The mental health of expatriate and Kosovar Albanian humanitarian aid workers 153

The mental health of expatriate and Kosovar Albanian humanitarian aid workersBarbara Lopes Cardozo, Timothy H. Holtz, Reinhard Kaiser, Carol A. Gotway, Frida Ghitis, Estelle Toomey and Peter Salama1

The mental health consequences of exposure to traumatic events and the risk factors for psychological morbidity among expatriate and Kosovar Albanian humanitarian aid workers have not been well studied. In June 2000, we used standardised screening tools to survey 285 (69.5%) of 410 expatriate aid workers and 325 (75.8%) of 429 Kosovar Albanian aid workers from 22 humanitarian organisations that were implementing health programmes in Kosovo. The mean number of trauma events experienced by expatriates was 2.8 (standard deviation: 2.7) and by Kosovar staff 3.2 (standard deviation: 2.8). Although only 1.1% of expatriate and 6.2% of Kosovar aid workers reported symptoms consistent with the diagnosis for post-traumatic stress disorder, 17.2% and 16.9%, respectively, reported symptoms satisfying the definition of depression. Regression analysis demonstrated that the number of trauma events experienced was significantly associated with depression for the two sets of workers. Organisational support services may be an important mediating factor and should be targeted at both groups.

Keywords: humanitarian aid workers, mental health, support services.

IntroductionA complex emergency has been defined as a relatively acute situation that affects a large civilian population and usually involves a combination of war or civil strife, food shortages and population displacement that results in significant excess mortality (Toole and Waldman, 1990). Since the end of the Cold War, complex emergencies have become more common, and international aid organisations have become important actors (Toole and Waldman, 1997). The mental health consequences of complex emergencies for both civilians and rescue personnel have only recently been recognised. With regard to civilians who have fled war or civil strife (Mollica et al., 1997; Sundquist and Johansson, 1996), or returned to their homes after the fighting (Lopes Cardozo et al., 2000), the psychological ramifications of experiencing traumatic events have been well described. Studies of psychological morbidity have also focused on military personnel (Armfield, 1994; McCarroll et al., 1997) and peacekeepers (Bramsen et al., 2000) and have attempted to identify risk factors for these groups. While the prevalence rates of psychological morbidity, particularly post-traumatic stress disorder (PTSD), have been high among rescue workers responding to natural disasters (Ursano et al., 1999), the pervasiveness of psychological morbidity among expatriate and national relief workers responding to complex emergencies is unknown. Anecdotal evidence, however, suggests that a syndrome known as ‘burnout’ is common

Disasters, 2005, 29(2): 152−170. © Overseas Development Institute, 2005Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

The mental health of expatriate and Kosovar Albanian humanitarian aid workers 153

and that staff turnover is high (Smith et al., 1996). Burnout, a poorly defined layman’s term, may encompass a combination of symptoms of anxiety and depression. More mundane but not insignificant stressors, such as poor job security, restricted career devel-opment opportunities, low salaries and poor living conditions, may lead to burnout. Despite the rapid expansion in the number and capacity of international aid organisa-tions, human resources policies concerning training, briefing, counselling and debriefing are not fully developed and vary considerably from organisation to organisation (McCall and Salama, 1999). The extent to which these organisational policies affect mental health outcomes among relief workers is unknown. National relief workers—relief workers recruited from the host population—generally make up the bulk of the staff of inter-national aid organisations. National relief workers typically receive less support from international aid organisations than their expatriate counterparts—relief workers who are hired by a humanitarian body and are working in a country other than their native one. Entitlements to health services (including basic healthcare, psychological support and medical evacuation) are normally much less comprehensive (McCall et al., 1999). Between February 1998 and June 1999, Serbian forces killed approximately 10,000 people, and more than 800,000 Kosovar Albanians became refugees in neighbouring states (Spiegel and Salama, 2000). On 20 June 1999, after the North Atlantic Treaty Organisation (NATO)-led intervention, Serbian forces withdrew from Kosovo and the United Nations Mission in Kosovo (UNMIK) assumed administrative control of the province. During the following months, more than 200 relief organisations implemented humanitarian assistance programmes in the food aid, healthcare, water and sanitation and other sectors. The prevalence of psychological morbidity was high among both the Kosovar Albanian and the Serb communities—the latter being subject to reprisal attacks (Lopes Cardozo et al., 2000; Salama and Spiegel, 2000). Relief workers were directly exposed to the violence and worked with both of these traumatised peoples, often in a mediating capacity. In June 2000, the US-based Centers for Disease Control and Pre-vention (CDC) carried out a mental health survey among expatriate and Kosovar Albanian humanitarian aid workers in Pristina, Kosovo, to identify specific risk factors for psychological morbidity among humanitarian aid workers.

