JAMA-2002-Hollifield-611-21

8/7/2019 JAMA-2002-Hollifield-611-21

1/11

REVIEW

Measuring Trauma and Health Statusin RefugeesA Critical ReviewMichael Hollifield, MD

Teddy D. Warner, PhD

Nityamo Lian, DOM, (NM)

Barry Krakow, MD

Janis H. Jenkins, PhDJames Kesler, MD

Jayne Stevenson, MD

Joseph Westermeyer, MD, PhD

. . . in ourcountry we dont have a thing calledbefore war and after war. Since we are bornwe come to the war . . . thats how we are cre-ated. . . . Maybe the person who [made] thosequestionnaires, maybe he didnt know aboutour situation. Maybe he just knows . . . bigcombat or big wars. . . .

A Kurdish Man

ARECENT REPORT BY THE USCommittee for Refugees es-timates there are 14.9 mil-lion refugees and 22 million

internally displaced persons in theworld.1 Most have experienced signifi-cant trauma, including torture,2-4 as evi-denced by prevalence studies in clin-ics and nonrepresentative communitysamples.5-12

Health problems of refugees have alsobeen documented. Clinical researchdemonstratesa high prevalence of post-

traumatic stress and depression symp-toms,6,10,13-15 and community studies us-ingself-rated scales2-4,8,10,16 andstructureddiagnostic interviews9,17-19 have foundwide variation in the prevalence of thesymptoms of posttraumatic stress (4%-86%) and depression (5%-31%). Refu-gees experience multiple symp-toms,4,5,20-26 perhaps due to the many

types of insults experienced,4,6,20,23,24,27,28

yet the significance of these symptomsis not clear since many are not charac-teristic of posttraumatic stress disorder(PTSD),depression,or other defineddis-orders.29-35 A few community studies

Author Affiliations are listed at the end of thisarticle.Corresponding Author and Reprints: Michael Holli-field,MD, Departments of Psychiatry andFamily andCommunity Medicine, University of New MexicoHealth Sciences Center, 2400 Tucker Ave NE, Albu-querque, NM 87131 (e-mail: [email protected]).

Context Refugees experience multiple traumatic events and have significant asso-ciated health problems, but data about refugee trauma and health status are oftenconflicting and difficult to interpret.

Objectives To assess the characteristics of the literature on refugee trauma and health,to identify and evaluate instruments used to measure refugee trauma and health sta-

tus, and to recommend improvements.

Data Sources MEDLINE, PsychInfo, Health and PsychoSocial Instruments, CINAHL,and Cochrane Systematic Reviews (searched through OVID from the inception of eachdatabase to October 2001), and the New Mexico Refugee Project database.

Study Selection Key terms and combination operators wereapplied to identifyEnglish-language publications evaluating measurement of refugee trauma and/or health status.

Data Extraction Information extracted for each article included author; year ofpublication; primary focus; type (empirical, review, or descriptive); and type/nameand properties of instrument(s) included. Articles were excluded from further analysesif they were review or descriptive, were not primarily about refugee health status ortrauma, or were only about infectious diseases. Instruments were then evaluatedaccording to 5 criteria (purpose, construct definition, design, developmental process,reliability and validity) as described in the published literature.

Data Synthesis Of 394 publications identified, 183 were included for further analy-ses of their characteristics; 91 (49.7%) included quantitative data but did not evaluatemeasurement properties of instruments used in refugee research, 78 (42.6%) re-ported on statistical relationships between measures (presuming validity), and 14 (7.7%)were only about statistical properties of instruments. In these 183 publications, 125different instruments were used; of these, 12 were developed in refugee research. Noneof these instruments fully met all 5 evaluation criteria, 3 met 4 criteria, and 5 met only1 of the criteria. Another 8 standard instruments were designed and developed in non-refugee populations but adapted for use in refugee research; of these, 2 met all 5 cri-teria and 6 met 4 criteria.

Conclusions The majority of articles about refugee trauma or health are either de-scriptive or include quantitative data from instruments that have limited or untestedvalidity and reliability in refugees. Primary limitations to accurate measurement in refu-gee research are the lack of theoretical bases to instruments and inattention to usingand reporting sound measurement principles.

JAMA. 2002;288:611-621 www.jama.com

2002 American Medical Association. All rights reserved. (Reprinted) JAMA, August 7, 2002Vol 288, No. 5 611

by guest on April 2, 2011jama.ama-assn.orgDownloaded from
http://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/

8/7/2019 JAMA-2002-Hollifield-611-21

2/11

have shown that unexplained somaticsymptoms are associated with low ac-culturation, hightreatment seeking, psy-chiatric disorders, and self-identifiedmedical problems, but thesestudieshavenot shown objective evidence of medi-cal disorders.3,16,36,37 In addition to psy-chiatric morbidity, refugees have a highprevalence of dental, nutritional, infec-tious, and pediatric illness,38 and theyhave greater self-rated impairment thanthe general population on the MedicalOutcomes Survey SF (short form)-36 or

SF-20,although neither survey hasbeenproven valid or reliable in refugees.4,8,39

Refugees clearly experience mul-tiple stressful events that are associ-atedwith adversehealth outcomes. Fur-thermore, they may have increasedmorbidity, decreased life expectancy,and a vulnerability to medical illnessandpoor healthhabits,as do other trau-matized populations.40-44 However, dataabout refugee trauma and health sta-tus are often conflicting and difficult tointerpret because various methods and

instruments are used for data collec-tion, analyses, and reporting.45 Othermethodological difficultiessuch astranslation and cultural differences,46

and inadequate resources to fully as-sess symptomscomplicate accuratemeasurement.

Under theauspices oftheNew MexicoRefugee Project (NMRP), created to

evaluate and improve the measurementof torture, trauma, and health status inrefugees, a systematic literature reviewand 2 levels of assessment were con-ducted: (1) to assess the characteristicsof the refugee trauma and health litera-ture, and (2) to systematically evaluateinstruments either developed in oradapted for refugee trauma and healthresearch using 5 criteria.

METHODS

Twoprimarysourceswere searched: (1)

onlinedatabasesusingOVIDfromthein-ceptiondateofeachdatabasethroughthefirst week of October 2001; MEDLINEfrom 1966,PsychInfo from1967, HealthandPsychosocialInstrumentsfrom1985,CINAHL from 1982, and CochraneSystematic Reviews from 1991, and (2)the NMRP database of 11487 citations,developed using Endnote (ISIResearch-Soft, Carlsbad, Calif), a commerciallyavailable softwarepackage for literaturearchiving and searching.

The key terms used in the initial

searches are shown in the BOX. Com-bination operators were applied to theprimary source citation results to iden-tify English-language publicationsevaluating (1)refugee health status, (2)refugee trauma, and (3) measurementof trauma or health status in refugees.This method initially yielded 216 and248 citations from the online and

NMRP databases, respectively. Re-moval of duplicates within and be-tween these databases left 181 and 135publications, respectively (FIGURE).Two authors (M.H., N.L.) then re-viewed all papers in the NMRP hard-

copy files, which yielded an addi-tional 78 publications, bringing the totalcitations found by search criteriato 394.

Data were extracted from the 394 ar-ticles (primarily by M.H.), with con-sensus obtained (between M.H. andN.L.) for 22articles, using a form to re-cord author; year of publication;whether the article was primarily aboutrefugees, health status, and/or trauma;if it was empirical, review, or descrip-tive; if it evaluated statistical proper-ties of instrument(s) (ie, reliability, va-lidity, item analyses, factor analyses),

and if so, which ones; and if it de-scribed the development or adapta-tion of instruments. Adaptation of in-strument wasdefined as an instrumentdeveloped in nonrefugee research thatwas used in refugee research to ad-equately testat least onestatistical prop-erty. The extracted data were enteredinto an Excel 2000 database (Micro-soft Corp, Redmond, Wash) for analy-ses. Publications were excluded if theywere reviews or were primarily theo-retical or descriptive, were not primar-

ily about refugee health or trauma, orwere only about infectious diseases.

