albanian and back-translated (Lopes Cardozo et al., 2005), and has been used in several studies with Albanian-speaking participants (Lopes Cardozo et al., 2005;Schick et al., 2013). ...
... The items are rated on a 4-point Likert scale. The HSCL-25 has been translated into Albanian and back-translated (Lopes Cardozo et al., 2005), and has been used in several studies with Albanian-speaking participants (Lopes Cardozo et al., 2005;Schick et al., 2013). ...
... The items are rated on a 4-point Likert scale. The HSCL-25 has been translated into Albanian and back-translated (Lopes Cardozo et al., 2005), and has been used in several studies with Albanian-speaking participants (Lopes Cardozo et al., 2005;Schick et al., 2013). ...
... The items are rated on a 4-point Likert scale. The HSCL-25 has been translated into Albanian and back-translated (Lopes Cardozo et al., 2005), and has been used in several studies with Albanian-speaking participants (Lopes Cardozo et al., 2005;Schick et al., 2013). ...
Background: In order to narrow the world-wide treatment gap, innovative interventions are needed that can be used among culturally diverse groups, e.g., immigrant populations in high-income countries. Research on cultural adaptation of psychological interventions indicates that a higher level of adaptation is associated with a higher effect size of the intervention. However, direct comparisons of different levels of adaptations are scarce and have not been done with self-help interventions.
Aims: This study will use a Smartphone-based self-help programme called Step-by-Step (Albanian: Hap-pas-Hapi) for the treatment of psychological distress among Albanian-speaking immigrants in Switzerland and Germany. Two levels of cultural adaptation (i.e., surface vs. deep structure adaptation) will be compared. We hypothesise that the deep structure adaptation will enhance the acceptance and effect size of the intervention. The deep structure adaptation was done based on an ethnopsychological study to examine the target population’s cultural concepts of distress.
Methods: We will conduct a two-arm, single-blind randomised controlled trial. Participants will be randomly assigned to the surface vs. deep structure adaptation version of Hap-pas-Hapi (1:1 allocation using permuted block randomization). Inclusion criteria are good command of the Albanian language, age above 18, and elevated psychological distress (Kessler Psychological Distress Scale score above 15). Primary outcome measures are the total score of the Hopkins Symptom Checklist and the number of participants who completed at least three (out of five) sessions. Secondary outcomes are global functioning, well-being, symptoms of post-traumatic stress, and self-defined problems. In addition, we will test a mediation model, hypothesizing that the deep structure adaptation will address fatalistic beliefs and enhance alliance with the self-help programme, which in turn increases the acceptance and effect size of the intervention. And finally, we will measure acculturation and hypothesise, that with higher levels of acculturation, the effect of the deep structure adaptation will diminish.
Discussion: This is the first study to directly compare two different levels of cultural adaptation of an online self-help programme for the treatment of psychological distress among immigrants in high-income countries. We aim to deliver theory-driven and methodologically rigorous empirical evidence regarding the effect of cultural adaptation on the acceptance and effect size of this self-help programme.
... In the humanitarian context, psychosocial risk assessment research and practice remains in its infancy; for example, there is no research on the JDC model to date. However, there is an emerging evidence base indicating a high prevalence of stress-related health problems [11][12][13][14][15] and associations between psychosocial stressors (ERI) and stress-related health problems (burnout, heavy drinking) [11,12]. As stress in different occupations may be marked by different types of psychosocial stressors [16,17] and have a multitude of organizational sources, it may be beneficial to include characteristics of both these leading psychosocial work environment models in efforts to assess and control stress. ...
... These rates are considerably higher than those found in general adult population [31] and workforce studies [28], while consistent with those found in contemporaneous high-stress occupation studies involving groups such as police officers [32] and UK Royal Navy personnel [33]. The prevalence rate for psychological distress found in our study is consistent with that of 50% observed among humanitarian aid workers in Darfur [34], while being considerably higher than the rate of 12% observed in humanitarian aid workers in Kosovo [14], suggesting that prevalence rates in the sector are likely to vary according to a range of personal and occupational characteristics. This highlights the need for further research to identify these characteristics with a view to the introduction of psychosocial risk reduction interventions where high rates are observed. ...
The Job Demand-Control-Support (JDC-S) and Effort-Reward Imbalance (ERI) models dominate psychosocial work environment research and practice, with their independent and collective contributions to employee health having been extensively demonstrated. Psychosocial risk assessment in the humanitarian aid sector is in its infancy, and there is a need to identify appropriate psychosocial work environment models to inform approaches to assessment. The aim of this study is to examine the efficacy of these models separately and in combination to identify psychological distress in humanitarian aid workers. Cross-sectional survey data were obtained from 283 humanitarian aid workers. Logistic regression analyses investigated the separate and combined ability of the models to identify psychological distress. More than half of the participant sample reported psychological distress, and one third reported high ERI and high job strain. When tested separately, each model was associated with a significantly elevated likelihood of psychological distress. When tested in combination, the two models offered a superior estimation of the likelihood of psychological distress than achieved by one model in isolation. Psychosocial risk assessment in the humanitarian aid sector encompassing the characteristics of both these leading psychosocial work environment models captures the breadth of relevant generic psychosocial work characteristics. These initial findings require corroboration through longitudinal research involving sector-representative samples.
... A survey of aid workers conducted by the Guardian newspaper in 2015 (Young, 2015) found that approximately twenty per cent of their 754 self-selected respondents had suffered from PTSD and panic attacks, whilst forty-four per cent suffered from depression. Academic studies addressing the health and wellbeing of aid workers have referred to the increasing instances of burnout in both national and international staff working in emergency settings (Cardozo et al., 2005;Eriksson et al., 2009). ...
... A syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity. (Maslach et al, 1996, cited in Schaufeli et al., 2009 Studies into burnout and other stress-related conditions in the aid sector use measuring tools that have been long established in Europe and the United States: these include the Maslach Burnout Inventory (Eriksson et al., 2009), the Harvard Trauma Questionnaire (Cardozo et al., 2005) and the Connor-Davidson Resilience Scale (Comoretto et al., 2011). ...
... Although some humanitarian workers cope with life in crisis situations without developing prolonged symptoms of mental ill-health (McKay, 2011), research confirms that common mental health problems, such as post-traumatic stress disorder (PTSD), depression, anxiety, burnout and hazardous alcohol consumption, are widespread among this occupation group (e.g. Ager, Pasha, Yu, Duke, Eriksson, & Cardozo, 2012;Lopes Cardozo et al., 2005;Lopes Cardozo et al., 2012;Lopes Cardozo et al., 2013;Shah, Garland, & Katz, 2007). This can have severe implications for the personal and professional lives of humanitarian workers. ...
... Even with additional training, career change is not guaranteed, and national staff's newly acquired skills oftentimes remain underutilised (IRIN, 2013). Restricted career opportunities can lead to increased stress and further setbacks in motivation and thus, impact the mental health and wellbeing of staff (Lopes Cardozo et al., 2005). Supporting career progression, for instance through needs-based training, supervision and feedback, and individual development plans, is hence beneficial for staff and organisations. ...
Humanitarian workers experience high symptom burdens of common mental health problems. This requires action from the organisations they are employed with. However, many studies have documented continuing weaknesses in organisational staff support, as well as disparities in access to the services for national and international staff. Systematic data capturing suggestions from humanitarian workers on how to tackle this situation within a specific crisis setting is rarely available. This study addresses this gap through qualitative content analysis of the suggestions from the 210 humanitarian workers based in South Sudan collected through an online survey in 2017. Five major themes emerged regarding proposed improvements: ‘Competitive benefit and salary packages’; ‘internal work climate and organisational culture’; ‘equality within and between organisations’; ‘skill enhancement and personal development’ and ‘physical safety and security’. For both national and international staff, improved access to psychosocial support services was the most frequent proposal. Apart from this suggestion, their top priorities for improvement of staff support differed greatly. National staff emphasised improvements related to training and greater equality between employees. International staff emphasised improvements related to time off and team cohesion. Findings provide a clear case for organisations to assess their services and offer a potential framework to inform future interventions that better address the priorities of the humanitarian community as a whole.
Key implications for practice Organisations need to ensure staff have adequate access to psychosocial support services National and international staff have different priorities regarding staff support and organisations need to reflect these in their provision of services A unified understanding of staff support is required to manage expectations of staff and hold organisations accountable.
... Humanitarianism as a career is often thwart with personal risk in environments and circumstances that often include psychological and/or physical threat to self (Bjerneld, Lindmark, Diskett, & Garrett, 2004;Bjerneld, Lindmark, McSpadden, & Garrett, 2006;Cardozo et al., 2005Cardozo et al., , 2012. For example, in 2014, 1,341 not-forprofit aid personnel were killed amid increased security threats and unstable political landscapes (Aid Worker Security Database, 2015). ...
... Upon homecoming, the participants did not report psychological disturbance or psychopathology. This is contrary to the vast majority of research on humanitarians, in which posttraumatic stress, depression, anxiety, and burnout abounds (Ager & Iacovou, 2014;Cardozo et al., 2005Cardozo et al., , 2012Connorton, Perry, Hemenway, & Miller, 2012;McCormack & Joseph, 2013). Similarly, they did not describe experiencing AID (McCormack & Joseph, 2012), found among humanitarians exposed to other catastrophic humanitarian events, including genocide (McCormack & Joseph, 2012;McCormack et al., 2009. ...