MethodsStudy design and study populationWe conducted a cross-sectional survey of all expatriate staff and a sample of national staff from selected organisations in Kosovo. Organisations were included if they provided health, water and sanitation, or nutrition and food security services. All 21 non-govern-mental organisations (NGOs) and one inter-governmental agency meeting these criteria agreed to participate, and provided a list of names of all 434 expatriates and some 3,000 Kosovar Albanian staff members on request. Because the prevalence of mental illness among relief workers is unknown, we conservatively erred towards a 50% prevalence for mental health outcomes with 95% confidence limits and five percent precision. Given these assumptions, a sample size of 278 was required. Allowing for a non-response rate of

Barbara Lopes Cardozo et al.154 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 155

30%, our objective was to sample around 400 in each stratum. We decided to sample all 434 expatriates and a systematic random sample of one in seven (435) Kosovar Albanians. Twenty-four expatriate relief workers were no longer working for their organisation. Of the remaining 410 expatriates, 285 (69.5%) participated in the survey. Response rates varied by organisation from 45% to 100%, and were greater than 70% for 16 of the 22 organisations. Although data on the 125 non-responders were incomplete, 51 (68.0%) of the 75 non-responders were men, a higher proportion than for participants (proportion: 49.1%; Pearson’s chi-square d=8.44 on 1 df, p=0.004). The mean age of non-responders was 35.4 years (standard deviation (SD): 8.4), and did not differ significantly from respond-ents (mean age: 36.3 years (SD: 9.4) (t=-0.10 on 408 df, p=0.53). In addition, 39 (53.5%) of 73 non-responders were in a managerial or administrative position, a lower proportion than for participants (proportion: 67.1%; Pearson’s chi-square d=4.79 on 1 df, p=0.029). Six Kosovar Albanian relief workers were no longer working for their organisation. Of the 429 remaining staff, 325 (75.8%) participated in the survey. Response rates for national staff varied by organisation from 14.3% to 100%, and were greater than 70% for 17 of the 22 organisations. Although data on the 104 non-responders were incomplete, 47 (77.1%) of the 61 non-responders were men, a similar proportion to participants (Chi-square: 1.07, p=0.3). The mean age of non-responders was 30.2 years (SD: 8.8) and also did not differ significantly from participants (Chi-square: 1.48, p=0.22). However, only nine (20.9%) of the 43 non-responders were in managerial or administrative positions, which was significantly different from participants (proportion in managerial or administrative positions: 35.5%; chi-square: 6.69, p=0.01). The survey of expatriate staff was conducted in English; as Kosovar Albanians made up around 99% of national staff, the survey of national staff was carried out in the Kosovar Albanian language—Serbian staff and personnel from other ethnic minority groups were excluded from the sampling frame. For the survey of Kosovar Albanians, the questionnaire was translated into Albanian and then back into English by two bilin-gual Albanian physicians to verify accuracy. Minor idiomatic adjustments were made to ensure that the direct translation made sense in the Albanian language. A contact person within each organisation distributed questionnaires. Names of individuals and organisations were not recorded on the questionnaire and participation was voluntary and confidential. Questionnaires were numbered so that the survey coor-dinators who held the code could identify non-responders and send out reminders. Questionnaires were collected from contact persons seven, ten and 14 days after distribution. The Human Subjects Review Committee at the CDC examined the study protocol and determined that it was exempt from further ethical review.

InstrumentsAll instruments used in this survey were self-report questionnaires. We used one question-naire to collect demographic and occupational data and three standard psychological screening tools: the Harvard Trauma Questionnaire (HTQ); the Hopkins Symptom Checklist-25 (HSCL-25); and the General Health Questionnaire (GHQ-28). The out-

Barbara Lopes Cardozo et al.154 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 155

comes measures were: PTSD, as assessed by the HTQ; depression, as assessed by the HSCL-25; non-specific psychiatric morbidity (NSPM), as assessed by the GHQ-28; and hazardous alcohol consumption. The latter was defined, using a modified inter-national standard (Rankin and Ashley, 1992), as consumption of three or more standard alcoholic drinks per day before and during the assignment in Kosovo. The HTQ combines the measurement of trauma events and symptoms of PTSD derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (Mollica et al., 1992). The trauma events chosen for the HTQ were derived from published literature on rescue workers and the military (Fullerton et al., 1992; Sutker et al., 1994), a previous survey of Kosovar Albanians (Lopes Cardozo et al., 2000), and our own experiences as relief workers. Since we wanted to collect information on the experiences of relief workers during previous missions in other countries, we asked them to list trauma events that they had experienced while performing relief work over the past five years. The timeframe for current PTSD symptoms was one week. PTSD was defined using a scoring algorithm proposed by the Harvard Refugee Trauma Group (Mollica et al., 1992). The HSCL-25 comprises a ten-item subscale for anxiety and a 15-item subscale for depression (Derogatis and Lipman, 1974). Each item is given a score of between one and four. Mean scores greater than 1.75 for either subscale are associated with elevated clinical symptoms of anxiety or depression that may require treatment. Particularly for the depression subscale, scores for an individual are stable when the instrument is administered at repeat visits within a short time period (Winokur et al., 1984). The timeframe for the HSCL-25 symptoms was one week. The GHQ-28 is a community screening tool for detecting NSPM and has four subscales—somatisation, anxiety, social dysfunction and depression—each of which is given a score between zero and seven; the total score range is zero to 28 (Goldberg and Hillier, 1979). The HTQ, the HSCL-25 and the GHQ-28 have been validated in many cross-cultural settings (Sartorius et al., 1993; Mollica et al., 1987; Jablensky et al., 1981). Since no cut-off score to define NSPM has been developed for broad international use, we used a score of nine, which is the highest cut-off found in community studies in 15 countries (Goldberg, 1986; Goldberg et al., 1997; Furukawa and Goldberg, 1999). The reliability of each instrument was assessed using Cronbach’s coefficient alpha. For the GHQ-28, α=0.83; for the HTQ, α=0.82; for HSCL-25 anxiety, α=0.84; and for HSCL-25 depression, α=0.88. All alpha coefficients are very high, indicating consistent responses within each survey instrument, as well as high internal reliability of the survey instruments, when measuring the respondents in this study. In addition to demographic information, we also gathered occupational data on the number of previous missions in complex humanitarian emergencies. We also collected data on staff support services provided by aid organisations, including stress management training prior to deployment, psychological counselling services while on mission and psychological debriefing after deployment. Certain questions, such as the adequacy of communication with family members at home, or the definition of prolonged separation from family, demanded subjective responses. The average daily consumption of standard

Barbara Lopes Cardozo et al.156 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 157

alcoholic beverages before and during assignments in Kosovo was recorded in this demographic section. Specifically, participants were asked: ‘on average how many standard drinks of alcohol did you drink per day prior to working for your humanitarian organi-zation in Kosovo?’; and ‘on average how many standard drinks of alcohol do you drink per day working in Kosovo now?’

