Health Care and Community-Based Interventions for War-Traumatized People in Croatia: Community-Based Study of Service Use and Mental Health
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Clinical Science Health Care and Community-based Interventions for War-traumatized People in Croatia: Community-based Study of Service Use and Mental Health Tanja Frančišković1, Zdravko Tovilović1, Zoran Šuković1, Aleksandra Stevanović1, Dean Ajduković2, Radojka Kraljević2, Marija Bogić3, Stefan Priebe3 1University of Rijeka School of Aim To explore the use of health care and community-based services in Medicine, Rijeka, Croatia war-affected regions of Croatia and its relation to mental health. 2Department of Psychology, Faculty of Philosophy, Methods A sample of 719 adults exposed to at least one war-related University of Zagreb, Zagreb, traumatic event were selected by random-walk technique from three Croatia Croatian counties and interviewed for socio-demographic data, men- 3Barts and the London School of Medicine, Queen Mary tal health status (Mini International Neuropsychiatric Interview), and University of London, London, service use (Matrix for the Assessment of Community and Healthcare United Kingdom Services) in the period from 1991 to 2006. Descriptive analysis of ser- vice use was performed. Relations between service use, current mental health, and recovery from posttraumatic stress disorder (PTSD) were analyzed using logistic regression models. Results The traumatized population used a wide range of health care and community-based services. Health care was the most frequently used service category, especially primary health care (92.5%), followed by accommodation support (57.9%), financial support (57.7%), and employment support (32.5%). Compared with participants without mental disorders, participants with current PTSD were more likely > Correspondence to: to use only legal support (odds ratio [OR], 2.15; 95% confidence in- Zdravko Tovilović terval [CI], 1.15-3.99), while participants with other mental disorders Center for Psychotrauma University of Rijeka School of Medicine were more likely to use social support and contacts (OR, 1.72; 95% 15 Cambieri Street CI, 1.08-2.75). Receiving accommodation support (OR, 2.05; 95% CI, 51000 Rijeka, Croatia 1.03-4.06) was the only significant predictor of recovery from PTSD, [email protected] while seeking legal support (OR, 0.28; 95% CI, 0.08-0.92) was related to slower recovery. Conclusion Although a wide range of services were organized to help > Received: February 14, 2008 the traumatized population in Croatia, only the solution of housing > Accepted: June 9, 2008 issue significantly predicted recovery. The organization of help services should take into consideration the existing infrastructure and local specificities, and respect the needs of people in war-affected areas. > Croat Med J. 2008;49:483-90 > doi: 10.3325/cmj.2008.4.483 www.cmj.hr 483 Croat Med J 2008;49:483-490 It has been widely accepted that victims of war in order to help developing the forms of help need organized help (1-4). However, the tim- that would satisfy the needs of traumatized ing and the type of this help are also impor- population and to identify the services related tant to best satisfy the complex and interrelat- to traumatic stress recovery. The aims of this ed needs of the victims. study were to identify organized forms of help Authors often disagree in their definitions in war-affected regions, determine the preva- of posttraumatic stress disorder (PTSD) and lence of use of certain services, examine the as- psychological trauma intervention. According sociation between service use and PTSD and to some, PTSD is mostly present in a popula- other mental disorders, and analyze the associ- tion that has survived a traumatic event (5,6) ations between PTSD recovery and use of cer- and usually comorbid with other psychiatric tain services. disorders, causing significant disabilities (7- 10). The widely accepted approach in PTSD Methods treatment is that interventions should focus on psychological trauma and that help should This study was a part of the international re- be provided through systems of mental health search project Components, Organization, care (1,2,11,12). However, the critics claim Costs, and Outcomes of Health Care and that such an approach creates a “pseudo-condi- Community Based Interventions for People tion,” which is as a product of Western culture with Posttraumatic Stress Following War and “exported” to other cultures and communities. Conflict in the Balkans (CONNECT) (16), According to them, it leads to medicalization co-financed within the 6th Framework Pro- of psychological distress, points to psychologi- gram of the European Union. cal interventions as the only solution, and dis- Participants regards the specificities, tradition, systems of meaning, and