The 2014 Ebola epidemic in Sierra Leone, West Africa, was a public health crisis that triggered international fear, border shutdowns, and a declaration of an unprecedented international public health emergency. However, no known research has explored the subjective experience of international humanitarian health care workers deployed to provide on-the-ground support during the Ebola epidemic. This phenomenological study explored the subjective interpretations of 5 career-international Red Cross/Red Crescent health care delegates who deployed to the 2014 Ebola epidemic. Data were collected using semistructured interviews, transcribed, and analyzed using the protocols of interpretative phenomenological analysis. One superordinate theme: Beyond human fear and catastrophe: I can't save you, but I am here; overarched four subordinate themes: Calm amidst hysteria; Living in a pressure cooker; Journeying alone; Altruistic authenticity. These themes reflect the heavy burden felt by these participants in response to a strong altruistic call-"Who will go if I do not?" "Like no other" humanitarian deployment, unquestionable allegiance and trust among in-the-field colleagues were the only barriers against sudden and untreatable death. Official and societal criticism postdeployment precipitated social retreat wherein feelings of isolation and invalidation threatened psychological well-being. However, a strong sense of altruistic commitment remained unwavering and protective against psychological debilitation, as did positive support from the deploying organization. Despite daily confrontation with death, hypervigilance, and fear, altruistic purpose remained the beacon for professional and personal integrity in these participants. It counterbalanced the distress of isolation and invalidation from societal criticism. We recommended that strength-based predeployment humanitarian training is prioritized by deploying organizations.
... Background: Purpose and Objectives of the Original Study While humanitarian workers and volunteers are highly susceptible to adverse mental health outcomes, including burnout, post-traumatic stress disorder, depression and anxiety (Cardozo et al., 2005Connorton et al., 2012;Corey et al., 2021;Thormar et al., 2010), there is growing evidence suggesting that organisational and managerial factors within humanitarian organisations can mitigate those adverse outcomes Aldamman et al., 2019;Cardozo et al., 2013;Thormar et al., 2013). In light of this, a realist evaluation was conducted in 2018 aiming to develop an MRT for 'how, why, and for whom organisational factors impact the well-being of humanitarian workers' (Aldamman, 2020) using a case study of humanitarian volunteers located in the White Nile Branch of the Sudanese Red Crescent Society (SRCS). ...
Realist evaluation methodology aims to understand social programmes by revealing what works, for whom, in what circumstances , and how and why. Realist evaluation starts with generating initial programme theories (IPTs), which are subsequently tested and refined systematically using a multi-methods approach. This article describes a case study of the utilisation of vignettes, or short hypothetical stories, as part of the teacher-learner cycles recommended within realist evaluation. First, we explore the methodological alignment between vignettes and realist evaluation. We then present a specific case example of the application of vignettes as a data collection tool and discuss the potential advantages and the challenges of using vignettes within realist evaluation. Finally, we offer recommendations for researchers who wish to employ vignettes as a powerful instrument that can be used to better explain IPTs to participants and, in turn, enrich their participation in theory refinement within the realist evaluation framework.
... For example, Wechtler et al. (Wechtler, Koveshnikov, and Dejoux 2015), applied socioemotional selectivity theory and argued that age is related to better emotional regulation processes associated with adjustment. Similarly, traumatic events seem to affect younger expatriates more (Cardozo et al. 2005). We included organisational tenure as this variable is typically associated with better performance. ...
... Figley (2002) shows that such work can result in consequences such as nightmares, insomnia, hopelessness, and other forms of secondary traumatic stress (indirect exposure to trauma through a traumatic event; Zimering et al., 2003). Cardozo et al. (2005) describe how Kosovan and Albanian aid workers implementing health programs in Kosovo and working with victims exposed to traumatic events reported symptoms of PTSD and depression, with support services being an important factor in ameliorating these. Similar symptoms have been reported for aid workers in Palestine (Veronese et al., 2017) and Uganda (Ager et al., 2012). ...
Introduction
In addition to the health crisis that erupted during the COVID-19 pandemic, the war between Russia and Ukraine is impacting the mental health and wellbeing of the Romanian population in a negative way.
Objectives
This study sets out to investigate the impact that social media consumption and an overload of information related to the armed conflict between Russia and Ukraine is having on the distribution of fake news among Romanians. In addition, it explores the way in which several psychological features, including resilience, general health, perceived stress, coping strategies, and fear of war, change as a function of exposure to traumatic events or interaction with victims of war.
Methods
Participants (N = 633) completed the General Health Questionnaire (GHQ), the CERQ scale with its nine subscales, the Perceived Stress Scale (PSS), and the BRS scale (Brief Resilience Scale), the last of which measures resilience. Information overload, information strain and the likelihood of the person concerned spreading fake news were assessed by adapting items related to these variables.
Findings
Our results suggest that information strain partially moderates the relationship between information overload and the tendency to spread false information. Also, they indicate that information strain partially moderates the relationship between time spent online and the tendency to spread false information. Furthermore, our findings imply that there are differences of high and moderate significance between those who worked with refugees and those who did not as regards fear of war and coping strategies. We found no practical differences between the two groups as regards general health, level of resilience and perceived stress.
Conclusion and recommendations
The importance of discovering the reasons why people share false information is discussed, as is the need to adopt strategies to combat this behavior, including infographics and games designed to teach people how to detect fake news. At the same time, aid workers need to be further supported to maintain a high level of psychological wellbeing.
... Echoing past research on distress in aid workers (Cardozo et al., 2005;Eriksson et al., 2009), we found aid workers had greater psychological distress than comparison samples: almost a quarter reported clinically significant levels of depression, anxiety, or stress. While people with high distress may be attracted to the aid sector, past longitudinal work suggests that this reverse causality is an unlikely explanation for the association: indeed, the mental health of aid workers tends to deteriorate from predeployment to post-deployment (Lopes . ...
Aid workers operate in stressful environments and tend to experience high psychological distress, but not enough is known about their wellbeing and how to improve their mental health. We surveyed 243 aid workers in 77 countries undertaking humanitarian and development work. They reported lower wellbeing and higher psychological distress than general populations. Wellbeing and distress emerged as two related, but distinct mental health outcomes – encouraging further research on wellbeing in the sector. Better mental health outcomes were predicted by the presence of meaning, psychological flexibility, and resilience. Presence of meaning was the strongest predictor, while resilience was the weakest. Meaning was a stronger predictor of good mental health for national workers, while psychological flexibility was a stronger predictor for female, older, and international workers. These results can support evidence-based approaches to staff care and mental health interventions for aid workers, expanding the current focus on resilience to include meaning and psychological flexibility.
This article is protected by copyright. All rights reserved
... Pero, aparte de la violencia, uno de los principales problemas que se plantea entre los equipos de trabajo humanitario, nacionales y expatriados, es el hecho de trabajar con una alta intensidad de estrés ya que, entre otras cuestiones, están expuestos al sufrimiento humano a gran escala y a condiciones de seguridad complicadas; ambas cuestiones inciden en que se genere un gran estrés psicológico a lo que además se une el tener que debatirse entre hacer lo que uno cree adecuado o la necesidad de hacer una elección no tan adecuada y que además no encaje con lo que uno cree adecuado que ha de hacer [13][14][15]. ...
A lo largo del presente trabajo, se realiza una reflexión actualizada sobre diversas cuestiones que afectan a la calidad de la Acción Humanitaria. Cuestiones como la formación de los profesionales de la ayuda, el estrés generado debido a la cantidad de tiempo que éstos permanecen en zonas de conflicto, la ética en la toma de decisiones, la diversidad de organizaciones y la necesidad de búsqueda de un conjunto de valores comunes. Cuestiones como la relación entre las organizaciones de ayuda y los gobiernos autoritarios, las prioridades de la ayuda sobre el terreno y quién toma las decisiones; si los interesados de los países afectados intervienen de manera adecuada en la toma de las decisiones que les afectan ante una catástrofe, la reticencia a la presencia militar, la utilización de la ayuda con fines políticos y las organizaciones con agendas ocultas. También se reflexiona sobre los casos de corrupción de la Acción Humanitaria y la Cooperación para el Desarrollo como mecanismo de prevención de las crisis humanitarias, sometida en los últimos tiempos a una profunda revisión.Una reflexión sobre las luces y las sombras en la Acción Humanitaria.
... This leads to the second point: analyticist-conceptual work is not merely scientific, it is also more useful for practitioners than large-n positivist-empirical findings. Consider three of the most widely cited articles on aid worker trauma (Eriksson et al. 2001;Putman et al. 2009;Lopes Cardozo et al. 2005). All three studies use self-reporting questionnaires to show there is a statistically significant correlation between exposure to "trauma events" and Post-Traumatic Syndrome Disorder (PTSD) for aid workers in their sample (one of which was 92% Caucasian). ...
... But so far, literature mainly provides broader data on the mental health of aid workers deployed abroad, to hostile environments in regions of crisis. Prevalence rates for depression reach up to 68% among international humanitarian staff [7][8][9][10][11] with alarming correlations to the assignment [12]. ...