AnalysisWe performed the analysis using Epi Info version 6.04b (28), SAS version 8.0 and SUDAAN version 7.5.4A. The organisation support variables were categorised into an aggregate variable using a scale from ‘poor’, if none of the three supports were available, to ‘good’, if one or two were available, to ‘excellent’, if all three were available. All original variables were treated with equal weight in the derived variable. We used regression analysis to gauge the effect of demographic and exposure variables on mental health outcomes (depression, NSPM and PTSD for Kosovar Albanian staff only); because PTSD prevalence was low among expatriates and alcohol consumption was low among Kosovar Albanians, it was not possible to perform these analyses for these strata. Our first regression analysis assessed the effect of nine demographic and occupational variables on the two relevant mental health outcomes for each stratum, controlling for all other demographic variables, and the mean number of trauma events experienced or witnessed. In the second regression analysis, we appraised individually the effect of selected trauma exposures on the relevant mental health outcomes for each stratum, controlling for all nine demographic and occupational variables listed in table 1. The statistics in the regression analyses have been adjusted for the survey design and weighted to account for the relative over-sampling of the expatriate population and non-response. Trauma exposures in the regression analysis were chosen that were: (1) significantly associated with outcomes found in univariate analysis; (2) highly traumatic or found to be associated with negative mental health outcomes in studies of military or rescue workers; or (3) reported relatively frequently by respondents in our study. Multivariate linear regression was used to evaluate the effect of demographic, occupational and exposure variables on continuous outcome variables like total GHQ score. Multivariate logistic regression was used for the dichotomous variables, depression and hazardous alcohol consumption. We performed statistical comparisons using Wald F tests from multivariate linear regression for continuous variables and Wald chi-squared tests from multivariate logistic regression for dichotomous variables. A p value less than 0.05 was considered statistically significant. Only limited information on non-responders was available. We compared the results for expatriates with those for Kosovar Albanians. In the regression analyses, relief workers were categorised as expatriate or Kosovar Albanian, and the type of relief worker was included in the analysis as an independent variable. Results were then adjusted for demographic variables and the number of trauma events experienced and witnessed. Finally, we compared results for this survey of Kosovar Albanian relief workers with those from a previous household survey conducted in Kosovo

Barbara Lopes Cardozo et al.156 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 157

Table 1 Demographic and occupational characteristics of expatriate and Kosovar

Albanian humanitarian aid workersa

Demographic characteristic Expatriate staff Kosovar Albanian

staff

No. %b No. %c χ2 (df=)d

Sex

Male

Female

136

141

49.1

50.9

220

92

70.5

29.5

50.44 (1)***

Age

16–29 years

30–39 years

40 or more years

69

122

83

25.2

44.5

30.3

148

84

57

51.2

29.1

19.7

66.78 (1)***

Marital status

Single/separated/divorced/widowed

Married/in a relationship

154

126

55.0

45.0

112

205

35.3

64.7

40.68 (1)***

Highest education level

University degree

Primary or high school

243

40

85.9

14.1

184

138

57.1

42.9

99.42 (1)***

Employment type

Managerial/administration

Technical—health, water, logistics, other

190

93

67.1

32.9

114

207

35.5

64.5

110.07

(1)***

Previous psychiatric history

Major psychiatric illness

No major psychiatric illness

26

250

9.4

90.6

22

297

6.9

93.1

2.22 (1)

Number of previous missions

0

1

2–4

5 or more

108

61

77

34

38.6

21.8

27.5

12.1

241

52

24

4

75.1

16.2

7.5

1.2

231.50

(3)***

Organizational support practices

0 of 3 policies

1–2 of 3 policies

3 policies

178

65

42

62.5

22.8

14.7

256

44

13

81.8

14.1

4.2

64.40 (2)***

Communication with family

Adequate

Not adequate

154

131

54.0

46.0

219

93

70.2

29.8

28.97 (1)***

Notes: a. The statistics have been adjusted for the survey design and weighted to account for the relative over-sampling of the

expatriate population and non-response; b. Unknown category accounted for between 0% and 3.9% of responses; c. Unknown

category accounted for between 0.9% and 4.0% of responses, with the exception of the age category where 11.1% of data

was missing; d. χ2 (df=) Chi-square (degrees of freedom =); *** p< 0.001.

Barbara Lopes Cardozo et al.158 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 159

(Lopes Cardozo et al., 2000). In this comparison, we adjusted for differences in study design and for age, sex and mean number of trauma events experienced.

