The study in Kosovo forms the second part of a multi-country epidemiological study on massive exposure to violence and its health impact among the affected population. The first study was implemented in Meherpur district of Bangladesh (score 4 on Political Terror Scale [14]) in February-March 2008 [15, 16]. A further study will be implemented at a third site in 2010. The key components of this methodology are: 1) collection of statistical data and mapping information; 2) a fact-finding mission and key informant interviews; 3) a population-based study consisting of two components: a household survey followed by detailed screening of selected victims of OPV and human rights violations at mobile clinics. Statistical data were collected from the Ministry of Health of Kosovo and the Organization for Security and Co-operation in Europe (OSCE) mission in Kosovo. Mapping was excluded from the Kosovo study since we were unable to obtain the vector layer.
Household survey
The study was conducted in three municipalities of Mitrovicë district of Kosovo (score 2 on Political Terror Scale [14]) from 12 September to 14 October 2008 using a standard methodology adapted from a WHO guideline [17].
Study areas
Mitrovicë district is located approximately 40 km north of the capital of Kosovo, Pristina. Since the 1999 conflict, the district and the town have been divided. The district contains six municipalities: the southern part of Mitrovicë, Skënderaj, and Vushtrri are inhabited by an Albanian majority, while Zubin Potok, Zvečan, and Leposavić are dominated by Serbs.
Mitrovicë municipality consists of one town and 49 villages. The southern part of the town is dominated by Kosovo Albanians. KFOR guards the bridges linking the two sides of the town and strictly regulates bridge crossing to prevent clashes between Albanians and Serbs. In the northern part of town, there are approximately 20,000 inhabitants, 17,000 of whom are Kosovo Serbs (displaced population estimated 5,000 to 7,000). The remaining 3,000 are Kosovo Albanians, Bosniaks, Turks, Roma, Ashkali, Egyptian and a small Gorani community. Vushtrri municipality consists of one town and 66 villages, located between the capital Pristina and Mitrovicë district. There is a Serbian population estimated at 4,000 in the villages of Gojbulje, Prelluzhë, and Grace. Kosovo Albanians and Kosovo Serbs live together in Banjska/Bajskë village. The Skënderaj municipality consists of a town and 52 villages. During the NATO bombing campaign many villages in Skënderaj municipality were systematically destroyed by the Serbian army, as they were the strongholds of the resistance movement.
Sample size
A standard statistical formula provided by the United Nations Children's Fund (UNICEF)[18] was used to calculate the sample size: n = [4 (r) (1-r) (f) (1.1)]/[(e2) (p) (nh)]. The total serious injury rate was estimated to be 15% in 1999 [19] and we expected to have a big margin of error in the violence-related injury rate. A minimum sample size of 336-818 households was necessary, based on the following assumptions: prevalence of lifetime experience of violence-related injury of 15-30% (r), estimated design effect 2 (f), estimated non-response rate of 10%, a margin of error of 10% (e), and an average household size of 6.1 (nh) in Kosovo. The sample size was increased by 25% given that a substantial number of family members might have been absent, being seasonal workers in Western Europe. Design effects can vary within the same survey. We assumed that the level of household exposure to violence and human rights violations varied. Some had higher exposure to massive violence (including torture or execution) because the family members were affiliated with Kosovo Liberation Army, while others were simply forced to leave their home towns. Although the families in a sampled cluster may have similar experience of violent attacks, the individuals were not likely to have similar experience of perceived pain or similar physical or mental disability characteristics. Key informant interviews showed that the households in the same neighbourhood did not have similar financial state. Their income depended on availability of financial support from relatives living abroad and on their involvement in underground economic activities. Therefore, we decided to estimate the design effect at 2 and then adjust for cluster effect for the outcomes. The sample size finally used was 1,100 households (22 clusters with 50 households per cluster), which was convenient for comparison with other study sites.
Sample selection
There has been no census in Kosovo since 1991. Population estimates from OSCE mission in Kosovo in 2005 were used as a sampling frame. The estimated population of the three municipalities in Mitrovicë district (Mitrovicë, Skënderaj, and Vushtrri municipalities, including the Serb-dominated areas) was 303,000 in 2008. Serbs were estimated to comprise 7% of the total population while Bosniaks, Roma and Turks comprised 1% of the total population. A method of two-stage cluster sampling using probability proportional to size was employed. The ratio of cluster numbers for the urban and rural area is based on the ratio of the population (42%: 58%). No household lists were available and population size of each village was also unknown. Therefore we treated each of 167 villages as a potential cluster. The housing units located within towns were included in the list of urban clusters. Nine urban clusters (five for Mitrovicë, one for Skënderaj, and three for Vushtrri) and 13 rural clusters (four for Mitrovicë, four for Skënderaj, and five for Vushtrri) were randomly selected for the household survey.
