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Prevalence of depression, anxiety and posttraumatic stress related symptoms in the Kashmir Valley a cross sectional study, 2015.
Research Protocol
March 2015
Second Version
Tambri Housen
MSFH India
First version 02.02.2015
Second version 07.06.2015
Study design Cross-sectional Household Survey
Study period June-October 2015
Study site 10 districts within the Kashmir division -
Srinagar, Anantang, Badgam, Bandipore, Baramulla, Ganderbal, Kulgam, Kupwara, Pulwama, Shupiyan.
Principal investigator Tambri Housen (Research Consultant) for MSF-India. Email: india-epidem@msf-oca.org
Co-investigators
Dr Maqbool (Director of the Department of Psychiatry) from the Institute of Mental Health and Neurosciences in Srinagar.
Dr Showkat Shah (Director of the Department of Psychology) from Kashmir University.
Dr Simon Janes (Medical Coordinator), MSFH-India, New Delhi, India.
Giovanni Pintaldi (Mental Health Advisor), MSFH, Amsterdam, Netherlands.
Annick Lenglet (Epidemiology Advisor), MSFH, Amsterdam, Netherlands.
Cono Ariti (Senior Research Analyst) MSF Manson Unit, United Kingdom
Data collection and analysis by MSFH-India
Protocol and study design
Tambri Housen (Research Consultant), MSFH-India, New Delhi, India.
Dr Simon Janes (Medical Coordinator), MSHF-India, New Delhi, India.
Giovanni Pintaldi (Mental Health Advisor), MSFH, Amsterdam, Netherlands
Annick Lenglet (Epidemiology Advisor), MSFH, Amsterdam, Netherlands.
Cono Ariti (Senior Research Analyst) MSF Manson Unit, United Kingdom
Collaborating institutions
The Department of Psychiatry at the Institute for Mental Health and Neurosciences (IMHANS) in Srinagar.
The Department of Psychology at the University of Kashmir.
Contents TOC \o "1-2" \t "Heading 3,3,Heading 4,4,Title,1"
Contents PAGEREF _Toc420501157 \h 3
List of Tables PAGEREF _Toc420501158 \h 5
List of Figures PAGEREF _Toc420501159 \h 5
List of Abbreviations PAGEREF _Toc420501160 \h 6
Study Summary PAGEREF _Toc420501161 \h 7
Introduction PAGEREF _Toc420501162 \h 8
1.1 Political context in Kashmir PAGEREF _Toc420501163 \h 8
1.2 Economic context PAGEREF _Toc420501164 \h 9
1.3 Mental Health in Kashmir PAGEREF _Toc420501165 \h 9
1.4 MSF presence in the Kashmir Valley PAGEREF _Toc420501166 \h 11
1.4.1 Current MSF program in Kashmir PAGEREF _Toc420501167 \h 11
1.4.2 Program statistics PAGEREF _Toc420501168 \h 12
Study Rationale PAGEREF _Toc420501169 \h 12
Objectives PAGEREF _Toc420501170 \h 13
1.5 Primary objective PAGEREF _Toc420501171 \h 13
1.6 Specific objectives PAGEREF _Toc420501172 \h 13
1.7 Goal PAGEREF _Toc420501173 \h 13
Study design and Setting PAGEREF _Toc420501174 \h 13
1.8 General design PAGEREF _Toc420501175 \h 13
1.9 Study setting PAGEREF _Toc420501176 \h 13
1.10 Study population - Quantitative PAGEREF _Toc420501177 \h 13
1.10.1 Sample size PAGEREF _Toc420501178 \h 14
1.10.2 Sampling Frame PAGEREF _Toc420501179 \h 14
1.10.3 Participant selection and enrolment PAGEREF _Toc420501180 \h 14
1.10.4 Inclusion and exclusion criteria PAGEREF _Toc420501181 \h 15
1.10.5 Withdrawal of study participants PAGEREF _Toc420501182 \h 15
1.11 Subsample for MINI psychiatric interviews PAGEREF _Toc420501183 \h 15
1.12 Participant selection and enrolment for qualitative interviews PAGEREF _Toc420501184 \h 16
Data collection and Analysis PAGEREF _Toc420501185 \h 16
1.13 Qualitative Data Collection PAGEREF _Toc420501186 \h 16
1.14 Qualitative Data Analysis PAGEREF _Toc420501187 \h 16
1.15 Quantitative Data Collection PAGEREF _Toc420501188 \h 17
1.15.1 Village Elder Questionnaire PAGEREF _Toc420501189 \h 17
1.15.2 Household Survey Questionnaire PAGEREF _Toc420501190 \h 17
1.15.2.1 Household Demographics PAGEREF _Toc420501191 \h 18
1.15.2.2 Individual demographics PAGEREF _Toc420501192 \h 18
1.15.2.3 Difficulty in completing daily activities PAGEREF _Toc420501193 \h 18
1.15.2.4 Problems of daily life PAGEREF _Toc420501194 \h 18
1.15.2.5 Substance Use PAGEREF _Toc420501195 \h 18
1.15.2.6 Screening Tools for Mental Health Disorders PAGEREF _Toc420501196 \h 18
1.15.3 Translation of Questionnaire into Kashmiri PAGEREF _Toc420501197 \h 19
1.16 Quantitative Data Analysis PAGEREF _Toc420501198 \h 19
Potential Bias/ Limitations PAGEREF _Toc420501199 \h 20
Ethical issues PAGEREF _Toc420501200 \h 21
1.17 Direct Benefits PAGEREF _Toc420501201 \h 21
1.18 Indirect Benefits PAGEREF _Toc420501202 \h 22
1.19 Direct Risks PAGEREF _Toc420501203 \h 22
1.20 Indirect Risk PAGEREF _Toc420501204 \h 22
1.21 Consent form PAGEREF _Toc420501205 \h 22
1.22 Data Handling and Record Keeping PAGEREF _Toc420501206 \h 22
Collaboration PAGEREF _Toc420501207 \h 23
Responsibilities PAGEREF _Toc420501208 \h 24
1.23 Timeframe in the field PAGEREF _Toc420501209 \h 25
Dissemination Plan PAGEREF _Toc420501210 \h 26
Budget PAGEREF _Toc420501211 \h 27
Appendix 1 Mental Health Survey Household Head- Kashmir 2014 PAGEREF _Toc420501212 \h 29
Appendix 2 Mental Health Survey Participant- Kashmir 2014 PAGEREF _Toc420501213 \h 33
Appendix 3: Information sheet PAGEREF _Toc420501214 \h 49
Appendix 4: Informed Consent Form PAGEREF _Toc420501215 \h 50
List of Tables
TOC \f T \t "Caption" \c Table 1: Kashmir Valley Statistics PAGEREF _Toc284537005 \h 8
List of Figures
TOC \f F \t "Caption" \c Figure 1: Map of the Kashmir Valley PAGEREF _Toc284537009 \h 10
Figure 2: Map of MSF Program Sites PAGEREF _Toc284537010 \h 12
List of Abbreviations
DMHP District Mental Health Plan
DSM-IV Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
EU Enumeration Area
FGD Focus Group Discussion
HPRT Harvard Program in Refugee Trauma
HSCL Hopkins Symptoms Checklist
HSCL-25 Hopkins Symptoms Checklist 25 items
HTQ Harvard Trauma Questionnaire
HTQ-PTSD-16 Harvard Trauma Questionnaire Post Traumatic Stress Disorder 16
Item checklist
HTQ-TE Harvard Trauma Questionnaire Traumatic Events.
ICD International Classification of Diseases
ICMR Indian Council of Medical Research
IMHANS Institute of Mental Health and Neurosciences
INGO International Non-government Organisation
MH Mental Health
MINI Mini-international Neuropsychiatric Interview
MoH Ministry of Health
MSF Mdecins sans Frontires
NGO Non-Government Organisation
NMHP National Mental Health Plan
OCA Operational Centre Amsterdam
OPD Outpatients Department
PSU Primary Sampling Unit
PTSD Post Traumatic Stress Syndrome
STATA Statistics and Data Analysis Software
UNCIP United Nations Commission for India and Pakistan
WHO World Health Organization
Study Summary
Title: Prevalence of Mental Health problems in the Kashmir Valley mixed methods research, 2015.
Primary Objective: To estimate prevalence of mental health related problems, specifically depression/anxiety and posttraumatic stress symptoms in Kashmir and to determine the accessibility to mental health services.
Study Design: Mixed methods research design incorporating cross-sectional household survey, clinical psychiatric interviews, key informant interviews and focus group discussions.
Inclusion Criteria: Participants will be included if they can meet the following criteria:
18 years of age or older.
Able to provide informed consent.
Exclusion Criteria: Participants will be excluded from the study if they meet the following criteria:
Unable to provide verbal informed consent.
Choose to withdraw their consent.
Intervention: The survey will be conducted in the Kashmiri language by interview enumeration. A sub-sample of the survey population will undergo a mini-international neuropsychiatric interview (MINI) by a trained psychiatrist interviewer. Key informant interviews and focus group discussions will occur concurrently with the household survey.
Sample Size: 3700 4800 probability sampled households from 10 districts, 128 households from each districtvillage. A sub-sample of 200300 individuals who test positive on validated screening tests will be probability convenience sampled for formal psychiatric interview (MINI). Two focus group discussions will be held in each district and will be comprised of 8-10 convenience sampled participants.
Primary Outcome Measure:
Point Prevalence of depression/anxiety and posttraumatic stress symptoms.
Qualitative data on access to mental health services and perceived needs.
Proposed Partners: The household survey will be conducted in collaboration with:
Department of Psychology at the University of Kashmir.
Department of Psychiatry at the Institute of Mental Health and Neurosciences (IMHANS) in Srinagar.
Introduction
This section will provide a contextual overview of the proposed study.
The Indian state of Jammu and Kashmir shares a border with China in the north and east and Pakistan in the west and northwest. The state consists of three separate administrative regions; Jammu, Kashmir Valley and Ladakh. The proposed research will be conducted in the Kashmir Valley region only, throughout this protocol therefore the term 'Kashmir' refers to the Kashmir Valley region of the state unless specified otherwise.
Table 1: Kashmir Valley Statistics
Population16 888 475 ReligionMuslim (97%), Hinduism, Sikh, Buddhism (3%)Human Development Index3*0.554Human Development Ranking3*136Per capita income*Rs 50 641Unemployment rate4*10% (highest in Northern India) Total land area1*15 948km2 Urban Population12735300 (39.7% of total population)Population under the age of 15 years1*25.6% Life expectancy*65.0 Males, 67.0 Females (SRS 2009)Maternal Mortality Ratio3*200Infant mortality2*42 Under 5 mortality rate2*52 Literacy Rate for population over 15 years152% (56% for J&K) 1. ADDIN EN.CITE Government of India201285[1]858512Government of India,Government of India2011 Indian National Census20143rd June2012OnlineCensus Organisation of Indiawww.census2011.co.in[ HYPERLINK \l "_ENREF_1" \o "Government of India, 2012 #85" 1], 2. ADDIN EN.CITE SRS201286[2]868627SRSCensus IndiaSample registration system statistical report 20122012New DelhiOffice of the registrar general, Ministry of Home Affairs, Government of Indiawww.censusindia.gov.in/vital_statistics/SRS_Report_2012/2_glance_2012.pdf[ HYPERLINK \l "_ENREF_2" \o "SRS, 2012 #86" 2], 3. ADDIN EN.CITE UNDP201388[3]888827UNDPUnited Nations Development ProgramHuman development report 2013: The rise of the South, human progress in a diverse worldHuman Development Report2013New YorkUnited Nations Development Program[ HYPERLINK \l "_ENREF_3" \o "UNDP, 2013 #88" 3], 4. ADDIN EN.CITE Government of India2014131[4]13113127Government of India,Ministry of Labour and Employment,Ministry of Labour and EmploymentReport on Youth Employment-Unemployment Scenario2014ChandigarhGovernment of India and the Ministry of Labour and Employment[ HYPERLINK \l "_ENREF_4" \o "Government of India, 2014 #131" 4]
*Statistics for Kashmir valley unavailable, figures representative of the state of Jammu & Kashmir.