ResultsThe demographic and occupational characteristics of participants are described in table 1. Approximately 50% of expatriate participants were women, 45% were married or in a relationship, 27% had children, and the majority (85.9%) had a university degree. Of 281 expatriates with nationality data, 154 (54.8%) came from Australia, Canada, New Zealand, the Republic of Ireland, the UK or the US, and another 75 (26.8%) came from other countries in Europe. Thirty-nine percent of expatriates were on their first humanitarian assignment. Only eight percent of respondents had served in their current position in Kosovo for more than 12 months, and 50% had held their current post for six months or less. Of 271 expatriates, 167 (61.6%) had worked in the humanitarian sector for less than two years and 54 (19.9%) had worked in the humanitarian sector for five or more years. The organisational support services available were characterised as poor for the majority of participants, and communication with family was reported as inadequate by 46%. The demographic profile of Kosovar Albanian relief workers was significantly different to that of expatriate relief workers, with the exception of previous psychiatric history. The mean age of the respondents was 31.5 years (SD: 8.5); more than two-thirds was male, almost two-thirds was married, and 158 (48.6%) had children. Most were on their first mission with an aid organisation, and most reported poor organisational support practices. The majority reported adequate communications with family at home. A large proportion of expatriate and national staff reported experiencing major trauma events (table 2). The mean number of trauma events experienced by expatriates was 2.8 (SD: 2.7) and by Kosovar staff 3.2 (S.D 2.8); 59 (20.7%) expatriates and 47 (15.6%) Kosovar staff members had not experienced trauma events, 115 (40.4%) expatriates and 142 (47%) Kosovar staff members experienced between one and three, and 105 (36.8%) expatriates and 113 (37.4%) Kosovar staff members experienced four or more. More than ten percent of expatriates and more than 20% of Kosovar Albanian personnel reported experiencing major trauma events, including sniper fire, verbal or physical threats to their lives, the bombing of a residence or workplace, forced separation from family and handling of dead bodies. Of the 105 expatriates who experienced four or more trauma events, three showed symptoms of PTSD; of the 174 expatriates who experienced between zero and three trauma events, none showed symptoms of PTSD. Subsequent analysis revealed that Kosovar Albanian staff members who experienced more trauma events had higher prevalence rates of PTSD. Of the 174 Kosovar staff members who experienced between zero and three trauma events, five had symptoms of PTSD; of the 128 national staff members who experienced four or more trauma events, 14 showed symptoms of PTSD (p=0.0049) Results for mental health outcomes and alcohol use among expatriates and Kosovar Albanian staff are summarised in table 3. The table shows the mean scores for the GHQ-28.

Barbara Lopes Cardozo et al.158 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 159

Table 2 Number and proportion of expatriate humanitarian aid workers who experienced selected trauma events over the past five yearsa

Trauma event Expatriate staff Kosovar Albanian staff

No. %b No. %c χ2 (df=1)

Situation that was very frightening 159 55.8 207 63.7 6.67**

Murder of a co-worker 20 7.0 20 6.2 0.31

Murder of a friend or family member 16 5.6 39 12.0 11.48***

Life in danger 95 33.3 64 19.7 26.41***

Being taken hostage 18 6.3 17 5.2 0.57

Armed attack or robbery 56 19.6 50 15.4 3.31

Bombing of workplace or residence 42 14.7 124 38.2 68.33***

Sniper shots 68 23.9 63 19.4 3.08

Landmine 12 4.2 7 2.2 3.96*

Rape/sexual violence 5 1.8 2 0.6 3.44

Verbal or physical threats against your life 100 35.1 111 34.2 0.10

Handling dead bodies 73 25.6 69 21.2 2.78

Hostility of local population 106 37.2 51 15.7 71.43***

Feeling close to death 37 13.0 132 40.6 95.26***

Participation in fighting by self or family member 9 3.2 82 25.2 87.46***

Torture 3 1.1 42 12.9 43.65***

Imprisonment 8 2.8 25 7.7 10.43***

Notes: a. The statistics have been adjusted for the survey design and weighted to account for the relative over-sampling of the expatriate population and non-response; b. Unknown category accounted for between 1.8% and 3.5% of responses; c. Unknown category accounted for between 5.2% and 12.3% of responses; * p < .05; ** p < 0.1; *** p < .001.

However, the distribution of the total GHQ score in this study was bipolar; 68 (23.9%) expatriate relief workers had total scores greater than nine, and 37 (11.5%) Kosovar Albanian staff members had total GHQ scores greater than eight. Forty-six of 284 expatriate staff (16.2%) reported drinking alcohol at hazardous levels. Hazardous alcohol consumption was reportedly uncommon among Kosovar Albanian personnel: 260 respondents (81.8%) reported not drinking alcohol.

Barbara Lopes Cardozo et al.160 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 161

Results of multivariate analysis for the effects of demographic and occupational variables on mental health outcomes are shown in table 4. Younger expatriates had substantially more depression and worse NSPM than older expatriates. Among Kosovar Albanian staff, women and older Kosovar personnel had substantially more depression and worse NSPM than men and younger staff respectively. Expatriates and Kosovar Albanian staff with a history of psychiatric illness were more likely to have depression and had higher total GHQ scores than those without this history. Expatriates who reported poor or good organisational support were significantly more likely to be depressed and had higher total GHQ scores than those reporting excellent support. NSPM was worse among expatriates reporting an inadequate ability to communicate with family. National personnel reporting inadequate communication with family members were more likely to be depressed than those reporting adequate communication. The association between depression and adequacy of communications was not statistically significant for expatriates, despite elevated odds ratios. The risk of depression was relatively high for those expatriates on their first assignment; it decreased with the next assignment and increased to peak with five or more assignments. Consistent with the adjusted odds ratio (AOR) for depression, the adjusted total GHQ score was relatively high for the first assignment, less for the next assignment and then gradually increased to peak for five or more assignments. The latter score, however, was not statistically significant.

