Vulnerability factors in conflict-related mental health.

INTRODUCTION: Societies marked by armed conflict face huge challenges in mental health care provision due to lowered resources and destruction of infrastructure along with an increased need for care. This especially affects the vulnerable groups already facing bigger challenges in terms of higher disease burden and limited access to care. AIM: To examine how the association between conflict-related trauma and mental health is affected by different factors affecting the individual's vulnerability, and to address the provision of and barriers in access to mental health services in conflict and post-conflict contexts. MATERIALS AND METHODS: Scoping literature review based on a focused literature search in PubMed and DIGNITY Documentation Centre and Library. RESULTS: Population mental health may be affected by violence and by general hardship by (1) causing new mental health conditions, predominantly PTSD, depression and anxiety, and (2) exacerbating pre-existing mental health conditions. Violence, stigmatization, social and physical capital, gender and access to health care were identified as the main vulnerability factors affecting the association between conflict and mental health conditions. DISCUSSION AND CONCLUSION: The associations between violence, vulnerability and mental health might be overlapping and multi-directed. Vulnerability is considered an effect-modifier on the associations between conflict/trauma and mental health.

Torture and torture practices in Tanzania: Knowledge, attitudes and practice among medical professionals.

INTRODUCTION: Medical professionals have a key role in addressing torture and need an awareness and knowledge of torture in relation to rehabilitation approaches, prevention and international standards. This study was undertaken with the aim of assessing the current knowledge, attitudes and practices of medical professionals in Tanzania, creating a baseline for possible future interventions. METHODS: Both quantitative and qualitative data were collected. A cross-sectional survey was carried out using an interviewer-administrated structured questionnaire with 31 questions. Five focus group discussions were held. 386 medical professionals participated in the study representing primary, secondary and tertiary levels of health care in five regions of mainland Tanzania: Arusha, Dar es Salaam, Kigoma, Mara and Mbeya. RESULTS: Around 95% of all professionals acknowledged the existence of torture in Tanzania, but only 7% could correctly identify six different acts as being actual acts of torture according to the definition of the UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Less than 15% were aware of relevant international standards like the Istanbul Protocol and the Mandela Rules. Up to 57% perceived that torture could be acceptable under certain circumstances. About 68% of all professionals reported to have encountered torture victims. The majority (82.9%) saw themselves as competent in the management of torture victims, but only 22% had received training specifically focusing on torture and its consequences. Most were interested in learning more on the subject. CONCLUSION: While medical professionals may be aware of the existence of torture in the country and report encountering torture victims in their daily work, both the professionals' skills and attitudes with regards to torture require development to intensify the work against torture in Tanzania. Intervention strategies should target training in medical schools and in-service training for medical profesionals at all levels within the health care system.

The Istanbul Protocol: A global stakeholder survey on past experiences, current practices and additional norm setting.

INTRODUCTION: The Istanbul Protocol (IP) principles and guidelines have served as international norms for the effective investigation and documentation of torture and ill-treatment since 1999. Given the widespread use of the IP and recent calls to update or enhance its norms, we conducted a large-scale study among stakeholders to understand current practices as well as opinions on additional IP norm setting. METHODS: Between February 20, 2017 and April 7, 2017, we conducted an online survey of IP users using a combination of criterion and chain sampling. The survey instrument included the following domains of inquiry: 1) respondent characteristics (demographics, anti-torture work, country conditions, and IP training); 2) IP use, importance and practices, and; 3) opinions on additional IP norm setting. RESULTS: The survey was distributed to 177 individuals and 250 organizational representatives with response rates of 78% and 47% respectively. The respondents came from a variety of clinical, legal, academic, and advocacy disciplines from around the world. The respondents indicated that they use the IP for a wide range of anti-torture activities: investigation and documentation, advocacy, training and capacity building, policy reform, prevention, and treatment and rehabilitation of torture survivors. The vast majority (94% of individual respondents and 84% of organizations) reported that the IP is important to their anti-torture work. A majority of individual (60%) and organizational (59%) respondents reported that updating or adding clarifications to the IP would help to address the challenges they face and provided specific suggestions. However, 41% of individuals and 21% of organizational respondents also reported concerns that additional IP norm setting could have negative consequences. DISCUSSION: The IP provides critical guidance for a wide range of torture prevention, accountability, and redress activities and can be enhanced through the development of additional updates and clarifications to respond to the current needs of torture survivors and stakeholders.

Quality of prison life, violence and mental health in Dubrava prison.

