Study design and implementation

The study was conducted in three Albanian-dominated areas of Mitrovicë district: Mitrovicë, Skënderaj and Vushtrri municipalities from September to October 2008[7]. The study design was based on a simple and rapid assessment protocol previously developed and tested in a study in Bangladesh. The assessment consists of two components: a household survey and a subsequent detailed examination of a group of victims identified in the household survey. The details are described elsewhere [5, 15].

The criteria for inclusion in the detailed study were the following experiences, reported by the families during the household survey: 1) torture and other cruel, inhuman or degrading treatment or punishment (TCIDTP); 2) sexual harassment, molestation, rape or insertion of a blunt object into a genital organ and/or the rectum; 3) arrest and detention without warrant or order; or 4) extrajudicial execution of family members, perpetrated by members of law enforcement agency. The definition of torture strictly followed the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment[16]. Altogether, 383 families with members who fulfilled the criteria were identified and they were invited to attend a mobile clinic for a more detailed physical and functional assessment. The selected families were given vouchers that outlined the objectives and the procedure of the study, including the offer of a free medical examination and treatment in the municipal family health centre. If a valid telephone number was available, the families were also contacted by phone before the deployment of three mobile clinics on 9-11 October, 2008. Transportation from the villages to the mobile clinic was arranged on request. Victims with severe mental illness or mental retardation had to be accompanied by a family member. A total of 126 victims took part in the examinations. The objectives and procedure of the study, guarantees of anonymity and confidentiality and the use of the data were explained when victims first arrived at the mobile clinic.

The mobile clinic team consisted of one coordinator, three medical doctors, one physiotherapist, one clinical psychologist from KRCT and 10 interviewers recruited from the Department of Psychology, University of Pristina. The medical doctors and the clinical psychologist had substantial experience in assessing and helping people with post-traumatic stress disorder (PTSD) and other mental disorders. All the team members attended a training workshop, where the principles of the study instruments and procedures were explained. They took the parts of the interviewer and respondent in a role-play practice and also practised doing interviews and physical measurements with the instructors and few patients.

Instruments used during the assessment

The trained interviewers used a structured questionnaire to collect personal information and elicit trauma experience. Information on physical functioning and activity, participation in social life and environmental factors was obtained in further interviews using a questionnaire based on the WHO International Classification of Functioning, Disability and Health[5, 17]. Subjective difficulties with mobility and body functioning were assessed on the following scale: "no", "yes" and "yes with some difficulty". Baseline pain level was assessed using a 4-point pain frequency and intensity scale. Perceived emotional well-being was assessed by the "WHO-5 Well-Being" questionnaire including five questions. For each, scores are given from 0 to 5. The scores for the five questions were summed to create a raw score from 0 to 25. A raw score of 0 represents the worst possible and the highest raw score of 25 represents the best possible quality of life. A raw score under 13 indicated poor emotional well-being and represented a poor quality of life. All questionnaires were translated into Albanian and Serbian.

The medical doctors carried out routine consultation and examination including a blood pressure measurement. All the injuries were noted using body diagrams to record the location, following the guidelines of the Istanbul Protocol: the UN manual on the effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment[18].

To assess physical fitness, the Body Mass Index (BMI) was calculated and muscle strength and equilibrium were tested. For calculation of the BMI, height and weight measurements were taken in a standing position without shoes. Muscle strength was assessed by measuring handgrip strength using a Jamar^® hydraulic hand dynamometer. This is a simple and easily-administered procedure, widely used for the measurement of the loss of hand strength[19–21], for outcome documentation after injuries of upper extremities[22], as a functional index of nutritional status and for determination of impairment[23, 24]. Handgrip strength was measured for the left and right hands, according to the recommended procedure of the American Society of Hand Therapists[25]. All participants were included, as none had upper limb deformities. After a demonstration by a trained interviewer or physiotherapist, each participant held the hand dynamometer in a standard position. We collected three measurements for each hand and used the highest value in all the analyses. Lacking the reference value for the general population in Kosovo and former Yugoslavia, we measured the handgrip strength of 72 female and 57 male employees of public and private health facilities (administrators, health and maintenance workers), matched as far as possible to the victims by sex and age, as well as municipality and residence location. The mean values for this group were used as reference values.

The ability to maintain physical equilibrium was assessed by a standard standing balance test. The method has been described in detail elsewhere[5]. If balance on one leg was held for more than 30 seconds, it was considered as a successful outcome[26]. None of the participants was blind or had deformities of lower limbs, so all could be tested.

Statistical analysis

Data were entered and validated in Microsoft Access 2000. Two times 100% cross-checking and one time 5% cross-checking were performed for quality control. Any discrepancy was eliminated by examining the original paper survey forms. One record was mismatched and consequently eliminated. Data analyses were carried out for 125 victims with Stata software, version 11.0 (StataCorp LP, Texas, USA, 2009). The null hypothesis was rejected at the 5% significance level (P < 0.05). We carried out a univariate analysis that included mean, standard deviation (SD) and 95% confidence interval (CIs). Bivariate analyses for differences in means were carried out using a two-sample Kolmogorov-Smirnov test or a generalised linear model adjusted for the effects of other variables and confounding factors. The Shapiro-Wilk test and skewness and kurtosis tests were used to determine the normal distribution and homogeneity of variance of height, weight and handgrip strength. Multiple regression analyses were carried out with handgrip strength as a dependent variable and a set of anthropometric variables as independent variables.

Ethical evaluation

The Declaration of Helsinki and Danish law were adhered to in the course of the study. Research approval was granted by the Ethics Committee of the Academy of Medical Sciences of Kosovo. All of the study participants gave oral informed consent; the information provided was kept confidential. Brief counselling was offered for simple cases of torture or abuse by the medical doctors and clinical psychologist. Severe cases were referred to the municipal family health centres where a group of health professionals trained by KRCT will follow up the cases.

Socio-demographic profile of victims of massive violence

Trauma experience and present health status

In total, 22 (18%) of the victims were diagnosed with hypertension, 59 (47%) with PTSD, 72 (58%) with depression and 46 (37%) with anxiety disorder, three were mentally retarded, three had phobias, three had psychoses. There was one with bipolar disorder, one who suffered from panic attacks, one with autism and one with neurosis. Sixty-six victims (53%) were currently taking medications against depression or anxiety. People who were ill or took regular medications didn't fast during the month of Ramadan.

Representativity of the study group

Ten years after a war has ended, there will inevitably be difficulties in asking victims to take part in a study, especially when some may have been asked to talk about their traumatic experiences in the past and deep-seated problems in the present. We were not able to follow up the people who did not attend the mobile clinic for the examination, so we cannot know how far our sample was representative of the whole population of victims living in Mitrovicë district. It seems probable that since medical attention and transportation were offered, the study participants were those who were most impaired or suffering. People who had a job and resumed a normal life would be less likely to volunteer to take part. At the other extreme, people who were severely ill or depressed may not have had the energy to become involved. It must also be pointed out that our study participants were still living in Kosovo. Many of the victims of the ethnic conflicts during the rule of Slobodan Milošević have emigrated and settled down in other countries. This type of bias must always be considered in conducting epidemiological studies in post-war settings or places where there have been violent conflicts.

Although our sample may not be representative for the whole population of the region who suffered from the ethnic conflict, they had features in common besides a history of trauma. A large proportion of them complained of pain, suffered from sleep disorders and was taking medications against depression or anxiety. They also tended to have low scores for emotional well-being. Besides the victims' self-reported problems with pain and perceived difficulties with various physical activities, objective measurement of physical functioning also showed that many of the victims had problems that affect their ability to cope with daily life and perhaps make them dependent on other family members for doing household chores and for earning a living[27–29].

Physical characteristics, health condition and employment

One of the instruments we used was the measurement of handgrip strength. The loss of muscle strength clearly makes it difficult to cope with everyday life, and particularly with jobs requiring manual strength. Some studies that have investigated the complex relationships among depression, pain complaints and disability using physical performance measurements[30, 31] have suggested that poor handgrip strength is a valuable indicator of disability. We had previously measured handgrip strength in a study of an oppressed population in Bangladesh[5] and found that the victims showed reduced handgrip strength in their dominant hands. This pattern was also observed in this study. We did not have a precisely-matched control group with which to compare the results, but handgrip strength among the victims was markedly lower than among the employees of the health facilities. Many victims reported difficulty in carrying weights. Poor handgrip strength performance in victims was found to be associated with physical size, pain complaints and poorer emotional well-being, which was also related to the level of violence exposure and to consumption of drugs against depression or anxiety. The results also provided evidence of effects of unemployment and a low education level against handgrip strength in victims.

Measurements of BMI showed that the victims tended to be overweight or obese. The factors affecting BMI are extremely complex. Possible causes include having an unbalanced diet and consumption of drugs against depression and anxiety and these in turn may be due to factors such as a low socio-economic background, unemployment and war exposure. Many of these factors were present in victims. An association between PTSD and obesity and inadequate physical activity has been documented previously in other settings[32–34]. However, it is hard to say, to what extent the problem of obesity among the victims is due to their war experience and current problems and how far it reflects a general trend in the population. There are no population-based statistics on obesity and related illness in Kosovo, but 30% of Kosovo civilians were diagnosed with hypertension (often associated with obesity) in a recent survey[35]. There has been an increase in excessive weight and obesity and obesity-related problems in nearby countries too, including post-war Croatia[36] and Bosnia and Herzegovina[37, 38]. A similar trend was observed in Albania and for the rural population in Serbia[39].

A further characteristic of the group of victims in our study was that they tended to be shorter in stature than the employees working at the health facilities. This characteristic may have had an effect on their past experiences and on some of their present problems. Many studies of bullying showed that the masculine norm of physical aggression or dominance was associated with body size and strength as well as with social competence and entitlement[40]. It has even been shown that taller people tend to have better success in the workplace[41, 42]. It is possible that taller people were less vulnerable and more capable of defending themselves and surviving the hardships of war and of life in post-war Kosovo because they were more physically fit and socially competent.

