Detainment and health: the case of the Lebanese hostages of war

Kidnapping-Induced Trauma and secondary stress in armed conflicts: a comparative study among women in hostage families, volunteers, and the General Population

BACKGROUND

Exposure to armed conflict negatively impacts health. However, there is limited data on secondary stress from ambiguous loss contexts, such as kidnapping. In this study we aimed to quantify changes in modifiable health behaviors and well-being among women in hostage families and hostage crisis volunteers versus the general female population within the first two months of the 2023 Israel-Hamas war.

METHODS

A cross-sectional online survey was conducted on 318 Hebrew-speaking women aged 18-75 in Israel comparing: (1) a general population sample (n = 245); (2) hostage crisis volunteers (n = 40); and (3) hostage family members (n = 33). Participants provided demographic information, details on chronic illnesses, and responded to Likert-scale questions covering self-rated health, mental health, and lifestyle habits before the conflict and in current state.

RESULTS

Hostage family members reported the most severe health impacts, followed by volunteers. Fair/poor physical health status increased significantly in all groups during the war, with hostages' families reporting the highest rate (61.6%). Mental health deterioration was more pronounced among hostages' families, with 84% expressing a need for mental health support. Hostages' families also reported the highest rates of sleep problems, reduced adherence to a healthy lifestyle, and weight loss. Mental and physical health declined significantly across the exposed groups, as measured by multiple assessments, with hostage families experienced the most pronounced impairments across various domains of well-being.

CONCLUSIONS

This period of conflict severely harmed the well-being of all women in the study population. Women from all three groups - hostage families, volunteers, and those from the general population - experienced health deterioration due to varying levels of stress and exposure to conflict-related factors. Hostage families faced the greatest impact with nearly all members of this group showing significant health damage. Long-term support is needed to help restore post-conflict health for all affected women. Further research may be needed to determine the most effective interventions for addressing these impacts across the different groups.

The psychological impact of genocide on the Yazidis

Background

The genocide against the Yazidis by the Islamic State of Iraq and Al-Sham (ISIS) in the Sinjar area of Northern Iraq has costed many lives and has also caused a psychological long-term impact in this minority. This impact can be seen among individual survivors. Additionally, there is a large number of direct and indirect victims and for this reason, the impact can also be observed on the level of the group and society in this region at large.

Methodology

The research examines three different population groups (Yazidis members who had been exposed to violence by terrorist group actions, those not exposed to this experience as they were living in an area not directly exposed to ISIS violence, and a control group of non – Yazidi general population members). In total, 425 participants (age range 15–78) took part in the study and participated in interviews using standard scales to measure general physical and mental health.

Results

The results demonstrate that psychological stress and suicidality are higher among the Yazidis survivors of violence than in the other Yazidi participants.

Conclusion

Psychological disorders after a genocide and war in post-conflict populations should receive more attention in the planning of mental health care and prevention and should be seen as a major problem, especially in camp settings and displaced persons besides the usual increased prevalence of posttraumatic stress and other disorders covered by research so far in this context.

Posttraumatic stress in adult civilians exposed to violent conflict, war and associated human rights abuses in the Eastern Mediterranean Region: A systematic review and meta-analysis

BACKGROUND

The Eastern Mediterranean Region (EMR) is the stage of the world's most violent conflicts and the origin of the largest refugee population worldwide. These conflicts can result in symptoms of posttraumatic stress (PTS). To date, no comprehensive meta-analysis on proportions of PTS in civilians from the EMR has been conducted. Sample characteristics, methodological, conflict-related and displacement-related factors might affect rates of PTS.

METHODS

A systematic literature search for studies investigating PTS in adult civilians from the EMR was conducted until March 2020 and resulted in 118 individual study samples that were suitable for inclusion. A quality assessment was conducted. A random effects meta-analysis on proportions and sensitivity analyses were performed, and a 95% prediction interval was calculated. Subgroup analyses to identify moderators (e.g. diagnostic instruments, displacement) were conducted.

RESULTS

The quality of the included study samples varied. The pooled estimate of proportions from all 118 study samples was 0.31 (95% CI: 0.27 - 0.35). Heterogeneity was considerable (Q = 10151.58, p < .0001; I² = 98.64%). The prediction interval was 0.01 to 0.76. The results remained unchanged after excluding nine outlier study samples. Heterogeneity remained high in all subgroups (range of I²: 87.91 to 99.62).