Political context in Kashmir
Following the partition of India in 1947, the Kashmir valley has been subject to continual political insecurity. Three Indo-Pakistan wars (1947, 1965, 1971) and one Indo-Chinese war (1962), have been followed by an internal resistance movement for self-determination. In 1987, disputes over a state election served as a catalyst for insurgency with the formation of new armed groups. By 1989 the insurgency had begun. Repetitive armed attacks on the Indian Government were conducted in Jammu/Kashmir. The Indian government initiated a military response. ADDIN EN.CITE Wikipedia201489[5]898912WikipediaHistory of Kashmir201410th May2014onlineWikipediahttp://en.wikipedia.org/wiki/History_of_Kashmir[ HYPERLINK \l "_ENREF_5" \o "Wikipedia, 2014 #89" 5]
The loss of human life, human rights abuses and a resulting context of on-going low-grade conflict has had its impact on Kashmirs population. According to ADDIN EN.CITE Varma201212Varma [6]121217Varma, S.Where there are only doctors: Counselors as Psychiatrists in Indian-Administered KashmirEthosEthos517-5354042012 HYPERLINK \l "_ENREF_6" \o "Varma, 2012 #12" Varma [6], since 1947 the majority of the Kashmiri population consider themselves to be living in a state of colonisation and occupation by the Indian state. There remains more than half a million troops in the region, making it the most heavily militarized in the world ADDIN EN.CITE Anjum201013[7]131317Anjum, A.Varma, S.Curfewed in Kashmir: Voices from the ValleyEconomic and Political WeeklyEconomic and Political Weekly10-1445352010[ HYPERLINK \l "_ENREF_7" \o "Anjum, 2010 #13" 7]. As of 2012, approximately 70,000 Kashmiris had lost their lives in the conflict with 10,000 missing persons reported. Frequent confrontations with violence have been reported including displacement, exposure to crossfire, ballistic trauma, round up raids, torture, rape, forced labour, arrests/kidnappings and disappearances ADDIN EN.CITE De Jong200817[8 9]171717De Jong, K.Van de Kam, S.Ford, N.Lokuge, K.Fromm, S.Van de Galen, R.Reilley, B.Kleber, R.Conflict in the Indian Kashmir Valley II: Psychosocial impactConflict and HealthConflict and Health2112008doi:10.1186/1752-1505-2-11Amin200966617Amin, S.Khan, A.W.Life in conflict: Characteristics of depression in KashmirInternational Journal of Health SciencesInternational Journal of Health Sciences213-223322009[ HYPERLINK \l "_ENREF_8" \o "De Jong, 2008 #17" 8 HYPERLINK \l "_ENREF_9" \o "Amin, 2009 #6" 9].
Economic context
The uncertain atmosphere in Kashmir over the past 25 years has prevented outside investment. A nationwide survey conducted by the Ministry of Labour and Employment in 2012-2013 found that Kashmir had the highest youth unemployment across India ADDIN EN.CITE Government of India2014131[4]13113127Government of India,Ministry of Labour and Employment,Ministry of Labour and EmploymentReport on Youth Employment-Unemployment Scenario2014ChandigarhGovernment of India and the Ministry of Labour and Employment[ HYPERLINK \l "_ENREF_4" \o "Government of India, 2014 #131" 4], with a high percentage of university graduates unemployed. At state level the number of registered job seekers increased 190% from 2008-2013. Employment generating sectors such as commercial agriculture, forestry, fisheries and floriculture have been limited due to the prevailing circumstances in the region. Where Tourism was once the source of employment and economic growth, in the past 25 years this industry has been fractured and undependable. A 2011 report by Mercy Corp reports the risks associated with high youth unemployment including feelings of failure, isolation, lack of social status, delayed marriages and the increase in tensions among disenfranchised young people have been compounded by the impact of future uncertainty related to the conflict. Conflict-related stress, mental illness, suicide and drug addiction; expressions of disappointment, anger and hopelessness are reported to be prevalent in Kashmir's young population ADDIN EN.CITE Mercy Corps2011132[10]13213227Mercy Corps,Youth entrepreneurship in Kashmir: challenges and opportunities2011KashmirMercy Corp[ HYPERLINK \l "_ENREF_10" \o "Mercy Corps, 2011 #132" 10].
Mental Health in Kashmir
The impact of prolonged exposure to violence on the psychological well-being of the population ADDIN EN.CITE De Jong200817[8 11]171717De Jong, K.Van de Kam, S.Ford, N.Lokuge, K.Fromm, S.Van de Galen, R.Reilley, B.Kleber, R.Conflict in the Indian Kashmir Valley II: Psychosocial impactConflict and HealthConflict and Health2112008doi:10.1186/1752-1505-2-11Margoob200670707017Margoob, A.M.Firdosi, M.MAli, Z.Hussain, A.Mushtaq, H.Khan, A.Y.Malik, Y.A.Rather, Y.H.Ahmad, S.A.Banal, R.Muzamil, M.Treatment seeking post traumatic stress disorder patient population - Experience from KashmirJammu Kashmir PractitionerJammu Kashmir PractitionerS57-S601312006[ HYPERLINK \l "_ENREF_8" \o "De Jong, 2008 #17" 8 HYPERLINK \l "_ENREF_11" \o "Margoob, 2006 #70" 11] has been confounded by natural disasters such as the earthquake of 2005 ADDIN EN.CITE Chaada20079[12 13]9917Chaada, R.K.Malhotra, A.Kaw, N.Singh, J.Sethi, H.Mental health problems following the 2005 earthquake in Kashmir: Findings of community-run clinics.Prehospital and Disaster MedicinePrehospital and Disaster Medicine541-5452262007Margoob200672727217Margoob, A.M.Khan, A.Y.Firdosi, M.MAhmad, S.A.Shaukat, T.One-year longitudinal study of snow storm disaster survivors in KashmirJammu Kashmir PractitionerJammu Kashmir PractitionerS29-S381312006[ HYPERLINK \l "_ENREF_12" \o "Chaada, 2007 #9" 12 HYPERLINK \l "_ENREF_13" \o "Margoob, 2006 #72" 13] and floods of 2014 ADDIN EN.CITE Iqbal2014135[14]13513548Iqbal, S.Z.Kashmir floods aggravate depression cases in the valleyNDTV201418th October 2014onlineNDTVEditorialhttp://www.ndtv.com/article/india/kashmir-floods-aggravate-depression-cases-in-the-valley-608712[ HYPERLINK \l "_ENREF_14" \o "Iqbal, 2014 #135" 14]. Conflict not only exposes a population to traumatic violent events but also has a negative impact on the social and material fabric of society. Survivors of violence associated with the conflict are also often concurrently subject to other stressors affecting everyday life and livelihood ADDIN EN.CITE Miller201095[15 16]959517Miller, K.E.Rasmussen, A.War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworksSocial Science and MedicineSocial Science and Medicine7-16702010Miller200697979717Miller, K.E.Kulkarni, M.Beyond trauma-focused psychiatric epidemiology: Bridging research and practice with war-affected populationsAmerican Journal of OrthopsychiatryAmerican Journal of Orthopsychiatry409-422764200610.1037/0002-9432.76.4.409[ HYPERLINK \l "_ENREF_15" \o "Miller, 2010 #95" 15 HYPERLINK \l "_ENREF_16" \o "Miller, 2006 #97" 16]. In Kashmir other confounders include widespread poverty, uncertainty, grief, oppression and fear in addition to high unemployment with limited development of employment generating sectors.
There is a public mental health (MH) crisis in Kashmir due to the compounded impact of long-term low-intensity conflict. The Institute of Mental Health and Neurosciences in the valleys capital, Srinagar, has experienced an increase in outpatient presentations from an average of 100 per week in 1980 to between 200-300 per day in 2013 ADDIN EN.CITE Hassan201342[17]424217Hassan, A.Shafi, A.Impact of conflict situation on mental health in Sinagar, KashmirBangladesh e-journal of sociologyBangladesh e-journal of sociology101-1261012013[ HYPERLINK \l "_ENREF_17" \o "Hassan, 2013 #42" 17]. Shoib et al. ADDIN EN.CITE Shoib2012100[18]10010017Shoib, S.Maqbool, D.Bashir, H.Qayoom, G.Arif, T.Psychiatric morbidity and the socio-demographic determinants of patients attempting suicide in Kashmir Valley: A cross-sectional studyInternational Journal of Health Sciences and ResearchInternational Journal of Health Sciences and Research45-532720122249-9571[ HYPERLINK \l "_ENREF_18" \o "Shoib, 2012 #100" 18] report that the number of suicide attempts increased by more than 250% between 1994-2012.
A number of research studies have been previously conducted in the Kashmir Valley examining the impact of the conflict on the mental health of the population. While these studies have been useful for advocacy and draw attention to the plight of the Kashmiri population, many of these studies are methodologically weak, leaving to question the reliability and representativeness of results.
In 2008 Yaswi and Haque ADDIN EN.CITE Yaswi200844[19]444417Yaswi, A.Haque, A.Prevalence of PTSD symptoms and depression and level of coping among the victims of the Kashmir conflict.Journal of Loss and Trauma: International Perspectives on Stress and CopingJournal of Loss and Trauma: International Perspectives on Stress and Coping471-4801352008[ HYPERLINK \l "_ENREF_19" \o "Yaswi, 2008 #44" 19] concluded that a 'high' number of victims of war associated trauma suffer from Post Traumatic Stress Disorder (PTSD) symptoms with those reporting personal experience directly related to the conflict suffering from chronic depression. However the nonprobability sample and small sample size of 80 individuals limits the generalizability of results. The tools used included the Beck Depression Inventory and the Everstine Trauma Response Index-Adapted, neither of which has been validated for the Kashmiri context. Other studies have used purposive sampling to target victims of conflict related trauma and assess the presence of psychiatric symptomology in this target group with non-standardised questionnaires ADDIN EN.CITE Hassan201342[17]424217Hassan, A.Shafi, A.Impact of conflict situation on mental health in Sinagar, KashmirBangladesh e-journal of sociologyBangladesh e-journal of sociology101-1261012013[ HYPERLINK \l "_ENREF_17" \o "Hassan, 2013 #42" 17]. Khan ADDIN EN.CITE Khan2013101[20]10110117Khan, J.I.Armed conflict: Changing instruments and health outcomes, a study of urban households in KashmirInternational Journal of Physical and Social SciencesInternational Journal of Physical and Social Sciences372013[ HYPERLINK \l "_ENREF_20" \o "Khan, 2013 #101" 20] measured mental health outcomes in 390 probability sampled urban households in 4 administrative regions of Srinagar. Among the sample 58% of households had experienced verbal violence and 32% physical violence related to the conflict. While the author does not state what tools were used in the survey he concludes that 46% of the sample reported anxiety and 32%, depression. Between 2003 and 2005 Margoob ADDIN EN.CITE Margoob200616[21]161617Margoob, A.M.Ahmad, S.A.Community prevalence of adult post traumatic stress disorder in south Asia: Experience from KashmirJK-PractitionerJK-PractitionerS18-S251312006[ HYPERLINK \l "_ENREF_21" \o "Margoob, 2006 #16" 21] conducted an assessment of mental health status of 2391 probability sampled individuals within 6 districts of the Kashmiri valley. The MINI screening tool and MINI clinical interview were used to assess psychiatric symptomology and establish a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. Prevalence of PTSD was found to be 7% with life-time prevalence rate of PTSD reported at 15%. While the MINI screening tool has not been validated for the Kashmiri context, the strength of this study is in the clinical interviews conducted by psychiatrists. Using the Self Reporting Questionnaire (SRQ) and probability sample of 510 households in 2 districts in the Kashmir Valley in 2005, ADDIN EN.CITE De Jong200817De Jong, et al. [8] [22]171717De Jong, K.Van de Kam, S.Ford, N.Lokuge, K.Fromm, S.Van de Galen, R.Reilley, B.Kleber, R.Conflict in the Indian Kashmir Valley II: Psychosocial impactConflict and HealthConflict and Health2112008doi:10.1186/1752-1505-2-11De Jong200616516516527De Jong, K.Kam SaskiaFromm, S.Van Galen, R.Kemmere, T.Van der Weerd, H.Ford, N.Hayes, L.Medecins Sans FrontieresKashmir: Violence and Health2006Amsterdam, NetherlandsMedecins Sans Frontiereshttp://www.msf.org/sites/msf.org/files/old-cms/fms/article-images/2006-00/KASHMIR2006-mentalhealth.pdf12th May 2014 HYPERLINK \l "_ENREF_8" \o "De Jong, 2008 #17" De Jong, et al. [8] [ HYPERLINK \l "_ENREF_22" \o "De Jong, 2006 #165" 22] reported that psychological distress was experienced by 33% of their sample, with one third reporting suicidal ideation. While cut-off scores were adapted from the previously validated Indian SRQ, these were not validated specifically for the Kashmiri context. Research has also been conducted on the impact of natural disasters on mental health in the Kashmir Valley. However, research limitations include small sample size and the lack of use of standardised and validated instruments ADDIN EN.CITE Hussain2006102[23]10210217Hussain, A.Margoob, A.M.Snowstorm disaster - learning and experience, first three monthsJammu Kashmir PractitionerJammu Kashmir PractitionerS26-S281312006[ HYPERLINK \l "_ENREF_23" \o "Hussain, 2006 #102" 23]
In 1999 the District Mental Health Plan (DMHP) was initiated with the intention of staggering a rolling out of community based mental health services in all states of India. The program commenced in Jammu/Kashmir in 2004-2005, however, the 2012 National Mental Health Plan (NMHP), report results from a review of the DMHP, stating it was barely functional in most districts. The 2012 NMHP suggests a renewed commitment by the government of India to address the mental health needs of its population and calls for research which can offer insights as well as pathways for change ADDIN EN.CITE Policy Group DMHP20122236[24]222227Policy Group DMHP,XIIth Plan District Mental Health Plan2012New DelhiPolicy Group DMHP[ HYPERLINK \l "_ENREF_24" \o "Policy Group DMHP, 2012 #22" 24]
Figure 1: Map of the Kashmir Valley
http://en.wikipedia.org/wiki/Kashmir_Valley#mediaviewer/File:Kashmir_border.JPG
MSF presence in the Kashmir Valley
Mdecins Sans Frontires (MSF), started working in the Kashmir Valley in 2001 with a Mental Health (MH) programme to provide MH support to the Kashmiri population affected by the chronic conflict, this being the entire population to a degree. The program expanded and evolved over time and included a Primary Healthcare (PHC) component in the remote areas of Kupwara district that was started in 2007. In 2012 it was decided to close the PHC programme and the MH programme refocused on the (more urban and more affected by the civil unrest) districts of Srinagar and Baramulla. MSF now work regularly in Ministry of Health hospital locations in Srinagar city, Baramulla town, Pattan, Bandipora and Sopore town. MSFs focus on the populations mostly affected by conflict remains the aim of our medical presence.
