Suraj Bahadur Thapa

Preparing Instruments for Transcultural Research: Use of the Translation Monitoring Form with Nepali-Speaking Bhutanese Refugees

Preparing instruments for transcultural research is a difficult task. Researchers typically do not publish their attempts to create equivalent translation. The quality of the translation depends mostly on the translators’ ability to be consistent in identifying and correcting incomprehensible, unacceptable, incomplete and irrelevant translated items. This paper presents a translation monitoring form to enhance the methodical preparation of instruments for transcultural use. Use of the form requires the systematic use of strategies advocated by previous translation and adaptation researchers. A detailed example of use of the translation monitoring form with Nepali-speaking Bhutanese refugees illustrates the usefulness of the form as well as the difficulties of creating equivalent translation.

Psychological distress among displaced persons during an armed conflict in Nepal

Most internally displaced persons (IDPs) live in low-income countries experiencing a war; their psychosocial health has not been well addressed. We carried out a comprehensive assessment of traumatic experiences, distress symptomatology, and factors independently associated with distress among IDPs in Nepal. A cross-sectional survey was conducted among 290 IDPs in Nepal during June–July 2003. We used the Hopkins Symptom Checklist-25 (HSCL-25) to assess depression and anxiety symptoms, and the Posttraumatic Stress Disorder (PTSD) Checklist—Civilian Version (PCL-C) to assess PTSD symptoms. All these instruments were validated against local corresponding syndromes and diagnoses of Composite International Diagnostic Interviews (CIDIs) as well. Almost everyone reported trauma and 53.4% had PTSD symptomatology. The rates of anxiety and depression symptomatology were 80.7 and 80.3%, respectively. Factors independently associated with anxiety symptomatology were illiteracy and feeling miserable on arrival at a new place. Female gender, age 41–50, and feeling miserable on arrival at a new place were associated with depression symptomatology. On the other hand, experiencing greater than three traumatic events and feeling miserable on arrival at a new place were associated with PTSD symptomatology, whereas evacuation after a weeklong preparation and lower caste appeared as protective factors. High rates of psychological distress and associated factors were identified among highly traumatized IDPs in Nepal, thereby underlining the need for collective assistance, not only for refugees, but also for IDPs. Risk and protective factors that we have identified can thus be utilized for any kind of psychosocial interventions among these IDPs.

Gender differences in factors associated with psychological distress among immigrants from low- and middle-income countries--findings from the Oslo Health Study.

Despite the high rate of migration from low- and middle-income countries to high-income countries, there is still a lack of comprehensive studies of gender-specific differences in psychological distress in a diverse group of immigrants. We compared psychological distress between male and female immigrants from low- and middle-income countries living in Oslo, and identified factors associated with distress for men and women, separately. A cross-sectional survey with self-administered questionnaires was conducted among 1536 immigrants from low- and middle-income countries living in Oslo. The Hopkins Symptom Checklist (HSCL-10) was used to measure psychological distress. Data on their sociodemographic characteristics, negative and traumatic life events, and social integration and possible discrimination in the Norwegian society were also collected. One-fourth of the study population was found to be psychologically distressed, with almost equal levels among men and women. Lack of salaried job and recent negative life events were independently associated with psychological distress for both genders. Furthermore, experience of denial of job and past traumatic experiences were other associated negative factors among men, while visits made by Norwegians appeared as a protective factor against distress among men. Older age, Middle East background, living without a partner, and experiencing denial of housing were other associated negative factors among women. Our findings show that, except for adverse living conditions, there are gender differences with regard to factors associated with psychological distress among immigrants living in Oslo. Such gender issues are relevant for assisting immigrants in the integration process as well as for future research in migration and health.

Political violence and mental health: a multi-disciplinary review of the literature on Nepal.

Implementation of current international consensus guidelines regarding mental health and psychosocial support in emergencies requires the consideration of findings from both the medical and social sciences. This paper presents a multi-disciplinary review of reported findings regarding the relations between political violence, mental health and psychosocial wellbeing in Nepal. A systematic search of six databases resulted in the identification of 572 studies, of which 44 were included in the review. These studies investigated the influence of political violence on contextual variables that shape mental health and psychosocial wellbeing, and examined psychological distress and mental disorders in the context of political violence. The majority of studies addressed the mental health of Bhutanese refugees in Nepal and the impact of the Maoist Peoples War. Based upon these results from Nepal, we discuss a number of issues of concern to international researchers and practitioners and present policy and research recommendations. Specifically, we consider (a) the need for longitudinal multi-disciplinary research into protective and risk factors, including agency, of psychological distress and mental disorders in situations of political violence, (b) the continuing controversy regarding the PTSD construct, and (c) the lack of robust findings regarding the effectiveness of mental health and psychosocial support.