LIMITATIONS

Due to heterogeneity the pooled estimate cannot be interpreted. Moderators contributing to heterogeneity could not be detected.

CONCLUSIONS

The proportion of symptoms of PTS in civilians from the EMR varies considerably. The prediction interval indicates that the true rate falls between 1% and 76%. Future studies need to identify variables that affect heterogeneity.

History of injury in a developing country: a scoping review of injury literature in Lebanon

BACKGROUND

Lebanon, an Eastern Mediterranean country, suffers a large burden of injury as a consequence of conflict and war, political instability, and the lack of policies and safety regulations. This article aims to systematically map and comprehensively describe the injury research literature in Lebanon and, to identify gaps for future research.

METHODS

MEDLINE, Embase, Eric and SafetyLit, and the grey literature, including conference proceedings, theses and dissertations, government and media reports, were searched without any date or language limits. Data were extracted from 467 documents using REDCap.

RESULTS

War-related injuries were the most prevalent type of injury in Lebanon, followed by homicide and other forms of violence. While existing literature targeted vulnerable and at-risk populations, the vast majority focused solely on reporting the prevalence of injuries and associated risk factors. There are considerable gaps in the literature dealing with the integration of preventive programs and interventions across all populations.

CONCLUSIONS

Lebanon, historically and currently, experiences a high number of injuries from many different external causes. To date, efforts have focused on reporting the prevalence of injuries and making recommendations, rather than implementing and evaluating interventions and programs to inform policies. Future injury related work should prioritize interventions and prevention programs.

Trauma exposure, mental health and tobacco use among vulnerable Syrian refugee youth in Jordan

BACKGROUND

Little is known about tobacco use among youth exposed to armed conflicts, or the influence of trauma on tobacco use in this context. This study examined patterns of smoking by tobacco product and gender among Syrian refugee youth living in host communities in Jordan and assessed the associations of post-traumatic stress disorder (PTSD) and depression symptoms, trauma exposure and social support with current smoking status in boys and girls.

METHODS

Syrian refugee students (mean [standard deviation] age = 14.9 [1.33] years) were identified through the public school system. Data were collected using an online Arabic questionnaire that included questions about demographics, trauma exposure, current smoking (cigarette and waterpipe), PTSD, depression and perceived social support. Logistic regression was used to assess the adjusted effects of independent variables on current smoking status.

RESULTS

One in 7 boys and one in 14 girls were current smokers, with boys reporting greater tobacco use than girls. Among boys, current smokers reported significantly higher family member loss and lower perceived family social support than nonsmokers; among girls, current smokers also reported significantly higher family member loss as well as greater PTSD symptoms and lower perceived significant other/special person social support.

CONCLUSIONS

Tobacco use is established among this vulnerable group. The findings highlight the potential role of psychosocial support for tobacco prevention and cessation strategies.

Potential trauma events and the psychological consequences for Yazidi women after ISIS captivity

BACKGROUND

Traumatic war experiences, like the ones the Yazidi had to undergo due to the attack of the so-called Islamic State (ISIS) in August 2014, are often followed by psychological consequences such as posttraumatic stress disorder (PTSD) and depression. A more detailed analysis of such specific survivor groups is needed, to develop and implement appropriate reparation and support measures.

METHODS

In this study, 194 Yazidi women were examined. PTSD was assessed using the Essen Trauma Inventory (ETI) and depression using Beck's Depression Inventory (BDI-II). The potential traumatic event (PTE) and further influential factors were compared between participants with PTSD and those with PTSD and depression, using inferential statistics.

RESULTS

Panticipants showed high rates in prevalence and comorbidity for PTSD and depression. Those diagnosed with comorbid PTSD and depression experienced a higher number of PTEs and had been captured more often and for longer compared to those with PTSD. The number of PTEs experienced was then used to predict comorbid PTSD and depression.

CONCLUSION

Further research should consider the specific situation and the cultural expression of the Yazidi.

Impact of armed conflict on cardiovascular disease risk: a systematic review

OBJECTIVES

Prolonged armed conflict may constrain efforts to address non-communicable disease in some settings. We assessed the impact of armed conflict on cardiovascular disease (CVD) risk among civilians in low/middle-income countries (LMICs).

METHODS

In February 2019, we performed a systematic review searching Medline, Embase, PsychINFO, Global Health and Web of Science without language or date restrictions. We included adult, civilian populations in LMICs. Outcomes included CVDs and diabetes, and eight clinical and behavioural factors (blood pressure, blood glucose, lipids, tobacco, alcohol, body mass index, nutrition, physical activity). We systematically reanalysed data from original papers and presented them descriptively.