A community survey conducted by MSF in the districts of Badgam and Kupwara in 2005 reported exposure to high levels of direct confrontations with violence with 85.7% of respondents reporting exposure to crossfire, 82.7% experienced roundup raids, 66.9% reported witnessing torture, 13.3% and 11.6% reported exposure to rape and sexual violence (respectively), 16.9% of participants reported having experienced arrest or kidnapping, 33.7% participated in forced labour and 12.9% experienced torture. One third of study participants reported symptoms of psychological distress ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_8" \o "De Jong, 2008 #17" 8 HYPERLINK \l "_ENREF_22" \o "De Jong, 2006 #165" 22 HYPERLINK \l "_ENREF_25" \o "De Jong, 2008 #14" 25]. This study was subsequently published in the journal Conflict and Health and has been repeatedly quoted by the media and other parties when discussing mental health in Kashmir.
Current MSF program in Kashmir
In 2014 the focus of MSF programing in Kashmir includes the following components
Individual counselling;
Provision of 'Psychological first aid (PFA)' to hospitalized victims of trauma directly related to violence;
Community outreach activities;
Advocacy and communication highlighting the mental health situation and needs in Kashmir.
MSF provides counselling in six strategic locations illustrated in Figure 2; Two hospitals within Srinagar city, Baramulla District Hospital, Sopore District Hospital, Bandipora District Hospital and Pattan District Hospital. A team of three trained lay counsellors and five clinical psychologists provide counselling services at these sites, working alongside the Ministry of Health (MoH) psychiatrists in most locations.
Figure 2: Map of MSF Program Sites
SHAPE \* MERGEFORMAT
Program statistics
During 2014 MSF counsellors and clinical psychologists conducted 2426 counselling sessions. Of the presenting complaints, 45% were anxiety related, and 24% mood related, with a further 17% presenting with physical complaints. Precipitating events were dominated by non-violence related incidents (64%) with a further 14% related to domestic discord or violence ADDIN EN.CITE Ulenberg201482[26]828227Ulenberg, C.Srinagar Mental Health Monthly Report May 2014Srinagar Mental Health Montly Report2014unpublishedMedecins Sans Frontieres[ HYPERLINK \l "_ENREF_26" \o "Ulenberg, 2014 #82" 26]. This is a common pattern reported by MSF counsellors, who in a free-listing activity identified common domestic issues such as family stress, exam stress, love affairs, relationship problems, chronic disease, unemployment and financial difficulties as the most common precipitating events for patients attending counselling. However, a caveat was provided stating that the root of all these issues is the trauma experienced by the individual and the family, which is thought to have decreased the populations coping ability when faced with everyday stressors. ADDIN EN.CITE Mdecins Sans Frontires201481[27]818126Mdecins Sans Frontires,Staff Interviews2014June 2nd-6th 2014Srinagar, Kashmir[ HYPERLINK \l "_ENREF_27" \o "Mdecins Sans Frontires, 2014 #81" 27]
Study Rationale
The World Health Organisation (WHO), recognising that "mental and addictive disorders are among the most burdensome in the world with their burden set to increase over the next decade" emphasise the need for rigorous population surveys that estimate the prevalence of mental disorders ADDIN EN.CITE WHO2014129[28]12912912WHO,WHOThe world mental health survey initiative20148th September2014onlineWHOwww.hcp.med.harvard.edu/wmh/[ HYPERLINK \l "_ENREF_28" \o "WHO, 2014 #129" 28]. Representative epidemiological data on psychiatric disorders in the Kashmir Valley is required in order to target limited resources and monitor trends over time. This research will use scientifically robust methods to estimate the prevalence of depression/anxiety and posttraumatic stress symptoms in the population of the Kashmir Valley. This is the first rigorous population survey conducted with a representative sample of the Kashmir Valley population; findings of this study could have a major influence in mental health care policy planning efforts in the coming years. This is acutely pertinent in a region that has a significant level of unmet needs regarding mental health service organisations, delivery of care and epidemiological research.
Objectives
Primary objective
To estimate prevalence of mental health related problems, specifically depression/anxiety and posttraumatic stress symptoms in the Kashmir Valley and to determine the accessibility to mental health services.
Specific objectives
Using validated screening tools determine the percentage of people with depression, anxiety and PTSD symptoms in Kashmir;
To correlate scores obtained on validated mental health screening tools with individual psychiatric evaluations using the mini international neuropsychiatric interview (MINI);
To explore local knowledge and perceptions of mental illness in Kashmir;
To determine the level of access to mental heath services across Kashmir;
To identify mental health service needs perceived by the Kashmiri community.
Goal
To provide an updated insight into current mental health needs in Kashmir, which will help MSF to increase relevance and impact of current activities in Kashmir and to advocate for supportive programming and policy review.
Study design and Setting
General design
This is a mixed methods research study incorporating qualitative and quantitative methodology;
Cross-sectional household survey based on multistage clustered area probability sample.
Clinical psychiatric interviews using a gold standard psychiatric interview will be conducted with a random convenience sample of survey participants scoring above the validated cut-off score on screening instruments.
Key informant interviews and focus group discussions exploring knowledge and perceptions of mental health, access to services and perceived community mental health needs.
Study setting
The ten districts within the Kashmir division - Srinagar, Anantang, Badgam, Bandipora, Baramulla, Ganderbal, Kulgam, Kupwara, Pulwama, Shupiyan.
Study population - Quantitative
The target population for the survey is defined as all 18 years old and over residents of private households in the Kashmir Valley. This definition excludes people living in non-private dwellings, residents of institutions or hospitals, prison inmates and others not residing in private households.
Sample size
The target population are all those over the age of 18 years living in the Kashmir Valley. Given that this is the first representative population survey of mental health across the Kashmir Valley a prevalence rate of 40% was assumed for the sample size calculation. Adopting a precision of estimate of 6%, an alpha error of 0.05 and design effect of 23 an estimated sample size of 370 480 households per district was calculated. In order to allow comparisons across districts and taking into consideration the heterogeneity between villages, 40 clusters in each district will be randomly selected, 128 households will be interviewed in each enumeration area. A non-response rate of 10% was considered in this calculation. All consenting individualsOne household member 18 years or and over, in a randomly selected household will be interviewed.
Sampling Frame
The sampling frame for selection of households used in the study is provided by the list of 2011 Census Enumeration Areas (EAs) for each of the study districts, with the number of households defined under administrative units called sub-districts. At the first stage of sampling a list of the sub-districts in each district and the number of households in the sub-district will be listed. 40 sub-districts will be selected as the Primary Sampling Units (PSU's) using Probability Proportional to Size ADDIN EN.CITE Yansaneh200539[29]393944Yansaneh, IUnited Nations Statistics Division,Overview of sample design issues for household surveys in developing and transition countriesHousehold Sample Surveys in Developing and Transition Countries.200511th September 2009New Yorkhttp://unstats.un.org/unsd/hhsurveys/pdf/Chapter_2.pdf[ HYPERLINK \l "_ENREF_29" \o "Yansaneh, 2005 #39" 29], which will be based on the number of households living in each sub-district at the time of Census (2011). The second stage will consist of selecting a sample of Secondary Sampling Units (SSUs) from each PSU. A list of villages/towns in each chosen sub-district will be collated and 1 village/town will be randomly selected as the SSU. The third stage-sampling unit in the multistage sampling will be the household.
Prior list dependent method
In the context of the Kashmir Valley where village heads keep a list of resident households, the prior-list-dependent method (PLD) with random number tables will be used to select sample households. A population census was carried out in 2011, at which time household lists were updated. The team supervisor will be required to sit with the village elder and further update the household list to only include the households eating and sleeping in the village at the time of data collection. Using the updated household list and a unique random number table for each SSU, the supervisor would select 8 households for interview.
In Urban settings households will be selected using the random selection of GPS points. The house closest to the selected GPS point will be approached to participate in the study. Any sensitivity associated with GPS sampling will be mitigated by clear explanation to the urban authorities. This will be conducted as part of the pre-survey security assessment.
The final stage requires the selection of individuals for interview. Information regarding the number of people aged 18 years or more living in the household will be collected via the household head demographics questionnaire. Each One person recorded, as over 18 years will be randomly selected and asked to participate in the study. National Census 2011 data reports the average household size in the Kashmir Valley to be 5.8 persons with 40% of the population 18 years of age or older ADDIN EN.CITE Government of India201285[1]858512Government of India,Government of India2011 Indian National Census20143rd June2012OnlineCensus Organisation of Indiawww.census2011.co.in[ HYPERLINK \l "_ENREF_1" \o "Government of India, 2012 #85" 1]; the total survey sample is estimated to be 7690 individuals, approximately 769 per district.
Participant selection and enrolment
Initial consent will be gained from the household head. The information sheet will be read to the household head and any questions answered. Once the household head has consented for his/her household to participate a short demographic questionnaire will identify individuals in the household over the age of 18 while also providing important demographic information about the household.
All individualsOne randomly selected household member over the age of 18 years residing in the selected household and meeting the inclusion criteria will be asked to participate in the study. The information sheet will be read to the individual by the enumerator, the study explained and questions answered in the appropriate language, the information sheet will remain with the participant. The consent form will then be signed and the participant enrolled in the study. Consent for participation in the MINI interview will be included within the main consent form so as to avoid any issues with an individual being singled out.
Inclusion and exclusion criteria
Inclusion Criteria: Participants will be included if they can meet the following criteria:
18 years of age or older.
Able to provide informed consent.
Present at the time of the survey.
Exclusion Criteria: Participants will be excluded from the study if they meet the following criteria:
Unable to provide verbal informed consent.
Choose to withdraw their consent.
Withdrawal of study participants
Participants who meet the exclusion criteria listed above will be removed from the analysis and the reason recorded accordingly. This will not impact on their access to care and treatment.
The interviewee may stop the survey or MINI interview at any time. The person does not have to give a reason for stopping the interview. In the case the interviewee stopped the survey or MINI interview due to emotional distress they will be counselled by the trained enumerator and if necessary referred to the best available mental health and psychosocial support worker. Referral to appropriate mental health support services will also be offered at this time.
Subsample for MINI psychiatric interviews
Following the recommendation by DeJong ADDIN EN.CITE De Jong201494[30]94946De Jong, K.Mass Conflict and Care in War Affected Areas2014Ecschede, The NetherlandsIpskamp Drukkers[ HYPERLINK \l "_ENREF_30" \o "De Jong, 2014 #94" 30] and Steel ADDIN EN.CITE Steel200996[31]969617Steel, ZChey, T.Silove, D.Marnane, C.Bryant, R.A.van Ommeren, M.Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacements: A systematic review and meta-analysis.American Medical AssociationAmerican Medical Association537-54930252009[ HYPERLINK \l "_ENREF_31" \o "Steel, 2009 #96" 31] that clinical interviews be included in mental health prevalence studies a subsample of 2030 individuals from those scoring above the Kashmiri validated cut-off scores will be selected from each district (providing a total sample of approximately 200300). Restrictions imposed by remote access and limitations on resources prevent a true random sample of individuals scoring above the cut-off on screening instruments.
Three clinical psychiatristsTwo trained clinical psychologists will be embedded with different research teams at various times throughout the data collection. Following administration of the interview an automated tally of the respondents score on the screening tools will be visible on the electronic data collection tablet. Enumerators will identify individuals scoring over the pre-validated cut-off score and ask if they would be willing to undergo a MINI psychiatric interview. with a clinical psychiatrist. A clinical psychiatrist from IMHANS trained clinical psychologist will then visit these individuals reconfirm consent has been obtained and conduct the MINI interview. in order to obtain a psychiatric diagnosis. In the case where more than one person in the household scored above cut-off the first individual scored will be selected for interview, this is to facilitate time management of interviews. When the sample size of 2030 is completed for a district, psychiatricMINI interviews will cease to be offered.
These interviews will test the robustness of the screening instruments to identify persons with likely mental health problems when implemented in a household survey. On cessation of the MINI interview the participant will be asked for their view on areas for prioritisation and possible interventions for mental health services in the Kashmir Valley.
The Mini International Neuropsychiatric Interview (MINI) is a short structured diagnostic interview, designed for epidemiological studies and based on the DSM-IV and the International Classification of Diseases (ICD) ADDIN EN.CITE Sheehan1998116[32]11611617Sheehan, D.V.Lecrubier, Y.Sheehan, K.H.Amorim, P.Janavs, J.Weiller, E.Hergueta, T.Baker, R.Dunbar, G.C.The Mini-international Neuropsychiatric Interview (M.I.N.I): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10Journal of Clinical PsychiatryJournal of Clinical Psychiatry22-3359201998[ HYPERLINK \l "_ENREF_32" \o "Sheehan, 1998 #116" 32]. The MINI is a reliable and valid diagnostic tool, reportedly widely used by psychiatrists in Kashmir and has been used previously in psychiatric epidemiological studies in the Kashmiri context ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Margoob, 2006 #72" 13 HYPERLINK \l "_ENREF_21" \o "Margoob, 2006 #16" 21 HYPERLINK \l "_ENREF_33" \o "Margoob, 2006 #27" 33 HYPERLINK \l "_ENREF_34" \o "Banal, 2010 #133" 34]. The administration of the interview takes about 20 minutes and has been validated against other standardised diagnostic interviews, including the Composite International Diagnostic Interview (CIDI) and the Structured Clinical Interview for DSM Disorders (SCID).