PURPOSE: The purpose of this paper is to explore the association between the quality of prison life and mental health among prisoners and the occurrence of violence. DESIGN/METHODOLOGY/APPROACH: In total, 203 prisoners from Dubrava Correctional Center in Kosovo participated. Data on background characteristics of the prisoners, quality of prison life, mental health symptoms and exposure to physical, psychological and sexual violence were collected through interviewer-administered questionnaires. Data were analyzed using general linear models (GLM) and manual backwards model search with step-wise exclusion. FINDINGS: The GLM analysis showed a significant negative association between anxiety symptom load (-1.4), physical violence (-1.5) and psychological violence (-1.9), and quality of prison life. Furthermore, it appeared that prisoners rating of quality of life (QoL) increased with time among prisoners not exposed to violence, while this was not seen among prisoners exposed to violence. Finally, there was an inverse association between the dimensions of respect, fairness, humanity and good staff/prisoner relations, and the proportion of prisoners exposed to violence. ORIGINALITY/VALUE: An environment with higher levels of respect, fairness, humanity and good relations between staff and prisoners was associated with lower levels of violence. Hence, a prison that focuses on promoting QoL and good mental health among prisoners will show lower levels of violence, thereby making the prison a more tolerable place for the prisoners and a better working environment for prison staff.

Voices of torture survivors in Tanzania: A qualitative study.

INTRODUCTION: No published research has been found on torture in Tanzania, but individual cases were documented by human rights organisations. The aim of this study was to explore the salient physical, mental and social effects of torture in the country, and help-seeking behaviour by giving voice to a group of torture survivors in Dar-es-Salaam and Zanzibar City (Zanzibar). METHODS: This explorative qualitative study consisted of 14 semi-structured in-depth interviews (12 males, 2 females) of which eight took place in Dar-es-Salaam and six in Zanzibar. Informants were selected purposefully through a mix of snowball and convenience sampling. Both the Standards for Reporting Qualitative Research (SRQR) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed. RESULTS: Using the UNCAT definition of torture, all informants reported having been tortured within the past two years. The most common form of torture was beating with clubs to the joints. Other torture included, but was not limited to, gun shot, toenail removal and 'poulet roti'. The most common physical consequence was persistent pain. Psychological consequences included suicidal ideation and sleep problems. Most interviewees lost their jobs as a result of the torture incident, instigating a cascade of financial and social problems. CONCLUSION: The findings present informants' exposure to deliberate torture at the hands of public authorities. Informants confirmed their exposure to torture methods that had been previously reported by nongovernmental organisations. They also talked about exposure to more advanced, and previously undocumented, torture methods. Informants displayed a dire need for mental and physical health care, but had limited access to such care. Research is needed to better understand the magnitude, prevalence and context of torture in Tanzania.

Impact of NET on torture survivors in the MENA region.

INTRODUCTION: Narrative Exposure Therapy (NET) is a brief cognitive-behavioural intervention for individuals with posttraumatic stress disorder (PTSD) which has mostly been used to treat traumatised asylum seekers and refugees in highincome settings. Evidence is scarce on the effectiveness of NET with torture survivors, especially in the Middle East and North African (MENA) region where health systems are unable to meet the increasing needs of mental health disorders caused by war and displacement. METHODS: During the period 2013 to 2016 DIGNITY - Danish Institute Against Torture, in collaboration with partners, implemented a capacity-building training programme on NET among 44 Arabic health professionals from highly specialised torture rehabilitation centers in Jordan, Palestine, Egypt, Lebanon, Iraq, Tunisia, Libya, Sudan and Syria. A multi-centre study was carried out across all centres comprising of the collection of client data on socio-demographic variables, torture exposure, and psychosomatic health indicators. Clinical assessment of mental health symptoms among torture survivors was performed by the NET therapists pre- and post NET therapy and at four months' follow-up, and means were compared. RESULTS: Our findings show a statistically significant reduction in average psychological symptom load for PTSD (from 3.20 to 1.80), anxiety (2.78 - 1.61) and depression (2.75 - 1.96) with the largest effect on PTSD symptoms, and a larger effect for women than men. The results indicate improvements in selfreported health (3.85-2.82) and physical disabilities (2.90-1.76), as well as reduction in pain perceptions after therapy (4.44 -3.44). The duration of treatment was three months on average with a span from one to eight months. DISCUSSION: This study provides new evidence suggesting a strong positive effect of NET in an Arab cultural setting which remains under-represented in the NET evidence base. However, some important limitations of the study preclude drawing firm conclusions, namely the lack of a control group, a high number of dropouts in follow up data and a potential risk of information bias. Contexts familiar to the torture survivor and shared cultural norms and language between the client and the therapist might positively affect the effect of NET on PTSD symptoms. This capacity-building training programme established a community of Arab trauma mental health experts in the MENA-region, and their implementation of NET was associated in time with a reduction of the mental health symptom load of survivors of torture and war.