Table 3 Mean scores for GHQ-28, and prevalence rates of PTSD, depression and alcohol consumptiona

Scale Expatriates(n=284)

Kosovar Albanians(n=321)

Mean SEb Mean SEb

GHQ-28a Total (0–28) 5.14 0.18 3.31 0.23

Prevalence

% SEb (%) % SEb (%)

PTSD Harvard algorithm 1.05 0.35 6.15 1.26

Depression Mean score >1.75 17.19 1.31 16.92 1.97

Anxiety Mean score >1.75 8.77 0.98 14.46 1.85

Alcohol 0 drinks1–2 drinks3–5 drinks>5 drinks

38.7345.0715.141.06

1.701.731.250.36

81.7615.72 2.52 0.00

2.051.930.830.00

Notes: a. The statistics have been adjusted for the survey design and weighted to account for the relative over-sampling of the expatriate population and non-response, but are not adjusted for demographic variables; b. Standard error.

Barbara Lopes Cardozo et al.160 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 161

Table 4 Effect of demographic variables on mental health outcomes among expatriate

and Kosovar Albanian staff a, b, c

Expatriates Depression (HSCL-25) n=245

Kosovar Albanians Depression (HSCL-25) n=229

Expatriates NSPM (total GHQ-28 score) n=245

AOR d (CI) χ2 AOR d (CI) χ2 Adjusted means (SE)

F Adjusted means (SE)

F

SexFemaleMale

1.0 (0.6–1.6)Referent

0.02 3.5 (1.5–8.6)Referent

7.81** 5.6 (0.27) 4.8 (0.25)

4.18* 8.9 (0.99)7.7 (0.93)

5.11**

Age16–29 30–39 40+

5.7 (2.5–12.6)3.5 (1.7–7.5)Referent

18.02***0.3 (0.1–0.8)0.4 (0.1–1.0)Referent

6.49*5.5 (0.34)5.9 (0.26) 3.8 (0.36)

10.79***7.7 (1.02)7.6 (0.99) 9.7 (0.99)

4.87**

Psychiatric historyYes No

3.2 (1.8–5.9)Referent

14.75*** 8.3 (3.0–22.5)Referent

17.18*** 7.7 (0.61)4.9 (0.18)

18.31*** 11.0 (1.19)5.6 (0.84)

12.59**

Number of previous missions5+ 2–4 1 0

5.1 (2.7–9.7)0.7 (0.4–1.2)0.7 (0.4–1.3)Referent

40.96*** 3.6 (0.1–91.3) c

0.9 (0.3–289)1.1 (0.4–3.4)Referent

0.436.3 (0.56)4.8 (0.35)4.2 (0.34)5.7 (0.29)

6.11***13.8 (2.77) 6.5 (1.00)6.5 (0.82)6.4 (0.66)

2.72*

Organisational supportPoor Good Excellent

10.8 (4.62-5.6)7.2 (2.5–20.2)Referent

32.09***

1.5 (0.1–16.2)1.9 (0.2–21.7)Referent

0.395.5 (0.24)5.0 (0.32)4.0 (0.34)

7.15***8.31 (0.88)7.29 (0.99)9.36 (1.40)

2.61

CommunicationsInadequate Adequate

1.5 (0.9–2.4)Referent

2.82 2.3 (1.1–4.9)Referent

4.36* 6.6 (0.27)3.9 (0.23)

50.53*** 8.85 (0.99)7.80 (0.91)

3.54

Notes: a. Adjusted for all other demographic variables and number of trauma events experienced and witnessed. The statistics have been adjusted for the survey design and weighted to account for the relative over-sampling of the expatriate population and non-response. The Chi-squared statistic is a Wald statistic from multivariate logistic regression and the F-statistics are Wald statistics from multivariate linear regression; b. Marital status, educational level and type of employment not shown in this table; c. Not a stable estimate; d. Adjusted Odds Ratio; * p < .05; ** p < 0.1.; *** p < .001.

Kosovar Albanians NSPM (total GHQ-28 score) n=229

Male Kosovar Albanian relief workers, 40 years of age or older, and with a previous psychiatric history, were more likely to have PTSD than those without such a history (p=0.04, p=0.006 and p<0.0001 respectively). Table 5 provides a comparison of mental health outcomes of expatriate and Kosovar Albanian staff. Total GHQ scores were not significantly different between the two

Barbara Lopes Cardozo et al.162 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 163

groups. Kosovar Albanian relief workers, though, had statistically significantly higher rates for PTSD, depression and anxiety and lower rates for alcohol abuse compared to expatriate aid workers. Regression analysis for the effect of trauma exposures on mental health outcomes demonstrated that, for expatriate and Kosovar Albanian relief workers, the number of trauma events experienced and the specific trauma events of sniper fire, threats to life and separation from family was significantly related to depression (table 6). There was a significant rise in depression with an increasing number of trauma events. For expatriates only, threats to life, separation from family and handling of dead bodies were associated with higher rates of NSPM. The mean number of trauma events witnessed was significantly linked with alcohol consumption; those witnessing more events were more likely to be consuming alcohol at hazardous levels. For Kosovar Albanian staff only, sniper fire, threats to life or separation from family were significantly associated with NSPM. In addition, PTSD was connected with experi-encing the murder of a family member or friend, separation from family or handling dead bodies. In a previous survey of the general community in Kosovo, PTSD prevalence was 17.1%, and the mean total GHQ score was 11.1 (Lopes Cardozo et al., 2000). After adjusting for age, sex and mean number of trauma events experienced, Kosovar Albanian relief workers

