Women health: Psychological and most prominent somatic problems in 3-year follow-up in Bosnian refugees

Abstract

Background:

Little is known about gender differences among people exposed to war related trauma. Aim of this study is to explore gender differences in health status and comorbidity of mental and physical disorders in a cohort of Bosnian refugees followed up for 3 years (1996–1999).

Methods:

This longitudinal study included 534 subjects followed up for 3 years. The interviews were conducted in refugee camps in Varaždin, Croatia in Bosnian language. Data were collected using Harvard Trauma Questionnaire (Bosnian version) and Hopkins Checklist-25, respectively. Physical health disorders were self-reported.

Results:

In both assessments there was a statistically significant difference between men and women in the number of physical health disorders, even when results were controlled for educational status. Although there was no difference in total number of symptoms in both assessments (F = 0.32; df = 1; p > 0.05 and F = 1.15; df = 1; p > 0.05), important physical health disorders were significantly more frequent among women than in men in different educational groups, namely high blood pressure and cardiovascular diseases, arthritis, and anaemia. Asthma, tuberculosis, cirrhosis of the liver, ulcer and epilepsy were more frequent in men than in women. There were no differences in frequencies of psychiatric disorders at baseline, but frequency of psychiatric disorders in women was higher at endpoint for uneducated respondents. There was significant difference compared to men in group of respondents without formal education, but only in comorbidity of PTSD and depression which was more often present in females (22.1%) than in males (3.6%).

Conclusion:

Our findings indicate the importance of gender and education on mental and physical health of people exposed to warrelated trauma. Long term health monitoring and programs, especially related to women’s health are needed in order to avoid lasting consequences.

Keywords

Posttraumatic stress disorder depression refugee women health longitudinal study

Introduction

Over past decades number of refugees came up to 26.0 million and it is estimated that half of refugee population consists of women and children (UNHCR, 2020). Mental and physical health in refugees is jeopardised due to adverse events during the war, refugee and adaptation to new environments. After being exposed to war civilians are usually forced to migrate, take refuge and live in different cultural context, supposed to adapt and go on with their lives. Refugees are often exposed to prolonged and repeated traumas and present with more complex symptomatology than described for PTSD in diagnostic manuals (Munjiza et al., 2019; Palic et al., 2014; Steel et al., 2009; Teodorescu et al., 2012). The PTSD, especially in comorbidity with depression has been repeatedly associated with large number of somatic comorbidities such as cardiovascular disease, chronic obstructive lung disease, diabetes and autoimmune disease (Boscarino et al., 2010; Britvić et al., 2015; Edmondson & Cohen, 2013; O’Donovan et al., 2015; Weinworth et al., 2012).

Longitudinal studies dealing with women health connected to war related trauma are rare yet necessary, given the increased number of forcibly displaced people in recent years. Between 1996 and 1999 we did one longitudinal study, to our knowledge first of that kind on European refugee population. In our initial findings we reported association between PTSD and depression, as well as other baseline risk factors with follow up status, chronicity of psychiatric disorders and disability and their relationship at both points of time. We looked at the risk adjusted association of psychiatric disorders and disability with the likelihood of mortality and emigration (Mollica et al., 2001). By reviewing the literature, we found that in period of last 20 years most studies are cross-sectional and deal with specific groups or sexual violence (Anderson et al., 2019; Baraković et al., 2014). We were particularly interested in consequences of war related trauma on Bosnian women and to our knowledge there is only one study covering period of 11 years (Comtesse et al., 2019). Bosnia and Herzegovina (BiH) is a country constituted of two entities: Federation of Bosnia and Herzegovina and Republic of Srpska and Brčko District, with highly decentralised system and lack of communication (Masic et al., 2006). The reform of mental health services from 2005 established a network of community mental health centres (Kučukalić et al., 2005; Pajević et al., 2020). There are two public health institutes without common register or programs connected to gender issues or women health (Public Health Institute of Republic of Srpska, 2018; Zavod za javno zdravstvo FBiH, 2019).

Objective of this study was to explore to what extent gender influences connection between somatic health and PTSD and/or depression in a group of Bosnian refugees whit particular interest to women health.