RESULTS

Sixty-five studies analysed 23 conflicts, and 66% were of low quality. We found some evidence that armed conflict is associated with an increased coronary heart disease, cerebrovascular and endocrine diseases, in addition to increased blood pressure, lipids, alcohol and tobacco use. These associations were more consistent for mortality from chronic ischaemic heart disease or unspecified heart disease, systolic blood pressure and tobacco use. Associations between armed conflict and other outcomes showed no change, or had mixed or uncertain evidence. We found no clear patterning by conflict type, length of follow-up and study quality, nor strong evidence for publication bias.

CONCLUSIONS

Armed conflict may exacerbate CVDs and their risk factors, but the current literature is somewhat inconsistent. Postconflict reconstruction efforts should deliver low-resource preventative interventions through primary care to prevent excess CVD-related morbidity and mortality.

PROSPERO REGISTRATION NUMBER

CRD42017065722.

Prevalence of depression and posttraumatic stress disorder in adult civilian survivors of war who stay in war-afflicted regions. A systematic review and meta-analysis of epidemiological studies

BACKGROUND

Epidemiological surveys on depression and posttraumatic stress disorder (PTSD) among civilian war survivors in war-afflicted regions have produced heterogeneous prevalence estimates of these conditions.

METHODS

To determine the prevalence of both depression and PTSD in civilian war survivors in the area of conflict, we conducted a systematic search of Medline, PsycInfo, and Pilots databases. We included epidemiological studies that had used structured clinical interviews. We conducted random effects meta-analyses on prevalence proportions as well as univariate mixed model meta-regressions.

RESULTS

We included 33 studies that assessed prevalences of depression (k = 18) and/or PTSD (k = 30). Across all studies, pooled point prevalences of 0.27 and 0.26 were found for depression and PTSD, respectively. Ten percent of participants fulfilled criteria for both disorders. Surveys with a higher mean age of participants reported higher prevalence of depression. Furthermore, samples with higher rates of unemployment and higher percentages of women reported higher prevalence of PTSD, whereas samples with a higher number of participants living with a partner reported lower prevalence of PTSD.

LIMITATIONS

The findings are limited by poor psychometric reporting practices.

CONCLUSIONS

Our findings suggest that both depression and PTSD are highly prevalent in war survivors who stayed in the area of conflict. Yet, future research on this topic need to focus on psychometric properties of instruments used to assess psychopathology among war survivors. Notwithstanding this limitation, there is an urgent need for large-scale mental health programs that are appropriate for war-affected countries with limited resources and address depression as much as PTSD.

Torture and Long-Term Health Effects Among Lebanese Female Political Prisoners

Lebanese prisoners during the Israeli occupation of Lebanon (1981-1999) were subject to regular torture. We examined the association between torture events and post-traumatic stress and cardiovascular diseases (CVDs) among former women political prisoners. We conducted a retrospective survey and performed health check-ups among 108 former women prisoners. Post-traumatic stress disorder (PTSD) was measured through the Clinician-Administered PTSD Scale (CAPS), and CVDs were assessed by physicians' diagnoses. The study was conducted between September 2008 and March 2010. All 67 participants in the study reported having been subjected to a variety of torture events. The prevalence of PTSD was 28.4% and that of CVD was 16.42%, respectively. PTSD and CVD were more likely to occur among women who had had longer imprisonment periods, and PTSD specifically was associated with exposure to torture (beating: OR = 1.49; 95% CI [0.48, 4.27] and threatening by rape: OR = 1.43; 95% CI [0.82, 9.30]). CVD was associated with asphyxia with water (OR = 3.86; 95% CI [0.03, 2.28]). Devoutness decreased the risk of PTSD (OR = 0.24; 95% CI [0.08, 1.41]). Torture had adverse long-term effects on prisoners' physiological and psychological health; devoutness played a significant protective role. This study highlights the importance of documenting torture events and identifying the indicators of associated morbidity among surviving political prisoners for the provision of additional resources to care.

