Title

Conflict in the Indian Kashmir Valley II: psychosocial impact

Creator

Kay de Jong

Saskia van de Kam

Nathan Ford

Kamalini Lokuge

Renate van Galen

Brigg Reilley

Rolf Kleber

Date

October 14, 2008

extracted text

Conflict and Health

Central

Research
Cqnflict in the Indian Kashmir Valley II: psychosocial impact

Kay de Jong*1, Saskia van de Kam1, Nathan l;ordl ?, Kamalini Lokugc1,
Sil|<e I'iomni1, Rcnale van Galen1, Brigg Reilley1 and Roll’Kleber1
A<lili|-v. 'M<ilr< ins S.ms I i<.n!iri.-s, I'l.mi.tjM Mnld.nl.in. II

11) I N I >1 ) Aiir.li-nl.iiu llu N< ih< 11 iiul-

I .i< tally . >1 1|..dlh S. i<ri.',1111. .n | i

I ImvfiMty, Vain ouvci. t ..inada and ’Drpat inienl i>l (.linn ,il l'sy< h<»l<»gK I Hire. hl 11 mv. isiiy, lh< Ni lhei lands
I-mail’ Kaz tie long* - kaz dc ionglfjainslrrtlain msf org; Saskia van de Kain • saski.i vandcrk;un(?£ nnsirrdain msforg;
Nalh.jn l-ord • nalhan fordtftlondon msf org, Kamalini loknge kaz dr jniig/TZ'.nnslrn la in msf org,
Silke liuinni • kaz <lr jongja'amsfcrdain msl org, Renalc van (.ah n kaz. de jongrriiamsicrdam msl mpv
Brigg Reilley • kaz.de jongtftiainsierdam insl.org, Roll Kirliri kaz.de.jong^ainsieidam msl eng

* Iknre.sponding author

Published: 14 October 2008
Confl^t end Heohh 2008. 2 I I

Received: 6 October 2008
Accepted’ 14 October 2008

doi: 10.1186/1752-1505-2-11

This article is available from: hrtp7/www.conflictandhcalrh,com/contcnt/2/l/l I
CO 20Q8 de Jong er al; licensee BioMed Central Ltd
This |s an Open Access ankle distributed under rhe terms of rhe Creative Commons Attribution license (htlpj/ufJUYUCQUlIllUlb.Olfi/llCCttiCh/by/ZQ).
which permits unrestricted use. distribution, and reproduction in any ipedium. provided the 01 igin.il woik is ptopeily cued

i
I

Abstract
Background: India and Pakistan have disputed ownership of the Kashmir Valley region for many
years, resulting in high levels of exposure ^to violence among the civilian population of Kashmir
(India). A survey was done as part of routine programme evaluation to assess confrontation with
violence and its consequences on mental health, health service usage, and socio-economic
functioning.

Methods: We undertook a twd-stagc cluster household survey in two districts of Kashmir (India)
using questionnaires adapted from other conflict areas. Analysis was stratified for gender.
Results: Over one-third of respondents (n =510) were found to have symptoms of psychological
distress (33.3%, Cl: 28.3-38.4); women scoring significantly higher (OR 2.5; Cl: 1.7-3.6). A third of
respondents had contemplated suicide (33.3%, Cl: 28.3-38.4). Feelings of insecurity were
associated with higher levels of psychological distress for both genders (males: OR 2.4, Cl: 1.3-4.4;
females: OR 1.9. Cl: 1.1-3.3). Among males..violation of modesty. (OR 3.3, Cl 1.6-6.8). forced
displacement, (OR 3.5, Cl I 7-7.1). and physical disability resulting from violence (OR 2.7, Cl: I 2
5.9) were associated with greater levels of psychological distress; for women, risk factors for
psychological distress included dependency on others for daily living (OR 2.4, Cl: 1.3-4.8). the
witnessing of killing (OR 1.9, Cl: 1.1-3.4), and torture (OR 2.1. Cl: 1.2-3.7). Self-rated poor health
(male: OR 4.4, Cl: 2.4-8.1; female: OR 3.4, Cl: 2.0-5.8) and being unable to work (male: OR 6.7,
Cl: 3.5-13.0; female: OR 2.6, Cl: 1.5-4.4) were associated with mental distress.
Conclusion: The ongoing conflict exacts a huge toll on the communities’ mental well-being. We
found high levels of psychological distress that impacts on daily life and places a burden on the
health system. Ongoing feelings of personal vulnerability (not feeling safe) was associated with high
levels of psychological distress. Community mental health programmes should be considered as a
way reduce the pressure on the health system and improve socio-economic functioning of those
suffering from mental health problems.