Background
Since 2015, more than 3 million refugees have reached the European Union. In order to receive and integrate them, societies heavily rely on relief organizations and private initiatives. Yet the well-being, work-satisfaction and possible health implications for refugee helpers have not been adequately addressed.
Methods
In a German national cross-sectional study, we gathered socio-demographic data on refugee helpers. Work satisfaction was examined by means of Neuberger and Allerbeck’s Work Description Inventory. We screened for depression by using the 5-item WHO Well-Being Index (WHO-5), and for post-traumatic stress disorder (PTSD) using the PTSD Short Screening Scale (PTSD-7). 1712 questionnaires were analyzed.
Results
Females accounted for 73.4% (1235), the mean age was 52.0 years (SD: 14.4). 61.6% were academics (1042). 87.0% (1454) were voluntary helpers who invested 9.4 hours (SD: 8.9) per week. Refugee helpers were more satisfied with the content than with the conditions or the organization of their work. Their work satisfaction and overall life satisfaction reached higher values than in representative samples. The mean WHO-5 index for refugee helpers was 68.2 points (SD: 19.0). Positive depression screening was found in 17.3% (226). 982 (57.4%) had experienced a traumatic event in their past or witnessed it during their work in refugee aid. 33 (2.8%) of the helpers had a positive PTSD screening.
Conclusions
Refugee helpers deliver invaluable services to migrants and receiving communities. Our data indicates above average well-being as well as work-satisfaction. Psychological traumatization is found frequently but fortunately PTSD is rare. All efforts should be made to uphold helpers’ keen spirit and contributions. They should be screened regularly with regards to work satisfaction, well-being and mental health. As part of a comprehensive health promotion strategy they should be instructed about depression, psychological trauma, PTSD and ways to find help.
A longitudinal qualitative study was conducted to explore the experiences of church leaders (10 priests, pastors, and pastors’ wives) who provided disaster spiritual/emotional care (DSEC) to the island of Puerto Rico during a period of intense and repeated crises from 2017 to 2022. Utilizing a narrative inquiry approach, 18 in-depth interviews were conducted and analyzed. Findings indicated that the participants engaged in psychological, social, and religious coping strategies to actively cope with the stress and trauma of being first responder rescuer/victims. Regional, cultural and contextual factors are considered in an effort to understand and enhance services to populations where disaster is the new normal.
Since Red Crescent employees are forced to perform various maneuvers such as speed, strength, endurance, etc. in emergency situations, in order to prevent injury and achieve high performance, in addition to having specialized knowledge and skills of physical fitness have a high The aim of the present study was to compare the effect of strength training with and without focusing on the trunk area on a selection of physical fitness factors of active employees of the Red Crescent population of Sardasht city. 45 subjects in two experimental groups (15 people in each group) and a control group (15 people) with the age range of 25 to 35 years voluntarily participated in this study. The exercises were performed for eight weeks, three sessions per week and each session was 45 minutes in two experimental groups with and without focusing on the trunk area. Sargent jump tests, Barfix stretching, Swedish swimming, Shuttle Run (4*9) and flexibility test were used to evaluate the physical fitness of the subjects. The t-test and covariance were used to analyze the data at a significance level of 0.05. A significant improvement was observed in the physical fitness of the two experimental groups compared to the pre-test. The training group focusing on the trunk showed more significant improvement. No significant changes were observed in the control group. It seems that performing strength exercises focusing on the trunk can probably be effective in improving the physical fitness of the subjects of the upcoming study in various maneuvers.
Since Red Crescent employees are forced to perform various maneuvers such as landing in emergency situations, therefore, in order to prevent injury, they must have high mobility readiness in addition to having specialized knowledge and skills. The aim of the present study was to investigate the effect of injury prevention exercises with and without knee control instructions on the function of the lower limbs of active employees of the Red Crescent population of Sardasht city. 45 subjects in two experimental groups (15 people in each group) and a control group (15 people) with the age range of 25 to 35 years voluntarily participated in this study. Exercises were performed for eight weeks, three sessions per week and each session was 45 minutes in two experimental groups with and without knee control instructions. Landing error scoring system was used to evaluate the performance of subjects' lower limbs. Analysis of variance with repeated measures and Bonferroni's post hoc test were used to analyze the data at a significance level of 0.05. A significant improvement was observed in the landing mechanics of the two experimental groups compared to the pre-test. The exercise group with knee control instructions showed more significant improvement. No significant changes were observed in the control group. It seems that doing injury prevention exercises, especially if it is focused on controlling the knee, can probably be effective in better controlling the condition of the knee in various maneuvers of the subjects of the present study.
Employees of faith-based international organizations have been shown to be uniquely at risk for mental health symptoms, including depression and posttraumatic stress, while social support has been demonstrated to be an important protective factor. Cultural humility, which is understood as an openness to appreciate and learn from others, has also been shown to contribute to wellbeing for cross-cultural employees. Eighty-eight cross-cultural faith-based workers completed the Hopkins Symptom Checklist, Social Provisions Scale, and Cultural Humility Scale as a part of a larger needs assessment conducted in late 2020 during the global COVID-19 pandemic. It was hypothesized that social support would relate inversely to mental health symptoms, and that cultural humility would moderate the relationship between support and symptoms. Path analysis confirmed this hypothesis. When participants reported moderate to high levels of cultural humility, there was a strengthened relationship between social support and lower mental health symptoms. Thus, cultural humility appears to activate the relationship between social support and reduced mental health symptoms. International organizations can contribute to employee resilience in traumatic contexts by promoting both cultural humility and social support.
Disaster relief workers face unique factors in their operating environments that can inhibit internal integration. For example, disaster relief often involves exposure to traumatic events affecting relief workers’ commitment to cooperation and the organization. As such, disaster relief organizations dedicate substantial amounts of scarce resources to support workers exposed to trauma. Unfortunately, contradictory views exist in the literature on how trauma exposure affects commitment and integrative behaviors and how supervisor support influences these relationships. Based on the approach‐avoidance coping theory, we test whether trauma exposure has positive or negative effects. We test our hypotheses on data from 300 disaster relief workers collected using a 2 × 3 factorial scenario‐based experiment. We find that trauma exposure evokes avoidance coping behaviors, which decrease individuals’ cooperative disposition and approach coping behaviors, which motivate organizational commitment. Next, we show that both forms of commitment have a nonlinear convex relationship with internal integration and mediate the relationship between trauma exposure and internal integration. Finally, we find that supervisor support amplifies these relationships. When exposed to trauma, supervisor approach and avoidance orientations provide higher internal integration levels than subjects exposed to no supervisor support. These findings extend the literature on disaster relief management, integration, and support, guiding decision‐making regarding support investments in disaster relief organizations.
This article is protected by copyright. All rights reserved
Despite an increased focus on trauma-informed care within the juvenile justice system, we still know very little about the impact of trauma on juvenile justice professionals or their perceptions of trauma-informed interventions. To fill this gap, this study used an organizational assessment to examine perceptions of trauma-informed care among juvenile professionals in a juvenile detention setting. Participants included 204 staff members in two secure juvenile detention facilities. Staff who reported greater availability of trauma-informed practices were more likely to perceive that youth and families felt safe and those who reported that the facility was taking steps to address secondary trauma were more likely to report a sense of staff safety. Regarding individual factors, only age and gender were related to perceptions of youth and family safety. Frontline staff were more likely than supervisory staff to feel they had received adequate training in trauma and had the skills necessary to deescalate youth. These findings suggest that staff are open to trauma-informed practices in juvenile detention, but a greater focus on supervisory staff is needed. Shifting from individual-level strategies to facility-level improvements could have a greater impact on enhancing staff members’ perceptions of safety, which improves their ability to care for youth.
Public sector social workers in the Occupied Palestinian Territories experience loss and trauma on a daily basis. Study objectives were to: (a) assess levels of three mental health outcomes and (b) examine workplace correlates among Palestinian social workers in the West Bank. Results revealed alarmingly high percentages of workers who met clinical thresholds for somatic symptoms (70.9%), distress (34.7%), and anxiety (19.3%). Multivariate regression models explained 25–32% of outcome variance. Job stress, exposure to violence, and job satisfaction were significant in two models, and physical health was significant in three models. Policy, practice, and future research implications are discussed.
This paper analyses the significance of specific ethical experiences for humanitarian aid workers' motivation. Following Emmanuel Levinas's understanding of ethics as arising from intersubjective face-to-face encounters, the study illuminates the experiential origins of the humanitarian commitment by analysing James Orbinski's memoir entitled An Imperfect Offering: Dispatches from the Medical Frontline. Orbinski, a former International Council President at Médecins Sans Frontières, was directly involved in humanitarian responses to several major crises during the 1990s, including those in Somalia, Afghanistan, Rwanda, and what was then Zaire. This paper explores three formative experiences from Orbinski's childhood and teenage years to analyse the personal ethics of humanitarian aid workers and to illuminate the intersection of the personal and professional level of humanitarian aid work. Illustrating that Orbinski's humanitarian commitment is a surrendering to the other's call, the paper argues for stronger inclusion of aid workers' lives and experiences to achieve a comprehensive understanding of humanitarian work.