Validation of an Arabic Version of the GHQ-28 against the Beck Depression Inventory for Screening for Depression in War-Exposed Civilians

This study estimates the psychometric properties of the Arabic GHQ-28 against the BDI–II for screening for depression in war-exposed civilians. Two data sets collected in a civilian sample from South Lebanon were analyzed. Internal consistency in the two samples was high for the GHQ-28 (0.91 and 0.80) and the BDI–II (0.88 and 0.84). The BDI–II was significantly correlated with the GHQ-28 total score and the Depression subscale. The GHQ-28 yielded similar findings for depression cut-off scores compared to the BDI–II: for the GHQ-28 total score, a cut-off at 5/6 is recommended for detecting “severe/moderate” depression, and 8/9 for “severe” only, while from the Depression subscale analysis the recommendation was to use 8/9 as a cutoff for “severe/moderate” and 9/10 for “severe” depression. The Arabic GHQ-28 was found to be a valid instrument for screening for depression in the studied population.

A systematic review on tobacco use among civilian populations affected by armed conflict

OBJECTIVE

To systematically examine evidence on tobacco use among conflict-affected civilian populations.

DATA SOURCES

Primary quantitative and qualitative studies published in English up to April 2014. Bibliographic databases searched were EMBASE, Global Health, MEDLINE, PsycEXTRA, PsycINFO, Web of Science, Cochrane; with the main terms of: (Smoke*, tobacco*, cigarette*, nicotine, beedi, bidi, papirosi, dip, chew, snuff, snus, smokeless tobacco) AND (armed-conflict, conflict-affected, conflict, war, refugee, internally displaced, forcibly displaced, asylum, humanitarian). Grey literature was searched using humanitarian databases, websites and search engines.

STUDY SELECTION

Studies were independently selected by two reviewers, with a study outcome of tobacco use and a population of conflict-affected civilian populations such as internally displaced persons, refugees, residents in conflict-affected areas, residents and returning forcibly displaced populations returning in stabilised and postconflict periods. 2863 studies were initially identified.

DATA EXTRACTION

Data were independently extracted. The Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Programme for qualitative studies were used to assess study quality.

DATA SYNTHESIS

39 studies met inclusion criteria and descriptive analysis was used. Findings were equivocal on the effect of conflict on tobacco use. Evidence was clearer on associations between post-traumatic stress and other mental disorders with nicotine dependence. However, there were too few studies for definitive conclusions. No study examined the effectiveness of tobacco-related interventions. The quantitative studies were moderate (N=13) or weak (N=22) quality, and qualitative studies were moderate (N=3) or strong (N=2).

CONCLUSIONS

Some evidence indicates links between conflict and tobacco use but substantially more research is required.

Public Health and Solitary Confinement in the United States

The history of solitary confinement in the United States stretches from the silent prisons of 200 years ago to today's supermax prisons, mechanized panopticons that isolate tens of thousands, sometimes for decades. We examined the living conditions and characteristics of the populations in solitary confinement. As part of the growing movement for reform, public health agencies have an ethical obligation to help address the excessive use of solitary confinement in jails and prisons in accordance with established public health functions (e.g., violence prevention, health equity, surveillance, and minimizing of occupational and psychological hazards for correctional staff). Public health professionals should lead efforts to replace reliance on this overly punitive correctional policy with models based on rehabilitation and restorative justice.

Human rights violations and smoking status among South African adults enrolled in the South Africa Stress and Health (SASH) study

Despite South Africa's history of violent political conflict, and the link between stressful experiences and smoking in the literature, no public health study has examined South Africans' experiences of human rights violations and smoking. Using data from participants in the nationally representative cross-sectional South Africa Stress and Health study (SASH), this analysis examined the association between respondent smoking status and both human rights violations experienced by the respondent and violations experienced by the respondents' close friends and family members. SAS-Callable SUDAAN was used to construct separate log-binomial models by political affiliation during apartheid (government or liberation supporters). In comparison to those who reported no violations, in adjusted analyses, government supporters who reported violations of themselves but not others (RR = 1.76, 95% CI: 1.25-2.46) had a significantly higher smoking prevalence. In comparison to liberation supporters who reported no violations, those who reported violations of self only (RR = 1.56, 95%CI: 1.07-2.29), close others only (RR = 1.97, 95%CI: 1.12-3.47), or violations of self and close others due to close others' political beliefs and the respondent's political beliefs (RR = 2.86, 95%CI: 1.70-4.82) had a significantly higher prevalence of smoking. The results of this analysis suggest that a relationship may exist between human rights violations and smoking among South Africa adults. Future research should use longitudinal data to assess causality, test the generalizability of these findings, and consider how to apply these findings to smoking cessation interventions.