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Background
I he Partition ol India in 1947 was the stait ol a long hisloiv of dispiue between Fudia and Pakistan tor lontiol ol
Kashmir, which today remains divided into (liter parts
governed by India, Pakistan and C.liina Over the Iasi 20
yrats, a liberation snuggle between India and Kashmiri
militants has led to .it least 20,000 deaths and 1,000 dis­
appearances in the Indian pan of Kashmir 111

covering expression ol distress, the’ total st ore < < »i respond­
ing lo lhe sum of positive responses Vaimus studies have
validated lhe use ol the XRQ m India | c» *>1 ( cmenrlv a c in
oil score ol I I oi I 2 is accepted |!0| although this has

A c ommunity survey done by Mc'dec ins Sans I rontieres in
2pOr> found high levels ol ongoing violence .moss the
region, with civilians caught in the middle The majority
o| people surveyed stated having been exposed to crossfire
(H6%) and round-up raids (8 1%). I ligh numbers ol peo­
ple repented being subjet led to maltreatment (44‘hi),
forced labour (33%), kidnapping (17%), torture (13%)
dpd sexual violence (I 2%) 12|

four categories ol closed questions were* applied lo estab­
lish use ol health services (categories: never; once; 2-3
times; 4 + ) and medications (Categories, never, 1-3 times;,
4-6 limes, 7 + ). Closed questions were also used to assess
coping mcc hamsms for dealing with stress l he c omposiUon ol categories lot ’ionsequemes ol violence’ and
’sources ol support’ was deme with input from national
stall

Exposure to violence has potentially important implica­
tions lor mental health |3|. This paper presents the find­
ings of the community assessment survey done by
Mediums Sans I'roniit'res In 2005. Hie study, which was
d«me to inform piogram planning, assessed die menial
health and socio-economic impact ol the ongoing Vio­
lence, and the suuu.es ol suppoil.
j

lo establish individual socio-economic functioning in
relation to health during the past thirty days the I I-sec lion
of the Wl lO-Disabililv Assessment Sc heclulu-ll (WIIOI )AS II) was used I his tool hasp,nod mteinal, c onvergent

Methods
|he survey was conducted in mid-2005 in the Indian pail
<il Kashmir (Kupwara and Badgam, totalling 101 villages
and a combined population 145,000 people) The myrhqdology Im tlesc ribed in detail elsewhere |2| Hi icily, sam
pie size calculation assumed a prevalence of tiaumarglaied psychological problems of 20% |4 |; using a preci­
sion of 5% (confidence interval 95%) and a design eflect
ol 2, the iniitiiiHim sample size w.ti estimated at -P>? A
two-stage cluster sampling design was used to covet 30 vil­
lages (randomly selected), resulted in 17 households per
village. Within the household participants aged > 18 years
were selected randomly*. Informed consent was attained
for all participants and M.SI ’s independent I thical Review
Hoard grained ethical approval.
|mtrurneriti

| he overall survey questionnaire assessed baseline demo­
graphics, confrontation with violence’ (results presented
elsewhere |2|), mental health, health service usage, socio­
economic functioning and sources of support. Mental
|iealth was assessed using a Sell-Reporting Questionnaire
(SRQ), with a reference period of U) days preceding the
survey.'Ihe SRQ is an instrument developed by the World
jleallh Organization (WHO) to measure general psycho­
logical distress, especially in developing countries. Il has
good validity and reliability lot adults (•• l'» years) |ri|,
and can be used both as a self- or interviewer-adminis­
trated questionnaire. It consists of 20 closed questions

been iiiliipted as being loo high jl l|

In out study we

used a conservative’ cut.oil score* ol 12, meaning those*
respondents scoring
I.’ arc considered to be' sulleung
from psychological distress.