current priorities of local popu- A random sample of inhabitants was selected lation (4,5,13,14). from three randomly selected Croatian coun- The 1991-1995 war in Croatia left a large ties directly exposed to war (Lika-Senj County, number of traumatized people and caused se- Karlovac County, and Sisak-Moslavina Coun- vere damage to social structures. National and ty). Households were selected by a random- international institutions and non-govern- walk technique (14). Within each household, mental organizations (NGO) created a range we selected a member aged between 18 and of programs in an attempt to reduce the ef- 65 years whose birthday was the closest to the fects of traumatization. Foreign and Croatian day of the interview. If the member was avail- NGOs providing psychosocial help joined in able and agreed to participate, he or she had to the National Program of Psychosocial Help meet the following inclusion criteria: born in to War Victims (15). This included accom- the former Yugoslavia, experienced at least one modation for refugees and displaced persons, war-related traumatic event, and aged at least humanitarian aid, development of recon- 16 at the time of the last war-related traumat- struction programs, programs for the return ic event. The traumatic experience was deter- of displaced persons, and unemployment re- mined by a brief screening list. Mental retar- duction programs (11,15). Previous research dation was the exclusion criterion. We made has mostly covered psychiatric and psychoso- contact with 1241 potential participants, 328 cial forms of help (11,12), but not service use. (26.4%) of whom refused to participate and However, research on service use is important 186 (15.0%) did not meet the criteria. This 484 Frančišković et al: Service Use and Mental Health of the War-traumatized in Croatia left 727 participants. Eight more participants (18). It is divided into modules, each corre- were excluded because we were not able to ob- sponding to a diagnostic category with DSM tain information on their use of health care Axis-I disorders (18). Modules consist of very and community-based services. The final sam- precise questions about psychological prob- ple consisted of 719 participants. Participants lems or symptoms, and clinical assessment were aged 45.9 ± 10.9 (mean ± standard de- consists of evaluation of the participants’ an- viation) years and 54.1% were women. There swers in terms of clinically relevant dimen- were 6.9% participants who had not com- sions (ie, time frame, frequency, severity). pleted primary school, 20.2% completed only Clinical judgment of each symptom is then primary school, 56.4% completed secondary registered in the form of yes (symptom was school, while 16.5% completed a two-year or clinically relevant) or no (symptom was not a four-year college. According to employment clinically relevant) answers. At the end of each status, 38.5% participants were currently em- module there is a diagnostic frame, which doc- ployed, 36.5% unemployed, 23.9% retired, uments if the diagnostic criteria were met for while 1.1% still attended school. According to each disorder. Compared with more extensive marital status, 70.3% participants were mar- and time-consuming clinical interviews (such ried and 21.6% were cohabiting. There were as Structured Clinical Interview for DSM Dis- 32.2% participants who actively participated orders), MINI has similar metrical characteris- in the war and 57.4% who became refugees or tics and satisfying levels of sensitivity and spec- displaced persons during the war. ificity (17,19). Use of health services and various forms of Instruments and method community-based help was assessed with the After being familiarized in detail with the ob- Matrix for the Assessment of Community and jectives, methods, and procedures of the study, Healthcare Services (MACSI) – a specific in- the participants gave their written consent and strument developed within the CONNECT underwent a face-to-face interview. The inter- project, designed for registering health care use views were carried out by a psychologist well and a specific and non-specific forms of help in trained in application of the instruments and the area of former Yugoslavia after war (house procedures. The research was approved by the reconstruction, refugee camps, humanitarian Ethics Committee of the University of Rijeka aid, support groups, etc.). The MACSI ques- School of Medicine. tionnaire is designed as a table and lists 9 basic Data on the participants’ age, sex, educa- help forms provided in war-affected areas from tion, employment, marital status, and war ex- the beginning of the war until the day of the perience (active participation in the war, refu- interview (going to the dentist, psychother- gee or a displaced person status) were obtained apy, house reconstruction, child benefit, and by