Participant selection and enrolment for qualitative interviews
Qualitative data collection will consist of a combination of key informant interviews and focus group discussions (FGDs). Key informants will be selected from individuals working in mental health in the Kashmir Valley and community leaders from sampled sub-districts and villages.
Snowball sampling ADDIN EN.CITE Patton2002207[35-37]2072076Patton, M.Q.Qualitative Research and Evaluation Methods3rd2002CaliforniaSage PublicationsRichards20073636366Richards, LMorse, J.M.Users Guide to Qualitative Methods2007Thousand OaksSage PublicationsLiamputtong20051451451456Liamputtong, P.Ezzy, D.Qualitative Research Methods (2nd ed.)2005South MelbourneOxford University Press[ HYPERLINK \l "_ENREF_35" \o "Patton, 2002 #207" 35-37] will be used to identify participants for focus group discussions and key informant interviews, with the use of the village elders as the primary point of contact. In each district 2 focus group discussions will be held, issues associated with mental health in the community, perceived needs, and access to services will be explored. In respect of the culture in Kashmir and to help facilitate discussion focus groups will be defined according to gender with 1 male and 1 female focus group conducted in each district, with 8-10 participants in each group.
Data collection and Analysis
This research uses multiple methods to explore the prevalence of depression/anxiety and posttraumatic stress symptoms and access to mental health services.
Qualitative Data Collection
Qualitative data will be obtained via key informant interviews and focus group discussions in order to gain insight into the lived experiences and perceived mental health needs of the Kashmiri population. The qualitative arm of the study is not intended as a separate in-depth qualitative study on mental health in Kashmir but rather as a complementary research method to more broadly investigate the research questions.
Few qualitative studies on mental health in conflict-affected countries have been undertaken; predominantly such studies have a strong quantitative focus. Therefore it is not possible to approach data with a set of conceptual categories. Pre-constructed interview guides will be used only to stimulate discourse. Prior theoretical expectations will be avoided and all inferences will be grounded in the data collected. Data collection and analysis will occur simultaneously and inform each other. Themes and concepts constructed from the analysis will guide decisions such as information sources ADDIN EN.CITE Cresswell200735[38 39]35356Cresswell, L.W.Clark, V.L.P.Designing and Conducting Mixed Methods Research.2007Thousand Oaks, CASage Sim20003434346Sim, JWright, CResearch in Health Care: Concepts, Designs and Methods.2000CheltenhamStanley Thornes Ltd[ HYPERLINK \l "_ENREF_38" \o "Cresswell, 2007 #35" 38 HYPERLINK \l "_ENREF_39" \o "Sim, 2000 #34" 39].
Verbal cConsent will be sought from all participants for interview and data to be audio recorded with mp3 technology ensuring an accurate and complete verbatim record of both researcher's questions and participant responses. In the case where a participant refuses consent for audio recording, data collection in these interviews will rely on note-taking and post-interview reflections. The researcher will document the demographics of interviewees, observations, reactions, impressions and other significant contextual information in an interview journal. Interview journals are recognised as a useful source of supplementary information ADDIN EN.CITE Rudestam2007143[40]1431436Rudestam, K.Newton, E.Rae, RSurviving your dissertation: A comprehensive guide to content and process3rd2007LondonSage Publications[ HYPERLINK \l "_ENREF_40" \o "Rudestam, 2007 #143" 40]. The interviews will be transcribed and then translated from Kashmiri to English.
Qualitative Data Analysis
Analysis of qualitative data will be based on thematic analysis where data is coded, sorted and organized ADDIN EN.CITE Liamputtong2005145[37]1451456Liamputtong, P.Ezzy, D.Qualitative Research Methods (2nd ed.)2005South MelbourneOxford University Press[ HYPERLINK \l "_ENREF_37" \o "Liamputtong, 2005 #145" 37]. The purpose of the analysis will be to identify themes from the data that are rooted in the reality of the lived experience of mental health needs and service provision in the context of the Kashmir Valley.
Continual referencing back to the data during analysis ensured that the analysis process is firmly grounded in the actual data. After regaining familiarity with the data open coding ADDIN EN.CITE Strauss1990144[41]1441446Strauss, A.Corbin, J.Basics of Qualitative Research: Grounded Theory Procedures and Techniques1990Newbury Park, CaliforniaSage Publications[ HYPERLINK \l "_ENREF_41" \o "Strauss, 1990 #144" 41] will be conducted in order to identify new ideas, relationships, patterns between experiences of mental health/illness. Once primary categories and relationships are developed the transcripts will once again explored in depth in a second stage of coding. During this stage connections between categories and relationships will be identified and existing codes sub-categorized into minor themes. This process is known in the literature as 'axial coding' or the practice of making connections ADDIN EN.CITE Strauss1990144[37 41]1441446Strauss, A.Corbin, J.Basics of Qualitative Research: Grounded Theory Procedures and Techniques1990Newbury Park, CaliforniaSage PublicationsLiamputtong20051451451456Liamputtong, P.Ezzy, D.Qualitative Research Methods (2nd ed.)2005South MelbourneOxford University Press[ HYPERLINK \l "_ENREF_37" \o "Liamputtong, 2005 #145" 37 HYPERLINK \l "_ENREF_41" \o "Strauss, 1990 #144" 41]. In this way more specific experiences concerned with perceptions of mental health needs and access to service will be given a title or name. The final stage of coding then gathers minor themes into major themes. Strauss and Corbin (1990) describe this phase as the process by which all categories are then structured around a central or 'core' category ADDIN EN.CITE Strauss1990144[41]1441446Strauss, A.Corbin, J.Basics of Qualitative Research: Grounded Theory Procedures and Techniques1990Newbury Park, CaliforniaSage Publications[ HYPERLINK \l "_ENREF_41" \o "Strauss, 1990 #144" 41]. Transcripts will be re-examined and quotes selected that illustrate each of the identified themes.
During this coding process common themes will be identified with respect to participants experience of mental health issues, health seeking behaviors and perceived service needs.
Quantitative Data Collection
DeJong ADDIN EN.CITE De Jong201494[30]94946De Jong, K.Mass Conflict and Care in War Affected Areas2014Ecschede, The NetherlandsIpskamp Drukkers[ HYPERLINK \l "_ENREF_30" \o "De Jong, 2014 #94" 30] identifies two criteria that are necessary for a rigorous mental health assessment. The cross-cultural validation of instruments and the use of validated clinical interviews to establish a mental health diagnosis. Quantitative methods for this research include the use of a household survey incorporating validated screening tools. In addition, a sub-sample of survey participants who score above the validated Kashmiri cut-off point on the screening tools will be selected for clinical interview using the mini-international neuropsychiatric interview (MINI) to determine whether the individual does have a psychiatric illness as defined by the DSM-IV.
Village Elder Questionnaire
A short questionnaire will be administered by the team leader to the village elder, asking specific information about the village, including presence of local healer in the community, distance (in walking minutes) to a primary health care centre, pharmacy and hospital.
Household Survey Questionnaire
The household survey questionnaire will be administered to all household membersto a randomly selected household member 18 years or and over. A separate household demographics questionnaire will be administered to the household head in order to capture specific demographic details of the household. The survey is broken up into the following sections;
Household Demographics - to be administered to the household head.
Individual questionnaire - all members of the household 18 years and over.
Additional demographic details
Difficulty in completing daily activities
Problems of daily life
Substance use
HSCL-25 culturally adapted, translated and validated tool.
Coping strategies
Traumatic Events
HTQ-PTSD-16 culturally adapted, translated and validated tool.
Household Demographics
This brief questionnaire administered to the household head is based on census demographic data, the purpose being to allow comparison of data across households. Data on each member of the household includes their position/relationship in the household, age, gender, marital status, literacy, education status and employment.
Individual demographics
This section asks for additional information specific to the individual being interviewed, including main activity, number of days per week they are engaged in employment.
Difficulty in completing daily activities
A list of common daily activities for men and women in Kashmir was constructed in June 2014 using free-listing exercises in groups representing individuals from various demographic backgrounds. During March 2015 further free-listing will be conducted to ensure an exhaustive list. The activities listed in the questionnaire in the appendix of this document may therefore be further adapted prior to translation. The respondent is asked how much difficulty they have experienced completing each task in the past month. The items are rated on a 6 point likert scale, the categories of response include; 'no difficulty', 'very little', 'a moderate amount', 'a lot' 'cannot complete the task', 'don't normally do this'.
Problems of daily life
A list of problems of daily life experienced by men and women of different ages and demographic backgrounds will be compiled using free-listing exercises in March 2015 and included in the questionnaire in order to gain data on the daily stressors Kashmiri people face in their everyday lives. Such stressors are now recognised by researches as a significant determinant of mental health in conflict-affected societies ADDIN EN.CITE Miller201095[15 42]959517Miller, K.E.Rasmussen, A.War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworksSocial Science and MedicineSocial Science and Medicine7-16702010Miller200898989817Miller, K.E.Omidian, P.Rasmussen, A.Yaqubi, A.Daudzai, H.Nasiri, M.Daily stressors, war experiences, and mental health in Afghanistan.Transucltural PsychiatryTransucltural Psychiatry45611-6392008[ HYPERLINK \l "_ENREF_15" \o "Miller, 2010 #95" 15 HYPERLINK \l "_ENREF_42" \o "Miller, 2008 #98" 42].
Substance Use
Substance use has received increasing attention in Kashmir, although substance use is not accepted by society and is against religious beliefs the use of tobacco, cannabis, alcohol, benzodiazepines, opiates and inhalants have been reported as increasing in the state of Jammu and Kashmir ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Khan, 2014 #137" 43-46]. The relationship between substance use and mental health is bi-directional. Substance use in conflict-affected populations is widespread and has been linked to health, social and protection issues, which are detrimental to mental health ADDIN EN.CITE Ezard2011141[47]14114117Ezard, N.Oppenheimer, E.Burton, A.Schilperoord, M.Macdonald, D.Adelekan, M.Sakarati, A.Ommeren, M.Six rapid assessments of alcohol and other substance use in populations displaced by conflictConflict and HealthConflict and Health51201110.1186/1752-1505-5-1[ HYPERLINK \l "_ENREF_47" \o "Ezard, 2011 #141" 47]. It is recognised that mental health problems can lead to alcohol and substance abuse when these substances are used as a form of self- medication ADDIN EN.CITE Khantzian1997142[48]14214217Khantzian, E.JThe self-medication hypothesis of substance use disorders: A reconsideration and recent applicationsHarvard Review of PsychiatryHarvard Review of Psychiatry231-244451997[ HYPERLINK \l "_ENREF_48" \o "Khantzian, 1997 #142" 48].
Questions were selected from the World Health Organisations ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test) questionnaire ADDIN EN.CITE World Health Organisation2010136[49]13613627World Health Organisation,ASSIST: The alcohol, smoking and substance involvement screening test. Manual for use in primary care.2010FranceWorld Health Organisation[ HYPERLINK \l "_ENREF_49" \o "World Health Organisation, 2010 #136" 49]. While the intent is not to use another screening instrument, by selecting a few questions on reported usage and impact of alcohol, smoking and substances an indication of the spread of substance use in the districts in the Kashmir Valley will be provided.
The formulation of questions related to substance abuse have been widely discussed with key informants and members of the community. They have been formulated with an opt out option to allow for non-participation in these questions if the respondent does not want to answer them, in this way we illicit answers only from those who feel comfortable answering questions about drug use and thereby increase the quality and reliability of our data on this highly sensitive topic.
Screening Tools for Mental Health Disorders
The Hopkins Symptoms Checklist for Depression and Anxiety (HSCL-25) and the Harvard Trauma Questionnaire Post Traumatic Stress Checklist (HTQ-PTSD-16) are reported as the most commonly used instruments in conflict-affected contexts for measuring depression, anxiety and post-traumatic stress disorder ADDIN EN.CITE Steel200996[31]969617Steel, ZChey, T.Silove, D.Marnane, C.Bryant, R.A.van Ommeren, M.Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacements: A systematic review and meta-analysis.American Medical AssociationAmerican Medical Association537-54930252009[ HYPERLINK \l "_ENREF_31" \o "Steel, 2009 #96" 31].
The Hopkins Symptoms Checklist for Depression and Anxiety was originally designed by Parloff, Kelman and Frank at Johns Hopkins University in the 1950s ADDIN EN.CITE Parloff1954110[50]11011017Parloff, M.B.Kelman, H.C.Frank, J.D.Effectiveness and self-awareness as criteria for improvement in psychotherapyAmerican Journal of PsychiatryAmerican Journal of Psychiatry343-35111151954[ HYPERLINK \l "_ENREF_50" \o "Parloff, 1954 #110" 50]. The HSCL-25 was created specifically for detecting anxiety and depression in the primary care setting. It is composed of 25 items with 10 items assessing symptoms of anxiety and a further 15 assessing symptoms of depression. Rating is via a 4-point Likert scale with categories of response being: 'never or no', 'sometimes', 'often', 'always'. Three scores are calculated from the responses; the depression score is the average of the 15 depression items and the anxiety score is the average of the 10 anxiety items. The total score is the average of all 25 items and has been shown in several populations to be highly correlated with severe emotional distress of unspecified diagnosis while the depression score is correlated with major depression as defined by the DSM-IV.