Methods

Participants/procedure

In 1995, NGO Ruke from Zagreb, Croatia, in partnership with Harvard Program of Refugee Trauma designed a protocol for a survey of families living in Varaždin, refugee camp established by Croatian government. The resulting study involved a census of the 573 families (1275 people) living in the camp as of February 1, 1996. In each household name, age, gender and family members (18+) were listed and provided by camp authorities. Respondents were selected randomly using first name and alphabet wheel. At the baseline 534 (93%) agreed to participate in the study.

Approximately 90 minutes interviews were done in Bosnian language. Respondents were informed about the purpose of the study, confidentiality, anonymity and voluntary participation and that they could choose not to answer specific questions. In 1999, the second assessment, following procedure established at baseline, was conducted and 376 (70.4%) of remaining participants were interviewed. Human subject committee of the Harvard Medical School and Ethical Committee, Clinical Hospital Centre Zagreb approved study design and informed consent procedure.

The assessment included Bosnian version of the Harvard Trauma Questionnaire (HTQ) a scale consisting of 16 of 17 diagnostic criteria for PTSD define by DSM-IV criteria and the Hopkins Symptom Checklist 25 (HCSL-25), a 15-item scale used as a screening instrument for depression (Mollica et al., 2001). In order to replicate DSM-IV criteria for diagnosis of depression (HCSL-25) and PTSD (HTQ) algorithm method was selected as scale cut-off points have not be established in this population (Kleijn et al., 2001; Mollica et al., 2001; Oruc et al., 2008).

Exposure to a traumatic event, which is criterion A, was deemed to have been met by all respondents. Further, for PTSD, the DSM-IV positive algorithm included positive response, 3 or 4 on HTQ, on at least 1 of the re-experiencing symptoms from criterion B, at least 3 of 7 avoidance and numbing symptoms from criterion C, and at least 2 of 5 arousal symptoms from criterion D. Both instruments have been widely used in a number of studies among diverse cultural groups (Mollica et al., 1992, 1996; Mughal et al., 2020; Wind et al., 2017).

Physical health disorders were defined as self-reported history and we were not able to reach participants medical records (Mollica et al., 2001).

Analysis

Chi-square test was used to compare differences between groups of nominal variables and Mann Whitney U for ordinal variables. For information on interaction between gender and education on total number of conditions we used ANOVA and one-way ANOVA for finding age difference in total number of symptoms. Prior to that we checked Skewness and Kurtosis for distribution of results. The level of statistical significance asset to alpha = 0.05.

Analysis were performed with SPSS software, version 17.01.

Results

Table 1 shows data from the baseline assessments of 534 (100%) participants and the endpoint assessments of 376 (70.4%) participants analysed in this study. The endpoint sample is significantly older than the baseline sample because younger people left camps (chi square = 13.03, p = 0.004). Table 2 reports that at the baseline half of the sample were asymptomatic similarly to the endpoint (59% asymptomatic) and there was significantly higher comorbidity (PTSD and depression) at baseline.

Table 1.

Study sample, N (%)*.

		Baseline N = 534 (100%)	Endpoint N = 376 (70.4%)	Statistics
Gender	F	315 (59.0)	244 (64.0)	χ² = 3.25; p = 0.072
Gender	M	219 (41.0)	132 (35.1)	χ² = 3.25; p = 0.072
Age categories (years)	18–34	105 (19.7)	47 (12.5)	χ² = 13.03; p < 0.004
	35–54	181 (33.9)	136 (36.2)
	55–64	137 (25.7)	85 (22.6)
	65+	111 (20.8)	106 (28.2)
Marital Status	Married	252 (47.2)	179 (47.4)	χ² = 5.27; p = 0.153
	Separated/divorced	65 (12.2)	34 (9.0)
	Widowed	118 (22.1)	100 (26.5)
	Never married	91 (17.0)	52 (13.8)
Ethnicity	Bosnian Muslim	320 (59.9)	210 (55.9)	χ² = 3.69; p = 0.158
	Croat	180 (33.7)	148 (39.4)
	Other	33 (6.2)	17 (4.5)
Education	No formal education	197 (36.9)	150 (39.9)	χ² = 3.16; p = 0.368
	Primary school (8 years)	113 (21.2)	90 (23.9)
	High school (12 years)	148 (27.7)	89 (23.7)
	University (14 years or more)	76 (14.2)	47 (12.5)

Data missing for 1–11 participants in some questions due to the fact that for some questions participants did not gave the answer.