validity and good sensitiviiy lor < Range | I

|

Hie’ survey was loiwardrd and back translated horn I ng
lish to Urdu and phonetic Kashmiri and piloted prior to
lull implementation
Anofysls

Data entry was standardised and checked by supervisors,
entered Into I Xt I I and analysed in ll’IINIl) 2(1(12
Because’ males and females dillrird significantly in lhe
number of confrontations with violence | J|, we used uni­
variate analysis to stiaiily loi gender to determine rela­
tionships between psyi hologie al distress (SRQ > 12) and

demographic details, living circumstances, confrontations
with violence (witnessing, self-experiencing), health out­
comes (physical symptoms, health service use), and soc-’to­
ri c mom ic lune lion i ng We rxc I lit led vai tables Midi as ‘lol

lure’ while being detained/held hostage' as these* responses
relate lo a sub-sample ol (hose surveyed. We also ex< fueled
exposure* lo violence horn this analysis because* the pioximily to tin* violent c was not diTinrd in detail

A niullivariaie .statistical model was coiistiuiled to inves­
tigate relationships between mental health (SRQ -- 12)
and the* above-mentioned variables We used a logistic
regression model inc hiding variables that were signdit ant
in the* univariate analysis (p <()()'») with backwaul elimi­
nation. In our model we expected each type of event con­
ferring an additional risk ewer and above- any other event
cxpeiicnceel. Ibis is in accordance with studies reporting
exposure io ( i iinid.it ive li.mmalh event*. a*, a i isk lai loi lor
the development of PI’S!) 113,141.

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Results
'»10 <>I 548 (*) 1%) inirivirws werecomplt'lcd Reasons lor t
o his.il h« p.iilii ip.iie ( 75) .Hid Mcippiiiglhr nilrivu w(M)

iipluilixl: lack of lime, distrust, and being emotionally
upset. The average age of respondents was 17 7 years
(hinge 1 7-90) with an cqti.il gendei disliibnlion (males
51%; 270; p > 0.0%). I)cmogi.iphics aie tlesc iibed in detail
elsewhere. |?|

A|cntol health status
I'syt hologii al disiiess was mostly expirssed ihioiigh
symptoms such as nervousness, tiicdness, being easily
I lightened and headache (Table I) Ihe pievaleiuc ol sui< iflal ideation is striking: one-third of those surveyed had
h.|d thoughts ol ending thcli lile in the past todays ())vei
a |hiid of respondents weie taiegoii/ed as sullei inp, 11|>m
psychological distress (SRQ ? 12) using the Indian v|ilid.ped SRQ (33.3%, 170, Cl: 28.3-38.4) The design effect
fot the SRQ was 1.4. Tcmales scored significantly higher
(43.8% vs. 24.1%, OR 2.5; Cl 1.7-3.6; p < 0.001).

Associations between psychological distress (SRQ ? I 2)
aryl violence, health, socio-economic and sources of
support
Unfvanate analysis of violence and psychological distress (SRQ > 12)
I-'ey lings of personal insecurity were significantly associ­
ated with psychological distress (SRQ > 12) for both
mqles and females (Table 2). Psychological distress
atpong males was significantly (p < 0.01) associated with
al) self-experiences (defined as 'ever happened to you')
ai)d most consequences <)f violence. Psychological distress
aipong females was significantly (p < 0.01) associated
with witnessing events (except hearing aboui/wi messing
rape), as well as the self-experience of some events (mal­
treatment, arrested/kidnapped) and feelings of lack of
safely and independence.
Multivariate analysis of mental health (SRQ > I 2) and violence
Tor both genders, not feeling safe is associated with at
lc(ist twice the odds of suffering from psychological dis-