A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo.

BACKGROUND: Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012-14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo. METHODS: A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score. RESULTS: Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45-137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance. CONCLUSIONS: The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability. TRIAL REGISTRATION: Clinicaltrials.gov (NCT01696578).

Testimonial Therapy: Impact on social participation and emotional wellbeing among Indian survivors of torture and organized violence.

INTRODUCTION: Traumatizing events, such as torture, cause considerable impairments in psycho-social functioning. In developing countries, where torture is often perpetrated, few resources exist for the provision of therapeutic or rehabilitating interventions. The current study investigated the effectiveness of Testimonial Therapy (TT) as a brief psycho-social intervention to ameliorate the distress of Indian survivors of torture and related violence. METHOD: Three outcome measures (the WHO-5 Well-Being Scale, Social Participation-Scale and Pain and Anger Analogue) were compared before and after receiving TT, and semi structured interviews were conducted with survivors who had previously received TT. FINDINGS: Participants showed significant improvements in emotional well-being, social participation, and self-perceived pain and anger. Furthermore, three qualitative interviews with survivors indicated that TT had a positive impact at the community level. DISCUSSION: Although the study was conducted without a control group for comparison, TT appeared to be an effective method for improving well-being and ameliorating distress among survivors of torture. Furthermore, TT can potentially promote community empowerment. However, more research on this aspect is needed.

Violence and social capital in post-conflict Guatemala.

OBJECTIVE: Violence in post-conflict Guatemala has serious public health consequences for the population. The objective of this study was to assess the relationship between violence and social capital. METHODS: Data from a cross-sectional victimization survey conducted in 2008 - 2010 in Guatemala were analyzed. Two-stage proportionate sampling was used in the survey. Households (n = 1 300) were randomly sampled within a random sample of communities (n = 118) in five administrative departments. The survey collected information on the six-month violence exposure of 6 335 individuals. Social capital was measured at the household level using the short version of the Adapted Social Capital Tool (SASCAT). The odds ratio for household violence exposure was estimated using multiple logistic regression. Community-level data from the latest national census were included as explanatory factors at the community level. Income, ethnicity, and social capital were included at the household level. Data were analyzed using SPSS 18.0. RESULTS: In total, 2.7% of individuals and 11.7% of households had been exposed to violence within the past six months. The multivariate analysis showed that 1) structural social capital (in this case, the level of participation in social networks and civil society) was a risk factor for violence and 2) cognitive social capital (measured as trust, norms, and sense of belonging) was a protective factor for violence. CONCLUSIONS: The opposite direction of the association between violence and structural and cognitive social capital challenges the use of social capital as a unified concept. If this finding is corroborated by other studies, structural and cognitive social capital will have to be treated as two distinctly different concepts.

Violence and social capital in post-conflict Guatemala / Violencia y capital social en la Guatemala posterior al conflicto

OBJECTIVE: Violence in post-conflict Guatemala has serious public health consequences for the population. The objective of this study was to assess the relationship between violence and social capital. METHODS: Data from a cross-sectional victimization survey conducted in 2008 - 2010 in Guatemala were analyzed. Two-stage proportionate sampling was used in the survey. Households (n = 1 300) were randomly sampled within a random sample of communities (n = 118) in five administrative departments. The survey collected information on the six-month violence exposure of 6 335 individuals. Social capital was measured at the household level using the short version of the Adapted Social Capital Tool (SASCAT). The odds ratio for household violence exposure was estimated using multiple logistic regression. Community-level data from the latest national census were included as explanatory factors at the community level. Income, ethnicity, and social capital were included at the household level. Data were analyzed using SPSS 18.0. RESULTS: In total, 2.7% of individuals and 11.7% of households had been exposed to violence within the past six months. The multivariate analysis showed that 1) structural social capital (in this case, the level of participation in social networks and civil society) was a risk factor for violence and 2) cognitive social capital (measured as trust, norms, and sense of belonging) was a protective factor for violence. CONCLUSIONS: The opposite direction of the association between violence and structural and cognitive social capital challenges the use of social capital as a unified concept. If this finding is corroborated by other studies, structural and cognitive social capital will have to be treated as two distinctly different concepts.