The Harvard Trauma Questionnaire, developed by Mollica et al. ADDIN EN.CITE Mollica1992114[51]11411417Mollica, R.F.Caspi-Yavin, Y.Bollini, P.Truong, T.Tor, S.Lavelle, J.The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees.Journal of Nervous and Mental DiseaseJournal of Nervous and Mental Disease111-11618021992[ HYPERLINK \l "_ENREF_51" \o "Mollica, 1992 #114" 51], measures exposure to specific traumatic events in addition to emotional symptoms with a recognised association to trauma. The HTQ consists of 4 parts; part one asks about specific traumatic events, part 2 is an open-ended description of the most traumatic events, part 3 looks specifically at head injury and part 4 includes 30 trauma symptoms ADDIN EN.CITE Harvard Program in Refugee Trauma2014112[52]11211212Harvard Program in Refugee Trauma,HPRT Questionnaire201402 May 20142014onlineHarvard Program in Refugee Traumahttp://hprt-cambridge.org/screening/harvard-trauma-questionnaire/[ HYPERLINK \l "_ENREF_52" \o "Harvard Program in Refugee Trauma, 2014 #112" 52]. The first 16 items of part 4 were derived from the DSM-IV criteria for posttraumatic stress disorder. This 16-point checklist is often used in isolation as a screening instrument for symptoms of PTSD (HTQ_PTSD-16). The checklist is comprised of 16 items rated on a 4 point Likert scale, similar to the HSCL the categories of response include; 'never or no', 'sometimes', 'often', 'always'. The DSM-IV PTSD score is calculated from averaging the scores, with a higher score suggesting an increased probability of PTSD ADDIN EN.CITE Lavelle2011115[53]1151155Lavelle, J.Mollica, R.F.Measuring trauma, measuring tortureTextbook of Global Mental Health:Trauma and Recovery, A companion Guide for Field and Cllnical Care of Traumatized People Worldwide2011Cambridge, USAHarvard Program in Refugee Trauma978-1-257-76697-0[ HYPERLINK \l "_ENREF_53" \o "Lavelle, 2011 #115" 53]. The 16-item checklist of part four of the tool has been culturally adapted and translated and is being validated for the Kashmiri population in a separate research project due to be completed in April 2015. The validated cut-off score will be used in analysis for the present survey.
Part one of the HTQ will also be included in the survey questionnaire; qualitative cultural adaptation is necessary to ensure the traumatic experiences listed are relevant to the Kashmiri population. During March 2015 further free-listing will be conducted to ensure an exhaustive list, the experiences listed in the questionnaire in the appendix of this document may therefore be further adapted prior to translation.
The HSCL and HTQ have been translated into over 30 languages and have often been used in tandem in cross-cultural research, specifically in conflict-affected contexts ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_54" \o "Shoeb, 2007 #113" 54-56]. It is important to note that these instruments are used as screening tests to facilitate detection of probable cases; therefore they express the likelihood of mental disorder. A clinical diagnosis can only be made following clinical interview.
Translation of Questionnaire into Kashmiri
The questionnaire will undergo translation into Kashmiri and back translation to English by a panel of experts from the University of Kashmir following principles described by van Ommeren ADDIN EN.CITE Van Ommeren1999108[57]10810817Van Ommeren, M.Preparing instruments for transcultural research: use of the translation monitoring form with Nepali-speaking Bhutanese refugeesTransucltural PsychiatryTransucltural Psychiatry285-301361999[ HYPERLINK \l "_ENREF_57" \o "Van Ommeren, 1999 #108" 57]. The tools will be pilot tested with a sample of 20 individuals randomly selected from one administrative area in Srinagar in order to identify areas for further revision.
Quantitative Data Analysis
Enumerators will enter household survey data directly into an electronic data collection system on android tablets. Electronic data collection saves time by providing results immediately and obviating the need for double data entry and cross-checking. A study conducted by King et al. ADDIN EN.CITE King2013134[58]13413417King, J.D.Buolamwini, J.Cromwell, E.A.Panfel, A.Teferi, T.Zerihun, M.Melak, B.Watson, J.A novel electronic data collection system for large-scale surveys of neglected tropical diseasesPLoS ONEPLoS ONEe7457089201310.1371/journal.pone.0074570[ HYPERLINK \l "_ENREF_58" \o "King, 2013 #134" 58] found that electronic data collection for a large scale household survey using android-based technology saved time, provided more accurate geographical coordinates, increased accuracy of data entered while also incurring a cost considered comparable to that of data entry and cross-checking of standard paper-based questionnaires.
Data will be exported daily into a main database and then exported into STATA or similar statistical software, cleaned and analysed using the same. Descriptive analysis will be used to provide an overview of general findings and demographic characteristics. The screening tools will be tallied to determine a scoring below or above the Kashmiri validated cut-off for each instrument. New variables will be coded for the following 5 categories;
Those scoring higher than cut-off for the HSCL anxiety related symptoms,
Those scoring higher than cut-off for the HSCL depression related symptoms,
Those scoring higher than cut-off for the HTQ PTSD related symptoms,
Those scoring higher than cut-off for both the HSCL and HTQ.
Using these variables, prevalence estimates can be calculated for each district and for the Kashmir Valley.
Using results from the sub-sample of MINI interviews calculation of effect size will be used to estimate the strength of relationship between the HSCL-25 and Depression/Anxiety diagnosis according to the MINI ADDIN EN.CITE Ghazali201459[59 60]595917Ghazali, S.R.Elklit, A.Balang, R.V.Sultan, M.A.Chen, Y.YDetermining the cut-off score for a malay language version of the Centre for Epidemiologic Studies Depression Scale (CESD)ASEAN Journal of PsychiatryASEAN Journal of Psychiatry146-1521522014deFouchier201263636317deFouchier, C.Blanchet, A.Hopkins, W.Bui, E.Ait-Aoudia, M.Jehel, L.Validation of a French adaptation of the Harvard Trauma Questionnaire among torture survivors from sub-Saharan African countries.European Journal of PsychotraumatologyEuropean Journal of Psychotraumatologyunknown32012[ HYPERLINK \l "_ENREF_59" \o "Ghazali, 2014 #59" 59 HYPERLINK \l "_ENREF_60" \o "deFouchier, 2012 #63" 60], and the HTQ-PTSD-16 and PTSD MINI diagnosis ADDIN EN.CITE Oruc200861[55]616117Oruc, L.Kapetanovic, A.Pojskic, N.Miley, K.Forstbauer, S.Mollica, R.F.Henderson, D.C.Screening for PTSD and depression in Bosnia and Herzegovina: validating the Harvard Trauma Questionnaire and the Hopkins Symptoms ChecklistInternational Journal of Culture and Mental HealthInternational Journal of Culture and Mental Health105-116122008[ HYPERLINK \l "_ENREF_55" \o "Oruc, 2008 #61" 55]. Concurrent validity coefficients will be obtained using Pearson's correlations and internal consistency calculated using Cronbach's alpha.
Potential Bias/ Limitations
Population based surveys are generally geographically representative of the general population, although groups that may be at high risk of psychiatric morbidity (such as sex workers, displaced people, army, police, prisoners etc) may not be included in the sample frame due to the fact that their living arrangements (group quarters) may not fall under those defined under the household survey. It is recognised that estimates derived from a rigorous population based survey are expected to under-estimate the true prevalence. However the extent to which this bias is likely to impact on results depends on the size of these high risk groups and the extent to which psychiatric morbidity exceeds the level of the normal population. To measure this, further research is required.
A source of bias thought to have a potentially greater impact on estimates is related to nonresponse of participants, either because they refuse to participate, are absent from the household, or become distressed during interview leading to an incomplete interview and exclusion from analysis.
Nonresponse due to households not being at home will be minimized by conducting the survey in rural areas in the months of June and July between planting andSeptember December after harvest seasons, maximizing the number of people who will be present in the household.
Nonresponse, due to refusal to participate, will be minimized by training enumerators to be thorough in explaining confidentiality, the purpose of the study and how data will be used.
Interviewee distress will be minimized by thorough training of enumerators in interviewing techniques, recognizing early signs of distress and how to manage these effectively.
Should non-response occur, the type of non-response will be recorded on the front page of the interview sheet and examined further during analysis.
A further source of error could be related to inconsistency between interviewers resulting in measurement error. This will be minimised by training of enumerators including practice interviews with a non-probability sample from an area in Srinagar. Inter-rater reliability between psychiatrists performing the clinical MINI interviews will be ensured by using the same psychiatrists that were used during the validation study where inter-rater reliability was tested and ensured prior to carrying out the validation.
A special caveat is required with respect to the impact significant events have on research outcomes, which may bias results. During the planning stages of this research study six districts in the Kashmir Valley experienced flash flooding on the 6th of September 2014 with subsequent landslides that has been estimated to have caused 5 000 Crore rupees (USD 815 million) in damage to the Jammu & Kashmir economy. While trajectories of mental illness after a natural disaster are not well researched a systematic review conducted by Santiago et al. ADDIN EN.CITE Santiago2013153[61]15315317Santiago, P.N.Ursano, R.J.Gray, C.L.Pynoos, R.S.Spiegel, D.Lewis-Fernandez, R.Friedman, M.J.Fullerton, C.S.A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: Intentional and non-intentional traumatic eventsPLoS MedPLoS Med201310.1371/journal.pone.0059236[ HYPERLINK \l "_ENREF_61" \o "Santiago, 2013 #153" 61] found that the median prevalence of PTSD increased immediately following a non-intentional traumatic event (30%), decreasing dramatically at 3 months (18%), with further decline noted at 6 months (13%). Onset of PTSD after 3 months represented a small proportion of total PTSD cases (3.5%). Fewer empirical studies examine the impact of disasters on depression and anxiety, although studies conducted in Honduras following Hurricane Mitch ADDIN EN.CITE Kohn2005155[62]15515517Kohn, R.Levav, I.Donaire, I.Machuca, M.Tamashiro, R.Psychological and psychopathological reactions in Honduras following Hurricaine Mitch: Implications for service planningReview of Panamerican Salud PublicationsReview of Panamerican Salud Publications287-2951842005[ HYPERLINK \l "_ENREF_62" \o "Kohn, 2005 #155" 62] and in Vietnam following Typhoon Xangsane ADDIN EN.CITE Amstadter2006156[63]15615617Amstadter, A.B.Acierno, R.Richardson, L.K.Kilpatrick, D.G.Gros, D.F.Gaboury, M.T.Tran, T.L.Trung, L.T.Tam, N.T.Tuan, T.Buoi, L.T.Ha, T.T.Thach, T.D.Galea, S.Posttyphoon prevalence of posttraumatic stress disorder, major depressive disorder, panic disorder, and generalised anxiety disorder in a Vietnamese sample.Journal of Traumatic StressJournal of Traumatic Stress180-188223200610.1002/jts.20404[ HYPERLINK \l "_ENREF_63" \o "Amstadter, 2006 #156" 63] reported higher rates of major depressive disorders (MDD) than PTSD in affected populations.
By delaying data collection until June September 2015 it is felt the risk of inflated prevalence rates due to the 2014 floods will be mitigated to some extent. However, the potential impact of damage to homes and livelihoods on the mental health of the affected population must be acknowledged, therefore estimates from this survey in affected districts will most likely be influenced by the impact of this disaster.
Ethical issues
The MSF ethical review board and the ethical review board at the Government Medical College in Kashmir will review the study protocol and it will not be implemented unless approval is obtained from both.
Direct Benefits
A direct benefit relates to the strengthening of MSF's current programming by providing essential information from which current activities can be reviewed with respect to relevance and effective targeting of at-risk groups.
Similarly dissemination of results will help inform other actors, such as, the Ministry of Health, psychiatric departments in hospital, the university of Kashmir and other organizations involved in mental health care in the Kashmir Valley.
Direct benefit to the individual participant is limited to the overarching benefit to the population as a whole.
A comprehensive survey using a validated screening tool will provide a scientifically robust baseline for which future research will benefit.
Indirect Benefits
The collaboration between MSF, the Department of Psychiatry at the IMHANS and the Department of Psychology at the University of Kashmir will strengthen these relationships, and increase MSFs credibility with these institutions
Contribution to research on mental health issues, policy making and planning in a context experiencing both protracted conflict and natural disasters.
Creation of knowledge base for advocacy to promote coherent policies and programming in mental health in addition to baseline data as a reference for future studies.
Direct Risks
Potential for further psychological stress related to answering sensitive questions about traumatic experiences felt by participants. Risk mitigations strategies include;
Selection of enumerators from psychology students at the University of Kashmir and individuals with prior survey enumeration experience (ie census enumerators).
All potential enumerators will receive training by psychiatrists at the IMHANS on how to ask sensitive questions and provide assistance to a distressed interviewee.