Etwa 25–30 % der Menschheit leidet im Laufe ihres Lebens an einer psychischen Störung, und Expatriates bilden hierbei keine Ausnahme. Ganz im Gegenteil, es gibt einige Hinweise auf höhere Prävalenzen von psychischen Störungen bei Expatriates. Dieses Kapitel versucht, einen Überblick über den Wissensstand zu psychischen Störungen bei Expatriates zu geben, und erste Erklärungsversuche für die erhöhten Fallzahlen werden formuliert. Es werden sowohl Maßnahmen zur Prävention als auch zur Behandlung von psychischen Störungen eingeführt, und es wird die Frage diskutiert, ob Onlinepsychotherapie das Mittel der Wahl für Expatriates mit psychischen Störungen ist. Schließlich werden konkrete Tipps für das Finden von passenden Therapeut*innen gegeben.
Despite evidence that faith-based and spiritual coping supports people’s mental health, stigmata prevail in the aid sector around the need for psychological support in general and around this coping mechanism in particular. This qualitative research examines female aid workers’ experiences and aims to elucidate how this mechanism supports mental health in stressful, conflict, or disaster-affected living and working environments. Inductive thematic analysis of 14 semi-structured interviews reveals three themes around (a) specificities of the aid work context, (b) benefits and gains through this coping mechanism and related processes, and (c) potential downsides. Interview findings suggest a faith-based and spiritual approach helped interviewees feel grounded, calm, resilient, and present in difficult environments. Participants experienced a resolute identity, space for self-care, as well as access to community, belonging, and connection across national, faith, and spiritual boundaries. Results raise the importance of de-stigmatizing faith-based and spiritual coping and invite further discussion among practitioners.
Organizations cannot function without healthy and safe employees, a stark reality evidenced by the COVID-19 pandemic in 2019-20: when lives are threatened, everything else becomes secondary. Few would question that there is a critical need to build HR-relevant knowledge of how to manage the health and safety of employees. Despite the duty of care carried by organizations and the fact that those who work across national borders are a particularly vulnerable group, there is surprisingly little discussion about their health and safety. We examined the literature relevant to the health and safety of international employees across four research disciplines. Our review of 180 papers found a growing yet fragmented field offering important insights with implications for HRM. Our paper is intended as both a review and a call for future advancement. We bring together disparate but related research streams in order to understand what is known about occupational health and safety related to working across national borders and to outline a roadmap for future research and practice.
Organizational scientists are paying increasing attention to the scientific study of humility, following a larger trend in scholarship which has emphasized the relational and interdependent nature of leadership and of business. A growing body of evidence identifies humility as vital to effective organizational leadership, facilitating positive organizational outcomes (e.g., lower voluntary turnover and higher follower job satisfaction, engagement, and performance). To date, existing research on humility has focused on certain specific organizational contexts, such as businesses, hospitals, and schools. The purpose of this paper is to review the existing literature and explore theoretical considerations on why humility may be an especially important leader trait for international humanitarian aid organizations and relief work—a context that is not only uniquely challenging, but also one that would seemingly stand to keenly benefit from humility. We argue that humility in humanitarian aid is vital to effective humanitarian aid leadership because it is normative of good character, it is predictive of positive outcomes, and it corresponds to a genuine representation of the nature of humanitarian aid work.
This article is protected by copyright. All rights reserved
Background: Humanitarian workers operate in traumatic contexts, putting them at an increased risk of adverse mental health outcomes. The quality of the support they receive from their organization, their supervisor, and team members are proposed as determinants of mental illness and well-being, via the stress-appraisal process.
Objective: Grounded in organizational support theory, we sought to understand the relationship between organizational factors, including perceived organizational support, supervisor support, and team support, and indicators of both adverse mental health and mental well-being among humanitarian volunteers. This relationship is hypothesized to be mediated by the perceived psychological stress.
Methods: A sample of 409 humanitarian volunteers from the Sudanese Red Crescent Society completed an online, anonymous, survey comprised of the Perceived Supervision, Perceived Organizational Support, Team Support, and Perceived Psychological Stress scales, as well as the Generalized Anxiety Disorder and Patient Health Questionnaire scales, (GAD-7 and PHQ- 8), and the Warwick-Edinburgh Mental Well-being Scale. Study objectives were tested using structural equation modelling (SEM) procedures.
Results: Perceived helplessness (PH) and perceived self-efficacy (PSE), as measures of psychological stress, were both found to fully mediate the relationship between perceived organizational support and mental health outcomes. Perceived organizational support was associated with PSE and inversely with PH. PH was associated with adverse mental health and inversely related to mental well-being. PSE was only associated with mental well-being. Perceived supervision was negatively associated with PSE.
Conclusions: Perceived organizational support is a key determinant of the mental health of humanitarian volunteers, with greater perceived support associated with lower distress symptomology and greater mental well-being. Humanitarian agencies should take actions to improve their internal organization support systems to mitigate the stress associated with working in traumatic contexts. Specifically, more attention should be paid to the organizational support of the volunteers as front-line workers in humanitarian settings.
Background
The latest data on major attacks against civilian aid operations have identified South Sudan as the most dangerous country for aid workers globally. Exposure to other traumatic events and chronic stress is also common in this population. No research exists on the mental health of humanitarian workers in South Sudan.
Objectives
This study examined symptom burden and predictors of posttraumatic stress disorder (PTSD), depression, anxiety, hazardous alcohol consumption, and burnout among humanitarian workers in South Sudan.
Method
We conducted a cross-sectional online survey with humanitarian workers (national and international staff, consultants, United Nations volunteers). We applied validated measures useful for this setting. We applied Least Absolute Shrinkage and Selection Operator (LASSO) regression to fit models with high prediction accuracy for each outcome and used ordinary least squares (OLS) regression to obtain final coefficients and perform inference.
Results
A total of 277 humanitarian workers employed by 45 organizations completed the survey (a response rate in the order of 10%). We estimated prevalence of PTSD (24%), depression (39%), anxiety disorder (38%), hazardous alcohol consumption in men (35%) and women (36%), and the burnout components emotional exhaustion (24%) and depersonalization (19%). Chronic stress exposure was positively associated with PTSD (p < .001), depression (p < .001), anxiety (p < .001), emotional exhaustion (p < .01), and depersonalization (p < .001). We found no significant association between emotion focused and problem focused coping and mental health outcomes. Associations between dysfunctional coping and depression (p < .001) and anxiety (p < .01) were positive. Higher levels of spirituality were associated with lower risk of hazardous alcohol consumption (p < .001). Contrary to expectations, working directly with humanitarian aid beneficiaries was significantly associated with lower risk for emotional exhaustion (p < .01).
Conclusion
Our results suggest that humanitarian workers in South Sudan experience substantial levels of mental ill-health. This study points to the need for staff support strategies that effectively mitigate humanitarian workers’ chronic stress exposure. The dynamics between coping and mental health among humanitarian workers require further study.
There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQ's cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.
Context
Since the beginning of the North Atlantic Treaty Organization intervention
in Kosovo in June 1999, few objective data have been available on relevant
health indicators for the Serbian ethnic minority in Kosovo.Objective
To determine the prevalence of undernutrition among Serbian adults aged
60 years or older and psychiatric morbidity among the adult Serbian population
in Kosovo.Design, Setting, and Participants
A systematic random sample survey of 212 households was conducted between
September 27 and October 2, 1999, in Pristina, the capital city, and in 10
towns in the rural municipality of Gnjilane in Kosovo. Of the 212 households
surveyed, 204 adults aged 15 years or older completed the General Health Questionnaire-28
(GHQ-28) and anthropometric measurements were taken for 98 adults aged 60
years or older and for a comparison group of 51 adults aged 18 to 59 years.Main Outcome Measures
Body mass index of less than 18.5 kg/m2 in older adults;
nonspecific psychiatric morbidity among adults; and self-reported use of health
care services, access to food rations, and primary sources of prewar and postwar
income.Results
Undernutrition was found in 11.2% (95% confidence interval [CI], 5.7%-19.2%)
of Serbian adults aged 60 years or older compared with 2.0% (95% CI, 0.1%-11.8%)
of Serbian adults aged 18 to 59 years. The mean (SE) total score for the GHQ-28
was 13.0 (0.52). In a comparison of the GHQ-28 scores of the Serbian adults
with the Kosovar Albanian adults (data from a recent survey), the mean (SE)
score adjusted for age and sex was 12.8 (0.52) vs 11.1 (0.58); P = .03, respectively. The GHQ-28 scores were also higher for the Serbians
in the subcategories of social dysfunction (2.8 [0.17] vs 2.2 [0.13]; P = .008) and severe depression (1.9 [0.15] vs 0.9 [0.09]; P<.001), respectively. Serbian women and persons living
alone or in small family units were more prone to psychiatric morbidity. Of
the 141 respondents reporting the need for health care services, 83 (57.6%)
reported not obtaining such services; 204 of 212 (96.2%) households were on
a food distribution list. The majority of prewar income came from government
jobs compared with farming and humanitarian aid for postwar income.Conclusions
The undernutrition of older Serbian adults in Kosovo should be monitored.
The high prevalence of symptoms of social dysfunction and severe depression
suggest the need for implementation of mental health programs in the Serbian
community.