Instruments that were either devel-oped or adapted and tested in refugeeresearch were then evaluated accord-ing to 5 criteria described by Weath-ers et al47: purpose, construct defini-tion, design, developmental process,and reliability and validity. To meetthese criteria, an article had to clearlystate the purpose of the instrument,what construct was being defined andmeasured, howthe instrument was de-

signed and why, by what methods andwith what rationale it was developed,and report at least one measure of va-lidity and reliability. Others previ-ously have reviewed general instru-ments for assessing trauma and healthstatus48,49; our evaluation focused onlyon instruments either developed oradapted for use in refugee research.

Box. Key Search Terms and Combination Operators

Key Search Terms

Refugee: refugee, asylum seeker, internally displaced, externally displaced, wartrauma, political violence, government oppression, ethnocide, governmental violence,ethnic cleansing, genocide, OR war population.

Trauma: war trauma, torture, human rights abuse, physical trauma, psychologi-cal trauma, OR psychological abuse.Health status: health status, health outcomes, symptoms, syndromes, illness, dis-

ease,psychiatric disorder,psychiatric disease,psychiatric illness, mental illness,physi-cal illness, physical disease, physical disorder, OR impairment.

Measurement: instrument, questionnaire, survey, measurement, assessment, ORpsychometric.

Combination Operators

Refugee trauma: Refugee (all terms) AND Trauma (all terms)Refugee health: Refugee (all terms) AND Health Status (all terms)Final Combination

Refugee Trauma OR Refugee Health AND Measurement (all terms)

TRAUMA AND HEALTH STATUS IN REFUGEES

612 JAMA, August 7, 2002Vol 288, No. 5 (Reprinted) 2002 American Medical Association. All rights reserved.


8/7/2019 JAMA-2002-Hollifield-611-21

3/11

RESULTSReview of Publications for Content

Of the 394 publications identified bysearch criteria for further review, 187were excluded for not meeting inclu-sion criteria (153 were not primarily

about refugees and 34 were nonempiri-cal or were not about trauma or healthstatus measurement) and 24 publica-tions had insufficient data for review(Figure). Thus, 183 articles were fur-ther analyzed. Of these, 178 (97%)wereabout healthstatus(61% mental health,16% physical health, and20% both), and82 (45%) about trauma. Ninety-one(49.7%) articles included quantitativedata but did not evaluate measurementproperties. Seventy-eight (42.6%) ar-ticlesreported on the relationshipof onemeasure to another, written with theas-

sumption that validity was deter-mined, even if the measures used hadnot shown validity. Fourteen articles(7.7%)were only about statistical prop-erties of a measure (ie, reliability, valid-ity, item analyses, factor analyses).

Review of Instruments

In the 183 relevant articles, 125 differ-ent instruments(ie, measurement toolssuch as questionnaires, surveys, and in-terview schedules) were described asbeing used to measure refugee trauma

and/or health status. Only 12 instru-ments were developed specifically in arefugee sample and had sufficient de-tail inat least 1 article to allow for evalu-ation of the measure by the 5 criteria.Forty-one (22%) of the articles used 1of these 12 instruments.TABLE 1 showscharacteristics of these 12 instruments.Four of these 12 instruments measurehealth status (3 of which focusedstrictlyon mental health), 3 measure trauma,4 measure both trauma and health sta-tus, and 1 measures quality of care pro-

vided to refugees. None of these instru-ments fully met all5 evaluation criteria.Three instruments completelymet 4 cri-teria: the Harvard Trauma Question-naire (HTQ),7,50 Vietnamese Depres-sion Scale (VDS),58 and an unnamedscale developed by Bolton60 that as-sesses mental health factors. Oneinstru-ment met 3 criteria, 3 met 2 criteria, and

5 met only 1 of the criteria completely.None of these 12 instruments are pub-lished in the literature evaluated for thisreview, although componentshavebeendescribed and the full instruments maybe availablefrom the instrument devel-opers or authors.

An additional 8 instruments devel-oped in nonrefugee research that havebeen adapted for use in refugees wereidentifiedandevaluated (TABLE 2). Twoof these instruments met all 5 criteria:Hopkins Symptom Checklist-25

(HSCL-25)67-69

andBeck Depression In-ventory.89 Theother 6 instruments met4 of the 5 criteria, but the purpose, con-struct definition, design, and develop-ment criteria were essentially met inWestern, nonrefugee populations, and6 of these instruments did not meetrefugee-specific validity and/or reliabil-ity criteria.

Instruments Developed

in Refugee Research

Developed and Described Trauma

Measures. According to this search ofthe literature, 4 instruments that mea-sure trauma have been developed inrefugee research and are well de-scribed in the literature. The HTQ, de-veloped by Mollica et al,7,50 is a self-report questionnaire with 4 parts. Thepurpose of part 1 is to measure 17 war-related traumaticexperiences. The scale

was conceptualized by expert, consen-sus methods from clinical experience,and designed to allow respondents tocheck as many of 4 responses for eachexperience that apply to them (didnothappen, experienced, witnessed,or heard about). The HTQ manual de-scribes its development, although it isnot clear how items were chosen anddesigned.50 A convenience sampleof 91Southeast Asian patients attending apsychiatric outpatient clinic were ad-ministered the HTQ, 30 of whom were

readministeredthe test a week later.Ex-cellent statistical properties were dem-onstrated: interrater reliability for allevents (=0.93); scale test-retest reli-ability (r=0.89); andinternal scale con-sistency (Cronbach=.90).7 In a sepa-rate study of 30 Asian refugees, full-scale 1-week test-retest reliability wasr=0.62, but test-retest reliability for in-dividual items ranged from poor(r=0.23) to excellent (r=0.90), mean-ing that some items were likely to beanswereddifferentlyon the 2 tests while

others were more stable.

51

TheHTQ,de-veloped by a team with extensive refu-gee experience, was used in 22 of the183 studies in this review. The traumascale is reliable in clinical samples, al-though some items may not be reli-able. It was rationally rather than em-pirically developed from clinical ratherthan community samples, and descrip-

Figure. Results of Literature Search and Instrument Evaluation

394 Articles Identified

181 From Online Databases

135 From New Mexico Refugee Project (NMRP) Database

78 From NMRP Hard Copy Files

183 Articles Eligible (125 Measurement Instruments)

12 Measurement Instruments Developed Specifically in a RefugeeSample With Sufficient Detail in at Least 1 Article for Evaluation

8 Measurement Instruments Designed in Nonrefugee ResearchWith Adequate Testing of at Least 1 Statistical Property inRefugee Research

211 Articles Excluded From This Review

187 Articles Did Not Meet Inclusion Criteria

24 Articles Had Insufficient Data for Review

105 Instruments Excluded From This Review(Not Developed in or Adapted forRefugee Research)

Literature Search




8/7/2019 JAMA-2002-Hollifield-611-21

4/11

tion about the construct and item de-velopment is scant. Thus, the 17-event list may be incomplete or biased,limiting generalizability. For ex-ample, experiences of women, as illus-trated in the work byAllotey52 andBon-

nerjea,

53

are not well represented.Furthermore, the design of multiplepossible responses may confuse the re-spondent and limit reliability and there-fore validity. Finally, validity and reli-ability of the torture item in particularhave not been reported.

The 32-item Resettlement StressorScale (RSS), developed by Clarke et al55

from their experience with Cambo-dian adolescents, was designed to mea-sure stress due to resettlement. In onestudy with 38 adolescents, theRSS scorediscriminated between those who hadpsychiatric illness and those who did

notusing diagnostic interviews, andac-counted for 11.7% of PTSD score vari-ance but did not account for the de-pression score variance.55 The WarTrauma Scale (WTS), alsodeveloped byClarke et al55 from their clinical expe-rience, consists of 42 items in both aninterview and self-report format, mea-suring traumatic experiences inflicted

by the Pol Pot regime. The WTS full-scale score had an adequate internalconsistency (= .74), acceptable inter-rater reliability (=0.88), and ac-counted for 15.4% of PTSD score vari-ance and 6.7% of depression score

variance.