Discontinuation of the interview if distress is observed, and referral to appropriate mental health support services.
Regular briefings will be held with enumerators throughout the research process to identify issues and provide further training as required.
Indirect Risk
Risk associated with the perception by respondents and other stakeholders that the research outcomes will result in the widespread provision of MH services by MoH or MSF programs within the short term, within the region. Clear communication with stakeholders will assist in harmonising perceptions and expectations.
Consent form
In order to ensure each participant provides informed consent, and in recognition of low literacy levels, a participant information sheet and consent form will be read out by the interviewer in a language with which they are familiar, and the main aims, format and implications of the study explained to participants. Participants will be informed regarding their right to withdraw from the study at any time without penalty and issues concerning confidentiality and consent will be upheld in accordance with ethical research standards ADDIN EN.CITE Frontires201367[64 65]676727Mdecins Sans Frontires,Mdecins Sans Frontires - Research ethics framework guidance document.2013Mdecins Sans FrontiresIndian Council of Medical Research200668686827Indian Council of Medical Research,Ethical Guidelines for Biomedical Research on Human Participants2006New DelhiIndian Council of Medical Research[ HYPERLINK \l "_ENREF_64" \o "Mdecins Sans Frontires, 2013 #67" 64 HYPERLINK \l "_ENREF_65" \o "Indian Council of Medical Research, 2006 #68" 65].
Templates for the consent form and an information sheet are provided in the appendix of this document. These will be translated into Kashmiri and the information sheet will remain within the household after conducting the interviews. No incentives or inducements will be provided to any respondents.
Data Handling and Record Keeping
Questionnaires will not identify the participant in any way; use of identification numbers will ensure anonymity in data analysis. The participants age, gender and demographic characteristics will be used as identifying features for analysis; this will be explained to participants at the same time consent is sought.
Confidentiality is paramount and no information about individual participants or their household members will be accessible to any individuals not directly involved in data entry, participant identifiers will not be included in results and disseminated reports. The research team will be required to sign a non-disclosure and privacy form stating that they will not discuss information about individuals participating in the study outside of the research team. The research team will ensure the ethical principles of beneficence, non-maleficence, justice, autonomy and respect of persons are adhered to throughout the study.
All data will remain anonymous throughout the data entry and analysis process. Nominal data will not be distributed outside the study location, or appear in any report or publication.
Participant names will only be known by the clinical psychologists and psychiatrists involved in the study. The primary investigator will have access to the identification numbers in order to link data from the clinical interviews and screening instruments, these codes will be safeguarded at MSF facilities for the duration of the study. The codes will not be made available to collaborating organisations.
Collaboration
This study will be carried out by MSFH-India in collaboration with the Department of Psychiatry at the Institute of Mental Health and Neurosciences in Srinagar and the Department of Psychology at the University of Kashmir.
MSFH-India is the principal investigator and study sponsor, responsible for the funding. MSFH is in charge of the field part of the study, the analysis and report writing. Permission for publication must be obtained from MSFH-India.
Study data will belong to MSFH-India, but can be made available to collaborators on written request, according to the MSF data sharing agreement.
Responsibilities
InstituteResponsibilityPersonPosition:
MSFH-India, New Delhi
Funding for the studyAkke Boere
Head of Mission
MSFH-India, New DelhiDrafting of initial study protocol
Ensuring submission for ERB approval from MSF and Kashmir
Dissemination
Report writing
Dr. Simon Janes
Medical Coordinator
MSFH-India, KashmirProvide study sites
Provide 2 clinical psychologists to participate as research assistants during the survey.
Preparation of data collections tools and forms.
James
Cheasty
Mental Health OfficerMSFH-India, KashmirProvide MSF vehicles and drivers as required.
Logistical support as required. Liesbeth Project Co-ordinator
MSFH-India, New DelhiDrafting of initial study protocol
Coordination of study at field level
Preparation of data collections tools and forms
Data Analysis, report writing and manuscript drafting
Tambri Housen
Principal investigator
MSFH-AmsterdamDrafting of initial study Protocol
Technical Epidemiology Guidance
Data Analysis, report writing and manuscript drafting
Annick Lenglet
Epidemiologist
MSFH-AmsterdamDrafting of initial study protocol
Technical Mental Health guidance and report writingGiovanni PintaldiMental Health AdvisorMSF Manson Unit, LondonTechnical support to statistical aspects of the study design, support in data analysis and manuscript drafting
Cono AritiSenior Research Analyst - Statistician
The Department of Psychiatry at the IMHANS, KashmirAssist with preparation of research tools, review and approval of study design
Provide training facilities for enumerator training
Provide trainers for the training of enumerators in interview techniques and management of distressed interviewee.
Provide 3 psychiatrists to administer gold standard clinical interviews
Collaborate in manuscript drafting
Dr Maqbool
Head of the Department of Psychiatry
Department of Psychology at the University of Kashmir.
Ensure ethics approval from the University of Kashmir
Assist with preparation of research tools, review and approval of study design
Provide 20 psychology students to act as enumerators for the household survey
Cultural adaptation and translation of screening tools.
Translation of support documents and abridged final report.
Collaborate in manuscript drafting
Dr Showkat Shah
Head of the department of Psychology
Timeframe in the field
20142015JuneJuly AugSept*Oct NovDecJanFebMarchApril MayJune JulyAugSeptOctNovDecConcept Paper#Construction of Draft Questionnaire#Construction of Research Protocol and Ethics ###Submission to Ethics Review Boards##Preliminary Research - Instrument Validation#####Questionnaire translation and pre-testing##Sampling design and sample selection#Design of data entry program for tablets##Data analysis Planning##Recruitment of staff#Training of Enumerators#Data Collection ###Data entry, cleaning and analysis###Final Report ###Dissemination#* The time-table was affected by flash flooding in the Kashmir Valley during September 2014
Dissemination Plan
Printed and electronic versions of the final report will be provided to all partners involved in the research and relevant ministry's and departments responsible for mental health services in Kashmir. Other interested parties will be provided with electronic versions only.
Results of the research will also be communicated to the study sites via an abridged translated version of the final report. These will be distributed to the district leaders with the request that they be given to the participating sub-district leaders and village leaders.
Manuscripts will be drafted based on the methodology and results for submission in peer-reviewed scientific journals. Examples of proposed manuscripts include;
Housen, Ta, Maqbool, Mb Shah, Sc, Ariti, C. 2015. Mental health needs of a state in turmoil: voices from Kashmir. Peer Reviewed Journal.
Housen, Ta, Maqbool, Mb Shah, Sc , Ariti, C. 2015. Mental health in a conflict affected population: individual and contextual risk factors for depression and anxiety disorders. Peer Reviewed Journal.
Housen, Ta, Maqbool, Mb Shah, Sc , Ariti, C. 2015. Post traumatic stress disorder in Kashmir: A cross-sectional community survey. Peer Reviewed Journal.
Housen, Ta, Maqbool, Mb Shah, Sc , Ariti, C. 2015. The epidemiological sandwich: mixed methods research in psychiatric epidemiology. Peer Reviewed Journal.
On behalf of the Mdecins Sans Frontires working committee - Dr. Simon Janes, Annick Lenglet, Giovanni Pintaldi, Shabnum Ara,
On behalf of the IMHANS Department of Psychiatry working committee - Arshard Tina, Zaid Wani, Yasir Rather.
On behalf of the Kashmir University working committee - Budget
Since the initial budget was proposed in 2014, the survey methodology has been updated and new expenditure items identified. This budget reflects expected expenditure with an anticipated commencement date of 6th September 2015INR Indian RupeeUpdated Budget 2015DescriptionCost INRQuantitySurvey Period daysUpdated BudgetUpdated BudgetCommentsHuman resourcesInternational StaffPrincipal InvestigatorINR 0.00 0 . 0 0 C u r r e n t l y e m p l o y e d b y M S F - O C A I n d i a A d d i t i o n a l L o g i s t i c i a n 1 4 m o n t h s 3 , 5 0 0 . 0 0 N a t i o n a l S t a f f E n u m e r a t o r R e m i t t a n c e 2 5 0 4 0 5 0 I N R 5 0 0 , 0 0 0 . 0 0 7 , 0 0 0 . 0 0 4 0 E n u m e r a t o r s f o r 8 w e e k s d a t a c o l l e c t i o n ( 4 0 d a y s ) i n c r e a s e d w i t h s a m p l i n g m o d i f i c a t i o n s - a l s o i n c l u s i v e o f 2 w e e k s t r a i n i n g . I n t e r v i e w e r R e m i t t a n c e 2 5 0 5 3 0 I N R 3 7 , 5 0 0 . 0 0 5 2 5 . 0 0 I n i t i a l b u d g e t i n c l u d e d P s y c h i a t r i s t r e m i t t a n c e , h o w e v e r f o r t h e s u r v e y t h e d e c i s i o n w a s m a d e t o u s e p s y c h o l o g y g r a d u a t e s f o r t h e q u a l i t a t i v e c o , m p o n e n t B a c k - u p e n u m e r a t o r s 2 5 0 5 1 0 I N R 1 2 , 5 0 0 . 0 0 1 7 5 . 0 0 B a c k - u p e n u m e r a t o r s w i l l r e q u i r e p a y m e n t d u r i n g t r a i n i n g ( 2 w e e k s ) R e s e a r c h A s s i s t a n t 5 0 0 0 0 1 3 I N R 1 5 0 , 0 0 0 . 0 0 2 , 1 0 0 . 0 0 F u l l - t i m e l o c a l r e s e a r c h a s s i s t a n t t o a s s i s t t h e e p i d e m i o l o g i s t i n q u a l i t y c o n t r o l a n d o t h e r r e s p o n s i b i l i t i e s r e l a t e d t o r e s e a r c h m e t h o d o l o g y 3 m o n t h s S U B T O T A L 7 0 0 , 0 0 0 . 0 0 1 3 , 3 0 0 . 0 0 R u n n i n g c o s t s T r a i n i n g C o s t s 5 0 0 1 1 0 I N R 5 , 0 0 0 . 0 0 7 0 . 0 0 R o o m C o v e r e d b y U n i v e r s i t y o f K a s h m i r - o n l y f o o d c o s t s C o m m u n i c a t i o n s , n e w s p a p e r a d d s a n n o u n c i n g s u r v e y 3 0 0 0 0 1 1 I N R 3 0 , 0 0 0 . 0 0 4 2 0 . 0 0 P r e - s u r v e y a d v e r t i s i n g a n d r a d i o i n t e r v i e w s T e l e p h o n e c o s t s 3 0 0 2 0 2 I N R 1 2 , 0 0 0 . 0 0 1 6 8 . 0 0 3 0 0 I N R c r e d i t t o p u p e a c h f o r T e a m L e a d e r ( x 1 0 ) , D r i v e r ( x 1 0 ) p e r m o n t h S i m C a r d s f o r t a b l e t s / W i f i H o t e l 4 0 0 4 0 1 I N R 1 6 , 0 0 0 . 0 0 2 2 4 . 0 0 E a c h e n u m e r a t o r w i l l r e c e i v e 4 0 0 I N R t o u s e h i s / h e r o w n p e r s o n a l p h o n e a s a h o t s p o t f o r d a t a t r a n s f e r D a i l y L u n c h f o r t e a m s 1 2 0 5 5 4 0 I N R 2 6 4 , 0 0 0 . 0 0 3 , 6 9 6 . 0 0 L u n c h w i l l b e s u p p l i e d b y a l o c a l h o t e l a n d p i c k e d u p e a c h m o r n i n g A c c o m m o d a t i o n f o r t e a m i n B a r a m u l l a 5 0 0 2 5 1 5 I N R 1 8 7 , 5 0 0 . 0 0 2 , 6 2 5 . 0 0 R e c r u i t i n g e n u m e r a t o r s f r o m e a c h d i s t r i c t w i l l m i n i m i s e a c c o m m o d a t i o n c o s t s , r e q u i r e d w h e r e a c c e s s i n g r e m o t e v i l l a g e s C a r g o C o s t s 1 0 0 0 0 1 1 I N R 1 0 , 0 0 0 . 0 0 1 4 0 . 0 0 T r a n s p o r t c o s t s f o r m a t e r i a l s f r o m D e l h i t o S r i n a g a r S U B T O T A L 5 2 4 , 5 0 0 . 0 0 7 , 3 4 3 . 0 0 M a t e r i a l c o s t s T r a n s l a t i o n o f S u r v e y s I N R 0 . 0 0 0 . 0 0 C o v e r e d b y t h e u n i v e r s i t y o f K a s h m i r T r a n s l a t i o n o f T r a i n i n g m a n u a l s I N R 0 . 0 0 0 . 0 0 C o v e r e d b y t h e u n i v e r s i t y o f K a s h m i r S m a r t p a d s f o r d a t a c o l l e c t i o n 7 5 0 0 4 0 1 I N R 3 0 0 , 0 0 0 . 0 0 4 , 2 0 0 . 0 0 4 0 t a b l e t s w i t h p r o t e c t i o n c a s e s a n d a n t i - g l a r e s c r e e n s S t a t i o n a r y I N R 0 . 0 0 0 . 0 0 E x t r a s t a t i o n a r y - c l i p b o a r d s , p e n s , o t h e r d o c u m e n t s I D c a r d s 5 0 5 0 1 I N R 2 , 5 0 0 . 0 0 3 5 . 0 0 M S F I D c a r d s f o r e n u m e r a t o r s B a c k p a c k s / b a g s 7 0 0 4 5 1 I N R 3 1 , 5 0 0 . 0 0 4 4 1 . 0 0 C a r r y b a g s o r b a c k p a c k s f o r e n u m e r a t o r s a n d i n t e r v i e w e r s C o n s e n t a n d I n f o r m a t i o n s h e e t s 2 3 5 0 0 1 I N R 7 , 0 0 0 . 0 0 9 8 . 0 0 P a p e r q u e s t i o n n a i r e s I N R 1 0 , 0 0 0 . 0 0 1 4 0 . 0 0 B a c k u p p a p e r q u e s t i o n n a i r e s f o r e a c h c a r i n c a s e o f i s s u e s w i t h t a b l e t s U S B c a r c h a r g e r s 9 0 0 1 0 1 I N R 9 , 0 0 0 . 0 0 1 2 6 . 0 0 c h a r g i n g t a b l e t s i n c a s e o f l o w b a t t e r y M u l t i p l u g s f o r c h a r g i n g t a b l e t s ( 4 s o c k e t s ) 1 0 0 0 1 0 1 I N R 1 0 , 0 0 0 . 0 0 1 4 0 . 0 0 S U B T O T A L I N R 3 7 0 , 0 0 0 . 0 0 5 , 1 8 0 . 0 0 T r a n s p o r t N a t i o n a l f l i g h t s t o s t u d y l o c a t i o n ( D e l - S r i n ) 8 0 0 0 5 1 I N R 4 0 , 0 0 0 . 0 0 5 6 0 . 0 0 S t u d y c a r s ( e a c h c a r 2 2 0 0 / d a y ) 2 2 0 0 4 4 0 I N R 3 5 2 , 0 0 0 . 0 0 4 , 9 2 8 . 0 0 F o u r h i r e c a r s i n c l u s i v e o f d r i v e r a n d f u e l - M S F h a v e 6 c a r s a v a i l a b l e f o r u s e D r i v e r s 6 2 2 6 4 0 I N R 1 4 9 , 2 8 0 . 0 0 2 , 0 8 9 . 9 2 M S F h a s 5 c a r s b u t r e q u i r e d r i v e r s f o r t h e s e c a r s - h i r e c a r i n c l u d e s d r i v e r F u e l ( D e i s e l ) 8 6 4 0 1 0 2 I N R 1 7 2 , 8 0 0 . 0 0 2 , 4 1 9 . 2 0 8 6 4 0 I N R / c a r / m o n t h f u e l c o n s u m p t i o n b a s e d o n 1 0 0 0 k m / m o n t h / c a r S U B T O T A L I N R 7 1 4 , 0 8 0 . 0 0 9 , 9 9 7 . 1 2