Table 5 Comparison of mental health outcomes of expatriate and Kosovar Albanian staffa

Mental healthstatus measure

Expatriate Kosovar Albanians

Adjusted mean

Adjusted SE Adjusted mean

Adjusted SE Test statistic

GHQ-28 4.19 0.35 3.67 0.24 F=1.22

Adjusted prevalence

Adjusted % Adjusted SE (%)

Adjusted % Adjusted SE (%)

Test statistic

PTSDb 1.05 0.35 6.15 1.26 χ2=6.67**

Depression 12.83 2.41 21.59 2.58 χ2=5.24*

Anxiety 7.00 1.45 16.38 2.32 χ2=11.52***

Alcoholc 12.67 2.88 1.87 0.93 χ2=11.14***

Notes: a. The statistics have been adjusted for the survey design and weighted to account for the relative over-sampling of the expatriate population and non-response. They are also adjusted for all demographic variables and the number of trauma events experienced and witnessed. The Chi-squared statistics are Wald statistics from multivariate logistic regression and the F-statistics are Wald statistics from multivariate linear regression. All statistics are based on 474 observations (245 expatriates and 229 Kosovar Albanians); b. Not adjusted for number of previous missions due to empty cells; c. In logistic regression analysis, this outcome was coded as 1 if the number of drinks was greater than 2, and 0 if the number of drinks was less than or equal to 2; * p < .05; ** p < 0.01; *** p < .001.

Barbara Lopes Cardozo et al.162 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 163

were found to be less likely to suffer PTSD than a general community sample of Kosovar Albanians in Kosovo (AOR: 0.56, 95% Confidence Interval (CI) 0.32–0.97, p=0.04). NSPM was also less among Kosovar Albanian relief workers than the general commu-nity; the adjusted total score was 3.5 (standard error (SE): 0.2) for relief workers and 11.1 (SE: 0.5) for the community sample (t statistic: 13.15, p<0.001).

DiscussionOur study demonstrates that relief workers are exposed to numerous stressors and traumatic events often without adequate support structures. Trauma events associated with depression were either related to bodily harm, such as sniper fire or verbal and physical threats to life, or to lack of social support, including separation from family. The importance of social factors (Mollica et al., 1987; Ursano, et al. 1995) like separation from family in the pathogenesis of depression is again underscored by our findings. Sniper fire and verbal or physical threats were experienced frequently by both expatriate and Kosovar Albanian relief workers and may represent important risk factors for psycho-logical morbidity among aid workers in general. The highly significant relationship between NSPM and inability to communicate with family members shows that better access to communications, to contact family, may prevent some of the psychological con-sequences of relief work. Some specific trauma events may be more likely to be connected with the development of PTSD (McCarroll et al., 1993; Ursano et al., 1995; Ursano and McCarroll, 1990; McCarroll, et al., 1996), whereas other events may be more closely linked with the development of other mental health outcomes. PTSD was related to highly traumatic events, such as the murder of a family member or friend or the handling of dead bodies (Ursano et al., 1990). The murder or unnatural death of relatives or friends is a well-documented risk factor for PTSD in populations affected by war and for disaster workers (Lopes Cardozo et al., 2000; Ursano et al., 1999). In our study, however, depression and NSPM were not associated with this specific trauma event but were associated with events like separation from family, verbal and physical threats to life and sniper fire. Occupational factors may be less important risk factors for psychological morbidity among Kosovar Albanian relief workers than among expatriates. Most Kosovar Albanian relief workers did not have access to any of the organisational supports described, but this was not associated with adverse mental health outcomes. Access to regular social supports, including immediate and extended family and friends, was probably far better for Kosovar Albanian relief workers than for expatriates and may have been a much more important mediating factor than organisational support for this group. Perhaps confirming the significance of social factors in the aetiology of psychological morbidity, inadequate communication with family members and friends was associated with poorer mental health outcomes among Kosovar Albanian relief workers. The prevalence of PTSD among expatriate relief workers was much lower than among returned international relief and development personnel from five humanitarian agencies (Eriksson et al, 2001), war veterans ( Kulka et al., 1990), rescue workers (McFarlane, 1988),

Barbara Lopes Cardozo et al.164 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 165

Table 6 Effect of exposures on mental health outcome among expatriate and Kosovar Albanian relief workersa

Expatriates

Depression

(HSCL-25)

AOR (CI)

χ2 Kosovar

Depression

(HSCL-25)

AOR (CI)

χ2 Expatriates

Adjusted

total mean

GHQ score

(SE)

F Kosovar

Adjusted

total

mean

GHQ score

(SE)

F

Mean number of

trauma events

experienced

1=4+

2=1–3

3=0

5.3 (2.5–11.2)

2.6 (1.2–5.4)

Referent

21.55***

12.1 (2.3–66.7)

4.2 (0.8–23.0)

Referent

12.86** 5.5 (0.31)

5.3 (0.26)

4.4 (0.36)

2.89* 4.7 (0.42)

3.0 (0.29)

1.7 (0.36)

16.22***

Sniper fire

0=experienced

1=not

2.6 (1.6–4.2)

Referent

14.07*** 3.9 (1.8–8.5)

Referent

12.11*** 5.2 (0.38)

5.2 (0.20)

<0.01 5.6 (0.66)

3.0 (0.22)

13.37***

Threats to life

0=experienced

1=not

3.1 (2.2–4.7)

Referent

27.52*** 3.1 (1.5–6.5)

Referent

9.08** 6.0 (0.31)

4.8 (0.21)

8.99** 5.5 (0.50)