55

Both the RSS and the WTSdemonstrated modest predictive valid-ity of psychiatricdisorder,andthe WTSdemonstrated acceptable reliability.They were developed by experiencedinvestigators using rational rather thanempirical methods. However, it is un-clear from the literature how the itemsfor each scale were constructed, devel-

Table 1. Evaluation of Instruments Developed in Refugee Research*

InstrumentMeasurement

Focus

Evaluation Criteria

InstrumentAvailable inthe Published

LiteraturePurpose

Described

ConstructDefinitionDescribed

DesignDescribed

DevelopmentDescribed

Testing in RefugeesDescribed

Validity Reliability

Harvard TraumaQuestionnaire(parts 1 and 4),Mollica et al,7

1992

Trauma andhealth status

Yes Yes Yes Part Yes Yes No

VietnameseDepression Scale,Kinzie et al,58

1982; Kinzie andManson,72 1987

Health status Yes Yes Yes Yes Yes No No

Unnamed, Bolton,60,61

2001Health status Yes Yes Part Yes Yes Yes No

Resettlement StressorScale, Clarke

et al,55 1993

Trauma Yes Yes Part Part Yes No No

War Trauma Scale,Clarke et al,55

1993

Trauma Yes Yes Part Part Yes Yes No

Unnamed, Beiser andFleming,59 1986

Health status Yes Yes Part Part Yes No No

Post Migration LivingDifficulties Scale,Silove et al,54 1998

Trauma Yes Part Part Part Yes No No

Unnamed, Ekbladet al,62 1999

Health status andquality of life

Yes Part Part Part Yes No No

Unnamed, Weineet al,64 2001

Quality of careprovided

Yes Yes Part No Yes No No

Survivor of TortureAssessmentRecord, VanVelsen et al,14

1996


Yes Part Part Part Yes No No

Unnamed, McCloskeyet al,66 1995


Yes Part Part Part No No No

Unnamed,Cunningham andCunningham,5

1997


Yes Part Part Part No No No

*Part indicates that criterion is only partially met.Published literature evaluated for this review.Focused primarily on mental health assessment.




8/7/2019 JAMA-2002-Hollifield-611-21

5/11

oped, or designed, and they were re-ported in only 1 article.

The Post Migration Living Difficul-ties Scale (PMLD), developed by Siloveet al,9,54 is used to assess current lifestressors of asylum seekers. Each of the

23 items of this administered survey israted on a 5-point scale from no prob-lem to a very serious problem, witha composite score determined.9,54 Itscon-struct,development,anddesignareonlypartially described. Principal compo-nent analysesyielded 5 factors account-ing for 69.8% of the variance of the 23items: refugee determination process;health, welfare, and asylum problems;family concerns; general adaptationstressors; and social and cultural isola-tion.54 These 5 factors were evaluatedamong asylum seekers,refugees,andim-

migrants. Asylum seekers scored higherthan immigrants on all 5 factors, andhigher than refugeeson factors 1, 2, and3. Refugees scored higher than immi-grants on factors 2 and 3.54 Thus, thePMLD is valid in discriminating be-tween these 3 groups, but no other va-lidity or reliability data are published.ThePMLD is an important concept mea-suring life experiences other than war,but its usefulness is limited because ofthe lack of description about its design,development,reliability andvalidity, and

scoring.

No refugee-specific instruments thatassess prewar/conflict or nonwar/conflict trauma-related experiences inrefugees were found. A number of gen-eral measures of lifetime trauma havebeen developed but have not been

adapted or used with refugees.

56

Developedand DescribedHealth Sta-tus Measures. From our review, 2 in-struments measuring health status thathave been developed in refugee re-search are well described in the litera-ture. Part 4 of the self-report HTQ, de-veloped from clinical experience byMollica et al,7 lists 30 symptom items,16generated from the Diagnostic and Sta-tistical Manual of Mental Disorders, Re-vised Third Edition (DSM-III-R) criteriafor PTSD, and 14 which are presum-ably, culture-specific symptoms associ-

ated with PTSD. Possible responses arenot atall, a little, quite a bit, or ex-tremely. In the same conveniencesample of 91 patients described earlier,internal consistency was excellent(=.96),thesymptom prevalence rangedfrom 44% to 92%, and the 1-week itemtest-retest reliability ranged from poor toexcellent(r=0.32-0.85;median, .59).7 Anaverageitem scoreof greater than 2.5waspredictive of a PTSD diagnosis by clini-cal interview (78% sensitive, 65%specific). The purpose, construct defi-

nition, and design of part 4 of the HTQ

is clear. Modest reliability and fair va-lidity in diagnosing PTSD was demon-strated in clinical populations. How-ever, ina communitystudy thesensitivityand specificity of the greater than 2.5cutoffscore indiagnosing PTSD was 16%

and100%, respectively, andthe most ef-ficient score for diagnosis was 1.17(sensitivity/specificity=98%/100%). 57

TheHTQ includesa limitedrange ofpos-sible symptoms, some are not reliable,and their ability to predict impairmenthas not been shown. Finally, as the au-thors discuss,generalizability oftheHTQand the construct validity of PTSD ingeneral and in refugees need furtherstudy.

The VDS, a self-report questionnairedevelopedby Kinzie etal58 to screen Viet-namese refugeesfor depression, was de-

veloped using a well described rational,consensus approach fromextensiveclini-cal experience. Culturally appropriateterms were added to existing Westernsymptoms of depression, and designedwith items on a 3-point Likert scale. Af-ter pilot testing, the final 15-item scalemeasures 3 symptom types: physicalsymptoms associated with depressioninthe West, Western psychological symp-toms of depression, and symptoms un-related to Western concepts. The VDS isvalid in discriminating between refugee

patientswithdepression and those with

Table 2. Evaluation of Instruments Adapted for Use in Refugee Research

InstrumentMeasurement

Focus

Evaluation Criteria

InstrumentAvailable in

the PublishedLiterature*

PurposeDescribed

ConstructDefinitionDescribed

DesignDescribed

DevelopmentDescribed

Testing in RefugeesDescribed

Validity Reliability

Hopkins SymptomChecklist-25

Health status Yes Yes Yes Yes Yes Yes Yes

Beck DepressionInventory

Health status Yes Yes Yes Yes Yes Yes Yes

Impact of Events Scale Health status Yes Yes Yes Yes Yes No Yes

Symptoms Checklist-90 Health status Yes Yes Yes Yes Yes No Yes

Health Opinion Survey Health status Yes Yes Yes Yes No No YesCornell Medical Index Health status Yes Yes Yes Yes No No Yes

Posttraumatic SymptomScale-10


Yes Yes Yes Yes No Yes No

Norbeck Social SupportQuestionnaire

Health status Yes Yes Yes Yes Yes No Yes

*Not necessarily in the literature for this review.Focused primarily on mental health assessment.Factor analysis verified constructs.No formal validity or reliability testing, but the instrument demonstrated stable and nonnormative symptoms.




8/7/2019 JAMA-2002-Hollifield-611-21

6/11

anxiety or schizophrenia, and a cutoffscore of 13 out of a possible 34 pointsdemonstrated 91% sensitivity and 96%specificity for diagnosing DSM-IIIdefined major depression in a commu-nity sample.58 Reliability hasnotbeen re-

ported.Less-Developed Health Status Mea-sures. Two additional refugee health sta-tus measureshave been reported,buttoour knowledge have not been formallynamed, used in other research, or pub-lished. Bolton59 used 3 ethnographicqualitative methods to investigate Rwan-dans perceptions of problems follow-ing the 1994 genocidal conflict and thelocal validity of Western concepts, andto adapt existing measures for local use.Two of the 18 identifiedproblems aboutmental health were further developed.

Guhahamuka (mentaltrauma), a con-cept that emerged after 1994, has 36symptom items while agahinda (deepsadness or grief), an older concept,con-sists of 16 items. Guhahamukaandaga-hinda include all symptoms required forDSM-IVmajor depression andPTSD di-agnoses, which was interpreted as sup-porting content validity of both syn-dromes inRwandans. Agahindawas95%sensitive and 38% specific for depres-sion measured by the published cutoffpoint on the HSCL-25, and its test-

retest reliability wasmodest butaccept-able (r=0.67).60 This instrument is newand its design is not well described.

Beiser and Fleming61 used principalcomponent analysis to identify 4 men-tal health factors (panic, depression, so-matization, and well-being) in South-eastAsian refugees andEuro-Canadiansfrom interviews using 6 existing scalesas sources. The final 52-item adminis-tered instrument demonstrated accept-able internal consistency ( for the 4scales ranged from .72-.91) and valid-

ityby discriminatingbetweenthe 23psy-chiatrically ill and the 30 well respon-dents.59 Refugees and Canadiansscoredsimilarly on all 4 scales. The design anddevelopment of this instrument is notwell described and reliability data werenot reported.