Figures in this Article
In June 1999, forces of the North Atlantic Treaty Organization (NATO)
took military control of Kosovo, and the United Nations Mission in Kosovo
became responsible for the civil administration of the province. Prior to
the NATO-led intervention, the majority Albanian population had been subject
to more than a decade of Serbian repression, culminating in a campaign of
"ethnic cleansing" that resulted in the deaths of approximately 12,000 people
from war-related injuries between February 1998 and June 1999 and the displacement
of more than 800,000 people.1 The withdrawal
of the Serbian forces on June 20, 1999, was followed by the swift, spontaneous
repatriation of Kosovar Albanians.2 The international
community responded by implementing large-scale humanitarian assistance programs
in shelter, food aid, health care, water, and sanitation, largely directed
toward the Kosovar Albanian community.
Reprisal attacks, particularly targeting the Serbians, and to a lesser
extent the Romas (gypsy population), who were widely accused of collaborating
with the Serbian military campaign, have been frequently reported since the
international community took control; by December 1999, 200 to 400 Serbian
civilians had been killed in Kosovo.3 As a
consequence of a campaign of repeated threats, cutting of phone lines, assault,
forced eviction, arson, crop burning, and murder, the majority of the Serbian
population of Kosovo has fled to Serbia proper (defined here as all provinces
of Serbia other than Kosovo) or to areas of Kosovo in which Serbians represent
the majority of the population.4 Of an estimated
prewar population of 200,000, approximately 97,000 Serbians remained in Kosovo
as of December 1999.3
The health status of the Serbian population, particularly those remaining
in large towns or in enclaves (areas of Serbian populations surrounded by
Albanian majority zones), has been of particular concern because many in these
communities are old and infirm. For many of these communities, access to humanitarian
services such as medical care and food aid, as well as access to markets and
agricultural lands, has been limited because of restrictions on movement.4 Nutritional indices in the older adults and psychiatric
morbidity were therefore thought to be of more relevance in this population
than standard indicators of population vulnerability in complex emergencies
in developing countries. These standard indicators include acute malnutrition
prevalence among children younger than 5 years and communicable disease incidence
rates. To obtain a broad overview of the health of the Serbian minority in
Kosovo, 2 international humanitarian organizations, the International Rescue
Committee and Action Against Hunger, in collaboration with the Centers for
Disease Control and Prevention, surveyed Serbians in Pristina, the capital,
and in the Gnjilane enclaves in Kosovo in September and October 1999.
Examined the extent of agreement between retrospective and prospective measures of variables in 7 different content domains: residence changes, anthropometrics, injuries, reading ability, family characteristics, behavior problems, and delinquency. Retrospective reports using data from a large sample of 18-yr-old youth who have been studied prospectively since their births were evaluated. The findings suggest that (1) psychosocial variables (e.g., reports about subjective psychological states and family processes) revealed the lowest level of agreement between prospective and retrospective measures and (2) even when retrospective reports correlated significantly with prospective data, the absolute level of agreement between the 2 data sources was quite poor. It appears that reliance on retrospective reports about psychosocial variables should be approached with caution. Moreover, it is suggested that the use of retrospective reports should be limited to testing hypotheses about the relative standing of individuals in a distribution and should not be used to test hypotheses that demand precision in estimating event frequencies and event dates. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study is concerned with the question whether extremely emotional experiences, such as being the victim of Nazi concentration camps, leave traces in memory that cannot be extinguished. Relevant data were obtained from testimony by 78 witnesses in a case against Marinus De Rijke, who was accused of Nazi crimes in Camp Erika in The Netherlands. The testimonies were collected in the periods 1943–1947 and 1984–1987. A comparison between these two periods reveals the amount of forgetting that occurred in 40 years. Results show that camp experiences were generally well-remembered, although specific but essential details were forgotten. Among these were forgetting being maltreated, forgetting names and appearance of the torturers, and forgetting being a witness to murder. Apparently intensity of experiences is not a sufficient safeguard against forgetting. This conclusion has consequences for the forensic use of testimony by witnesses who were victims of violent crimes.
The psychological responses of two groups of fire fighters were examined following the performance of rescue work. Four types of responses were reported: identification with the victims, feelings of helplessness and guilt, fear of the unknown, and physiological reactions. Stress was found to be mediated by availability of social support, type of leadership, level of training, and use of rituals. Implications of these findings for preventive intervention measures are discussed.
Conducted a 14-yr follow-up of 120 survivors (mean age 53.5 yrs) of the Buffalo Creek dam collapse to determine whether there were lingering psychological effects of the collapse in the 2nd decade, with a focus on longitudinal stability and change. Decreased symptoms were noted in all areas measured on the Psychiatric Evaluation Form, although significant psychopathology in the form of posttraumatic stress disorder (PTSD) remained in about one-quarter of the survivors. A small group with delayed onset of symptoms was identified.
More than 700,000 refugees from Southeast Asia have settled in the United States since 1975. Although many have suffered serious trauma, including torture, few clinical reports have described their trauma-related symptoms and psychosocial problems. The authors conducted a treatment study of 52 patients in a clinic for Indochinese. They found that these patients were a highly traumatized group; each had experienced a mean of 10 traumatic events and two torture experiences. Many of the patients had concurrent diagnoses of major affective disorder and posttraumatic stress disorder as well as medical and social disabilities associated with their history of trauma. The authors also found that Cambodian women without spouses demonstrated more serious psychiatric and social impairments than all other Indochinese patient groups.
This article describes a large longitudinal multicenter collaborative study that investigated the form, frequency, course, and outcome of psychological problems that were seen in primary health care settings in 15 different sites around the world. The research employed a two-stage sampling design in which the 12-item General Health Questionnaire was administered to 26,422 persons aged 18 to 65 years who were consulting health care services. Of these persons, 5604 were selected for detailed examinations using standardized instruments and were followed up at 3 months and 1 year to provide information on course and outcome. All assessment instruments have been translated into 13 different languages. The project has produced a database that allows for the exploration of the nature of psychological disorders experienced by patients in general medical care and their association with physical illness, illness behavior, and disability over time.
The nature of traumatic memories is currently the subject of intense scientific investigation. While some researchers have described traumatic memory as fixed and indelible, others have found it to be malleable and subject to substantial alteration. The current study is a prospective investigation of memory for serious combat-related traumatic events in veterans of Operation Desert Storm.
Fifty-nine National Guard reservists from two separate units completed a 19-item trauma questionnaire about their combat experiences 1 month and 2 years after their return from the Gulf War. Responses were compared for consistency between the two time points and correlated with level of symptoms of posttraumatic stress disorder (PTSD).
There were many instances of inconsistent recall for events that were objective and highly traumatic in nature. Eighty-eight percent of subjects changed their responses on at least one of the 19 items, while 61% changed two or more items. There was a significant positive correlation between score on the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder at 2 years and the number of responses on the trauma questionnaire changed from no at 1 month to yes at 2 years.
These findings do not support the position that traumatic memories are fixed or indelible. Further, the data suggest that as PTSD symptoms increase, so does amplification of memory for traumatic events. This study raises questions about the accuracy of recall for traumatic events, as well as about the well-established but retrospectively determined relationship between level of exposure to trauma and degree of PTSD symptoms.
In recent years the 12-item General Health Questionnaire (GHQ-12) has been extensively used as a short screening instrument, producing results that are comparable to longer versions of the GHQ.
The validity of the GHQ-12 was compared with the GHQ-28 in a World Health organization study of psychological disorders in general health care. Results are presented for 5438 patients interviewed in 15 centres using the primary care version of the Composite International Diagnostic Instrument, or CIDI-PC.
Results were uniformly good, with the average area under the ROC curve 88, range from 83 to 95. Minor variations in the criteria used for defining a case made little difference to the validity of the GHQ, and complex scoring methods offered no advantages over simpler ones. The GHQ was translated into 10 other languages for the purposes of this study, and validity coefficients were almost as high as in the original language. There was no tendency for the GHQ to work less efficiently in developing countries. Finally gender, age and educational level are shown to have no significant effect on the validity of the GHQ.
If investigators wish to use a screening instrument as a case detector, the shorter GHQ is remarkably robust and works as well as the longer instrument. The latter should only be preferred if there is an interest in the scaled scores provided in addition to the total score.
Populations affected by armed conflict have experienced severe public health consequences mediated by population displacement, food scarcity, and the collapse of basic health services, giving rise to the term complex humanitarian emergencies. These public health effects have been most severe in underdeveloped countries in Africa, Asia, and Latin America. Refugees and internally displaced persons have experienced high mortality rates during the period immediately following their migration. In Africa, crude mortality rates have been as high as 80 times baseline rates. The most common causes of death have been diarrheal diseases, measles, acute respiratory infections, and malaria. High prevalences of acute malnutrition have contributed to high case fatality rates. In conflict-affected European countries, such as the former Yugoslavia, Georgia, Azerbaijan, and Chechnya, war-related injuries have been the most common cause of death among civilian populations; however, increased incidence of communicable diseases, neonatal health problems, and nutritional deficiencies (especially among the elderly) have been documented. The most effective measures to prevent mortality and morbidity in complex emergencies include protection from violence; the provision of adequate food rations, clean water and sanitation; diarrheal disease control; measles immunization; maternal and child health care, including the case management of common endemic communicable diseases; and selective feeding programs, when indicated.
This report describes a 1-year follow-up study of survivors of a mass shooting incident. Acute-phase data from this incident were previously reported in this journal.