ticss (Table i) H»i males, violation ol modesty, (oncd
displacement, and disability weir .ill assoc iatrd with a sig
nlfkaiitly iinoascd likelihood (time times the odds) ol
suffering Irom psychological distress. Tor women, the wit­
nessing of people being killed or lorluied or dependency
on outside assistant c doubled the otitis ol siillcnug psv
c holt igit al disti css
Associations hrtwrrn psytholagK ill distress (SRQ 12). health and
satin r< anomic outcomes
The maiotilv ol icspondc tils (<» I
!.'(») had iciciilly
visited a health pcisloi clinic, iicaily hall had visited a
health lac ility moie than omc (46. 1%, 2 15) in the past 10
days Overall, nearly half (49 6%. 25 1) of lespondents
latfd tin health la, ill lie *s as pool Women moir lie
qucmlv lalctl ihrii physical health as bad oi veiv bad
(male 24 l%vs lrm.de <6 1%, OR 18,(1 12 2 (», p
0.005), and visited the* health facilities more than men
(male: 4 0.0% vs female: 54.7%, OR I .8, Cl. 1.3-2.6; p =
0 005). I he number of women who had been on medica­
tion for six or more’ days was significantly higher than
men (male. 30 7% vs. female 46.0%, OR 1.9; Cl 1.3-2.8;
p < 0.001) A high level of psychological distress (SRQ >
12) was significantly (p < 0,01) associated with poor or
vcryz poor self-rated health for both males (OR 4.4) and
females (OR I 4) lor males this was also associated with
a higher likelihood ol visiting the < linic two times or more
( Table 4 ). Tor both male's and females, high psyc hologic al
distress was also associated with a higher likelihood of
being unable' to or having to cut hac k on work or perform­
ance of daily ac livities

Coping mechanisms
I he most common ways of coping were withdrawal (iso­
lation, not talking to people) and aggression ( Table 5).
Religion was also reported as a hclplul sonic e ol support

Discussion
The.data presented in this article were gathered to inform
MSF's programme to provide mental health support in

T|ble I: Self-reporting questionnaire 20 (n = 510)
Items SRQ 20

YES

Items SRQ 20

YES

1

Do you often have headaches?

53.6% (272)

11

Do you find it difficult to enjoy your daily activities?

50.0% (255)

2

Is your appetite poor?
Do you have sleep disturbances?
Are you easily frightened?

40.8% (208)
45 5% (232)
55.9% (285)

12
13
14

39.6% (202)
51.8% (264)
31.0% (158)

Do you feel nervous, tense, or worried?
Do your hands tremble?
Is your digestion poor?
Do you have trouble thinking clearly?
Do you feel unhappy?
Do you cry more than usual?

62.7% (320)
IS
50 2% (256)
16
17
25.1% (128)
50.2% (256)
18
50.0% (255) . 19
20
45.1% (230)

Do you find it difficult to make a decision?
Is your daily work suffering'
Do you feel you are usefully contributing in life?"*
Have you lost interest in things'
Do you feet that you are a worthless person?
Have you thought about ending your life?
Do you feci tired all the time'
Do you have uncomfortable feelings in your stomach?
Are you easily tired?

3
A
s

6
7

a

9
IP

4S 1% (230)
37.8% (193)
33.9% (173)
62.5% (319)
39 8% (203)
66.7% (340)

• This question was changed from the original SRQ 20 qiiculonnaire (Are you unable to play a useful part in life')
• Jn the current format the No-answer was used as sign of psychological distress).

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1 «l»l«t 2; Univariate analysis of cases (SRQ I 2) with non-cmm tin demographic variables, living clrcumstancos, confrontations with
violence (sell-experience, witnessing), and personal consequences stratified by gender (n « 510)

Varlaliln

1 J Mules n - 270
SRQ
N
OR
P

Cl

SRQ ■ 1 ) 1 rntnlrs n ” J40
N
OR
Cl

SRQ
N

1) nil n - SKI

P‘

OR-

Cl

P“*

60
176

10 33

0865

125
379

1
1.8*

1128

0.023

264

1

224

2.1**

1 4-3.1

0.000

pornographies
Maiiial iianis
-Not mamed
■Mnrncd

65
203

1
1.7

1
1 8

08-3.6

0.178

120

1

1 3-4.1

0006

118

20 *

1.2-3.3

0.014

185

1

53

1
7 4”

