The British rule over Jammu and Kashmir terminated in 1947. During partition, the Kashmiri population – the majority of whom is Muslim – was promised a choice of joining either India or Pakistan through a popular vote but this plebiscite never took place. Instead, partition was the start of a long history of conflict affecting the roughly 8 million inhabitants of Kashmir [1]. Both India and Pakistan have made control of a unified Kashmir an essential cornerstone of their national identities and have fought several wars between 1947 and 2002 on this issue. The ceasefire line between Pakistan and India, named the "Line of Control" in 1972, still exists today, separating this territory of around 2.2 million square kilometres into three parts. India controls the largest part, with the rest governed by Pakistan and China [1].

Up to twenty years ago the conflict was mainly an interstate affair between Pakistan and India, but in 1988 Kashmiri militants started a liberation movement. The low level war ('militancy') between the liberation movement and the Indian army spiralled into a cycle of armed conflicts with the civilian population caught between the fighting parties. Officially, 20,000 have died and 4, 000 have disappeared since the start of the militancy – in 2004 alone, 1587 militancy incidents and 1263 deaths including 479 civilians were officially recorded [1] – however, according to other sources these figures are substantially higher [2]. The conflict has also led to displacement of Kashmiri Hindu or Pundits and Muslims from the Kashmir Valley.

Violence affects nearly everybody living in Kashmir. A recent population survey [3] found a lifetime prevalence of traumatic events of 59% among the inhabitants of four districts of the Indian part of Kashmir. The most frequent traumatic events encountered were: firing and explosions (81%) and exposure to combat zones (74%). Traumatic events and the way people cope with them have a crucial role in the development of psychological distress and pathology such as anxiety disorders (including Post Traumatic Stress Disorder) and major depressive disorder [4]. Very little is known about the psychological impact of the insecurity on the Kashmiri population.

To assist in determining the future direction of medical humanitarian assistance in the Indian part of Kashmir, Médecins Sans Frontières (MSF) undertook a quantitative population survey to assess the frequency and nature of violence confronted by the population living in the Indian part of Kashmir and its impact on psychological health and socio-economic functioning. This paper presents the main findings related to exposure, witnessing and self-experiencing of violence. Data on the mental health impact of the conflict is presented in a separate paper [5]

The study design was based on a methodology previously used in other conflict settings [6]. A two-stage cluster design was executed in two districts in the Indian part of Kashmir (Kupwara and Badgam). These districts were chosen because MSF intended to start working there, an operational decision based on anecdotal evidence of mental health problems among populations living in these areas. The districts have a combined population of 145,000 residents living in 101 villages (3750 square kilometres). The predominantly Muslim, rural and indigenous population of these districts do not differ from other districts in Kashmir except for the capital, Srinagar. Both districts are close to the Line of Control and have experienced high numbers of violent incidents, although to what degree the level of violence differs from other districts is unknown due to lack of reliable information.

For the calculation of sample size we assumed a prevalence of trauma-related psychological problems of 20% [4], and using a precision of 5% (confidence interval 95%) and a design effect of 2, the minimum sample size was estimated at 492. A two-stage cluster sampling design was used to cover 30 villages, resulting in 17 randomly selected households per village. Research teams started at the centre of the village, spun a bottle, and began the interviews according to the direction in which the bottle pointed. The first encountered household was selected, after which the next household in the same direction was approached. Within the household the participant was also selected randomly.

510 of 548 (93%) interviews were completed. Reasons for refusal to participate (25) and stopping the interview (13) included: lack of time, distrust, and being emotionally upset. The survey was interrupted for 10 days due to security incidents and official strikes. The number of incidents that occurred was not considered exceptional for the area.

The average age of respondents was 37.7 years (range 17–90) with an equal gender distribution (males = 53%; 270; p > 0.05), similar to general statistics on household composition in the district (53.4% males) [19]. Respondents reported having an average household of nine persons (8.94; males: 2425, females: 2126). Nearly all respondents were originally from the Kashmir area (498; 97.6%). The majority of respondents were married (75.2%; 379) and half (52.6%; 266) had no formal schooling. A quarter of respondents (24.9%; 127) reported high or total dependence on financial/material assistance from the authorities or from charity.

In all categories, but particularly for witnessing and self-experiencing, males reported significantly more confrontations with violence. Males had an increased likelihood of being subjected to physical/mental maltreatment (OR 3.9, CI: 2.7–5.7), forced labour (OR 3.7, CI: 2.5–5.5), violation of modesty (OR 3.6, CI: 1.9–6.8) and injury (OR 3.5, CI: 1.4–8.7), and had a higher odds of being arrested/kidnapped (OR 8.0, CI: 4.1–15.5).

This paper presents findings related to confrontation with violence among the conflict-affected Kashmiri population. We did not assess who was responsible for the violence because it was not relevant for our medical needs assessment. We found a high exposure to violence (being in the vicinity but not witnessing or self-experiencing) among the civilian participants in our survey, reflecting a pervasive climate of violence in which the population is living. The frequency of exposure to violence on multiple occasions (>5 times) since the start of the conflict (Table 1) is high and comparable to a study from Afghanistan reporting that 62.0% of the participants experienced at least 4 traumatic events during the previous 10 years [11]. The violence in Kashmir, which began in 1989, was noted up until the date of the survey (August 2005).

High levels of confrontation with violence have been reported in another recent study from Kashmir. In this study, no substantial differences between males (59.51%) and females (57.39%) were found for lifetime prevalence of traumatic experiences. [3] The study also lacks details of specific violence-related events, and does not differentiate between exposure, witnessing and self-experiencing. Our study found the number of confrontations with violence was significantly higher for males, particular for events such as witnessing persons being arrested, maltreated, tortured, or wounded, or hearing about and witnessing rape. Males also 'self-experienced' more violence such as maltreatment, forced labour and forced housing of one of the warring parties. Our findings are in line with a recent meta-analysis that showed a significant higher confrontation with violence for males than for females in other contexts [10], and may be due to the socio-economic activities of males that mean they spend a significant amount of time outdoors whereas women tend to spend more time in the home.

The high level of people reporting being tortured while detained or taken hostage is a particular concern, indicating that the violence against civilians is not simply circumstantial. We used "violation of modesty" as the local equivalent for sexual violence [8]. The fact that men reported this more frequently than women that is surprising: in most studies females are more frequently subjected to sexual violence, partly because males are reluctant to report sexual violence [12, 13]. People may have misunderstood the concept 'violation of modesty' despite extensive piloting and consultation with national staff and counsellors many of whom are males themselves. The high frequency of violation of modesty reported by males might be partly explained by the high frequency of body searching to which Kashmiri men are subjected. Whether the body searching is perceived as inappropriate touching (part of the definition of 'Modesty violation') or the way of touching is remains unclear. A substantial number of males that reported being detained or taken hostage also reported being tortured (77%), and this may also have been understood as a 'violation of modesty'.

This survey aimed to determine exposure to violence and mental health impact as part of a routine programme assessment. We found that the Kashmiri population is confronted with high levels of violence committed by all parties to the conflict, with potentially substantial implications for mental health. This confrontation with violent events is not simply an environmental effect of living in a conflict-affected area, as demonstrated by the high frequency of deliberate events as detention, hostage, and torture. The conflict continues with no end in sight, with civilian deaths reported as this article goes to print [15].

The authors declare that they have no competing interests.