The Diagnostic Interview Schedule/Disaster Supplement was used to assess 136 survivors at 1-2 months and again a year later, with a 91% reinterview rate.
In the acute postdisaster period, 28% of subjects met criteria for posttraumatic stress disorder (PTSD), and 18% of subjects qualified for another active psychiatric diagnosis. At follow-up, 24% of subjects reported a history of postdisaster PTSD (17% were currently symptomatic), and 12% another current psychiatric disorder. Half (54%) of all 46 individuals identified as having had PTSD at either interview were recovered at follow-up, and no index predictors of recovery were identified. There were no cases of delayed-onset PTSD (beyond 6 months). Considerable discrepancy in identified PTSD cases was apparent between index and follow-up. Inconsistency in reporting, rather than report of true delayed-onset, was responsible for all PTSD cases newly identified at 1 year. The majority of subjects with PTSD at index who were recovered at follow-up reported no history of postdisaster PTSD at follow-up, suggesting considerable influence of fading memory.
This study's findings suggest that disaster research that conducts single interviews at index or a year later may overlook a significant portion of PTSD. The considerable diagnostic comorbidity found in this study was the one robust predictor of PTSD at any time after the disaster. Disaster survivors with a psychiatric history, especially depression, may be most vulnerable to developing PTSD and therefore may deserve special attention from disaster mental health workers.
The authors' goal was to study the contribution of predeployment personality traits and exposure to traumatic events during deployment to the development of symptoms of posttraumatic stress disorder (PTSD) in individuals involved in military peacekeeping activities.
Five hundred seventy-two male veterans who participated in the United Nations Protection Force mission in the former Yugoslavia completed a short form of the Dutch MMPI before deployment. Following deployment, they participated in a survey of all Dutch military veterans who had been deployed in the years 1990-1995 and completed the Self-Rating Inventory for PTSD.
Exposure to traumatic events during deployment had the highest unique contribution to the prediction of PTSD symptom severity, followed by the personality traits of negativism and psychopathology, followed by age.
Both pretrauma vulnerabilities and exposure to traumatic events were found to be important factors in the etiology of posttraumatic stress symptoms. The current study replicates in a non-American sample of peacekeepers findings obtained among American Vietnam veterans. Particularly, there is accumulating evidence for an etiological role of the personality trait of psychoneuroticism in the development of posttraumatic stress symptoms.
Uncertainties exist about prevalence and correlates of major depressive disorder (MDD).
To present nationally representative data on prevalence and correlates of MDD by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, and on study patterns and correlates of treatment and treatment adequacy from the recently completed National Comorbidity Survey Replication (NCS-R).
Face-to-face household survey conducted from February 2001 to December 2002.
The 48 contiguous United States.
Household residents ages 18 years or older (N = 9090) who responded to the NCS-R survey.
Prevalence and correlates of MDD using the World Health Organization's (WHO) Composite International Diagnostic Interview (CIDI), 12-month severity with the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR), the Sheehan Disability Scale (SDS), and the WHO disability assessment scale (WHO-DAS). Clinical reinterviews used the Structured Clinical Interview for DSM-IV.
The prevalence of CIDI MDD for lifetime was 16.2% (95% confidence interval [CI], 15.1-17.3) (32.6-35.1 million US adults) and for 12-month was 6.6% (95% CI, 5.9-7.3) (13.1-14.2 million US adults). Virtually all CIDI 12-month cases were independently classified as clinically significant using the QIDS-SR, with 10.4% mild, 38.6% moderate, 38.0% severe, and 12.9% very severe. Mean episode duration was 16 weeks (95% CI, 15.1-17.3). Role impairment as measured by SDS was substantial as indicated by 59.3% of 12-month cases with severe or very severe role impairment. Most lifetime (72.1%) and 12-month (78.5%) cases had comorbid CIDI/DSM-IV disorders, with MDD only rarely primary. Although 51.6% (95% CI, 46.1-57.2) of 12-month cases received health care treatment for MDD, treatment was adequate in only 41.9% (95% CI, 35.9-47.9) of these cases, resulting in 21.7% (95% CI, 18.1-25.2) of 12-month MDD being adequately treated. Sociodemographic correlates of treatment were far less numerous than those of prevalence.
Major depressive disorder is a common disorder, widely distributed in the population, and usually associated with substantial symptom severity and role impairment. While the recent increase in treatment is encouraging, inadequate treatment is a serious concern. Emphasis on screening and expansion of treatment needs to be accompanied by a parallel emphasis on treatment quality improvement.
Human righls workers in humanitarian relief settings may be exposed to traumatic events that put them at risk for psychiatric morbidity. We conducted a cross‐sectional survey in June 2000 to study the prevalence of psychiatric morbidity among 70 expatriate and Kosovar Albanian staff collecting human rights data in Kosovo. Among those surveyed, elevated levels of anxiety, depression, and posttraumatic stress disorder symptoms were found in 17.1, 8.6, and 7.1% respectively. Multiple regression analysis revealed that human rights workers at risk for elevated anxiety symptoms were those who had worked with their organization longer than 6 months, those who had experienced an armed attack, and those who experienced local hostility. Our study indicates that human rights organizations should consider mental health assessment, care, and prevention programs for their staff.
International relief and development personnel may be directly or indirectly exposed to traumatic events that put them at risk for developing symptoms of Post‐traumatic Stress Disorder (PTSD). In order to identify areas of risk and related reactions, surveys were administered to 113 recently returned staff from 5 humanitarian aid agencies. Respondents reported high rates of direct and indirect exposure to life‐threatening events. Approximately 30% of those surveyed reported significant symptoms of PTSD. Multiple regression analysis revealed that personal and vicarious exposure to life‐threatening events and an interaction between social support and exposure to life threat accounted for a significant amount of variance in PTSD severity. These results suggest the need for personnel programs; prede‐ployment training, risk assessment, and contingency planning may better prepare personnel for service.
More than 30 million refugees and internally displaced persons in developing countries are currently dependent on international relief assistance for their survival. Most of this assistance is provided by Western nations such as the United States. Mortality rates in these populations during the acute phase of displacement have been extremely high, up to 60 times the expected rates. Displaced populations in northern Ethiopia (1985) and southern Sudan (1988) have suffered the highest crude mortality rates. Although mortality rates have risen in all age groups, excess mortality has been the greatest in 1- through 14-year-old children. The major causes of death have been measles, diarrheal diseases, acute respiratory tract infections, and malaria. Case-fatality ratios for these diseases have risen due to the prevalence of both protein-energy malnutrition and certain micronutrient deficiencies. Despite current technical knowledge and resources, several recent relief programs have failed to promptly implement essential public health programs such as provision of adequate food rations, clean water and sanitation, measles immunization, and control of communicable diseases. Basic structural changes in the way international agencies implement and coordinate assistance to displaced populations are urgently needed.(JAMA. 1990;263:3296-3302)
This study tested the association between psychosocial stressors extracted from a previous qualitative study, and psychological distress, long-term illness and self-rated ill-health among Latin American refugees in Lund, Sweden, and among repatriated Latin Americans. The study was designed as a population-based cross-sectional study. A structured questionnaire from the Swedish Annual Level-of-Living Surveys 1989: 2 was translated into Spanish. Latin American refugees in Lund (n=338) and those who had lived in Lund and were repatriated to Santiago de Chile (n=51) and Montevideo, Uruguay (n=9), were interviewed in their homes in Sweden and in Latin America. The data were analysed unmatched with logistic regression in main effect models. Torture was an independent risk indicator for psychological distress, with an estimated odds ratio of 2.71 (1.45–4.85). There was a significant association between discrimination, not feeling secure in everyday life and psychological distress, with estimated odds ratios of 1.93(1.02–3.56) and 3.23(1.62–6.16), respectively. Torture and not feeling secure in everyday life were independent risk factors for long-term illness. Torture, discrimination and not feeling secure in everyday life were significant strong risk factors for ill-health. Repatriated refugees had significantly higher shares of not feeling secure compared with Latin Americans in Sweden. As risk factors of psychological distress and illness, torture, discrimination and not feeling secure proved to be as important as traditional risk factors such as material factors and lifestyle.
International relief and development personnel may be directly or indirectly exposed to traumatic events that put them at risk for developing symptoms of Posttraumatic Stress Disorder (PTSD). In order to identify areas of risk and related reactions, surveys were administered to 113 recently returned staff from 5 humanitarian aid agencies. Respondents reported high rates of direct and indirect exposure to life-threatening events. Approximately 30% of those surveyed reported significant symptoms of PTSD. Multiple regression analysis revealed that personal and vicarious exposure to life-threatening events and an interaction between social support and exposure to life threat accounted for a significant amount of variance in PTSD severity. These results suggest the need for personnel programs; predeployment training, risk assessment, and contingency planning may better prepare personnel for service.
The 25-item Hopkins Symptom Checklist ( HSCL -25) was used on two occasions four weeks apart to identify self-reported symptoms of anxiety and depression in patients attending a family planning service. Only 28 per cent of patients classified as anxious to start with remained so four weeks later, but 62 per cent of those with high depression scores and 74 per cent of those with high depression and high anxiety scores maintained significant levels of depression. The implications of these findings for routine screening are discussed.