Table 2.

Mental health disorders*, N (%).

	Baseline N = 534 (100%)	Endpoint N = 376 (70.4%)	Statistics
No symptoms	294 (55.1)	223 (59.3)	χ² = 2.061; p = 0.151
Depression	99 (18.5)	86 (22.9)	χ² = 2.558; p = 0.110
PTSD	30 (5.6)	15 (4.0)	χ² = 1.245; p = 0.256
Depression + PTSD	110 (20.6)	52 (13.8)	χ² = 6.910; p < 0.009

Algorithm method was selected that replicated DSM IV criteria for diagnosis of depression (HCSL 25) and PTSD (HTQ).

Table 3 regarding baseline, shows that there is no difference in the frequency of mental health disorders in men and women in depression (χ² = 2.88; p = 0.090), PTSD (χ² = 0.01; p = 0.918) and comorbidity (χ² = 3.03; p = 0.082). However, the total number of mental health disorders, regardless of their type, differs between men and women, that is, there is more men (62.4%) than women (50.2%) without psychological symptoms (χ² = 7.79; p < 0.01**). Data from the endpoint assessments indicate that there is a statistically significant difference in the frequency of mental health disorders between men and women for all measured variables: while in men we can note a significantly higher frequency of people without symptoms (68.2%) and with PTSD symptoms (6.8%) in comparison to women (54.5% and 2.5%), in women there is significantly higher frequency of depression (26.2%) and comorbidity (16.8%) than in men (16.7% and 8.3%).

Table 3.

The presence of mental and physical health disorders depending on the sex of the examinees on the baseline (a) and endpoint (b) sample of the examinees.

Symptoms	Baseline (a)			Endpoint (b)
Symptoms	Male N = 218 (40.9%)	Female N = 315 (59.1%)	χ²	Male N = 132 (35.1%)	Female N = 244 (64.9%)	χ²
No symptoms	136 (62.4)	158 (50.2)	7.79; p < 0.01**	90 (68.2)	133 (54.5)	6.64; p < 0.01**
Depression	33 (15.1)	66 (21.0)	2.88; p = 0.090	22 (16.7)	64 (26.2)	4.44; p < 0.05*
PTSD	12 (5.5)	18 (5.7)	0.01; p = 0.918	9 (6.8)	6 (2.5)	4.25; p < 0.05*
Depression + PTSD	37 (17.0)	73 (23.2)	3.03; p = 0.082	11 (8.3)	41 (16.8)	5.16; p < 0.05*
Anaemia	32 (14.6)	99 (31.4)	19.73; p < 0.01**	12 (9.1)	73 (29.5)	20.88; p < 0.01**
Arthritis	43 (19.6)	91 (28.9)	5.89; p < 0.05*	32 (24.2)	108 (43.9)	14.24; p < 0.01**
Asthma	49 (22.4)	41 (13.0)	8.07; p < 0.01**	23 (17.4)	34 (13.8)	0.871; p = 0.351
Kidney diseases	32 (14.6)	64 (20.3)	2.85; p = 0.091	16 (12.1)	58 (23.6)	7.16; p < 0.01**
Cardiovascular diseases	51 (23.3)	116 (36.8)	11.02; p < 0.01**	36 (27.3)	89 (36.2)	3.08; p = 0.079
Liver cirrhosis	14 (6.4)	22 (7.0)	0.08; p = 0.781	7 (5.3)	5 (2.0)	2.99; p = 0.084
Ulcer	33 (15.1)	39 (12.4)	0.77; p = 0.379	10 (7.6)	15 (6.1)	0.29; p = 0.589
Diabetes	11 (5.0)	28 (8.9)	2.85; p = 0.091	10 (7.6)	30 (12.2)	1.94; p = 0.164
Epilepsy	9 (4.1)	2 (0.6)	7.73; p < 0.01**	5 (3.8)	0 (0.0)	9.52; p < 0.01**
Stroke	26 (11.9)	23 (7.3)	3.30; p = 0.069	7 (5.3)	6 (2.4)	2.12; p = 0.145
Cancer	4 (1.8)	11 (3.5)	1.31; p = 0.252	2 (1.5)	5 (2.0)	0.13; p = 0.722
Tuberculosis	12 (5.5)	3 (1.0)	9.70; p < 0.01**	8 (6.1)	3 (1.2)	7.13; p < 0.01**
High blood pressure	70 (30.2)	131 (41.6)	5.10; p < 0.05*	47 (35.6)	103 (41.9)	1.41; p = 0.235

(a)** = statistically significant difference in the results in two groups of examinees with 1% risk (p < 0.01).