D i s s e m i n a t i o n F i n a l R e p o r t a n d A b r i d g e d r e p o r t p r i n t i n g 3 0 0 5 1 I N R 1 , 5 0 0 . 0 0 2 1 . 0 0 f i n a l r e p o r t f o r s u b m i s s i o n t o u n i v e r s i t y , a n d M o H - o t h e r s w i l l b e s e n t e l e c t r o n i c a l l y A b r i d g e d f i n a l r e p o r t 5 3 0 0 1 I N R 1 , 5 0 0 . 0 0 2 1 . 0 0 f i n a l a b r i d g e d r e p o r t f o r e a c h p a r t i c i p a n t v i l l a g e P r e s e n t a t i o n o f R e s u l t s 0 0 0 I N R 0 . 0 0 0 . 0 0 c o v e r e d u n d e r f l i g h t s - 1 f l i g h t t o s r i n a g a r t o p r e s e n t D i s t r i b u t i o n o f A b r i d g e d r e p o r t 2 2 0 0 1 5 I N R 1 1 , 0 0 0 . 0 0 1 5 4 . 0 0 1 c a r f o r 5 d a y s t o d i s t r i b u t e a b r i d g e r e p o r t t o d i s t r i c t a d m i n i s t r a t o r t o d e l i v e r t o v i l l a g e s ( 2 d i s t r i c t s p e r d a y ) M i s c e l l a n e o u s 1 0 0 0 . 0 0 0 u n f o r s e e n e x p e n d i t u r e s S U B T O T A L I N R 1 4 , 0 0 0 . 0 0 1 1 9 6 . 0 0 T O T A L 2 , 3 2 2 , 5 8 0 . 0 0 3 7 , 0 1 6 . 1 2
M e n t a l H e a l t h Survey Household Head- Kashmir 2014
Instructions for Tablet in green
Pre-Survey Information for the Interviewer HH questionnaire number |4|4|5|_(This will be entered by the interviewer)
These questions will be programmed on to a tablet and administered electronically with checks and controls to mitigate recording errors.
Section 1: Basic information SPECIAL CODES 98 respondent does not know 99 no answer
Question codeQuestionL1*District Drop down of all 10 Districts L2*Sub district I will have a list printed and they can type in the codeL3* Block I will have a list printed and they can type in the codeL4* Village I will have a list printed and they can type in the codeL5Size of locality (from community leader)
Less than 100 inhabitants101-300 inhabitants301-1000 inhabitants1001-5000 inhabitantsMore than 5 000 inhabitantsL6Area UrbanRuralL7Name of interviewer (they will have individual codes which they will type in ) L8Interview date (automated)|__|__| date |__|__| monthInterviewer start time (automated)|__|__|:|__|__|Interviewer end time (automated)|__|__|:|__|__|
Identify the household
L9 Record the correct code in the columnL10 Reason given for consent being refusedHousehold Head Consented to be interviewed
Nobody at home
Household next door selected for interview
HH member not at home but another member of HH randomly selected and consented to be interviewed
Refused Consent ( L10
House not found
Other (specify)Not enough time
HH head not present to give consent
Refused and did not want to give a reason
Other (please type in reason for refusal)
Here there needs to be an option to continue or to save and exit this way we keep a record of the households that refused consent and why, or HH that could not be located important for analysis.
We appreciate you giving permission to interview a member of your family. Before we do so we would like to ask you a few questions about your household. The information we collect is for our research only and will not be shared with anyone else.
FOR THE HOUSEHOLD HEAD
Section 2: Household Demographics[all individuals in the household, start with household head] SPECIAL CODES respondent does not know [98] no answer [99]
HHH1At this time how many people live in this household?
A household member is someone who has lived in the household for more than 3 months in the past 12 months.|__|__| persons
HHH2
We will go thru each member of the household one at a time and ask some questions about their age, gender, occupation etcHHH3HHH4HHH5HHH6Household head
Spouse of household head
Child of household head
Sister/brother of Household head
Grandchild of household head.
Parent of Household head
Other relatives
Other non-relativesRecord in years.
If less than 1 year record as <1
Female
Male
Not Married
Married
Separated/ Divorced
Widowed
Half Widow
Muslim
Hindu
Buddhist
Christian
None
OtherNontas can there be a drop down where the interviewer can choose who this person is as per the categories above then it goes thru each of the following questions and when it gets to HHH9 it then asks if they want to add another person if yes it starts again at this drop down list if no it moves on to the question HHH10 about making sure they have included everyone.
HHH8
(highest level reached)HHH9
What is the main activity of each member of the Household?No formal schooling
Primary
Middle School
High School
12th/ higher secondary
Graduate
Post-graduate
Vocational
OtherEmployed
Self - employed
Contract worker (labor)
Unpaid work on family farm/ business
Student
Unemployed
Home duties
Too young to work or retiredTo make sure I have a complete listing of all persons in the household ask the following question and add any people not previously mentioned
HHH10. Are there any other person(s), such as small children, infants, or old person that we have not listed? A household member is someone who has lived in the household for more than 3 months in the past 12 months.
YES/NO Option (if yes, return to the drop down list HHH2)
HHH11Who is the main earner in the household? [Is it possible to generate a drop down list with a summary of age and gender from the initial list made above?] If the household has no income from anywhere type 0 in the answer box.|__|__|
HHH12
HHH13To what degree does the family depend on others for livingDoes your family have at least two meals a day?
Are you self supportive (don't need any extra help).
Are you nearly self-sufficient (get some help from others)
Are you highly dependent on charity but have some additional income of our own.
Are you totally dependent on assistance from others.
Always (7 days per week)
Sometimes (3-5 days per week)
Rarely (1-2 days per week)
Never
HHH14Has anyone in your family suffered from a mental illness?Yes
No
HHH15Did the mental illness stop them from carrying out their normal daily activities?Yes
No
HHH16Do you know about the radio show Alaw Bay AlawYes
NoIf yes then a new question should pop up
How often did you use to listen to Alaw Bay Alaw?I didnt listen to it
Sometimes
Always
HHH17Do you know about the television show Alaw Bay AlawYes
NoIf yes then a new question should pop up
How often did you watch Alaw Bay Alaw?I didnt watch it
Sometimes
Always
Thank you for your time, now we would like to randomly select one person over the age of 18 years from your household to interview.
Now, using the household list you must randomly select one individual over the age of 18yrs). (is it possible to automatically generate a drop down list with age/gender of the household members listed above this could be restricted to those reporting an age over 18years or just include everyone if easier and the interviewer can select those over 18years)
Then a box or circle next to each persons details so the one randomly selected can be marked as such.
Ask to see this person and Now explain the research using the consent information sheet.
Appendix 2 Mental Health Survey Participant- Kashmir 2014
FOR THE PARTICIPANT HH questionnaire number |_|4|4|5| (automatically generated from above if possible)
Individual questionnaire number |__|__|__|__| (is it possible to automatically generate from the HH number with an I in front eg I445
Make sure you have read the information sheet and have a signed consent form Read the following statement
It is important we have some privacy for our conversation because some of the questions may be sensitive
L11 Record the correct code in the columnL12 Reason given for consent being refusedIndividual consented to be interviewed
Individual not at home
Individual Refused Consent ( L10
Other (specify____________________)Not enough time
Refused and did not want to give a reason
Other (please type in reason for refusal__________)L13
In the case of refusal of consent or absence of randomly selected member of the household another member of the household >18 years was randomly selected Yes
No
Participant Demographics (PD) SPECIAL CODES respondent does not know [98] no answer [99]
PD1PD2PD3PD4PD5Gender Age (in years)What is your main activity
If employed How many days a week do you workWhat is your main employment activity?Female
MaleEmployed ( PD4
Contract worker ( PD4
Self Employed ( PD4
For all answers below ( PD6
Unpaid work on family farm/ business
Student
Unemployed
Home duties
Too young to work or retiredRecord the number of daysRefer to Industry codes and record the correct code below
(These I will have a as a laminated separate list they will carry with them and type in )
PD6 In general how would you say your physical health isExcellent
Good
Ok
Poor
Very Bad Section 5: Daily Activities
I am going to read a list of activities and duties. These are task and duties that other Kashmiri's have told us are important to them. For each one I am going to ask you how much difficulty you have in completing this task compared to other men/women your age. Take a look at this picture (show then the visual cue card) and let me know which picture shows how much difficulty you have with each activity. If you do not normally do this activity please tell me.
SPECIAL CODES respondent does not know [98] no answer [99]
In the past month how much difficulty have you had in completing these tasks?NoneVery LittleA moderate amountA lotCannot doI dont normally do thisDA1Employment012345DA2Cooking012345DA3Providing for the family012345DA4Looking after family affairs and problems012345DA5Caring for family members012345DA6Household work012345DA7Manual labour/ agricultural work012345DA8Pray012345DA9Studying012345DA10Giving advice to other community members012345DA11Exchanging ideas with others012345DA12Having harmonious relationships with husband/wife and family012345DA12Bringing up children correctly012345DA14Sympathising with others012345DA15Visiting and socialising with others in the community012345DA16Asking for and getting help when you need it012345DA17Making decisions012345DA18Taking part in family activities or events012345DA19Taking part in community activities or events012345DA20Attending mosque 012345DA21Attending shrines012345DA22Attending religious gatherings012345
Nontas the pics below we will laminate and print as a separate thing that interviewers can give people to hold throughout these questions and they can point to the picture that is most relevant so dont worry about including them in the tab.
Non-Verbal Response Card for Kashmiri Functioning Questions
0 1 2
3 4
DA22In the past 4 weeks how much of the time did you have to cut down on what you did and did not get as much done as usual because you had tension or parishani All of the time
Most of the time
Some of the time
A little of the time
None of the timeDA21In the past 4 weeks how much of the time were you totally unable to carry out your normal daily activities because you had tension or parishaniAll of the time
Most of the time
Some of the time
A little of the time
None of the time
Problems of Daily Life
PDL1 Can you tell me the main problems you face in daily life?
(dont read the list just mark the ones the person mentions)
Needs to be a list with circles for each so interview can tap the ones that are relevantNot enough money
Life is too expensive
Unemployment
No job security
Technology abuse of internet/phones
Nothing to do sitting at home
Social breakdown so people keep to themselves now
Lack of social interaction
Domestic violence
Substance Abuse
Tension or Pareshani
Poor physical health of self
Poor physical health of another family member
Section 6: Drugs and Alcohol (DA) SPECIAL CODES respondent does not know [98] no answer [99]
Now in Kashmir, people face many problems and some take medicines to help them relax and sleep.