One of the most striking problems among the victims was that only 10% were in paid employment. It is clear that, in a country with an unemployment rate of 42% in 2008, the generally poor health of the victims would have made it difficult for them to compete in the job market. More specifically, it is known that obese adults with impaired lower extremity performance are less likely to be hired and they experience decreased quality of life[43, 44]. We found that in victims not only was obesity common but also standing balance was poor, which was something we also observed in an oppressed population in Bangladesh[5]. Our results also showed that the victims with a job achieved better outcome in maintaining standing balance. Many victims showed poor standing balance outcomes and reported difficulties in walking in the neighbourhood. The distance that they can walk could be limited and they may move slowly - this could be one of barriers for them entering employment. It is recommended to conduct a comprehensive balance and mobility assessment for those with poor standing balance performance.

We also considered the question of whether there was a relationship between current employment status of victims and their past history of trauma, but we found no evidence that the victims with a job had been exposed to less violence or human rights violations than the others. However, the employed ones demonstrated better test outcomes for emotional well-being and physical functioning than the others. A further study would be needed to examine why this small group had been able to obtain jobs - whether they were more physically fit, had better education, or had a good social network, or simply had a more resilient character.

Good and bad effects of being in organisations

One of the important aims of our study was to identify factors that help or hinder the reintegration of victims of massive violence and the return to normality. On one hand, active participation in political and social movements increases the exposure to organised crime and political violence under a regime that represses any potential challenge to its power and resources[5, 45]. Around 40% of victims in this study reported their affiliation with the Kosovo Liberation Army or militia while 25% of all families in the household survey reported such an affiliation[7]. Associates or family members of Kosovo Liberation Army fighters tended to be targeted by the law enforcement agencies and paramilitaries. On the other hand, political and social involvement may have brought some psychological benefits as has been mentioned in other studies[46, 47], particularly among historically deprived citizens. Our study showed that individuals, who had taken part in demonstrations, strikes or human rights rallies against the authorities and who fought for and supported the self-determination of Kosovo, often scored better for emotional well-being. People who play an active role in the community develop a collective identity, and collective response to repression and violence can generate various mechanisms for resistance, survival, healing and restoration at individual and population level, which should never be underestimated[48]. In addition, affiliation with a group could bring concrete benefits like better access to the job market, financial resources or humanitarian aid.

Usefulness of the study procedure for planning and monitoring interventions

The problems in Kosovo are not over. In recent years, clustering of ethnic groups and recurrence of violence and growing resistance to Kosovo authority in the northern region and Serb enclaves echo the past ethnic struggle. Unresolved ethnic and identity issues in the past always show up in every conflict in the present. Interventions to promote social participation and community coherence can empower the victims and may improve the emotional well-being of a marginalised population[49, 50]. For example, the victims in our study did have some outdoor and social activities, but additional physical exercises to improve physical functioning might be instrumental in increasing mobility and in improving emotional well-being, which may in turn promote community reintegration [28, 51, 52]. Our results also suggested that emotional vulnerability and reduced physical functioning were associated with various personal factors like unemployment and low education level. One goal of rehabilitation should be to address the particular problems that make it difficult for people to find employment.

Feeling entangled with the past may sabotage emotional well-being of war victims and the peace-building in the region in the future. In order to develop rehabilitation programmes, which aim to reduce emotional vulnerability and to improve mental health, we need to understand what factors could empower victims to deal with their struggle in the past and in the present. The survey procedure we used, which had already been developed in Bangladesh[5, 15], allowed us to collect detailed information about a group of 125 victims exposed to massive violence. The data now can be used in the planning of programmes for rehabilitation and prevention of violence in this area, to provide baseline data and to monitor the quality and outcome of interventions.

Limitations and strengths

A strength of the study was that the methods used for physical assessment were simple and inexpensive. The results provided both objective measurements and confirmation of the subjective difficulties in physical functioning reported by the study participants. The oral reports given by participants were also validated by the physical functioning assessment or medical examination that found injury traces on the body.

The problems of selecting a representative group among victims of massive violence living in a disturbed environment have already been discussed. The health-seeking behaviour of the individuals is a major source of selection bias, which limits the extent to which the findings can be generalized. There is, in addition, some risk of memory bias that might have affected the participants' answers to the questionnaire. Many study participants had suffered from memory loss during the two weeks before the study. Some had been diagnosed with PTSD or depression and there is a tendency for these conditions to cause problems with memory and concentration. Interviewer and physician bias also need to be considered. Data analysis would have been strengthened if standardised data for the general population in Kosovo were available. We did have some reference values, for example, for height, weight and handgrip strength from a group of employees of health facilitates, but they were not strictly matched to the group of victims. However, it would have been difficult to find a control group of largely unemployed people with no experience of violence. The timing of the study may have slightly affected the answers to the questions on actively visiting friends and relatives, because it was conducted shortly after the end of Ramadan, when family gatherings are frequent.