(b)** = statistically significant difference in the results in two groups of examinees with 1% risk (p < 0.01) * = statistically significant difference in the results in two groups of examinees with 5% risk (p < 0.05).

Regarding total number of physical symptoms, the Mann–Whitney U test shows that in both assessments there is a statistically significant difference between men and women in the number of physical symptoms (Z = 3.20, p < 0.01–3.20, p < 0.01, Z = −3.35, p < 0.01). In both cases, women are in a worse position; that is, they have a higher average rank (284.97/203.03) for symptoms compared to men (242.37/164.28).

Further we checked differences in mental and physical difficulties in regards to education of participants. Since we have only frequencies, separate chi-square tests were conducted instead of analysis of variance to detect differences in mental difficulties.

The results of the baseline sample at all four levels of education (as described on Table 1) show that there is no statistically significant difference in the percentage of mental disorders between men and women for any measured variable: no symptoms (χ² = 2.70; p > 0.05; χ² = 0.84; p > 0.05; χ² = 0.01; p > 0.05; χ² = 0.73; p > 0.05), depression (χ² = 0.48; p > 0.05; χ² = 0.00; p > 0.05; χ² = 0.05; p > 0.05; χ² = 0.17; p > 0.05), PTPS (χ² = 3.25; p > 0.05; χ² = 0.31; p > 0.05; χ² = 0.25; p > 0.05; χ² = 0.51; p > 0.05) and comorbidity (χ² = 0.03; p > 0.05; χ² = 0.75; p > 0.05; χ² = 0.09; p > 0.05; χ² = 3.46; p > 0.05).

The results of the endpoint sample on the separate groups of respondents show that there is no statistically significant difference in the percentage of mental disorders between men and women for the variables: asymptomatic (χ² = 1.64; p > 0.05; χ² = 0.03; p > 0.05; χ² = 0.03; p > 0.05; χ² = 0.17; p > 0.05), depression (χ² = 0.01; p > 0.05; χ² = 0.17; p > 0.05; χ² = 0.65; p > 0.05), PTPS (χ² = 1.55; p > 0.05; χ² = 1.55; p > 0.05; χ² = 1.12; p > 0.05; χ² = 0.22; p > 0.05). The only statistically significant difference, when males and females with same levels of education were compared, was found for the variable comorbidity of depression and PTSD (χ² = 5.17; p < 0.05) for respondents without completed formal education. It is shown that comorbidity is more often present in females (22.1%) than males (3.6%). On other educational levels there were no gender differences in comorbidity (χ² = 0.00; p > 0.05; χ² = 0.14; p > 0.05; χ² = 0.00; p > 0.05).

We examined whether there were differences in physical symptoms between men and women regards to education. The results of the baseline sample in the group of subjects without completed formal education show that there is a statistically significant difference in: heart disease (χ² = 3.82; p < 0.05) and high blood pressure (χ² = 5.55; p < 0.05). Both high blood pressure and heart disease were statistically significantly more pronounced in women (49.4%/55.2%) than in men (32.6%/34.4%).

Statistically significant differences in asthma (χ² = 6.42; p < 0.01) and tuberculosis (χ² = 7.91; p < 0.05) were found in the group of respondents who completed primary education in the baseline sample. Both asthma and tuberculosis were statistically significantly more pronounced in men (11.1% /28.9%) than in women (0.0% and 10.3%).

Statistically significant differences in anaemia (χ² = 8.13; p < 0.01), asthma (χ² = 8.22; p < 0.01) and liver cirrhosis (χ² = 4.39; p < 0.05) were found in the group of respondents who completed secondary education in the baseline sample. While asthma and cirrhosis of the liver were statistically significantly more pronounced in men (16.1%/6.9%) than in women (1.6%/0.0%), anaemia was statistically significantly higher in women (21.3%) than in men (5.7%).