379

0 147

1 1 46

0 007

127

2 0~

till

0 002

0 068

229
7

1 8

04 8 1

0 152 “

487
16

1
28

10 76

007

1 15

1

188

1

125

1.8*

10 3 1

0 030

322

2 0”

1 3 30

0 002

125

1

1 2 J6

0018

385

2.3”

1 4 3 7

0.001

306

1

204

1.8”

12 2 6

0 004

Living
Circumstances

Currently Feeling Sale

-Alwoysfmost

144

1

-Occosionolly/never

126

2.3 ♦*

-Self supportive, nearly

194

1

1 llglily. total dependant
1 laving Two meals a day

74

1 6

09 10

■Always, sometimes
• Rarefy, never

258
9

1

1 1 159

4 1

Dependency lor Living

Witnessing

Seeing wounded people
-No

-Yes
Witnessed people being arrested

73

1

197

2 r

1 1 4.5

0043

44

i

III

1

226

28*

1 1 7.7

0.044

159

20’

151
119

1
1 6

155

1

0 9 2.8

0.123

85

20’

16 3 4

0018

-No

68

1

169

1

-Yes

202

1.7

0.9 J 4

0.179

139

2 J”

14 40

0 003

341

2 1”

1 3 3.1

0 001

46
224

1
1 6

0I J 8 |

0 101

90
ISO

) r

12 16

0016

136
.174

1
1 9”

12 11

0 005

117

1

184

1

173

1 0

0 6 16

0 958

126

1 1

09 70

0 256

219

442
68

1
1 8’

10 1 1

0045

285
225

1
7 7”

1 4 3.1

<0 001

118

1

172

1 9”

1 3 29

0 003

426

1

94

1 5.1'

0 95 2.5

0.100

1 6”

1 1 62

20 62

•0 000

1.7 8.5

0.001

No

•Yes
Witnessed propio being killed
-No
-Yes

Witness people being tortured
101

Witnessed people being maltreated/
molested

-No

-Yrs
Heard about cases of rape
■No

•Yrs

Witnessed rape
-No
-Yrs

67

1

201

2 7

1 0 4 5 :

0 054

223

4/

1
1 R

0 9 IS

0 114

21

1
. 1 H

07 4S

0 269

110
160

1
2 4”

1 3 4.5

0 007

175
65

1
2 0’

113 5

0032

194

1

1 4-4.4

0002

46

1 4

0 7 2.7

0 396

1 3 4.3

0008

0.3 1.7

0 621

Jjclf-cxpcrlcnccd
being maltreated
-No

-Yes
being forced to do labour
•No
-Yes
lining forced housing any <>l the pat tins

-No
-Yes
being aire.sted/kldnap|>ad

144

1

126

2 5”

203

1

67

2.4*“

213

1

27

0.7

424

■No

195

■ Yps

75

)

224

1

in sr

‘ 0 001

2 1 H 1

<0 000

1.8-10.5

0.002

86

229

1

II

6 1”

1 1 10 0

227

1
2 )

0 7 69

0 1416

1
2.7

0.S-I4.9

0.452

1

0 010"

<0.000
Modesty being violated

-No
•Ym
Ueing injured because of conflict

-Not injured
-Injured

46

248

22

1
4.3 **

’?

234
6’

451
59

1
j 5”

484

1

28

3 8”

1‘uyo 4 ol 8
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Table 2: Univariate analysis o( cases (SRQ
12) with nun-caves on demographic variables, living circumstances, confrontations with
violence (self-experience, witnessing), and personal consequences stratified by gender (n c 510) iLoniniued)

Consequences of violence
gloving voluntarily for safety Feasons
-No
-Yes

131
139

forced to move (being displaced)
No
.