Political violence and mental health in Nepal: prospective study.

BACKGROUND Post-conflict mental health studies in low-income countries have lacked pre-conflict data to evaluate changes in psychiatric morbidity resulting from political violence. AIMS This prospective study compares mental health before and after exposure to direct political violence during the Peoples War in Nepal. METHOD An adult cohort completed the Beck Depression Inventory and Beck Anxiety Inventory in 2000 prior to conflict violence in their community and in 2007 after the war. RESULTS Of the original 316 participants, 298 (94%) participated in the post-conflict assessment. Depression increased from 30.9 to 40.6%. Anxiety increased from 26.2 to 47.7%. Post-conflict post-traumatic stress disorder (PTSD) was 14.1%. Controlling for ageing, the depression increase was not significant. The anxiety increase showed a dose-response association with conflict exposure when controlling for ageing and daily stressors. No demographic group displayed unique vulnerability or resilience to the effects of conflict exposure. CONCLUSIONS Conflict exposure should be considered in the context of other types of psychiatric risk factors. Conflict exposure predicted increases in anxiety whereas socioeconomic factors and non-conflict stressful life events were the major predictors of depression. Research and interventions in post-conflict settings therefore should consider differential trajectories for depression v. anxiety and the importance of addressing chronic social problems ranging from poverty to gender and ethnic/caste discrimination.

Immigration, social integration and mental health in Norway, with focus on gender differences

BackgroundStudies have shown that social integration may have a positive as well as a negative effect on the mental health of immigrants, depending on the social circumstances.Aims of the studyTo investigate the relationship between social integration and psychological distress in immigrants in Oslo, Norway, with focus on gender differences.MethodsThe study was based on data from a community survey in Oslo (N = 15899), and included 1448 immigrants from non-Western and 1059 immigrants from Western countries. Psychological distress was measured by a 10 items version of Hopkins Symptom Check List (HSCL-10), and social integration was measured by an index based on four items: Knowledge of the Norwegian language, reading Norwegian newspapers, visits by Norwegians and receiving help from Norwegians. Information on paid employment, household income, marital status, social support and conflicts in intimate relationships was also included in the study.ResultsThe non-western immigrants showed a higher level of psychological distress than the immigrants from western countries. In men this could be explained by the combination of less social integration, less employment, lower income, less social support and more conflicts in intimate relationships among non-western compared to western immigrants. In women the difference in level of psychological stress could not be explained by these variables, even if it was reduced. A reason for this seemed to be that social integration in non-western immigrants had a different effect on mental health in men and women. In men, social integration showed a positive effect through employment and income, as well as a positive effect in other areas. Also in non-western women social integration showed a positive effect through greater access to employment and income, but this effect was levelled out by integration causing problems in other areas.ConclusionUnexpectedly, social integration in non-western immigrants was associated with good mental health in men, but not in women. A possible explanation for this might be that the traditional female role in these countries is more challenged by social integration into a Western country than the male role, resulting in conflicting norms, threat to the self and/or loss of identity.

Disability associated with psychiatric symptoms among torture survivors in rural Nepal.

Our objective was to explore the relationships between psychiatric symptom categories (posttraumatic stress disorder (PTSD), anxiety, and depression) and disability among torture survivors. We conducted a cross-sectional study of help-seeking torture survivors in highly affected conflict areas in rural mid-Western Nepal, using rating scales to assess symptomatology and disability. Validated screening instruments for the Nepali setting revealed that a high amount of psychopathology was present. Exploration of the relationships between psychiatric symptomatology and disability showed a central role for PTSD and anxiety complaints, but not for depressive complaints. A recursive model in which PTSD has (a) a direct relationship with disability and (b) an indirect relationship with disability mediated by anxiety and depression best fits the data. Findings are consistent with research on tortured refugees, suggesting the importance of a PTSD–anxiety mechanism. Implications for refugees in Western settings are discussed. Complexity of the mental status of torture survivors indicates multidisciplinary treatment.