OBJETIVO: La violencia en la Guatemala posterior al conflicto tiene graves consecuencias para la salud pública de la población. El objetivo de este estudio fue evaluar la relación entre la violencia y el capital social. MÉTODOS: Se analizaron los datos de una encuesta transversal sobre victimización realizada del 2008 al 2010 en Guatemala. Se empleó el muestreo proporcional en dos etapas. Se obtuvo una muestra aleatoria de hogares (n = 1 300) seleccionados de una muestra aleatoria de comunidades (n = 118) de cinco departamentos administrativos. La encuesta recopiló información sobre la exposición de 6 335 personas a la violencia durante seis meses. El capital social se midió a escala doméstica mediante la versión abreviada de la Herramienta Adaptada de Evaluación del Capital Social (SASCAT, por sus siglas en inglés). Se calculó la razón de posibilidades de exposición a la violencia doméstica mediante regresión logística múltiple. Se incluyeron los datos a escala comunitaria del último censo nacional como factores comunitarios explicativos. A escala doméstica, se incluyeron el nivel de ingresos, el grupo étnico y el capital social. Los datos se analizaron mediante el SPSS 18.0. RESULTADOS: En total, 2,7% de las personas y 11,7% de los hogares se habían visto expuestos a la violencia en los seis últimos meses. El análisis multifactorial mostró que 1) el capital social estructural (en este caso, el nivel de participación en las redes de relaciones sociales y la sociedad civil) constituía un factor de riesgo de violencia; y 2) el capital social cognitivo (medido como la confianza, las normas y el sentido de pertenencia) constituía un factor protector frente a la violencia. CONCLUSIONES: La dirección opuesta de la asociación entre la violencia y el capital social estructural y el cognitivo cuestiona el empleo del capital social como un concepto unificado. Si este hallazgo se corrobora en otros estudios, el capital social estructural y el cognitivo deberán considerarse como dos conceptos marcadamente diferentes.

Survivors of war in northern Kosovo (III): The role of anger and hatred in pain and PTSD and their interactive effects on career outcome, quality of sleep and suicide ideation.

BACKGROUND: The management of chronic debilitating health conditions after trauma remains a challenge in post-conflict settings. The study aimed to expand current understanding of the diagnostic overlap of pain and PTSD and explore their independent and interactive effect on career change, sleep disorder and suicide ideation. The role of anger and hatred as contributing factors to the persistence of pain and PTSD were also examined. METHODS: 125 victims of torture and massive violence identified in a household survey took part in the in-depth assessment. Socio-demographic data and information on trauma, emotional disturbance, injuries and medication history were collected. PTSD was diagnosed according to DSM-IV criteria. Pain was assessed using the McGill Pain Questionnaire and the Margolis Pain Diagram. RESULTS: Nearly 95% participants experienced pain during the last 2 weeks, 47% were diagnosed with PTSD, 50% were taking medication against depression and anxiety. There is substantial overlap of pain, PTSD and emotional disturbance. Injury history, PTSD and negative emotions were related to the pain score and the number of pain locations. Anger, hatred or an inferiority complex particularly amplified pain experience. Headache was constant and especially prevalent in those with recent experience of anger, aggressiveness and hatred. The risk of having chest and abdominal pain within 2 weeks was very high in those who had chest injury and had recently been crying. An increased risk of changing jobs or stopping work or schooling due to depression or injury was observed for those with a higher pain score, and for pain in neck, shoulder and upper limbs. The prevalence of sleep disorders was 80%, that of suicide ideation 70%, and these were found to be associated with greater pain and anger. PTSD was also related to suicide ideation. CONCLUSIONS: The findings provide an overview of pain characteristics in individuals with PTSD and injury and confirm the hypothesized effects on career outcome, sleep disorders and suicide ideation. The study revealed a high level of persistent anger and hatred. The findings suggest the need for new approaches to rehabilitation in a post-war setting, including ways in which to address collective emotional hurt in the society.

Survivors of war in the Northern Kosovo (II): baseline clinical and functional assessment and lasting effects on the health of a vulnerable population.