Underdeveloped Potential Instru-ments. Five authors report work with-

out fully discussing the construction ofthe actual instrument (eg, type or num-ber of items,scoring).We include theseworks because the concepts and meth-ods hold promise for refugee research.Ekblad et al62 used a 7-question quali-

tative interview to define and com-pare quality of life (QOL) between 14Iranian refugees and 8 Swedes at a pri-mary health care clinic in Sweden. Theauthors found that 3 of their thematicdomains parallel 3 of 6 domains of theWorld Health Organization quality oflife instrument (social relationships,level of independence, environment),demonstrating a form of validity.63 Ira-nian refugees endorsed more social con-cepts of quality of life than Swedes,demonstrating discriminant validity.While this measure is incomplete, it is

important since QOL is understudiedin refugees45 and is an important com-ponent of overall health and welfare.63

Further development of QOL mea-sures in refugees is needed.

Weine et al64 report on an interviewto investigate importantconcepts of pro-vider (primary care professionals, so-cial service workers, or refugee mentalhealthprofessionals) knowledge,as wellas attitudes toward, and service provi-sion patterns for, Bosnian refugees withPTSD. Theinstrument wasdeveloped by

the authors using rational, consensusmethods. In their study of 30 ran-domly selected providers, primary careprofessionals had less knowledge aboutand provided less service to refugeeswith PTSD than did mental health or so-cial service workers, demonstrating aform of discriminant validity.64 No fur-ther design, development, or metricproperties were reported.

Van Velsen et al14 report the devel-opment of the Survivor of Torture As-sessment Record (STAR), a semistruc-

turedclinicalinterviewthatincorporatesmany instrumentssuch as theHSCL-25andother investigator-chosenitemsto determine 3 scaled scores: trauma(scored0-7), loss of health (scored 0-9),and social losses (scored 0-6). Validitywas shown by the correlation betweenthe trauma and loss-of-health scales(r=0.59), and bythe fact that all 3 scales

distinguished between depressed andnondepressed refugees in London. De-velopment wasnotdescribed further andto ourknowledge reliability hasnotbeenreported. McCloskey et al65 used simi-lar methods to integrate DSM-III-R cri-

teria for PTSD, the Child BehaviorChecklist,66 11 items about political vio-lence, and 3 items about family conflictinto an evaluation of trauma and healthstatus for Mexican and Central Ameri-canwomen andtheir children.65 The au-thors report quantitative data butno sta-tistical testing of these measures. Whilethere are significant limitations to VanVelsens and McCloskeys work, eachdemonstrate the integration of quanti-tative measures into a qualitative clini-cal interview, which can be used to en-hance the validity of measures.

Cunningham and Cunningham5 de-veloped 3 checklists to gather data aboutsymptoms, trauma, and resettlementproblems from case records at a treat-ment program for multinational refu-gees in Australia. Thechecklists were de-veloped from literature aboutsymptomsand trauma inrefugees, and fromthe au-thors experience with resettlement prob-lems. Principal component analysesyielded 6 trauma factors and 6 symp-tom factors, with 2 trauma items ac-counting for 43% ofthe PTSDscore vari-

ance. This research demonstrates theconcept of using factor analyses to de-fine potentially relevant trauma andhealth constructs for refugees, but thechecklists are limited by not being em-piricallydeveloped or testedfortheir sta-tistical properties.

Nonrefugee Instruments Adapted

for and Tested in Refugees

We found 8 instruments developed innonrefugee research that had at least 1statistical property tested in refugee re-

search (Table 2). Two instruments, theHSCL-25 and the Beck Depression In-ventory, met all 5 evaluation criteria.

The HSCL-25,67-69 a self-adminis-tered questionnaire originally de-signed to measure change in 15 anxi-ety and 10 depression symptoms inpsychotherapy,70 has been validated inthe general US population68 and used




8/7/2019 JAMA-2002-Hollifield-611-21

7/11

in many refugee studies. The contentand design on a 4-point severity scaleis acceptable to Indochinese popula-tions, and reviews in the cultural psy-chiatry literature consider the mea-sure valid.71,72 An average-item score

greater than 1.75 indicates clinicallysignificant distress.7 Mollica et al69

tested the HSCL-25 in 3 Indochinesegroups, showingexcellent test-retest re-liability (r=0.89 for total scale; r=0.82for each scale), good validity in pre-dicting diagnosed depression (88%sen-sitivity, 73% specificity) or the pres-ence of any major DSM-III-RdefinedAxis I disorder with either scale or thetotal score (93% sensitive, 76%specific). The greater than1.75 average-item score used as a diagnostic proxyfor anxiety and depression is consis-

tent with community data in general USpopulations.67,68 TheHSCL-25 hasgoodreliability and validity in clinical refu-gee samples, but is limited to symp-toms of anxietyand depression, maynotbe a valid indicator of the full range ofsymptoms in refugees, and its abilitytopredict impairment has not been wellstudied in refugees.

The Impact of Events Scale (IES)73

has been used in 8 of the 183 studiesin this review. The15-item measure has7 intrusion and 8 avoidance items on

3-point descriptive scales measuringin-trusive thoughts and body sensationsand avoidance behaviors after trauma.It is valid and reliable in general popu-lations,74 and itsdevelopment is well de-scribed.The 2 scaleshad satisfactoryin-ternal consistency (=.82 and .74,respectively) and accounted for 41% ofthe variance in IES scores in a study of1787 Croatian and Bosnian chil-dren,75 confirming the 2-scale con-struct, although individual items fit dif-ferently than in the original 20-item

version of the scales. Principal compo-nent analysis suggests a third scale,named numbing, which requires fur-ther validation.75,76 Higher intrusion andtotal scores in children with moretrauma events demonstrated validity, al-though trauma events did not predictavoidance scores. The IES scores alsodistinguish between 3 groups of adult

refugees who have experienced tor-ture, nontorture trauma, and mi-grants who have not experienced wartrauma.10 Neither scale nor item test-retest reliability was reported.

The Symptom Checklist-90 (SCL-

90),

77,78

developed to measure changein psychological symptoms with treat-ment, consists of 10 scalesandhasbeenused in 4 of the 183 studies in this re-view. The SCL-90 depression scale wasvalid in differentiating depressed fromnondepressed Hmong refugees whowere either patients in a psychiatricclinic or who were from a communitysample, and the depression scale cor-related well with the Zung DepressionScale (r=0.67), demonstrating concur-rent validity.79,80 Further, the somati-zation scale correlated well (r=0.40-

0.52) with the somatic concern item ofthe Brief Psychiatric Rating Scale andthe somatic anxiety subscale of theHamilton Anxiety Scales.81 The depres-sion scale of a translated Vietnameseversion of the SCL-90 correlated wellwith the VDS (r=0.81).3 However, wefound no reliability testing of theSCL-90 in refugee research.

Other adapted instruments weretested in singlestudies identified in thisreview. The anxiety and depressionscales from the Health Opinion Survey

(HOS),82

an instrument derived from thegeneral Cornell Medical Index to mea-sure psychophysiological symptoms,were administered at time of interviewto a community sample of 2180 South-east Asian refugees from 3 countries. Afactor analysis demonstrated that anxi-ety and depression were common andhad thesame meaning for all 3 groups.83

Further analyses reported in a subse-quent article demonstrated that a singlefactor resembling the concept of neur-asthenia accounted for 40% of the dis-

tress scores on the HOS.