SYNOPSIS
This study reports the factor structure of the symptoms comprising the General Health Questionnaire when it is completed in a primary care setting. A shorter, 28-item GHQ is proposed consisting of 4 subscales: somatic symptoms, anxiety and insomnia, social dysfunction and severe depression. Preliminary data concerning the validity of these scales are presented, and the performance of the whole 28-item questionnaire as a screening test is evaluated. The factor structure of the symptomatology is found to be very similar for 3 independent sets of data.
A population of the fire fighters who had been exposed to a natural disaster were screened using the General Health Questionnaire 4, 11, and 29 months after a natural disaster. On the basis of these data, a high-risk group of subjects who had scored as cases and probable cases and a symptom-free comparison group were interviewed using the Diagnostic Interview Schedule 42 months after the disaster. The prevalence of posttraumatic stress disorder (PTSD), affective disorders, and anxiety disorders was examined. Only 23% of the 70 subjects who had developed a PTSD did not attract a further diagnosis, with major depression being the most common concurrent disorder. Comorbidity appeared to be an important predictor of chronic PTSD, especially with panic disorder and phobic disorders. The subjects who had only a PTSD appeared to have had the highest exposure to the disaster. Adversity experienced both before and after the disaster influenced the onset of both anxiety and affective disorders.
More than 30 million refugees and internally displaced persons in developing countries are currently dependent on international relief assistance for their survival. Most of this assistance is provided by Western nations such as the United States. Mortality rates in these populations during the acute phase of displacement have been extremely high, up to 60 times the expected rates. Displaced populations in northern Ethiopia (1985) and southern Sudan (1988) have suffered the highest crude mortality rates. Although mortality rates have risen in all age groups, excess mortality has been the greatest in 1- through 14-year-old children. The major causes of death have been measles, diarrheal diseases, acute respiratory tract infections, and malaria. Case-fatality ratios for these diseases have risen due to the prevalence of both protein-energy malnutrition and certain micronutrient deficiencies. Despite current technical knowledge and resources, several recent relief programs have failed to promptly implement essential public health programs such as provision of adequate food rations, clean water and sanitation, measles immunization, and control of communicable diseases. Basic structural changes in the way international agencies implement and coordinate assistance to displaced populations are urgently needed.
The onset of post-traumatic stress disorders in a group of firefighters who had an intense exposure to a bushfire disaster was investigated using a longitudinal research design. Contrary to expectation, the intensity of exposure, the perceived threat, and the losses sustained in the disaster, when considered independently, were not predictors of post-traumatic stress disorder. By contrast, introversion, neuroticism, and a past history and family history of psychiatric disorder were premorbid factors significantly associated with the development of chronic post-traumatic stress disorders.
This study examined the utility of the DSM-III diagnostic criteria for posttraumatic stress disorder (PTSD) in a high-risk group of 50 firefighters who had had an intense exposure to a natural disaster 8 months before being interviewed. Follow-up over the next 3 years allowed examination of the ability of these diagnostic criteria to predict a pattern of chronic posttraumatic morbidity. They predicted a pattern of chronic disorder, demonstrated by the finding that eight of the 15 subjects who had definite or borderline PTSD at 8 months remained symptomatic 3 years later. A disturbance of attention and concentration appeared to be the best predictor of chronic PTSD. The longitudinal course of posttraumatic morbidity in these 50 firefighters was compared with a matched group of 96 uninterviewed subjects 11 and 29 months after the disaster. Although the interview provoked an emotional catharsis in a number of firefighters, the long-term morbidity in the two groups was comparable. Fourteen subjects who did not have PTSD continued to experience intense imagery 8 months after the disaster. This observation raises questions about whether such thoughts and feelings have adequate specificity as diagnostic criteria for PTSD in a group that has recently been exposed to a traumatic event.
This report describes the historical evolution, development, rationale and validation of the Hopkins Symptom Checklist (HSCL), a self-report symptom inventory. The HSCL is comprised of 58 items which are representative of the symptom configurations commonly observed among outpatients. It is scored on five underlying symptom dimensions—sommatization, obsessive-compulsive, interpersonal sensitivity, anxiety and depression—which have been identified in repeated factor analyses. A series of studies have established the factorial invariance of the primary symptom dimensions, and substantial evidence is given in support of their construct validity. Normative data in terms of both discrete symptoms and primary symptom dimensions are presented on 2,500 subjects—1,800 psychiatric outpatients and 700 normals. Indices of pathology reflect both intensity of distress and prevalence of symptoms in the normative samples. Standard indices of scale reliability are presented, and a broad range of criterion-related validity studies, in particular an important series reflecting sensitivity to treatment with psychotherapeutic drugs, are reviewed and discussed.
The paper is a report on results obtained in the course of a multi-centre international study on depressive disorders in four countries, which was sponsored and co-ordinated by the World Health Organization. A screen form was developed and tested in order to select depressive patients among psychiatric in-patient and out-patient populations. The patients selected in this way were assessed clinically by experienced investigators using the WHO schedule for Standardized Assessment of Depressive Disorders (SADD). A total of 53 patients were evaluated in the five research centres, and the data were utilized in uni- and multivariate statistical analyses aiming to establish whether similar cases of depression could be found in different cultures, to describe their characteristics and to ascertain the extent to which diagnostic concepts and classification categories could be applied in different settings. The results point to a considerable degree of similarity in depressive symptomatology across the cultures if particular selection criteria are applied, and suggest that broad diagnostic groupings such as 'endogenous' and 'psychogenic' depressions could be used consistently by clinicians working in different cultures.
Military personnel are at high risk for developing post-traumatic stress disorder (PTSD), historically 10 to 50% of all casualties. The best treatment is to provide an opportunity for rest and ventilation of feelings and then to return the person to duty and to his or her peer group. Preventing the cycle of PTSD from starting and thus decreasing psychiatric casualties is feasible. This can be done by promoting unit cohesion and morale, ensuring that individuals know their jobs, inducing stress during training so individuals will be better prepared to cope, providing realistic information about what to expect in combat, and holding group debriefings immediately after any traumatic event. This paper discusses various models for preventing PTSD and examines future directions for the prevention of PTSD.
Little is known of the specific effects of exposure to traumatic death, an important dimension of many disasters. This study examined acute and long-term intrusive and avoidant symptoms, depression, and posttraumatic stress disorder (PTSD) in disaster workers exposed to traumatic death after the USS Iowa gun turret explosion. Fifty-four volunteer body handlers were assessed at 1, 4, and 13 months. They were compared with 11 non-body handler disaster worker volunteers. The Impact of Events Scale, Zung Depression Scale, Symptom Checklist-90-Revised, and a multi-method assessment of PTSD were used. Intrusive and avoidant symptoms were elevated at 1, 4, and 13 months, and decreased over time. Probable PTSD was present in 11% at 1 month, 10% at 4 months, and 2% at 13 months. The frequency of depression was not increased. Single body handler disaster workers reported more avoidance (times 1 and 2) and somatization (time 1) than did married workers. Body handlers reported more intrusion, avoidance, hostility, and somatization at 1 month than did non-body handler volunteers. These results indicate that exposure to traumatic death increases intrusive and avoidant symptoms, hostility, somatization, and the risk of PTSD and that symptoms can persist for months.
This clinical report describes symptoms of psychological and physical distress and psychiatric disorders in 24 Army Reservists who served war zone graves registration duty in support of Operation Desert Storm. Troops underwent comprehensive assessment for evidence of psychopathology that might be associated with war zone duty as one component of a debriefing protocol scheduled during regular drill exercises eight months after their return to the United States. Troops endorsed items suggestive of high war zone stress exposure, common symptoms of anxiety, anger, and depression, and multiple health and somatic concerns. Almost half of the sample met criteria for post-traumatic stress disorder, and diagnosis of this disorder was strongly associated with evidence of depressive and substance abuse disorders. The gruesome aspects of body recovery and identification in a war zone setting were cited as stressor elements of significant negative impact.
Persons who handled human remains in Operation Desert Storm (N = 116) were compared with those who did not handle remains (N = 118) on symptoms of posttraumatic stress disorder. Subjects who handled remains reported more intrusive and avoidant symptoms than other subjects. Subjects who were inexperienced at handling remains had more symptoms than those who were experienced. Within the experienced group, there was a significant correlation between the number of remains handled and level of symptoms reported.
This study was conducted to determine risk factors for posttraumatic stress in medical care professionals who perform postmortem identifications.
Thirty-one dentists (29 men and two women) who had identified the dead from the fire at the Branch Davidian compound in April 1993 were compared to 47 dentists (45 men and two women) who lived in the area but had not identified any of these remains. Posttraumatic symptoms in both groups were measured by using the Impact of Event Scale and the Brief Symptom Inventory. For the remains handlers only, the subjective distress of handling remains and the social support received during the procedure were reported.
Higher scores on the Impact of Event Scale intrusion subscale, the overall Impact of Event Scale, and the obsessive-compulsive subscale of the Brief Symptom Inventory were found for the remains handlers than for the comparison group. Within the remains handler group, distress was significantly related to the hours of exposure to the remains, prior experience handling remains, age, and the support received from spouses and co-workers during the identifications.
Posttraumatic stress symptoms can be expected in some health professionals who perform postmortem identifications. Prior experience and social support may mitigate some of these responses.