Brief multi-disciplinary treatment for torture survivors in Nepal: a naturalistic comparative study.

Background: Little is known about the effectiveness of treatment for torture survivors in low-income settings. Multi-disciplinary treatment is an often used approach for this target group. Aims: This study was aimed at examining the effectiveness of brief multi-disciplinary treatment for torture survivors in Nepal. Methods: A naturalistic comparative design with help-seeking torture survivors and internally displaced persons assigned to a treatment and a comparison group respectively ( n = 192; treatment group n = 111, comparison group n = 81), with baseline measurements on psychiatric symptomatology, disability, and functioning and a five-month follow-up (n = 107; treatment group n = 62; comparison group n = 45), was employed. Intervention consisted of brief psychosocial services, minimal medical services and/or legal assistance. Results: Study groups were generally comparable and non-completers did not significantly differ from completers. The treatment group improved more than the comparison group on somatic symptoms, subjective well-being, disability and functioning, with mostly moderate effect sizes. Conclusion: Treatment was moderately effective, with regards to reducing the nonspecific mental health consequences of torture, but disability scores remained high. For clients presenting with more severe mental health problems, other treatments that are realistic in the resource-poor Nepali context need to be sought.

Psychological distress among immigrants from high- and low-income countries: Findings from the Oslo Health Study

This study compared psychological distress between immigrants from high- and low-income countries living in Oslo, and investigated whether pre- or post-migration factors could explain any such differences in distress levels. A cross-sectional survey with self-administered questionnaires was conducted between 2000 and 2001 among 812 immigrants from high-income countries and 1434 immigrants from low-income countries living in Oslo. The Hopkins Symptom Checklist (HSCL)-10 was used to measure psychological distress. The prevalence rates of psychological distress among immigrants from high- and low-income countries were 10.3% and 24.3%, respectively (P=0.001). Unadjusted odds ratio (OR) of distress among the latter group was 2.38 with 95% confidence interval (CI) 1.73–3.29. The first adjustment (socio-demographic variables) hardly attenuated the difference reported (adjusted OR =2.25, 95% CI 1.58–3.21), the second adjustment (socio-demographic and pre-migration variables) reduced the difference (adjusted OR =1.86, 95% CI 1.28–2.69) while the last adjustment (socio-demographic and pre- and post-migration variables) attenuated the difference below the level of significance (adjusted OR =1.33, 95% CI 0.88–2.01). This means that both pre-migration and post-migration factors were associated with the higher level of distress among immigrants from low-income countries, the post-migration factors in the host country probably being the most important.

Perceived needs, self-reported health and disability among displaced persons during an armed conflict in Nepal.

BackgroundMost internally displaced persons (IDPs) live in low-income countries and have experienced war. Few studies have assessed their psychosocial needs and disability. We carried out a comprehensive assessment of perceived needs, self-reported health, and disability among IDPs in Nepal and examined factors associated with disability.MethodA cross-sectional survey among 290 IDPs in Nepal was conducted between June and July 2003. We used the World Health Organization’s Disability Assessment Schedule-II (WHO-DAS II) with additional local items to assess disability symptoms and a separate checklist to identify their perceived needs. Depression and anxiety symptoms were measured using the Hopkins Symptom Check List (HSCL-25), while the Posttraumatic Stress Disorder Checklist Civilian Version (PCL-C) was used to assess Posttraumatic Stress Disorder (PTSD) symptoms.ResultsDifferent perceived needs such as financial help (70%), housing (40%), food and education for their children (20%) were expressed by the IDPs. Self-reported health status was strongly associated with distress and disability scores. Factors independently associated with disability were higher age, self-reported health, depression, anxiety but not PTSD. There was good correlation between WHO-DAS II and the locally identified items of disability measurement.ConclusionsThe reporting of findings only about psychiatric symptoms is insufficient in studying the mental health of displaced and potentially traumatized populations living in low-income countries. Assessments of perceived needs and factors associated with disability give a more comprehensive understanding of the underlying needs among crisis populations, and this can inform intervention programs. Depression and anxiety should be treated effectively to avoid disability.