2.6 (0.21)

28.43***

Murder of family

member/friend

0=experienced

1=not

1.9 (0.9–4.1)

Referent

2.52 1.9 (0.7–5.1)

Referent

1.74 5.2 (0.87)

5.2 (0.17)

<0.01 3.4 (0.71)

3.6 (0.25)

0.03

Separation

from family

0=experienced

1=not

4.5 (2.5–8.1)

Referent

25.77*** 2.5 (1.2–5.4)

Referent

6.00** 6.8 (0.62)

5.0 (0.18)

7.82** 5.3 (0.59)

3.0 (0.24)

12.57***

Handling

dead bodies

0=experienced

1=not

0.52 (0.3–0.9)

Referent

5.47** 2.2 (0.9–5.2)

Referent

3.00 3.9 (0.31)

5.6 (0.20)

21.89*** 4.3 (0.59)

3.4 (0.26)

1.83

Notes: a. Adjusted for all demographic variables; * p < .05; ** p < 0.01; *** p < .001.

human rights workers (Holtz et al., 2000) or war-affected populations (Mollica et al., 1987). Given the strong relationship between trauma exposure and PTSD (McCarroll et al., 1997; Mollica et al., 1987; Mollica et al., 1998; McFarlane and Papay, 1992), and the intensity of the trauma events reported by relief workers in Kosovo, the low prevalence of PTSD is surprising. The first possible explanation may be selection bias; those suffering PTSD tend to abandon relief work and would not have been available for our survey. It is also possible that those with PTSD chose not to respond to the survey. Those able to continue working may represent a self-selected group of healthy or resilient individuals

Barbara Lopes Cardozo et al.164 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 165

who are still able to fulfil their professional responsibilities. Second, recent studies have demonstrated that disaster workers who identify with victims are more likely to suffer from PTSD than those who do not (Ursano et al., 1999). Due to ethnic and cultural differences, expatriate relief workers may identify less with victims than national relief workers do. Third, the course of PTSD is variable and the reporting of PTSD is inconsistent (North et al., 1997). The prevalence of PTSD symptoms may decrease over time (Green et al., 1990), and if symptoms were transitory among relief workers, rather than chronic and persistent, PTSD would not have been captured by our cross-sectional survey carried out in Kosovo one year after the height of the fighting. Kosovar Albanian relief workers had significantly higher rates of PTSD than their expatriate counterparts. Kosovar Albanian relief workers were members of the Kosovar Albanian community, which had been subject to military aggression for more than ten years, and hence much of their trauma experience may have predated their association with aid organisations. However, identification with victims has been linked with a higher risk of PTSD among disaster workers (Ursano et al., 1999). In view of their shared culture and experiences, Kosovar Albanian relief workers would be expected to identify much more closely than their expatriate counterparts with the Kosovar Albanian victims of the recent conflict in Kosovo, and this may also explain their higher prevalence of PTSD. Given the high reported frequency and severity of trauma events suffered by Kosovar Albanian relief workers, though, the prevalence of PTSD was still unexpectedly low and significantly less than that found in a 2000 population-based sample of Kosovar Albanians (Lopes Cardozo et al., 2000). PTSD prevalence rates were significantly lower among Kosovar Albanian relief workers than the general Kosovar Albanian community, even after adjusting for age and sex differences, suggesting that true differences exist in PTSD prevalence rates between the two groups. Kosovar Albanian relief workers are a highly educated subset of the Kosovar Albanian community, who may have access to substantially more coping strategies than members of the general community, and this may decrease their likelihood of suffering psychological morbidity. Prevalence rates for depression were elevated in comparison to 12-month prevalence rates for US adults (Kessler et al., 2003). Although the community prevalence rates for depression in Kosovo are not known, prevalence rates for depression among Kosovar relief workers were significantly higher than those found among expatriate relief workers in Kosovo. In this study, total GHQ scores, a measure of NSPM, were similar to those reported in community-based surveys in a number of developed countries (Goldberg et al., 1997). NSPM rose with the increasing number of trauma events experienced and was highest for those individuals on their first mission and for those who had been involved in five or more previous missions. A large proportion of expatriate relief workers are ‘volunteers’ who may be at particular risk if they are poorly trained or have very high expectations of effectiveness. Career relief workers may also be at greater risk of psycho-logical morbidity because of cumulative traumatic experiences. NSPM, however, was less severe for Kosovar Albanian relief workers than for expatriates, perhaps reflecting the better social supports available to this group than to expatriates whose families and

Barbara Lopes Cardozo et al.166 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 167

friends were generally not in-country. Although no specific GHQ cut-off scores for the definition of NSPM have been validated for use in Kosovo, mean total scores for national relief workers were also much lower than those in the general population in Kosovo in 1999 (Lopes Cardozo et al., 2000) and 2000 (Lopes Cardozo et al., 2003). Using a score of nine—the highest cut-off score found in studies in 15 countries (Goldberg et al., 1997; Furukawa and Goldberg, 1999)—though, the prevalence rate for NSPM was 11.5% among Kosovar Albanian relief workers, indicating that the distribution was bimodal; the majority of relief workers had little or no NSPM but a substantial minority was suffering a high degree of psychological morbidity.