DX1DX2DX3Do you take medicine to help you relax and get a good sleep?
Who recommended you take this medicine?For how long have you been taking this medicine?Yes
No
Doctor
Traditional Healer (Pear Sahib)
Friend
Family member
Other
One week or less
Less than one month
1-3 months
3-6 months
6months 1 year
2years
3years
>3 years
As you may be aware, many people in Kashmir have Tension or Pareshani, some of these people take other medicines or substances to help them relax and cope with life. As people working in mental health we understand how these substances are used by people to make them feel better for a period of time, we also understand how dangerous these substances are on peoples health. There are not many services available to help people in Kashmir with addiction problems. We hope our survey can bring more attention to this important issue that is affecting many Kashmiri households. But to do this we need to know how widespread the problem is in Kashmir. We understand this is a sensitive topic and many people do not want to talk about these issues. We want to remind you that your name or your familys name is nowhere on this questionnaire, it is not recorded by any of us and everything you tell us will be mixed together with what other people tell us, so that no-one will know what you have said.
Now we would like to ask your assistance to find out more about addiction problems in Kashmir.
DX4DX5DX6Do you feel comfortable to tell us about drug use in your community?Have you ever used any of the following substances, now or in the past? (if relevant circle more than one)
Have a yes/no option for eachHas a family member ever used any of these substances now or in the past? (if relevant circle more than one)
Have a yes/no option for eachYes
No ( go to HSCL questionsBrown Sugar (Medicinal Opiods)
Chalas (Marijuana)
Cough Syrup
Spazmo proxafin
Alcohol
Other (name)Brown Sugar (Medicinal Opiods)
Chalas (Marijuana)
Cough Syrup
Spazmo proxafin
Alcohol
Other (name)
DX7Do you know of someone in your community who uses any of these substances? (if relevant circle more than one) Have a yes/no option for eachBrown Sugar (Medicinal Opiods)
Chalas (Marijuana)
Cough Syrup
Spazmo proxafin
Alcohol
Other (name)
Administer validated Diagnostic tool for depression/ anxiety / PTSD / Trauma
Can the answers be added and divided by the number of questions for each tool and shown at the completion of the whole interview.
. HSCL Anxiety Score = HSCL1-10/10, HSCL Depression Score = HSCL11-25/15.
Read out the instructions in Bold and Italics to the respondent
Anxiety Symptoms Hopkins Checklist
I will read a list to you. Can you please tell me how often you have experienced these items in the
Last 4 weeks F F ' 2F
K e h e e n n e z e h a e n n e
N e v e r o r N o FP 3'9*
K u u n i s a a t i
S o m e t i m e s '+1
A k s a r
O f t e n E4
H a m e e s h a
A l w a y s H S C L 1 *O E' PH F * EF H'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T u e h m a t c h e i v h a n g h t e m a n g a e k h o e c a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n w h e r e y o u s u d d e n l y S c a r e d f o r n o r e a s o n
1
2
3
4 H S C L 2 *H E'PH .HA ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h u k h o o f b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l F e a r f u l
1
2
3
4 H S C L 3 *H E'PH4 ' H1 H ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h u g u s h y a g y o o r h u e b a s s a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l F a i n t n e s s
1
2
3
4 H S C L 4 *H E' PH ~FOF ~'F H31HEO* H('3'F/ *O E' PH ('E(1'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h u p a n u n p a a n v a e s r o e m u t h h u e b a s a a n / T u e h m a t c h e i v b a m b r a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l N e r v o u s n e s s
1
2
3
4 H S C L 5 /PD E' PH ND'F/ /P D E' PH1'H'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e D i l m a t c h u c a e l a a n / d i l m a t c h u r a v a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l y o u r H e a r t p o u n d i n g o r r a c i n g f a s t
1
2
3
4 H S C L 6 *1 *1 E' H HH*'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T h a r t h a r m a t c h e v o t h a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l T r e m b l i n g
1
2
3
4 H S C L 7 ( F E' H ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e B e c h a n e e m a t c h u b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l T e n s e
1
2
3
4 H S C L 8 D /H/E' PH 1'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e K a l i d o a d m a t c h u k a r a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l H e a d a c h e s
1
2
3
4 H S C L 9 *HP E' PH EF2 ** HE ('3'F 2( E' E1 HF
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h u m a n z i h t u e t h v a h m e h b a s a a n z e b e h m a r e h v a e n i
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l E p i s o d e s o f t e r r o r o r p a n i c
1
2
3
4 H S C L 1 0 ,3E3 E' ( B1'1 ('3'F 2*O PHF '3 ,' /1'F / F ,'P /1'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e J i s m a s m a t c h e b e k a r a r e e b a s a a n z e h t u e h t c h e i v n e h a k s e e j a y e h d a r a n e e / k u n i h j a y e h d a r a n e e
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u F e e l r e s t l e s s , c a n t s i t s t i l l
1
2
3
4 D e p r e s s i o n S y m p t o m s H o p k i n s C h e c k l i s t H S C L 1 1 *HP E' F * EF ~FOF ~'F .7'H'1 / B5H1H'1 ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a h a n g h t e m a n g a e p a n u n p a a n k h a t a h v a a r / k a s o o r v a a r b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u B l a m e y o u r s e l f f o r t h i n g s
1
2
3
4 H S C L 1 2 *H E' F * EF HN/F HH'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a h a n g h t e m a n g a e v a d u n h u e y e v a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u C r y e a s i l y , f o r n o r e a s o n
1
2
3
4 H S C L 1 3 *HP E' ,F3 .H'4F EF2 E ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a j i n s e e k h a h i s h a n m a n z k a m e e b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l L o s s o f s e x u a l i n t e r e s t o r p l e a s u r e
1
2
3
4 H S C L 1 4 *HP E'F'HHE/ 4 ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a n a u m e e d i h i s h b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l F e e l i n g h o p e l e s s a b o u t t h e f u t u r e
1
2
3
4 H S C L 1 5 :EF E' PH 1H2'F ( 3H1 2NF /2'F H ('3'F)
P a t m a e v t c o e r a v h a f t a v p a e t h e e G a m g e e n m a t c h e i v r o z a a n ( s o e r i z a n e h d a z a a n h u e b a s a a n )
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l S a d n e s s
1
2
3
4 H S C L 1 6 *HP E' H ~FF ~'F OF 8HF ('3'F/ ~1HF ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h u p a n u n p a a n k u n z o e n b a s a a n / p a e r c o e n b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l L o n e l y
1
2
3
4 H S C L 1 7 *HP E' .H/4/ ~FF ~'F E'1F .'D H'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a k h o d h k a s h e e y a p a n u n p a a n m a r n u k h k h a y a l y e v a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u T h i n k a b o u t e n d i n g y o u r l i f e
1
2
3
4 H S C L 1 8 *HP E' ('3'F 2F E5(*H F'D HHDE*
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a b a s a a n z a n e h m u s e e b a t o o n a a l v o l m u t h
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u h a v e t h e f e e l i n g o f b e i n g N o t f r e e o r c a u g h t
1
2
3
4 H S C L 1 9 *HP E' F * EF A1 1H2'F/ ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a h a n g h t e m a n g a h f i k i r r o z a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u W o r r y t o o m u c h a b o u t t h i n g s
1
2
3
4 H S C L 2 0 *HP E' HF F 3* /D3~ ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h a e n e h k u n i h s e i t h d i l c h a s p e e b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u f e e l a L o s s o f i n t e r e s t i n t h i n g s
1
2
3
4 H S C L 2 1 *H E' HF ~FF3 ~'F3 'F HB9* ('3'F/ *HP E' H ~NFF ~'F ('BH F4 E ~'P ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h a e n e h p a n e n i s p a a n a s k h a n e v u k h t e e b a s a a n / T o e h i m a t c h u e p a n u n p a a n b a k e y a e v n i s h k a m p a y e e b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u F e e l i n f e r i o r t o o t h e r s , t h i n k y o u r s e l f a s w o r t h l e s s
1
2
3
4 H S C L 2 2 ( * E' H ('3'F/ E * E' H ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e B e h a k h t e e m a t c h u b a s a a n / k a m h a k h t e e m a t c h u b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u F e e l l o w i n e n e r g y , s l o w e d d o w n
1
2
3
4 H S C L 2 3 FF/1EF2 E' H F B3E .DD/ /B* H'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e N e e n d r e m a n z m a t c h u k u n i h k i s m i c h k h a l a l / d i k a t h y e v a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u e x p e r i e n c e D i f f i c u l t y s l e e p i n g
1
2
3
4 H S C L 2 4 *H E' H ~1* 'F 'E ~' 4 ' E4D ('3'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h e p r a e t h k a h k a e m m u s h k i l b a s a a n / p a h a a d h i s h b a s a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u F e e l t h a t e v e r y t h i n g y o u d o i s d i f f i c u l t
1
2
3
4 H S C L 2 5 *HP E'H(H E ('3'F/ E'D E' 1HHE*
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a t c h e b o e c h e e k a m b a s a a n / m a e l m a t c h u r o e v muth
In the last four weeks how often did you experience Poor appetite
1
2
3
4KS1*In the last four weeks how often did you wish you were dead*1234KS2In the last four weeks how often have you had stomach upset (medau doad)1234KS3In the last four weeks how often have you had a burning sensation in your body (saersee paanas naar vothaan)1234KS4In the last four weeks how often have you had body pain (saersi paanas dash basasn)1234KS5In the last four weeks how often have you experienced a choking feeling (Dum Gacaan)1234
Section 9: Coping SPECIAL CODES respondent does not know [98] no answer [99]
When you are feeling tension or pareshani what do you do? (let the person talk and mark the ones they mention do not read as a list)
Will need a circle for each one that can be pressed if relevant.
C1Pray
Go to mosque or shrine
Talk to friend/family member
Take medicine given to me by a doctor
Take medicine I buy myself
Go to doctor
Go to traditional healer (pear sahib)
I try to keep busy
I want to be alone
I go for a walk
I cry
I become angry/aggressive
I take tobacco smoking/chewing
I take other drugs (cannabis, opiods, sniff substancesSection 10: Security SPECIAL CODES respondent does not know [98] no answer [99]
S1
Do you feel safe in your environment?Always
Most of the time
Occasionally
Never
Life Event Checklist Modified
I am going to read out a difficult or stressful experience that sometimes happen to people. For each one, I will ask you if it has (a) happened to you personally, (b) you saw it happening to someone else, (c) you know someone who has experienced this or (d) it does not apply to you or anyone you know.
Be sure to consider your entire life (growing up and in adulthood)Happened to me
Witnessed it happening to someone else
Know someone who this has happened to but did not witness it
Does not apply to me or anyone I know
LE1Natural disaster (flood, earthquake, snow slide, avalanche, landslide?)4321LE2Fire or explosion4321LE3Transportation accident (for example sumo, bus, motorbike, car)4321LE4Serious accident at work, home or during an activity4321LE5Physical assault (being hit, attacked, beaten)4321LE6Sexual assault (rape, attempted rape, made to perform a sexual act through force or fear or harm)4321LE7An unwanted or uncomfortable sexual experience4321LE8Assault with a weapon (for example Being shot, stabbed, threatened with a gun or knife)4321LE9Combat or exposure to militant or military attacks (example cross fire, explosion of mines/grenades)4321LE10Combat related attacks (round up raids, crackdown, frisking)4321LE11Sudden violent death of someone you know4321LE12Captivity (kidnapped, imprisoned, abducted, held hostage)4321LE13Interrogation or harassment with threats to life4321LE14Torture4321LE15Friends or family members have disappeared4321LE16Sudden unexpected death of someone you know (suicide, accident, natural disaster)4321LE17Forced to separate from friend or family members4321LE18Life-threatening illness or injury 4321LE19Los of property or belongings4321LE20Severe human suffering4321LE21Any other stressful event or experience (name)4321
Section 4: Post Traumatic Stress Disorder tool Total PTSD Score = PTSD1-16/16
Harvard Trauma Questionnaire Part IV - symptoms of PTSD
The following are problems that people sometimes have after experiencing h u r t f u l o r t e r r i f y i n g e v e n t s i n t h e i r l i v e s .
F o r e a c h p r o b l e m p l e a s e s t a t e h o w o f t e n y o u h a v e h a d i t i n t h e l a s t 4 w e e k s i n c l u d i n g t o d a y . F F ' 2F
K e h e e n n e z e h a e n n e
N e v e r o r N o F 3'9*
K u u n i s a a t i
S o m e t i m e s '+1
A k s a r
O f t e n E4
H a m e e s h a
A l w a y s P T S D 1 *HP E' H F -'D .HAF' H'B .'D H'F * H'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a k u u n i h a a l e y k h o o f n a a k v a a k a e h i k h k h a y a l y e v a a n t e y e v a a n
I n t h e l a s t f o u r w e e k s h o w o f t e n d i d y o u e x p e r i e n c e R e c e n t t h o u g h t s o r m e m o r i e s o f t e r r i f y i n g o r h u r t f u l e v e n t s
1
2
3
4 P T S D 2 *HP E' 'F .HAF' H'B9 'F (1HF F H'F * H'F
P a t m a e v t c o e r a v h a f t a v p a e t h e e T o e h i m a k h a n e h k h o o f n a a k v a a k a h a e c h a n b r o n k h a n e y e v a a n t e y e v a a n
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