221

1

48

Yes
|3cmg disabled
■No
-Yes
Having lost house
•No
-Yes
Having lost possessions
•No
Yes

1
2.3”

1 3 4 1

0007

143
97

1
1 8’

4 2‘”

2 2 8 2

<0 000

199
40

232
38

1
3 9”*

1 9 80

<0 000

253
17

1
1 3

0.4 3 9

197
73

1
2.6”

1 4 4 5

1.0 3.0

0 048

274
236

1
2 0”

1 3 29

<0 000

2.0

1 0 39

0 0/5

420
88

1
2 9”

1 H 46

<0 000

228
10

1
3.2

0 8- 12 7

0079

460
48

1
37”

20 / 1

<0 000

0 404

225
13f

1
1.6

05 4 9

0 592

4 78
30

1 5

0 7 3 1

0 468

0 002

183
57

1
1 6

09 3 0

0 1417

380
130

1
2 1

1 1 3 1

0 001

1

I P Chi square Yates corrected unless indicated differently
li Fisher exact test
pi OR adjusted for gender
jiii P Mantel Hcimel Chi square corrected unless indicated differently
* Signifiant P < 0.05
rJ Significant P < 0.01
*“** Significant P < 0.001
£ Chi-square for differing Odds Ratios by gender is significant (p = 0.028) suggesting interaction

Kashmir. Using the SRQ (a tool that has been validated in
other Indian studies 16-101) we found the population had
been exposed to high levels of violence |2| which resulted
tn one third of the respondents suffering from psycholog­
ical distress and considering suicide. I:or both genders,
<, urrently not feeling safe was associated with psychologi­
cal distress, l-’or males 'violation of modesty', displace­
ment, and disability were associated with psychological
distress while risk factors for females included witnessing
killing and torture. Respondents with high psychological
distress rated their own health and socio economic func­
tioning as poor. The most common coping mechanism
was withdrawal.

Overall, one-third of respondents repot led psychological
distress.This compares to a prevalence ol 36% found in a
study done in among Afghan women in a refugee camp
1I5| using the same instrument and similar cutoff score,
but differs substantially from another SRQ study done in
a non-conflici area in India 116| where 18% prevalence of
psychological distress was found among low-income
urban women, using a relatively low cut-oil score (7/8).
(Using this lower cut-off would have given a prevalence of
psychological distress of 71.4%). Ihe contextual differ­
ence In thehC Mtidirh - expoMiic to chitmu violence as
compared to 'common* stiessois ol daily I tie lot women in
low urban settings - may account lor this dillerenc v.
The Self Reporting (Questionnaire (SRQ) showed that a
third of respondents had tomcmplaicd suicide Suicidal

thoughts ate common loi dept essive disorders 11 7| but do
not always lead to a suicide attempt. Our findings arc in
line with a previous study that reported high suicide rates
in this region 118| A high prevalence' ol suit idal thoughts
is more often reported among populations suffering from
chronic violenc e, with a similar prevalence ( t3%, 96, n =
297) ivpoiird in a population ol Afghan iclugce women
in Pakistan using the same* quest it iiinaiie (SRQ)

In our study women had significantly higher psychologi­
cal distress than man. This is in line with other studies
showing women suffering more from anxiety disorders
than men after confrontation with violence |20|. reeling
safe was found in other studies to be an important pre­
condition foi being able to deal with atlveisr traumatic
experiences 12 1,221, and this was also found in our study.

I'or males, the most important risk factors for developing
psychological distress were' 'Violation of modesty', dis­
placement and disability. It is possible that these experi­
ence’s arc the most distressing because they interfere with
the cultural values and roles of males in Kashmir society:
upholding their dignity and being able lo protec t and feed
their .families. Those who self-experienced ‘violation of
modesty' had a thicelold i hattic of sulleting horn psvi ho
logical clisticss (p
1).0U I). Violation ol modesty* is
regatded as veiy degrading and in the lew studies on male
sexual violence is associated with multiple pci pelt alots
and high levels of physical beating |23,241, which can furthei conttibulr to psyt hologual di.Mie.vt

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Cl millet and I In tilth ?()08. 2

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T^ltlc 3: Significant multivariate associations between
psychological distress (SRQ
12) and demographic variables,
violent Incident* (seK-eaperlent e, wltne«*lng), and personal
consequences by gender(A ■ 5 10)

