title: Psychological distress during pregnancy in a conflict-affected area in Pakistan: A study of prevalence, risk factors, and an intervention to improve awareness
Creators: name: Khan, Muhammad
Publisher: name: University of Liverpool Repository
Year: 2015

description: Background Humanitarian emergencies, including conflict, are a known risk factor for common mental disorder. The impact of such an emergency on the mental health of women in the perinatal period has not been studied. This is important because, in addition to personal and family distress, poor perinatal mental health has a negative impact on infant development and contributes to inter-generational disadvantage. Lack of awareness about such conditions hinders appropriate help seeking. This study, which was conducted in a post-conflict area in Swat, Pakistan, had the following aims: a) to determine the prevalence and associations of psychological distress in perinatal women, and; b) to evaluate the feasibility of a psycho-educational intervention to improve awareness of common mental disorder amongst such women and their families. Methods The study was conducted in a rural area in Swat that had witnessed a decade-long armed conflict between the military and local insurgents. Study participants included all pregnant women on the list of local community health workers (Lady Health Workers) aged 17 to 45, living in the study area and not suffering from a physical disorder. Psychological distress was assessed using the Self Reporting Questionnaire (SRQ). Conflict-related traumatic events were measured with the Harvard Trauma Questionnaire (HTQ). Stressful life-events and perceived social support were measured by the Life Events Checklist and the Multidimensional Scale of Perceived Social Support (MSPSS), respectively. Information was also collected on demographic and socio-economic variables. Half of the women who scored =&gt;9 on the SRQ (n=34) were randomised to receive a 2-session psychoeducational intervention, and the remaining (n=37) acted as controls. