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Johns Hopkins Bloomberg School of Public Health
Maternal Mental Health in Post-Conflict Settings: Findings from Timor-Leste
Wietse A. Tol, PhD
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Lots of debate:• In post-conflict settings, which experiences are critical for mental health?
• Past conflict traumavs.
• Ongoing stressors
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Why focus on maternal mental health in post-conflict settings?
1. Important concern in its own right: in LMIC maternal depression 15.6% prenatal, 19.8% postnatal; depression 2nd largest contributor DALY in women aged 15-44)
2. Key risk factors highly present: poverty, intimate partner violence, lack social support, negative life events
3. Negative impact on children: suboptimal growth, diarrhea, febrile episodes, suboptimal breastfeeding and immunization
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Timor-Leste
• 1.2 million people• Low development: 147/
187 HDI (UNDP, 2011)
• 49.9% under poverty line
• 35% spousal physical/ sexual violence
• 33% children under 5 severely stunted; 15% severely underweight
Timor-Leste Timeline
1600’s – 1975 Portuguese colony
1975 – 1999Indonesian occupation
- 200,000 killed- Human rights violations on large scale1999 referendum: 78% vote for independence from Indonesia; followed by large-scale violence;
destruction of infrastructure2006 violence
2008 assassination attempts
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Current studyIn preparation for birth cohort study
Objectives:
– Check recruitment methods– Feasibility/properties of
instruments in this specific group
– Initial exploration of cross-sectional relationships
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Current study2 districts; 8 suco’s (mix rural/urban)Sample recruitment through:
– 1. Visit chefe and health post– 2. Liaise with partner NGO (Safe Motherhood
Program) and SISCa volunteers– 3. Door-to-door
Aim to find all pregnant women and those with 4-5 month old infants
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Socio-demographic characteristics
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Which stressors?• Daily stressors (between 20% and 30%):
• no clean water• not enough money (school fees, clothes)• Lia
• Intimate partner violence (39% prenatal, 29% postnatal)
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Maternal Mental Health
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.
Relationships between adversity and maternal mental health
Header/Full Bleed Image
Name/Subject Subhead Title/captionTitle/caption
© 2014, Johns Hopkins University. All rights reserved.
PTSD symptoms
Perinatal Depression
Human Rights trauma
Witnessing murders
Extreme deprivations
PAST CONFLICT TRAUMATIC EVENTS
Intimate partner violence
INTIMATE PARTNER VIOLENCE
Ongoing adversity
ONGOING ADVERSITY (DAILY STRESSORS)
Header/Full Bleed Image
Name/Subject Subhead Title/captionTitle/caption
© 2014, Johns Hopkins University. All rights reserved.
PTSD symptoms
Perinatal Depression
0.11
0.22
0.10
Human Rights trauma
Witnessing murders
Extreme deprivations
PAST CONFLICT TRAUMATIC EVENTS
Header/Full Bleed Image
Name/Subject Subhead Title/captionTitle/caption
© 2014, Johns Hopkins University. All rights reserved.
PTSD symptoms
Perinatal Depression
0.11
0.22
0.10
Human Rights trauma
Witnessing murders
Extreme deprivations
PAST CONFLICT TRAUMATIC EVENTS
Intimate partner violence
0.15
0.15
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Result #1
Traumatic events and IPV predict both PTSD and perinatal depression
conflict events and IPV should be taken into account for maternal mental health
Header/Full Bleed Image
Name/Subject Subhead Title/captionTitle/caption
© 2014, Johns Hopkins University. All rights reserved.
PTSD symptoms
Perinatal Depression
Ongoing adversity
0.26
0.12
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Result #2
Ongoing adversity predicts PTSD and depression
Treatment of symptoms alone will not be effective on the longer term if ongoing adversity is not addressed
Header/Full Bleed Image
Name/Subject Subhead Title/captionTitle/caption
© 2014, Johns Hopkins University. All rights reserved.
PTSD symptoms
Perinatal Depression
Ongoing adversity
0.26
0.12
Header/Full Bleed Image
Name/Subject Subhead Title/captionTitle/caption
© 2014, Johns Hopkins University. All rights reserved.
PTSD symptoms
Perinatal Depression
Human Rights trauma
Witnessing murders
Extreme deprivations
PAST CONFLICT TRAUMATIC EVENTS
Intimate partner violence
Ongoing adversity
0.26
0.12
0.13
0.15
0.13
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Result #3
Traumatic events predict both ongoing adversity and psychological symptoms
conflict events are carried over into the present (‘caravan of loss’)
Header/Full Bleed Image
Name/Subject Subhead Title/captionTitle/caption
© 2014, Johns Hopkins University. All rights reserved.
PTSD symptoms
Perinatal Depression
Human Rights trauma
Witnessing murders
Extreme deprivations
PAST CONFLICT TRAUMATIC EVENTS
Intimate partner violence
Ongoing adversity
0.26
0.12
0.13
0.15
0.13
0.40
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Result #4
PTSD is strongly related to depression
Need to think of maternal mental health beyond depression symptoms
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
Coming back to beginning: which is more important?
Current debate over-simplifies: BOTH past traumatic events and ongoing adversity are important for post-conflict mental health
They influence each other in complex ways
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.
AcknowledgementsUniversity of New South Wales, Sydney, AustraliaDerrick Silove, MDSusan Rees, PhDNatalino TamLazaro Lelan Sila
The Alola Foundation, Dili, Timor-LesteTeresa Verdial
Universidade de Paz, Dili, Timor-LesteNelson Martins, MD, PhD
Funding: National Health and Medical Research Council, Australia
MeasuresADVERSITY
Daily stressors Locally constructed
Domestic violence Based on WHO survey
Traumatic events Harvard Trauma Questionnaire
MATERNAL MENTAL HEALTH & DISABILITY
Psychological distress Kessler Psychological Distress Scale (K10) + additional items
.85
PTSD Harvard Trauma Questionnaire (HTQ)
.87
Anger Locally constructed .76
Perinatal depression Edinburg Postnatal Depression Scale (EPDS)
.81
Disability WHO Disability Assessment Schedule (WHODAS) 12-item
.89