Finally, in the group of respondents with a university degree, no statistically significant difference in physical symptoms was found.

The results of the endpoint sample only in the group of subjects without completed formal education show that there is a statistically significant difference in: arthritis (χ² = 3.80; p < 0.05), ulcer (χ² = 8.44; p < 0.01) and epilepsy (χ² = 4.42; p < 0.05). Ulcers and epilepsy were statistically significantly more pronounced in men (21.4%/3.6%) than in women (4.9%/0.0%), and arthritis in women (56.1%) more than in men (35.7%).

Statistically significant differences in asthma (χ² = 6.81; p < 0.01), stroke (χ² = 6.21; p < 0.01) and tuberculosis (χ² = 6.21; p < 0.05) were found in the endpoint sample of the group of respondents who have completed primary education. Both asthma, stroke and tuberculosis were statistically significantly more pronounced in men (23.3%/10.0%/10.0%) than in women (5.0%/0.0%/0.0%).

Statistically significant differences in anaemia (χ² = 16.39; p < 0.01) and arthritis (χ² = 3.85; p < 0.05) were found in the endpoint sample of the group of respondents who completed secondary education. Both anaemia and arthritis were statistically significantly more pronounced in women (41.0%/33.3%) than in men (5.9%/15.7%).

Finally, no statistically significant difference was found in the endpoint sample of respondents in the group of respondents with a university degree.

We also checked the total number of symptoms. Although the distribution of statistical results is statistically significantly different from the normal distribution, we used parametric statistic so we can see the interaction between education and gender on the number of physical symptoms. Indicators of Skewness and Kurtosis do not exceed the limit values (3 and 10) that Kline (2015) mentions as endpoints with a sufficiently large number for parametric statistics. The results of ANOVA show that there is no statistically significant difference in the total number of physical symptoms between men and women in the baseline (F = 0.32; p > 0.05) or endpoint sample of examinees (F = 1.15; p > 0.05). On the other hand, it was shown that there is a statistically significant difference in the number of physical symptoms depending on the education of the subjects in baseline (F = 8.82; p < 0.01) as well as in the endpoint sample (F = 8.81; p < 0.01) of examinees. The results also show that there is no statistically significant interaction between gender and education variables on the total number of physical symptoms in the baseline (F = 1.28; p > 0.05) nor in the endpoint sample (F = 0.84; p > 0.05) of examinees. In Table 4 shows that mean values at the baseline, as well as at the endpoint sample. The number of physical symptoms is statistically significantly higher in persons without primary education in relation to all other groups of examinees. No other differences were found.

Table 4.

Mean values for total number of physical health disorders depending on the education at the baseline T1 and endpoint T2 sample of the examinees.

Gender	Education	Mean
Gender	Education	T1	T2
Male	No formal education	2.23	2.50
	Primary school (8 years)	1.91	1.73
	High school (12 years)	1.46	1.25
	University (14 years or more)	1.91	1.39
	Total	1.79	1.65
Female	No formal education	2.90	2.81
	Primary school (8 years)	1.88	1.78
	High school (12 years)	1.28	1.95
	University (14 years or more)	1.88	1.21
	Total	2.26	2.27

We were also interested in whether there were age differences in psychological and physical symptoms in the baseline and endpoint sample. Earlier it was found that there is no difference in the samples of female and male respondents in the baseline and endpoint sample by age, so no analyses were done that include age and gender together, but we still wanted to check what differences are obtained in symptoms depending on age of the respondents.

Chi-square tests were performed for individual psychological and physical symptoms on the baseline and endpoint sample. Results show that number of depressed and people with comorbidity is significantly higher in the two older age groups (55–64 y.o. and 65+ y.o.) than in the two younger ones (18–35 y.o. and 35–54 y.o.), while with the number of asymptomatic subjects the situation is reversed (more in two younger groups than in the two older groups).

All obtained differences show an increase in the number of physical symptoms depending on the age of the subjects. Additional results regarding age differences, which are not part of this paper, are available on request.