OH

Cl

P value

13 44

0 007

1 6 68

0 001

1 7 7 1

<0001

1 2 59

0 015
i

1 I

0 02,0
i

1 1 4 II

o<x|z

1 1 J4

0 029

1 1 I 1

0 OOH

HALL SHQ ; 1 2

Currently not feeling safe
No

1

Yes
Mndesiy being violated

Nn

1

Yrs

Being forced io move
No

1

Being disabled
No

1

Yrs

27*

FEMALE SHQ ? 1?
Cm c cntly not feeling safe
No

1

Yre

1 T

1 1

Being dependent for dally living

No

1

Yet
Witnessed people being killed
No

Yes

1.9*

Witnessed people being tortured
No
Yrc

1 Multi logistic regression
* Signifiant. P < 0.05
** Significunt P < 0 01
1 Significant P < 0.001

1

I
2 I**

,

I t if women most psychologic.il distress was associated
with feelings of powerlessness - dependency on others lor
dajly living, and witnessing killing and loutne. Women
have lower confrontations with violence, which can be
partly explained by their being largely confined to the
home |21. The significant association til witnessing and
psychological distress among females may lelate to feel­
ings of helplessness and guilt caused by the witnessing
mjy be more traumatic than experiencing the violence
themselves.

Both males and females with high levels ol psychological
dihlirsh rated theii own health as much pooiei lompaied
to (hose who did not have high levels ol psyt hologit al dislH»t<h (male: OK 4 4; lemale OH 14) Nonspcuilic health
ttgnplaiiils have been associated with (iiaiimatii) siicsn
in other studies 125-2 71. Il is also possible that people do
iiqi understand the relationship between physical symp­
toms anti mental stiess |2K| or have difficulty to articulate
their cinoilon.il slams and use physical symptoms io aitic •
ulaic menial distress |29|.

High psychological distress among males was signifi­
cantly associated with visiting heahh sei vices more fiequviillv It m cased use ol medical services bv those
suflenng horn tiaumain -stiess related problems .tie com­
mon | It), 111, with up to a Jr»% inc lease in nuinbei ol vis­
its to health care l.uihlies repotted m olhci studies | I.1
34 |. We found this relationship in oui survey lor males,
but nc’it Im females I his may be explained by the lac l that
lor both cultural and security reasons females depend on
male escorts in order to access health sei vices, lestiiiling
then movements

In our population, high psychological distress is associ­
ated with substantially increased likelihood ol socio-eco­
nomic dysfunction, and this has been icpoited in both
Western | 35,36| and Asian 11 5| contexts Socio-economic
clvshmc lion can have broad implic a Hous, lol example bv
reducing capac ity ol females to give c aie to the c hildien oi
loi males io generate income (according to traditional
roles)

rhe* most common coping mechanisms such as with­
drawal (sell isolation, slop speaking) and aggression may
also be' symptomatic ol depression and/or anxiety clisoi
del (inc hiding post iiaumalic stiess disoidei, PISH) Heli
gion and family assistance- aie mentioned less licc|uently
as sources of support Hus is in c outlast io a study con
dueled in Afghanistan ihtii showed ichgion and leading
the Koian as du- two mam coping inn hamsms loi two
being confronted with violence- 11 ’>|

Potential limitation!
Geneial methodological limitations, im hiding sampling
methodology, retrospective study design, and terminol­
ogy, have been discussed pieviously |2|. Iheie aie, in
addition, a number of potential limitations related to this
specific analysis I list, as this is a cioss sectional survey,
no,'causal inferences between violence and mental health
can be- conclusively made. Second, individual respond­
ents may have- implicitly used the piesemc of mental
heahh symptoms as a deciding lactoi loi whether they
have- expeiiemed a iiaumalic event in case- of doubt (i.e.
recall bias 1171) We- consider this as unlikely as we- asked
respondents io lecall violent events but did not ask them
to identity which events weie tiaumalic finally, we used
tin- SHQ to avoid labelling, populations with a psvc hiali it
diagnosis, but using a sell repotting c|iiesiioimain* has
obvious limitations. A comparative- study in India ol live'
questionnaires showed good internal icmsisiemy and a
high disc liimmiling ability with tlie SIU > having the best
results |‘)|, but in compaiison to clinical mleiview, ques­
tionnaires only showed strong positive predictive value
when a considerable compromise- on sensitivity was
made h was concluded that the (hone ol an optimum
cut-oil scene (to balance sensitivity and positive piediclive