84

A commu-nity sample of Vietnamese refugeesdemonstrated high and persistent lev-elsof physical and psychological symp-toms on the Cornell Medical Index(CMI),a general health-status question-naire, compared with normative datafrom the United States and Britain.85-87

Neither the HOS nor the CMI have had

validity (vs a standard) or reliabilitytested in refugee samples. The Posttrau-m ati c S y m pto m S cal e- 1 0 , a 1 0 -question surveymeasuring symptomsofPTSD, was found to have excellent in-ternal consistency (=.92) and test-

retest reliability (r=0.89) in Bosnianrefugees, but has not been tested for va-lidity in refugees.88 The Beck Depres-sion Inventory89 demonstrated excel-lent internal consistency (=.93) andexcellent test-retest reliability (r=0.92),and distinguished depressed vs nonde-pressed Hmong refugees against a cli-nician interview (94% sensitivity, 78%specificity), demonstrating validity.79

The Norbeck Social Support Question-naire (NSSQ), which measures dimen-sions of support that demonstrate ex-cellenttest-retestreliabilityand moderate

concurrent validity in Western stud-ies,90 was adapted to study the relation-ship of 3 kinds of support (social net-work size, emotional support, esteemsupport) to health in Namibian refu-gees.The authors foundthat support andcoping style moderated the relation-ship between chronicstress (yearsin ex-ile) and health status (anxiety, physi-cal symptoms, physical signs, andhospitalization in the previous year),demonstrating a form of predictive va-lidity. 91 The NSSQ showed good inter-

nal consistency (=.83), but no fur-ther adaptations or reliability testinghave been conducted among refugees.

COMMENT

Half (n=91) of the 183 articles aboutmeasurement of refugee trauma andhealth evaluated for this review re-ported quantitative data but did not re-port evaluation of association be-tween or statistical properties of theinstruments used. Forty-three percent(n= 78) reported associations be-

tween measures, assuming that valid-ity had already been determined. Inthese 183 articles, 125 different instru-ments were used. However, only 12 in-struments have been developed andtested specifically in refugee research;3 of these met 4 of 5 evaluation crite-ria, but none fully met all 5 criteria rec-ommended for a developed instru-




8/7/2019 JAMA-2002-Hollifield-611-21

8/11

8/7/2019 JAMA-2002-Hollifield-611-21

9/11

methods where data are only obtainedrationally via expert and consensus ap-proaches.1 2 8 , 1 2 9 Qualitative tech-niques, such as in-depth interviews andfocus groups, help identify the range,depth, and meaning of possible re-

sponses in a population,

130-133

and al-low for development of culturally in-formed quantitative measures. Thesenew instruments must then be vali-dated using iterativestatistical and fieldtesting methods. Further, culturally in-formed quantitative instruments mustbe designed to be linguistically and vi-sually acceptable and understandableto various refugee groups.

Testing Statistical Properties: Va-lidity and Reliability. There are manykinds of validity and reliability thatmust be demonstrated for a measure to

be accurate across groups. For ex-ample, the HTQ reports the validity ofthe greater than2.5 average item scorein predicting PTSD, but this was in out-patient psychiatric patients, and thisscore was not corroborated in a com-munity based sample. Nevertheless, thiscutoff scorehas been used in other com-munity samples of refugees, assumingits validity. Data from broad commu-nity sources are important for testingvalidity because demand characteris-tics may bias data from specific popu-

lations, such as clinical samples or re-search volunteers.13 4 For example,refugees who seek asylum may be mo-tivated, even without awareness, to en-dorse high levels of trauma and symp-toms to obtain refugee status or toplease the interviewer.94 Although theHTQ and VDS were developed to beculturally appropriate, they may havelimited validity because they were de-veloped and tested in outpatient psy-chiatry clinics. Validity and generaliz-ability of a measure can only be

estimated by including people who ex-press the full range of events or healthstatus; extrapolation of clinical data torefugees in general would be a clini-cians illusion.135

There are few studies that have es-tablished good reliability and validityin some aspects of instruments in refu-geeresearch. Forexample, a cutoffscore

of 13 on the VDS demonstrated excel-lent validity to DSM-III-R major de-pression diagnosis in a communitysample, and the HSCL-25 anxiety anddepression scales demonstrate excel-lent test-retest reliability in Southeast

Asian refugees. However, proper in-strument development should demon-strate internal consistency (ie, item in-tercorrelation), stability (ie, consistentscores over time, such as test-retest re-liability), and validity of the construct(ie, correlation with a standard). In-strument validity for psychiatric disor-ders is difficult to establish, since psy-chiatric diagnostic interviews asstandards may be insufficiently valid.136

Thus, determining what standards touse for validity testing can be a diffi-cult methodological problem. Per-

haps measures of impairment that arevalid predictors of future health out-comes may be thebest standards againstwhich developed mental health mea-sures should be tested.

Limitations

There arelimitations to thisreview.First,electronic searches of the literature arenot error free, andcitations to somestud-ies and instruments may not be in-cluded in the literature. A recent meta-analysis of psychological consequences

offorced displacement in Yugoslavia thatsearched2 databases that we did not use(PsychLit and PILOTS) found 95 pub-licationsabout refugee mental health, 12of which were appropriate for theiranalyses and10 of which our search didnot initially find.137 The only other re-view of refugee mental health that welo-cated was published in 2000 and in-cluded only 12 studies.138 In addition,our review was limited to English-literature publications. Second, it is dif-ficult to extract accurate data from all

publications. Some articles are difficultto obtain, some do not disclose all ma-terials or methods used, and results areoften unclear and difficult to interpret.Third, categorizing articles by type ispartly subjective, and excluding ar-ticles about infectious diseases nar-rowed our review of instruments. De-spite these limitations, our review

indicates the need for improvements inthe development, use, and reporting ofinstruments used to measure traumaandhealth status in refugee research.

AuthorAffiliations: Departmentsof Family andCom-munity Medicine (Dr Hollifield)and Psychiatry(Drs Hol-lifield, Warner, Lian,and Stevenson), University of New

Mexico Health Sciences Center, Albuquerque; Sleepand Human Health Institute, Albuquerque, NM (DrKrakow); Departments of Anthropology and Psychia-try,Case WesternReserveUniversity, Cleveland, Ohio(Dr Jenkins); Northern Colorado FamilyPractice Cen-ter, Greeley (Dr Kesler); University of Minnesota andthe Minneapolis Veterans Affairs Center, Minneapo-lis, Minn (Dr Westermeyer).Author Contributions: Study concept and design:Hollifield, Warner, Krakow, Jenkins, Westermeyer.Acquisition of data: Hollifield, Lian, Kesler, Stevenson.Analysis andinterpretationof data: Hollifield,Warner,Lian, Jenkins.Drafting of the manuscript: Hollifield, Warner, Lian,Stevenson.Critical revision of the manuscript for important in-tellectual content: Hollifield, Warner, Lian, Krakow,Jenkins, Kesler, Westermeyer.Statistical expertise: Hollifield, Warner, Jenkins.

Obtained funding: Hollifield, Warner, Kesler.Administrative, technical, or material support: Lian,Kesler, Westermeyer, Stevenson.Studysupervision:Hollifield, Warner,Krakow, Jenkins,Westermeyer.Qualitative methods: Jenkins.Funding/Support: This work was supported by Na-tional Institute of MentalHealthgrantR01 MH 59574.Acknowledgment: We thank James Ruiz and Valo-rie Eckert, MPH, for helping to assemble material forthis work.

REFERENCES

1. UnitedStates Committee for Refugees. WorldRefu-geeSurvey 2002. Washington, DC: UnitedStatesCom-mittee on Refugees; 2002. Available at: http://www.refugees.org. Accessibility verified June 25, 2002.2. Carlson EB, Rosser-Hogan R. Cross-cultural re-

sponse to trauma: a study of traumatic experiencesand posttraumatic symptoms in Cambodian refu-gees. J Trauma Stress. 1994;7:43-58.3. Hauff E, VaglumP. Vietnamese boat refugees:theinfluence of war and flight traumatization on mentalhealth on arrival in the country of resettlement. ActaPsychiatr Scand. 1993;88:162-168.4. Mollica RF, Donelan K, Tor S, et al. The effect oftrauma andconfinement on functional health and men-tal health status of Cambodians living in Thailand-Cambodia border camps. JAMA. 1993;270:581-586.5. CunninghamM, Cunningham JD. Patterns of symp-tomatology and patterns of torture and trauma ex-periences in resettled refugees. Aust N Z J Psychia-try. 1997;31:555-565.6. MollicaRF, Wyshak G, Lavelle J. Thepsychosocialimpactof wartrauma andtorture on SoutheastAsianrefugees. Am J Psychiatry. 1987;144:1567-1572.7. MollicaRF, Caspi-Yavin Y, Bollini P, TruongT, Tor

S, Lavelle J. TheHarvard TraumaQuestionnaire:vali-dating a cross-cultural instrument for measuring tor-ture, trauma and posttraumatic stress disorder in In-dochinese refugees.J Nerv Ment Dis. 1992;180:111-116.8. Allden K, Poole C, Chantavanich S, Ohmar K, AungNN, Mollica RF. Burmese political dissidents in Thai-land: trauma and survival among young adults in ex-ile. Am J Public Health. 1996;86:1561-1569.9. Silove D, Sinnerbrink I, Field A, Manicavasagar V,Steel Z. Anxiety, depression and PTSD in asylum-seekers: assocations with pre-migration trauma and




8/7/2019 JAMA-2002-Hollifield-611-21

10/11

post-migration stressors. Br J Psychiatry. 1997;170:351-357.10. Thompson M, McGorry P. Psychological se-quelae of torture and trauma in Chilean and Salva-dorean migrants: a pilot study. Aust N Z J Psychiatry.1995;29:84-95.11. Tan ES, Kripinski J, Chiu E. Stresses ExperiencedPrior to Arrival in Australia. Sydney, Australia: Per-gammon Press; 1986.