Table 5 reports differences in the total number of physical symptoms depending on the age of the study participants. Based on earlier information on distribution measures, we used parametric statistics: a one-way analysis of variance. Results show that there is a statistically significant difference in the number of physical symptoms depending on the age of the subjects in the baseline (F = 52.72; p < 0.01) as well as in the endpoint (F = 43.43; p < 0.01) sample of subjects. Differences are significant between all age groups except the last two oldest groups which are equal in both the baseline and the endpoint sample. In all cases number of symptoms increases with the age of the subjects.

Table 5.

Mean values for total number of physical health disorders depending on the age at the baseline T1 and endpoint T2 sample of the examinees.

	18–34 g	35–54 g	55–64 g	65+ g
T1	0.56	1.66	2.81	3.25
T2	0.53	1.38	2.76	3.04

Discussion

A major finding in our study is that difference between women and men when it comes to burden of different conditions exists and change over three-year period. We believe that results change more due to the fact that on the endpoint most of those who were younger left the camp and those who stayed were mostly over 55 as we reported previously.

Results show that there is significant statistical difference in number of physical health disorders between woman and man on both measurements. We have been particularly interested in cardiovascular diseases, anaemia, arthritis, asthma and epilepsy as there is growing body of evidence on connection between psychiatric disorders such as depression and PTSD.

All over, women were more affected with the presence of psychological symptoms due to traumatic experiences. Results on our severely traumatised population also show that the high blood pressure and cardiovascular diseases were significantly higher in woman than in man and are in accordance with previously findings.

We did not find significant difference between woman and man when it comes to diabetes but limitation can be that we did not call for co-morbidity and linkage between physical health disorders. We believe that it does not exclude our hypothesis that diabetes and psychosocial factors like leaving in refugee camp, having high-risk diet, smoking, having lack of physical activity were at higher risk for developing and/or aggravating symptoms of cardiovascular diseases. In our study arthritis was more prominent in woman in baseline and at the endpoint. We also noticed that anaemia was more prominent in woman than in man in both measurements. It is interesting that anaemia is third leading cause of somatic complaints in our study sample, after cardiovascular diseases and high blood pressure and arthritis in woman and fourth in man.

There is a growing body of knowledge in last 20 years and research and clinical practice move towards person centred medicine and precision medicine. Sex and gender differences may be critical component in determining causes and developing treatments (Stolarz & Rusch, 2015).

Literature shows that acute and chronic emotional stress, and stress-induced physiological perturbations, predict future cardiovascular diseases (Steptoe & Kivimäki, 2013). PTSD symptoms have been consistently connected to increased risk of cardiovascular disorders. In their prospective study Kubzansky and colleagues showed that PTSD in woman can increase risk of ischaemic heart disease threefold higher compared with those who do not have PTSD symptoms, independent of cardiovascular disease and depression (Kubzansky et al., 2009).

There are multiple possible mechanisms linking depression, PTSD, and psychological trauma to cardiovascular diseases as well as to other somatic diseases. The study of alterations in neurobiological stress response pathways which lead to increased inflammation and chronic autonomic dysregulation has gained interest as growing body of literature indicates that pro-inflammatory factors markers can directly modulate affective behaviour (Michopoulos et al., 2017). In addition to having a higher prevalence of psychosocial stressors, women may be more vulnerable to the adverse effects of these stressors (Vaccarino & Bremner, 2017).

In more recent years, several studies have also shown that the impact of diabetes on development of coronary heart disease is greater in women (Peters et al., 2016). In their study Huxley et al. (2015) also documented excess risk of fatal coronary heart disease among women with type 1 diabetes than in men.

Psycho-neuroendocrinology and immunology are inevitably connected. Lee et al. (2016), in their cohort study of female nurses, followed for over 22 years, found that women with high PTSD symptomatology have en elevated risk for rheumatoid arthritis, independent of smoking. This study is first to examine the association between PTSD and rheumatoid arthritis risk in woman and suggests further studies to examine the role of other cofounders/mediators and their association.