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Male*

-

1 rmalct

n

OR

Cl

P value

n

OR

Cl

P value

65

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Health Outcomes
!jpll Mind hrahh had or vriy bad

.SRQ * 12
SRQ 'll
ViMled health clinics
SRQ <12

2 tunes
1

\KQ ? 12

1

Mndii inn uso * 6 days
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SRQ 2/2

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120

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2 6 II 0

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$<»cl<>-economlc Outcomes

Uibdilr to wutk/daily Ai llvHlct

4 days

SRQ < / 2
SRQ ? 12
Cut back/rcducc work or daily activities Z 4 days
SRQ < 12

SUQ .• 11

i

1

1

11' Chi stpiate Yates corrected unless indicated diflri cully
U Fisher exact test
* Significant P < 0 05
** Significant P < 0.01
• '* hignilii an! P •'0.001

value) should be adapted lo hulividu.il sellings, and rei
mnmend a higher cut-ofl score lor resource-limited pri­
mal? one sellings |9| We used .1 high 1 ill oil sone ol I
ill line with this recommendation Hut in the absent e ol
clinical interview no detailed analysis ol the menial health
s|.nus is possible.
hi the context ol predominantly llidu speaking popula
tjon sve considered, but did not use, cm ofl scores from
oilier Urdu speaking cultures such .is in Pakistan. A nicla.inalysis of psychiatric rating scales in Urdu |18| con<luded dial only a small nmnhei ol insliunienls (rm bid
111g SRQ) were sullii iemly evaluated. Hie same review
concluded that for the SRQ no cross-iullmally validated
gold standard was used, cut-oils varied considerably, as
did sensitivity (78-91%) and specilhily (77-Hrr%). We
fable 5: Overview support mechanism used by the participants
(up lo three answers possible, n ■ 510).
Jiourcci of support

Frequency '

Isolation
Aggressive behaviour
piaying/incdltailon

327 (64 1%)
235 (46.1%)
201 (I9HX)

Stop speaking to people
Talking to others

188 (36.9%)
186 (36.5%)
117(22.9%)

Keeping busy
Seeking support from family

106 (20.8%)
63 (12 4%)

prug and alcohol use

Other

consider the Indian validation studies |9| as more appio
priale because they used clinical interview as gold stand­
ard
Conclusion
The high levels ol violence confronted by the Kashrniii
population have resulted in high prevalence ( 11%) ol
menial health problems Pom sell i.ued lieahli and likeh
hood of pool socio-economic functioning wete assoc i.ued
with high levels ol psychological distress. Mental health
problems in this conle.xl of chronic violence should
ie< elve lull a lien I ion 1 lirough the pi o vis ion ol appnrpr lair
community based services dial would improve access to
caie and reduce the burden on the health system.

Conflicts of interests
The am hr us dec I.lie llial lliev have mi competing ii ileiesls

Authors' contributions
KI designed and co oidin.ilrd the study and wrote die fust
di.ill ol du* paper NT suppoiled die ioniepm.il darning
ol the lindmgs. assisied with die analysis, and led subse­
quent drafts. SK and KI.provided statistical support for the
design and analysis, and helped with the writing ol the
paper. SI', IKI and HR oversaw die implementation ol the
survey, managed data collection in the lield, and contrib­
uted io the writing of die paper. RK provided conceptual
oversight and conuibuted lo the writing ol the papci.

44 (116%)

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Conflict mill llnnlth ZX18, 2 I I

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A( knowlp(lg(Hnrn(|

1

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Wp gratefully acknowledge rhe itippoti piovidcd by a nuiubei <d Kathmii
national staff contributed to the conduct of chit. survey but whose names

21.

canpoc be mentioned lor security reasons. We also thank all survey partic­
ipant x foi (Ihmi time Finally, thank* io Clair Mills far (iitkal comment* on
eiarllei (halts of this aiih Io
!

77
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I.

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