12. Gong-Guy E. California Southeast AsianMentalHealth Needs Assessment: Contract 85-76282A-2.Oakland, Calif:Asian Community Mental HealthSer-vices: California State Dept of Mental Health; 1987.13. Mollica RF, Wyshak G, Lavelle J, Truong T, TorS, Yang T. Assessing symptom change in SoutheastAsian refugee survivors of mass violence and torture.Am J Psychiatry. 1990;147:83-88.14. Van Velsen C, Gorst-Unsworth C, Turner S. Sur-vivors of torture and organized violence: demogra-phy and diagnosis. J Trauma Stress. 1996;9:181-193.15. Weine S, Laub D. Narrative constructions of his-torical realities in testimony with Bosnian survivors ofethnic cleansing. Psychiatry. 1995;58:246-260.16. Cervantes RC, Salgadode Snyder VN, PadillaAM.Posttraumatic stress in immigrants from CentralAmerica and Mexico. Hosp Community Psychiatry.1989;40:615-619.

17. Basoglu M, Paker M, Ozmen E, Tasdemir O, Sa-hin D. Factors related to long-term traumatic stressresponses in survivors of torture in Turkey. JAMA.1994;272:357-363.18. Basoglu M, Paker M, Paker O, et al. Psychologi-cal effects of torture: a comparison of tortured withnontortured political activists in Turkey. Am J Psy-chiatry. 1994;151:76-81.19. Cheung P. Posttraumatic stress disorder amongCambodian refugees in New Zealand. Int J Soc Psy-chiatry. 1994;40:17-26.20. Allodi FA, Cowgill G. Ethical and psychiatric as-pects of torture: a Canadian study. Can J Psychiatry.1982;27:98-102.21. Castillo R, Waitzkin H, Ramirez Y, Escobar JI.So-matization in primary care, with a focus on immi-grants and refugees. Arch Fam Med. 1995;4:637-646.22. Eitinger L. The symptomatology of mental dis-

ease among refugees in Norway. J Ment Sci. 1960;106:947-966.23. Hougen HP. Physical and psychological se-quelae to torture: a controlled clinical study of exiledasylum applicants. Forensic Sci Int. 1988;39:5-11.24. Hougen HP, Kelstrup J, Petersen HD, Rasmus-senOV. Sequelaeto torture: a controlled studyof tor-ture victims living in exile. Forensic Sci Int. 1988;36:153-160.25. Pederson S. Psychopathological reactions to ex-treme social displacements (refugee neuroses). Psy-choanal Rev. 1949;36:344-354.26. Weinstein HM,DanskyL, IacopinoV. Tortureandwar trauma survivors in primary care practice. West JMed. 1996;165:112-118.27. Chester B, Holtan N. working with refugee sur-vivors of torture. West J Med. 1992;157:301-304.28. PetersenHD, Christensen ME, Kastrup M, Thom-senJL, FoldspangA. General healthassessment in refu-

gees claiming to have been tortured. Forensic SciInt.1994;67:9-16.29. American Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorders, Fourth Edi-tion. Washington,DC: American PsychiatricAssocia-tion; 1994.30. Brett E, OstroffR. Imagery andposttraumatictressdisorder: an overview. Am J Psychiatry. 1985;142:417-424.31. Brett E, Spitzer R, WilliamJ. DSM-III-Rcriteriaforpost-traumaticstress disorder. Am J Psychiatry. 1988;145:1232-1236.

32. Foy D. Treating PTSD: Cognitive-Behavioral Strat-egies. New York, NY: Guilford Press; 1992.33. GreenBL, LindyJD, GraceMC. Posttraumaticstressdisorder: towardDSM-IV.J NeurolMentDisord. 1985;173:406-411.34. Horowitz M, Wilner N, Kaltreider N, Alverez W.Signs and symptoms of post-traumatic stress disor-der. Arch Gen Psychiatry. 1980;37:85-92.35. Vander Kolk BA,Pelcovitz D, Roth S, MandelFS,

McFarlane A, Herman JL. Dissociation, somatization,and affect dysregulation: the complexity of adapta-tion of trauma. Am J Psychiatry. 1996;153:83-93.36. Cheung P. Somatisation as a presentation in de-pression and post-traumatic stress disorder amongCambodian refugees. Aust N Z J Psychiatry. 1993;27:422-428.37. Westermeyer J, BouafuelyM, NeiderJ, CalliesA.Somatizationamong refugees: an epidemiologicstudy.Psychosomatics. 1989;30:34-43.38. Gavagan T, Brodyaga L. Medical care for immi-grants and refugees. Am Fam Physician. 1998;57:1061-1068.39. MollicaRF, McInnes K, Sarajlic N, Lavelle J, Sara-jlic I, Massagli MP. Disability associated with psychi-atric comorbidity and health status in Bosnian refu-gees living in Croatia. JAMA. 1999;282:433-439.40. Eitinger L. Concentration Camp Survivors. Lon-don, England: Oslo University Press; 1964.

41. Segal J, Hunter EJ, Segal Z. Universal conse-quences of captivity: stress reactions among diver-gent populations of prisoners of war and their fami-lies. Int Soc Sci J. 1976;28:593-609.42. Ursano R, BoydsteinJ, Wheatley R. Psychiatric ill-ness in US AirForceViet Namprisoners of war: a five-year follow-up. Am J Psychiatry. 1981;138:310-314.43. Friedman MJ, Schnurr PP. The relationship be-tweentrauma,posttraumatic stressdisorder, andphysi-calhealth. In:Friedman MJ,Charney DS, DeutchAY,eds. Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to PTSD. Philadel-phia, Pa: Lippincott-Raven; 1995:507-524.44. Schnurr PP. Trauma, PTSD, and physical health.PTSD Res Q. 1996;7:1-6.45. DeVries J,Van HeckGL. Qualityof life and refu-gees. Int J Ment Health. 1994;23:57-75.46. Westermeyer J, Janca A. Language, culture and

psychopathology: conceptual and methodological is-sues. Transcultural Psychiatry. 1997;34:291-311.47. Weathers F, Keane T, King L, King D. Psycho-metric theory in the development of posttraumaticstress disorder assessment tools. In: Wilson J, KeaneT,eds. AssessingPsychologicalTrauma andPTSD.NewYork, NY: Guilford Press; 1997:98-135.48. McDowell I, Newell C. The Quality of Well-Being Scale (formerly the Index of Well-Being). In:MeasuringHealth. NewYork, NY: OxfordUniversityPress; 1996:483-492.49. Wilson JP, Keane TM. Assessing PsychologicalTrauma andPTSD. NewYork, NY:GuilfordPress;1997.50. Mollica R. The Harvard Trauma QuestionnaireManual: IndochineseVersions. Cambridge, Mass: Har-vard University; undated.51. Wyshak G. The relationship between change inreports of traumatic events and symptoms of psychi-atric distress. Gen Hosp Psychiatry. 1994;16:290-

297.52. Allotey P. Travellingwith excess baggage: healthproblems of refugee women in Western Australia.Women Health. 1998;28:63-81.53. Bonnerjea L. Shaming the World: The Needs ofWomen Refugees. United Kingdom: Change Inter-national Reports and World University Service; 1985.54. Silove D, Steel Z, McGorry P, Mohan P. Traumaexposure, postmigration stressors, and symptoms ofanxiety, depression and post-traumatic stress in Ta-mil asylum-seekers:comparisonwith refugees andim-migrants. Acta Psychiatr Scand. 1998;97:175-181.