BACKGROUND: This study documents torture and injury experience and investigates emotional well-being of victims of massive violence identified during a household survey in Mitrovicë district in Kosovo. Their physical health indicators such as body mass index (BMI), handgrip strength and standing balance were also measured. A further aim is to suggest approaches for developing and monitoring rehabilitation programmes. METHODS: A detailed assessment was carried out on 63 male and 62 female victims. Interviews and physical examination provided information about traumatic exposure, injuries, and intensity and frequency of pain. Emotional well-being was assessed using the "WHO-5 Well-Being" score. Height, weight, handgrip strength and standing balance performance were measured. RESULTS: Around 50% of victims had experienced at least two types of torture methods and reported at least two injury locations; 70% had moderate or severe pain and 92% reported constant or periodic pain within the previous two weeks. Only 10% of the victims were in paid employment. Nearly 90% of victims had experienced at least four types of emotional disturbances within the previous two weeks, and many had low scores for emotional well-being. This was found to be associated with severe pain, higher exposure to violence and human rights violations and with a low educational level, unemployment and the absence of political or social involvement.Over two thirds of victims were overweight or obese. They showed marked decline in handgrip strength and only 19 victims managed to maintain standing balance. Those who were employed or had a higher education level, who did not take anti-depressant or anxiety drugs and had better emotional well-being or no pain complaints showed better handgrip strength and standing balance. CONCLUSIONS: The victims reported a high prevalence of severe pain and emotional disturbance. They showed high BMI and a reduced level of physical fitness. Education, employment, political and social participation were associated with emotional well-being. Interventions to promote physical activity and social participation are recommended. The results indicate that the rapid assessment procedure used here offers an adequate tool for collecting data for the monitoring of health interventions among the most vulnerable groups of a population exposed to violence.

Survivors of the war in the Northern Kosovo: violence exposure, risk factors and public health effects of an ethnic conflict.

BACKGROUND: The aim of this population-based study was to assess the long-lasting effects of ethnic conflict on health and well-being (with a focus on injury and persistent pain) at family and community level. We have also investigated possible risk factors for victimisation during the conflict and factors contributing to healing. METHODS: We conducted a district-level cross-sectional cluster survey of 1,115 households with a population of 6,845. Interviews were carried out in Mitrovicë district in Northern Kosovo from September to October 2008, using standardised questionnaire to collect lifetime violence exposure, lifestyle factors and health information on individual and household. RESULTS: Ethnic Albanians made up 95% of the sample population. Crude mortality and under-five mortality rate was not high in 2008. Over 90% of families had been exposed to at least two categories of violence and human rights violations, and 493 individuals from 341 families reported torture experiences. During the two weeks before the survey, 20% of individuals had suffered physical or mental pain. There were differences in pain complaints according to gender and age, and whether people had been injured within 12 months, had lifetime exposure to violence-related injury, or had been tortured. Patterns of social and political participation in a family could affect the proportion of family members complaining of pain. The proportion of family members with pain complaints was related to a decline in the household income (coef = 9.31, 95% CI = 6.16-12.46, P < 0.001) and the fact of borrowing money (coef = 6.11, 95% CI = 2.91-9.30, P < 0.001) because of an injured person in the household. Families that were affiliated with the Kosovo Liberation Army, or had participated in a protest before or during the war, were likely to be targeted by Serbian paramilitary and law enforcement agencies. CONCLUSIONS: Mitrovicë district is currently characterised by a low level of violence, but the effects of ethnic conflict on health and well-being have not gone. The level of lifetime exposure to violence, the proportion of family members reporting pain and lifetime violence-related injury, and family's financial burden were found to be inter-correlated. The sample confined to one ethnic group in one district limits the generalizability of the findings.

Household exposure to violence and human rights violations in western Bangladesh (II): history of torture and other traumatic experience of violence and functional assessment of victims.