Case definitions used during the survey
"Household" was defined as a group of individuals who live under the same roof and eat together. The definitions of "torture and other cruel, inhuman or degrading treatment or punishment" and "forced or compulsory labour" were those provided by the relevant UN Conventions, the Geneva Convention additional protocol II, which addressed the protection of objects indispensable to the survival of the civilian populations (Article 14) and the prohibition of forced movement of civilians (Article 17). The convention specifically defines torture as: any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person, information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions. The definition of "violence" was adapted from the WHO's definition [20]. The classification of "injury and death case" is provided by the WHO [17] and the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10)[21]. "Violence-related injury" includes injury resulting from interpersonal violence and self-directed violence. It also includes injury in the context of collective violence such as legal intervention, war, civil insurrection and disturbances (demonstrations or riots). Violence-related deaths therefore included homicide and suicide. Deaths that had occurred within the last 12 months were reported by household members. Both types of pain, physical and mental, were self-reported. Mental pain is highly subjective and it includes emotional, psychological and spiritual pain.
Study implementation
Interviews with key informants (municipality officials, treatment providers and war survivors) were carried out ahead of the household survey, to obtain an overview of ongoing conflict in this border region between Kosovo and Serbia, and collect qualitative data on the well-being of war survivors. Many of the victims among the key informants had been connected with the Kosovo Liberation Army, and were still very hostile to Serbs. We were also informed that although unemployment is extremely high in Kosovo, the underground black economy is blooming. Families tend to hide income or forge income information to avoid taxes.
The self-reported structured questionnaire used in the household survey was developed in English and translated into Albanian and Serbian. The questionnaire was modified on the basis of the knowledge generated from the interviews with key informants. The interviewer team was composed of seven women and four men. We included more women because we expected that the majority of respondents during the daytime would be women. The team included a Turkish social worker who spoke both Albanian and Turkish, one Serb nurse and two Serbian-speaking psychology students of Albanian ethnicity. The team members received a four-day training in survey and safety procedures.
Each municipality office was informed in advance of the purpose and procedure of the proposed study. The interviewer visited a sample of households, chosen using an appropriate household sampling interval (n), which depended on the approximate estimate of village size. For the selection of households, a team of interviewers chose at random a direction at the main square or centre of the village. The first surveyed house was the n-th house on the street in the selected direction, and subsequently the interviewers walked along the street from the centre to the periphery. In a block of apartments in the urban area the n-th apartment from the ground floor was selected. If the household was empty, the next one was chosen. The interviews were conducted with the household heads or their spouses after obtaining their informed consent. The other adult household members were asked to stay around to confirm the information provided. The interviewer and principal investigator reviewed all answers for completeness at the end of each day. One cluster was completed when 50 households had been visited or there were no more households. When the first part of the study, household survey, was completed, a selected group of primary victims and secondary victims (family members who were also traumatised by being witnesses to the incident) were invited to attend the subsequent mobile clinics for a detailed assessment. The recruitment criteria, methods and the results will be presented elsewhere.
Quality assurance
During the household survey, every tenth participating household was randomly selected for spot-check by deputy team leaders. The dataset was checked three times for discrepancies.
Statistical analysis
Data entry, processing, and analysis were carried out using Microsoft Access 2000, Epi Info™ 6.04 (CDC Atlanta, USA, 2001), and Stata 9.2 (StataCorp LP, Texas, USA, 2003). The household income level was classified as: 0 € per month, 1-50 € per month, 51-100 € per month, 101-200 € per month, 201-400 € per month, and higher than 400 €. Descriptive analyses were performed to estimate the frequency distribution of outcome variables. A generalised linear model was used to assess the association between binary outcomes and explanatory variables.
Ethics evaluation
This study abides by the Declaration of Helsinki and Danish law. Ethical clearance was granted by the Ethics Committee of the Academy of Medical Sciences of Kosovo. There was no financial incentive for participation in the household survey and the subsequent visit to the mobile clinic. Confidentiality was guaranteed for all the participants.