Anaemia causes changes in cognitive performance (Leonard et al., 2014; Lomagno et al., 2014), due to iron status, and has negative association with, cognitive processing, attention, working memory and planning activities (Murray-Kolb, 2011). This can be important for people suffering of PTSD and depression because both conditions affect cognitive status and memory. Comorbidity with anaemia can aggravate symptoms and decreases level of overall functioning.

Numerous studies have shown that mental health problems such as PTSD and depression can have bilateral influence on physical health and we believe that studies to come on refugee population should deal also with women health particularly.

Roberts et al. (2012) in their large population-based study found that parental trauma exposure does not need to occur during the child’s lifetime to affect the child. Further, it is well known that predisposition for good self-regulation is secure attachment. Studies indicate that trauma is usually followed by prolonged distress and specific emotion regulation strategies such as avoidance, difficulties in acknowledging and showing emotions as well as accusing social support due to blunting coping strategies (Benoit et al., 2010). From these facts it can be concluded that poor self-regulation may be predisposing vulnerability factor for PTSD. It can be hypothesised that good attachment and consequently optimal self-regulation can be one of resilience factors opposed to trauma. By paying more attention to women health in adverse traumatic situations, especially in vulnerable populations such as refugee population clinicians may develop better strategies in recognising and treating PTSD and its sequels.

Limitations

The study has both strengths and limitations. As 20-year long period from data collection can be limitation, to our knowledge no-one did or replicated such comprehensive longitudinal study. Our study data base allows investigation of association among psychiatric disorders, physical health and gender over time. This data allows a prospective look at refugee experience, women and men respectively, of their health status as a refugee cohort adjust to conditions in a post-conflict society.

Limitation of our study is that the majority of the variables are based on self-reported data such as measures of trauma, physical functioning and health status. Due to the fact that we conducted the study during war and early post-war period, applied study design was only possible to carry through with highly vulnerable refugee population. It was not possible to use medical records or do physical examination due to the facts explained previously. Additionally, we did not control for cumulative burden of traumas (number of traumatic events). The accuracy of reporting trauma events by refugees has been shown earlier and structured clinical interviews were not used. HTQ and HCSL-25 have been validated against a clinical criterion standard in other refugee settings supported by cross-validation the links checklist positive diagnosis and disability. Multi-dimensional DSM-IV algorithm wasted in the large-scale epidemiological study with Kosovo Albanians (Cardozo et al., 2000).

Furthermore, since our study was conducted diagnostic criteria in DSM and ICD has changed. DSM-IV diagnostic criteria were official until 2013 (APA, 1994) and were used in our study. Since 2013, DSM-5 is in use, and PTSD is in category Trauma- and Stressor-Related Disorder (APA, 2013; Pai et al., 2017). In 2018, the World Health Organisation released a pre-final version of the ICD-11 and conceptualisation of PTSD holds significant changes (Reed et al., 2019). Further elaboration on differences is out of scope of this study. HTQ was modified consistent with current DSM-5 diagnostic criteria (Berthold et al., 2018). Recent studies comparing DSM-5 and DSM-IV diagnostic criteria for PTSD in traumatised refugees (Hollander et al., 2019; Schnyder et al., 2015) and examining the construct validity of HTQ and HSCL-25 suggest applicability of these instruments in refugee population (Wind et al., 2017).

Conclusion

The global burden of disease has changed significantly over the past decades: the greatest burden of death and disability among women is attributable to non-communicable diseases (NCDs), cardiovascular diseases, cancers, respiratory diseases, diabetes, dementia, depression and musculoskeletal disorders (Peters et al., 2016). Gender roles can be influenced by those huge changes in human life. Being a woman can be particularly sensitive because of the responsibility to take care of children in often broken families. Further, long term mental and physical health consequences of trauma are burden for healthcare systems because they are usually combined and produce low functional level what is often a burden on healthcare systems. More longitudinal studies are needed for better understanding of possible factors related to bio-psycho-social consequences of adverse events on both, men and women. Communication between authorities and common programs are necessity in order to provide continuous health care and avoid burden on systems.

Footnotes

Acknowledgements

We are thankful to all participants for sharing their most intimate experiences with us. We acknowledge interviewers, many themselves refugees at the time, who made data collection possible

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was supported by grant MH57806-02 from the National Institute of Mental Health, Bethesda, Md.

ORCID iD

Iris Sarajlić Vuković

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