BACKGROUND: Organised crime and political violence (OPV) and human rights violations have marred Bangladesh history since 1971. Little is known about the consequences for the oppressed population. This study describes the patterns of OPV and human rights violations in a disturbed area of Bangladesh and assesses the physical, emotional and social functioning of victims. METHODS: A total of 236 of selected participants in a household survey in Meherpur district were recruited for a detailed study. Interviews and physical examinations were used to obtain information about history of torture and other cruel, inhuman or degrading treatment or punishment (TCIDTP), and about injuries, pain frequency and intensity. Handgrip strength and standing balance performance were measured. The "WHO-5 Well-being" scale was used to assess the subjective emotional well-being of study participants. RESULTS: The majority of the reported cases of TCIDTP occurred in 2000-2008, 51% of incidents occurred during winter; 32.0% between 20:00 and midnight. Police involvement was reported in 75% of cases. Incidents took place at victims' homes (46.7%), or at the police station, military camp, in custody or in prison (21.9%). Participants experienced 1-10 TCIDTP methods and reported 0-6 injury locations on their bodies; 77.5% reported having at least two injuries. Less than half of the participants were able to stand on one leg for 30 seconds. Only 7.5% of males aged 25-44 had handgrip strength in both hands exceeding average values for healthy people at the same age. Over 85% of participants scored low (<13) on the 25-point "WHO-5 Well-being" scale. The number of years since the TCIDTP event, pain frequency, the need to quit a job to take care of an injured family member, political involvement, personal conflicts and the fear of neighbourhood violence strongly affected emotional well-being. Good emotional well-being correlated with increased political and social participation. CONCLUSION: A detailed picture of characteristics of the victimisation is presented. The participants showed poor emotional well-being and reduced physical capacity. The results indicated that the simple and rapid method of assessment used here is a promising tool that could be used to monitor the quality and outcome of rehabilitation.

Household exposure to violence and human rights violations in western Bangladesh (I): prevalence, risk factors and consequences.

BACKGROUND: The ruling parties in Bangladesh have systematically used violence against political opponents and criminals. It is essential to 1) determine the magnitude and burden of organised crime and political violence (OPV) and human rights violations in the affected community, and to 2) identify the risk factors and key indicators for developing effective health intervention and prevention measures. METHODS: The population-based study consisted of two parts: a household survey and OPV screening at mobile clinics (presented in Part II). A cross-sectional, multistage cluster household survey was conducted in the Meherpur district in February-March 2008; 22 clusters with a sample size of 1,101 households (population of 4,870) were selected. RESULTS: Around 83% of households reported being exposed to at least two categories of OPV or human rights violations: 29% reported that the family members had been arrested or detained; 31% reported torture or other cruel, inhuman or degrading treatment or punishment. Crude mortality rate was 17.9/1,000 and under 5 mortality rate was 75/1,000. The annual injury rate was 36%, lifetime experience of violence-related injury was 50%, and pain experience within 2 weeks was reported by 57%. Over 80% of the population over 35 years old complained of pain. High prevalence of injury, lifetime experience of OPV-related injury and pain complaints are related to the level of exposure to OPV and human rights violations. A financial burden was imposed on families with an injured person. A geographical variation was revealed regarding reports of torture and lifetime experience of violence-related injury. A combination of individual, relational, community and societal factors, including variables such as political party affiliation, conflict with other families, household income and residential area, affected the risk of victimisation in the household. The odds ratio for reporting extrajudicial execution of a family member was 9.22 for Awami League supporters, 9.15 for Bangladesh Nationalist Party supporters; and 3.97 for Jamaat-e-Islami Party supporters compared with families with no political involvement. CONCLUSION: The level of violence and human rights violations is high. The affected population suffers from violence-related injuries and traumas, which could be a factor contributing to poverty. Victimisation is not random.

Development in self-rated health among older people as determinant of social relations.

AIM: The purpose of this study was to analyse whether development in self-rated health (SRH) over four years was associated with the structure of and satisfaction with social relations, at four and eight years follow-up, among elderly women and men. METHODS: A longitudinal questionnaire-based study was undertaken of non-institutionalized Danes, aged 70-95 years, with baseline in 1986. The response rate at baseline was 69%, n= 1,231. First follow-up was carried out in 1990, with 91% of eligible individuals participating (n=911). Second follow-up took place in 1994, where 83% of eligible individuals participated (n= 542). The association was studied between development in SRH from 1986 to 1990 and social relations in 1990 and in 1994. RESULTS: A sustained poor SRH predicted low contact frequency OR= 1.7 (1.1-2.6), small contact diversity OR= 1.6 (1.0-2.6) and low contact satisfaction OR=3.4 (2.3-5.2) in the two-point analyses. Furthermore, a deterioration in SRH predicted poor contact satisfaction OR=2.8 (1.7-4.5). All analyses were adjusted for age, gender, mental health, functional ability, cohabitation status, and a measure of social relations at baseline. Results for the three-point analyses were similar to those for the two-point analyses. The associations were weaker for contact satisfaction OR=2.8 (1.7-4.7), but stronger for contact frequency OR=2.5 (1.4-4.4) and diversity OR=2.1 (1.2-3.6). CONCLUSION: Sustained poor SRH and, to some degree, deterioration in SRH were predictors of poor social relations after four and eight years.