LimitationsThere are a number of limitations to this study that should be taken into account when interpreting these results. First, no clinical interviews were performed to validate these self-report instruments within this population. Although we chose instruments that have been validated in many cross-cultural settings, and although the HTQ and HSCL-25 have been previously validated against clinical diagnoses, the extent to which self-reported symptoms would match diagnoses of PTSD and depression in this population is not known. Moreover, the timeframe for PTSD symptoms in this survey was only one week. Despite the heterogeneous population of expatriate relief workers surveyed, however, more than 80% of expatriates came from countries, predominantly in Europe and North America, for which the instruments used in this survey have been validated. A quantitative survey, by its nature, lacks interpretation and anecdotal information from respondents. But it has the advantage that the results can be quantified, interpreted and compared in more objective ways than would be possible in a qualitative survey. Moreover, many anecdotal reports have described the experiences of aid workers, but to date only one quantitative survey has been conducted of aid workers (Eriksson et al., 2001). Nevertheless, a qualitative component could have generated important information for the paper, but it would have required more time and resources. Second, although response rates were high for a self-report survey, approximately 30% of expatriate relief workers and 24% of Kosovar Albanian staff members chosen to participate did not respond. This may represent an important non-response bias in our study if non-responders differed in such a way from participants that they were more or less likely to have a particular mental health outcome. The data, however, suggest that participants and non-responders did not differ significantly in terms of age and sex. Third, because this survey was cross-sectional, we do not have adequate baseline information about the mental health status or alcohol use of expatriate relief workers prior to deployment. As a result, we do not know if expatriates had these symptoms before starting work or if the nature of the work contributed to the development of symptoms. In addition, factors other than specific trauma events, such as lack of clarity with respect to the assignment, conflicts within a team or general poor morale, could have contributed to psychological morbidity. Similarly, because Kosovar participants came from a population that had suffered widespread trauma, it was not possible to differentiate

Barbara Lopes Cardozo et al.166 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 167

trauma suffered specifically as a consequence of humanitarian work from trauma resulting simply from membership of an ethnic group that was targeted by military and paramilitary forces. Because we have only reported associations, results should thus be interpreted with caution. Fourth, retrospective studies involving recollection of trauma events may be limited by inaccurate recall (Southwick et al., 1997), particularly if those suffering psychological symptoms are more likely to remember trauma events than those who are not suffering such symptoms. Yet, some studies have found recall to be accurate, despite long intervals between the trauma experience and the time of recollection (Wagenaar and Groeneweg, 1990; Henry et al., 1994). Since we did not specifically ask if the trauma events took place in the current employment setting, some exposures may have occurred prior to employment with the humanitarian agency. In war-exposed populations, it is frequently difficult to assign the degree to which symptoms are due to war, civil strife or employment-related experiences. Regardless of the specific origin of the trauma event, psychological morbidity among aid workers is an important occupational health problem that is likely to affect their ability to carry out their duties. Finally, while the specific situation in Kosovo may be described as a complex emer-gency, the situation there was relatively stable by the time of the survey and a large proportion of expatriates had taken up long-term positions. Our results, therefore, may not necessarily be generalisable to relief workers operating in more acute emergencies with ongoing high levels of civilian mortality.

Conclusion Although complex and logistically difficult because of the short-term nature of assign-ments and the high turnover of relief workers, a long-term prospective study is required to answer definitively some of the remaining questions. Additional cross-sectional studies of relief workers in different emergency situations would also contribute to our understanding of their level of psychological morbidity. International aid organisations need to recognise that the important traumatic exposures experienced by their staff have substantial psychological effects. This study may also have implications for the selection of relief workers. Organisations need to be aware that those relief workers with a history of psychiatric illness are more likely to experience psychological morbidity while abroad. They should also routinely enquire about alcohol consumption among potential recruits and target educational messages. Relatively simple interventions, such as improving communication with family members at home and offering psychological support services, may prove quite effective in preventing or alleviating psychological morbidity. Other interventions that improve social support structures for expatriate relief workers, such as peer support networks and enabling spouses and partners to accompany relief workers on assignment, may also be of benefit. International aid organisations clearly need to respond to the burden of psychological morbidity among their national relief workers. As Kosovar Albanian staff

Barbara Lopes Cardozo et al.168 The mental health of expatriate and Kosovar Albanian humanitarian aid workers 169

members are more likely to identify with the victims of the recent conflict in Kosovo, modifying assignments and duties where appropriate may be helpful in alleviating some of the exposure to traumatic stressors. Such interventions may prevent burnout and other psychological morbidity among national and expatriate relief workers, improve work performance and staff retention rates and ultimately result in a more effective humanitarian response.

AcknowledgementsWe would like to thank all of the NGO contact persons for their assistance in coordinating this survey and all of the participants for sparing the time to complete the questionnaire. We would also like to extend our thanks to the members of the field office of the International Rescue Committee in Pristina, Kosovo, particularly Jennifer Syme, for their continuing support of CDC activities in Kosovo. Additionally, we would like to acknowledge Dr Idriz Gerqari of Pristina University Hospital and the staff of Doctors of the World, USA for the logistical support that they provided. This study was made possible by funds from the CDC.

Endnotes1 Barbara Lopes Cardozo MD MPH International Emergency and Refugee Health Branch, National

Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA; Timothy H. Holtz MD MPH International Research and Programs Branch, Division of TB Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, and Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA; Reinhard Kaiser MD MPH Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA, and International Emergency and Refugee Health Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA; Carol A. Gotway PhD Division of Environ-mental Hazards and Health Effects, Centers for Disease Control and Prevention, Atlanta, GA; Frida Ghitis MA International Insights Inc., Decatur, Georgia; Estelle Toomey MSW International Rescue Committee, Pristina, Kosovo; and Peter Salama MBBS MPH (senior author) International Emergency and Refugee Health Branch, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, and Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA.

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