55. Clarke G,SackWH,GoffB. Three forms ofstressin Cambodian adolescent refugees. J Abnorm ChildPsychol. 1993;21:65-77.56. Norris F, Riad J. Standardized self-report mea-sures of civilian trauma and posttraumatic stress dis-order. In: Wilson J, Keane T, eds. Assessing Psycho-logical Trauma and PTSD. New York, NY: GuilfordPress; 1997:7-42.57. Smith Fawzi MC,Murphy E, Pham T, LinL, Poole

C, Mollica RF. The validity of screening for post-traumaticstressdisorderand major depression amongVietnamese former political prisoners. Acta PsychiatrScand. 1997;95:87-93.58. Kinzie JD, Manson SM, Vinh DT, Tolan NT, AnhB, PhoTN. Development andvalidation of a Vietnam-ese-language depression rating scale. Am J Psychia-try. 1982;139:1276-1281.59. Bolton P. Local perceptions of the mental healtheffects of the Rwandan genocide. J Nerv Ment Dis.2001;189:243-248.60. Bolton P. Cross-cultural validity andreliabilitytest-ing of a standard psychiatric assessment instrumentwithout a gold standard.J Nerv Ment Dis. 2001;189:238-242.61. Beiser M, Fleming JAE. Measuringpsychiatric dis-order among Southeast Asianrefugees. Psychol Med.1986;16:627-639.62. Ekblad S, Abazari A, Eriksson N-G.Migrationstress-

related challenges asociatedwith perceived quality oflife: a qualitative analysis ofIranian refugees andSwed-ish patients. Transcultural Psychiatry. 1999;36:329-345.63. Sartorius N, Janca A. World Health Organiza-tion Quality of Life Assessment Instrument. In:Thornicroft G, Tansella M, eds. Mental Health Out-comes Measures. New York, NY: Springer; 1996:153-177.64. Weine SM, Kuc G, Dzudza E, Razzano L, Pavk-ovic I. PTSDamong Bosnianrefugees: a survey ofpro-viders knowledge, attitudes andservice patterns.Com-munity Ment Health J. 2001;37:261-271.65. McCloskey LA, Fernandez-Esquer ME, South-wick K, Locke C. Thepsychological effects of politicalanddomestic violenceon Central Americanand Mexi-canimmigrantmothersand children.J CommunityPsy-chol. 1995;23:95-116.66. AchenbachT, Edelbrock C.Manual forthe Child

Behavior Checklist and Revised Child Behavior Pro-file. Burlington, Vt: University Associates in Psychia-try; 1983.67. Derogatis LR, Lipman RS, Rickels K, UhlenhuthEH, Covi L. The Hopkins Symptom Checklist (HSCL):a measure of primary symptom dimensions. In: BaselP,ed.ModernProblems in Pharmacopsychiatry. Basel,Switzerland: Karger; 1974.68. WinokurA, WinokurDF, Rickels K, CoxD. Symp-toms of emotional distress in a family planning ser-vice: stability over a four-week period. Br J Psychia-try. 1984;144:395-399.69. Mollica RF,WyshakG, de-Marneffe D, Khuon F,Lavelle J. Indochinese versions of the Hopkins Symp-tom Checklist-25: a screening instrumentfor the psy-chiatric care of refugees. Am J Psychiatry. 1987;144:497-500.70. Parloff M, KelmanH, FrankJ. Comfort, effective-ness, and self-awareness as criteria of improvement

in psychotherapy. Am J Psychiatry. 1954;111:343-351.71. Butcher JN. Psychological evaluation. In: Wes-termyer J, Williams C, NguyenA, eds.Mental Health Services for Refugees. Washington, DC: Govern-ment Printing Office; 1991:111-122.72. KinzieJD, MansonSM. Theuse ofself-ratingscalesin cross-cultural psychiatry. Hosp Community Psy-chiatry. 1987;38:190-196.73. Horowitz NJ, Wilmer N, Alvarez N. Impact ofEvents Scale: a measure of subjective stress. Psycho-som Med. 1979;41:209-218.




8/7/2019 JAMA-2002-Hollifield-611-21

11/11

74. PatonD. Assessing theimpact of disasters onhelp-ers. Couns Psychol. 1990;3:149-152.75. DyregrovA, Kuterovac G, Barath A. Factor analy-sis of the Impact of Event Scale with children in war.Scand J Psychol. 1996;37:339-350.76. SchwartzwaldJ, Solomon Z, WeisenbergM, Miku-lincer M. Validation of the Impact of Event Scale forthe psychological sequelae of combat. J Consult ClinPsychol. 1987;55:251-256.

77. Derogatis L, Cleary P. Confirmation of the di-mensional structure of the SCL-90: a study in con-struct validation. J Clin Psychol. 1977;33:981-989.78. Lipman RS, Covi L, Shapiro AK. The HopkinsSymptom Checklist (HSCL): factors derived from theHSCL-90. J Affect Disord. 1979;1:9-24.79. Westermeyer J, Vang T, Neider J. A comparisonof refugees using and not using a psychiatric service:an analysis of DSM-III criteria and self-rating scalesin cross-cultural context. J Operational Psychiatry.1983;14:36-41.80. Westermeyer J. Two self-rating scales for depres-sion in Hmongrefugees: assessment inclinical andnon-clinical samples. J Psychiatr Res. 1986;20:103-113.81. Westermeyer J, Neider J, Callies A. Psychosocialadjustment of Hmong refugees during their first de-cade in the United States. J Nerv Ment Dis. 1989;177:132-139.82. Leighton D, Harding J, Macklin D, Macmillan A,Leighton A. The Character of Danger. New York, NY:Basic Books; 1963.83. Chung RC, Kagawa-Singer M. Predictors of psy-chological distress among southeast Asian refugees.Soc Sci Med. 1993;36:631-639.84. Chung RC-Y, Singer M. Interpretation of symp-tom presentationand distress:a Southeast Asianrefu-gee example. J Nerv Ment Dis. 1995;183:639-648.85. Brodman K, Erdmann AJ Jr, Wolff HG. Manualof Cornell Medical Index-Health Questionnaire. NewYork: New York Hospital and the Departments ofMedicine (Neurology) and Psychiatry, Cornell Uni-versity Medical College; 1956.86. Brown AC, Fry J. The Cornell Medical Index-HealthQuestionnaire in the identification of neuroticpatients in general practice. J Psychosom Res. 1962;6:185.87. LinM, TazumaL, MasudaM. Adaptationalprob-lems of Vietnamese refugees. Arch Gen Psychiatry.1979;36:955-961.

88. Thulesius H, Hakansson A. Screening for post-traumatic stress disorder symptoms among Bosnianrefugees. J Trauma Stress. 1999;12:167-174.89. Beck A, Ward C, Mendelson M, Mock J, Er-baugh J. An inventoryfor measuringdepression. ArchGen Psychiatry. 1961;4:561-571.90. Norbeck JS, Lindsey AM, Carrieri VL. The devel-opment of an instrument to measure social support.Nurs Res 1981;30:264-249.91. ShisanaO, Celentano DD. Relationshipof chronicstress,socialsupport,and copingstyleto healthamongNamibian refugees. Soc Sci Med. 1987;24:145-157.92. Summerfield D, Toser L. Low intensity war andmental trauma in Nicaragua: a study in a rural com-munity. Med War. 1991;7:84-99.93. Solomon Z, Mikulincer M, Flum H. Negative lifeevents, coping responses, and combat-related psy-chopathology: a prospective study. J Abnorm Psy-chol. 1988;97:302-307.

94. Steel Z, Silove D, Bird K, McGorry P, Mohan P.Pathways from war trauma to posttraumatic stresssymptomsamongTamil asylumseekers, refugees, andimmigrants. J Trauma Stress. 1999;12:421-435.95. Rasmussen OV, Dam AM, Nielsen IL. Torture: Astudy of Chilean and Greek victims. In: Evidence ofTorture. London, England: AmnestyInternational Pub-lications; 1977.