This study tested the association between psychosocial stressors extracted from a previous qualitative study, and psychological distress, long-term illness and self-rated ill-health among Latin American refugees in Lund, Sweden, and among repatriated Latin Americans. The study was designed as a population-based cross-sectional study. A structured questionnaire from the Swedish Annual Level-of-Living Surveys 1989: 2 was translated into Spanish. Latin American refugees in Lund (n = 338) and those who had lived in Lund and were repatriated to Santiago de Chile (n = 51) and Montevideo, Uruguay (n = 9), were interviewed in their homes in Sweden and in Latin America. The data were analysed unmatched with logistic regression in main effect models. Torture was an independent risk indicator for psychological distress, with an estimated odds ratio of 2.71 (1.45-4.85). There was a significant association between discrimination, not feeling secure in everyday life and psychological distress, with estimated odds ratios of 1.93 (1.02-3.56) and 3.23 (1.62-6.16), respectively. Torture and not feeling secure in everyday life were independent risk factors for long-term illness. Torture, discrimination and not feeling secure in everyday life were significant strong risk factors for ill-health. Repatriated refugees had significantly higher shares of not feeling secure compared with Latin Americans in Sweden. As risk factors of psychological distress and illness, torture, discrimination and not feeling secure proved to be as important as traditional risk factors such as material factors and lifestyle.
To measure the effect of war trauma on the functional health and mental health status of Cambodian adolescents living in a refugee camp on the Thai-Cambodian border.
A multistage probability sample identified 1,000 households in the camp known as Site Two. Interviews were conducted in each household with randomly selected adults 18 years of age and older. All adolescents aged 12 and 13 years old, along with one parent were interviewed. One hundred eighty-two adolescents (94 girls, 88 boys) and their parents participated. Culturally sensitive instruments were used including Cambodian versions of the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR).
Parents and adolescents reported the latter having experienced high levels of cumulative trauma, especially lack of food, water, and shelter. Mean Total Problem scores were in ranges similar to those of adolescents receiving clinical care in the United States, Netherlands, and Israel. Nearly 54% (53.8%) had Total Problem scores in the clinical range by parent report on the CBCL and 26.4% by adolescent report on the YSR. The most commonly reported symptoms were somatic complaints social withdrawal attention problems, anxiety, and depression. The dose-effect relationship between cumulative trauma and symptoms was strong for parent reporting on the CBCL; the subscales on both the YSR and CBCL for Anxious/Depressed and Attention Problems revealed dose-effect associations. Dose-effect relationships between cumulative trauma and social functioning or health status were lacking.
The high levels of emotional distress in this population of Cambodian adolescents and corresponding dose-effect relationships reveal the important negative psychosocial impact of violence on Cambodian adolescents. Lack of findings related to physical health status and the presence of positive social functioning of many youths should not deter health care providers and public health officials from diagnosing and treating underlying high levels of psychological distress.
We reviewed U.S. Army medical boards (136 cases) held between October 1990 and July 1994 for posttraumatic stress disorder (PTSD) that involved participation in the Persian Gulf War of 1990 to 1991. Thirty-five percent of these soldiers (34 cases) had also served in Vietnam. Their records were compared with the records of 102 other soldiers also medically retired for PTSD who served in the Persian Gulf War but did not serve in Vietnam. Approximately one-half of the Vietnam group developed PTSD symptoms in anticipation of deployment to the Persian Gulf. Those soldiers with prior Vietnam service had statistically significant odds ratios for PTSD (between about 5 and 24) compared with soldiers without Vietnam service. These findings indicate that for some persons with prior war experience, the threat of another war is sufficient to exacerbate symptoms or provoke a new episode of PTSD and this risk is substantially greater than that for soldiers without such experience.
The purpose of this study was to determine in Vietnamese ex-political detainees newly arrived into the United States a) the prevalence of torture and psychiatric symptoms and b) the dose-effect relationships between cumulative torture experience and the psychiatric symptoms of posttraumatic stress disorder (PTSD) and major depression. The study population included Vietnamese ex-political detainees (N = 51) and a comparison group (N = 22). All respondents received culturally validated instruments with known psychometric properties including Vietnamese versions of the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire. The ex-political detainees, in contrast to the comparison group, had experienced more torture events (12.2 SD = 4.2 vs. 2.6 SD = 3.1) and had higher rates of PTSD (90% vs. 79%) and depression (49% vs. 15%). Dose-effect relationships between cumulative torture experience and psychiatric symptoms were positive with the PTSD subcategory of "increased arousal" revealing the strongest association. These findings provide evidence that torture is associated with psychiatric morbidity in Vietnamese refugees. The demonstration of significant dose-effect responses supports the hypothesis that torture is a major risk factor in the etiology of major depression and PTSD. The generalizability of these results to other torture survivor groups is unknown. The interaction between torture and other pre- and post-migration risk factors over time in different cultural settings still needs to be examined.
Although emergency relief workers are at considerable physical and psychological risk, their mental health has been studied little. Procedures for recruitment selection, training, field support, and follow up of relief workers vary widely. Preventive mental health measures for relief workers receive little attention. Discounting the effects of psychological trauma on workers reflects disregard for their wellbeing and that of the populations they seek to serve. Relief organisations should develop a coordinated and cooperative approach to training and managing field workers.
Disaster workers who work with deceased victims are at increased risk of posttraumatic stress disorder (PTSD). Identification with the deceased has been proposed as one of the mechanisms in this stress-illness relationship. To examine this hypothesis, this study investigated three types of identification with the dead in a group of disaster workers: identification with the deceased as oneself, identification with the deceased as a friend, and identification with the deceased as a family member.
Fifty-four volunteer disaster workers who worked with the dead following an explosion on the USS Iowa naval ship were assessed 1, 4, and 13 months after the disaster. PTSD symptoms (measured with the DSMPTSD-IV scale), intrusive and avoidant disaster-related symptoms (measured with the Impact of Event Scale), somatization and general distress (measured with the SCL-90-R), and health care utilization were assessed.
Disaster workers who reported identification with the deceased as a friend were more likely than those who did not to have PTSD, more intrusive and avoidant symptoms, and greater levels of other posttraumatic symptoms including somatization. Disaster workers who reported identification with the deceased as a family member had greater intrusive symptoms 1 month after the disaster than those who did not. There were no differences between those who did and did not identify with the deceased as self. Health care utilization was not associated with identification.
Identification with the deceased is a risk factor for PTSD and posttraumatic symptoms in disaster workers exposed to the dead. Identification with the dead as a friend is specifically associated with higher risk for these workers.
The total number, rates, and causes of mortality in Kosovo during the last war remain unclear despite intense international attention. Understanding mortality that results from modern warfare, in which 90% of casualties are civilian, and identifying vulnerable civilian groups, are of critical public-health importance.
In September 1999 we conducted a two-stage cluster survey among the Kosovar Albanian population in Kosovo. We collected retrospective mortality data, including cause of death, for the period of the conflict.
The survey included 1197 households comprising 8605 people. From February, 1998, through June, 1999, 67 (64%) of 105 deaths in the sample population were attributed to war-related trauma, corresponding to 12,000 (95% CI 5500-18,300) deaths in the total population. The crude mortality rate increased 2.3 times from the pre-conflict level to 0.72 per 1000 a month. Mortality rates peaked in April 1999 at 3.25 per 1000 a month, coinciding with an intensification of the Serbian campaign of "ethnic cleansing". Men of military age (15-49 years) and men 50 years and older had the highest age-specific mortality rates from war-related trauma. However, the latter group were more than three times as likely to die of war-related trauma than were men of military age (relative risk 3.2).
Raising awareness among the international humanitarian community of the increased risk of mortality from war-related trauma among men of 50 years and older in some settings is an urgent priority. Establishing evacuation programmes to assist older people to find refuge may prevent loss of life. Such mortality data could be used as evidence that governments and military groups have violated international standards of conduct during warfare.
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.
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.
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.
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.
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.
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
Human rights workers in humanitarian relief settings may be exposed to traumatic events that put them at risk for psychiatric morbidity. We conducted a cross-sectional survey in June 2000 to study the prevalence of psychiatric morbidity among 70 expatriate and Kosovar Albanian staff collecting human nights data in Kosovo. Among those surveyed, elevated levels of anxiety, depression, and posttraumatic stress disorder symptoms were found in 17.1, 8.6, and 7.1% respectively. Multiple regression analysis revealed that human rights workers at risk for elevated anxiety symptoms were those who had worked with their organization longer than 6 months, those who had experienced an armed attack, and those who experienced local hostility. Our study indicates that human rights organizations should consider mental health assessment, care, and prevention programs for their staff.
A cross-sectional cluster sample survey was conducted in June 2000 in Kosovo to assess the prevalence of mental health problems associated with traumatic experiences, feelings of hatred and revenge, and the level of social functioning among Kosovar Albanians approximately 1 year after the end of the war. Findings of the second cross-sectional survey were compared with those from our 1999 mental health survey in Kosovo. Included in the survey were 1399 Kosovar Albanians aged 15 years or older living in 593 randomly selected households across Kosovo. Twenty-five percent of respondents reported PTSD symptoms, compared with 17.1% in 1999. The MOS-20 social functioning score improved to 69.8 from 29.5 in 1999. In the 2000 survey 54% of men felt hatred toward the Serbs, compared with 88.7% in 1999.