96. Turner S, Landau T, Hinshelwood J, Bamber H.Torture of Turkish Kurds. Lancet. 1989;1:1319.97. Turner SW, Gorst-Unsworth C. Psychological se-quelae of torture: a descriptive model. Br J Psychia-try. 1990;157:475-480.98. Mollica RF, Caspi-Yavin Y. Measuring torture andtorture-related symptoms. Psychol Assess. 1991;3:581-587.99. Shrestha NM,Sharma B, VanOmmerenM, et al.

Impact of torture on refugeesdisplaced within the de-veloping world. JAMA. 1998;280:443-448.100. VanWilligan LHM, Hondius AJK, Vander PloegHM. Health problems of refugees in The Nether-lands. Trop Geogr Med. 1995;47:118-124.101. National Institute of Mental Health. MentalHealthResearch forSurvivors of Torture andRelatedTrauma. Rockville, Md: National Institute of MentalHealth; 1998.102. Green BL. Traumatic stress and disaster: Men-tal health effects and factors influencing adaptation.In: Mak F, Nadelson C, eds. International Review ofPsychiatry. Washington, DC: American PsychiatricPress; 1996:177-210.103. Wilson JP. The need for an integrative theoryof posttraumaticstressdisorder.In: WilliamsMB, Som-mer JF, eds. Handbook of Posttraumatic Therapy.Westport, Conn: Greenwood Press; 1994:3-18.104. Litz BT, Orsillo SM, Friedman M, Ehlich P, Ba-tres A. Posttraumatic stress disorder associated withpeacekeeping duty in Somalia for U.S military per-sonnel. Am J Psychiatry. 1997;154:178-184.105. Soloman Z. The effect of prior stressful experi-ence in coping with war trauma and captivity. Psy-chol Med. 1995;25:1289-1294.106. Yehuda R, McFarlane AC. Conflictbetweencur-rent knowledge about posttraumatic stress disorderandits original conceptual basis.Am J Psychiatry. 1995;152:1705-1713.107. Brown GW. Life-events and psychiatric illness:some thoughts on methodology and causality.J Psy-chosom Res. 1972;16:311-320.108. Holmes TH, Rahe RH. The Social ReadjustmentRating Scale. J Psychosom Res. 1967;11:213-218.109. KrakowB, Hollifield M, Schrader R, et al.A con-trolled study of imagery rehearsal for chronic night-mares in sexual assault survivors with PTSD: a pre-liminary report. J Trauma Stress. 2000;13:589-609.110. HarrisLE,LuftFC, RudyDW, TierneyWM. Clini-

cal correlates of functional status in patients withchronic renal insufficiency. Am J Kidney Dis. 1993;21:161-166.111. Hollifield M, Katon W, Skipper B, Chapman T,Ballenger JC,Fyer A. Panic disorder and quality of life:variables predictiveof functionalimpairment. AmJ Psy-chiatry. 1997;154:766-772.112. Julius M, Hawthorne VM, Carpenter-Alting P,Kneisley J, Wolfe RA, Port FK. Independence in ac-tivities of daily living for end-stage renal disease pa-tients: biomedical and demographic correlates. Am JKidney Dis. 1989;13:61-69.113. SullivanMD, LaCroix AZ,BaumC, GrothausLC,Katon WJ. Functional status in coronary artery dis-ease: a one-yearprospectivestudyof theroleof anxi-ety and depression. Am J Med. 1997;103:348-356.114. Kleinman A. Rethinking Psychiatry: From Cul-tural Category to Personal Experience. 7th ed. NewYork, NY: The Free Press; 1988.

115. Allodi FA. Assessment and treatment of torturevictims: a critical review. J Nerv Ment Dis. 1991;179:4-11.116. Goldfeld AE, Mollica RF, Pesavento BH, Fara-one SV. The physical and psychological sequelae oftorture: symptomatology and diagnosis.JAMA. 1988;259:2725-2729.117. Herman JL. Complex PTSD: a syndrome in sur-

vivors of prolonged and repeated trauma. J TraumaStress. 1992;5:377-391.118. Jenkins JH. Cultural comments on adjustmentand stress disorders. In: Mezzich JE, Kleinman AMD,Horacio F Jr, Parron DL, eds. Culture and PsychiatricDiagnosis: A DSM-IV Perspective. Washington, DC:American Psychiatric Association; 1996.119. Kalucy RS. The health needs of victims of tor-ture. Med J Aust. 1988;148:321-323.

120. RothS, NewmanE, Pelcovitz F,Van der KolkB,MandelFS. Complex PTSD in victimsexposedto sexualandphysical abuse:resultsfrom theDSM-IVField Trialfor Posttraumatic Stress Disorder. J Trauma Stress.1997;10:539-555.121. TurnerSW, Gorst-Unsworth C. Psychologicalse-quelae of torture. In: Wilson J, Raphael B, eds. Inter-national Handbook of Traumatic Stress Syndromes.New York, NY: Plenum Press; 1993.122. deGirolamo GD, McFarlane AC. The epidemi-ology of PTSD: A comprehensive review of the inter-national literature. In: Marsella A, Friedman M, Ger-rity E, Scurfield R, eds. Ethnocultural Aspects ofPosttraumaticStress Disorder. Washington, DC: Ameri-can Psychological Association; 1996.123. Punakami RI. Political violence and mental health.Int J Ment Health. 1989;17:3-15.124. Idler EL, Kasl S. Health perceptions and sur-vival: do global evaluations of health status really pre-dict mortality? J Gerontol Soc Sci. 1991;46:55-65.125. Mossey JA, Shapiro E. Self-rated health: a pre-dictor of mortality among the elderly. Am J PublicHealth. 1982;72:800-808.126. SingerE, GarfinkelR, Cohen SM,Strole L. Mor-tality and mental health: evidence from the midtownManhattan restudy. Soc Sci Med. 1976;10:517-525.127. Zola IK. Culture and symptoms: an analysis ofpatients presentingcomplaints. Am Sociol Rev. 1966;31:615-630.128. WeissMG, DoongajiDR, SiddharthaS, etal. TheExplanatory Model InterviewCatalogue (EMIC): con-tribution to cross-cultural research methods from astudy of leprosy and mental health. Br J Psychiatry.1992;160:819-830.129. Weiss M. Explanatory Model Interview Cata-logue (EMIC): frameworkfor comparative studyof ill-ness. Transcultural Psychiatry. 1997;34:235-263.130. Pelto PJ, Pelto GH. Anthropological Research:The Structure of Inquiry. 2nd ed.Cambridge, Mass:

Cambridge University Press; 1984.131. Spradley JP. The Ethnographic Interview. NewYork, NY: Holt Rinehart & Winston; 1977.132. Bernard HR. Research Methods in Anthropol-ogy: Qualitative and Quantitative Approaches. 2nded.Thousand Oaks, Calif: Sage Publications; 1994.133. Helitzer-AllenDL, MakhamberaM, Wangel AM.Obtainingsensitive information: theneed formore thanfocus groups. Reproductive Health Matters. 1994;3:75-82.134. Cook TD, Campbell DT. Quasi-experimenta-tion: Designand Analysis Issues forFieldSettings. Bos-ton, Mass: Houghton Mifflin; 1979.135. Cohen P, Cohen J. The clinicians illusion. ArchGen Psychiatry. 1984;41:1178-1182.136. Brugha TS,BebbingtonPE, Jenkins R, et al. Crossvalidation of a general population survey diagnosticinterview: a comparison of CIS-R with SCAN ICD-10diagnostic categories. Psychol Med. 1999;29:1029-

1042.137. Porter M, Haslam N. Forced displacementin Yu-goslavia: a meta-analysis of psychological conse-quences andtheir moderators.J Trauma Stress. 2001;14:817-834.138. Keyes EF. Mental health status in refugees: anintegrative review of current research. Issues MentHealth Nurs. 2000;21:397-410.



by guest on April 2 2011jama ama assn orgDownloaded from

JAMA-2002-Hollifield-611-21

Documents

Transcript of JAMA-2002-Hollifield-611-21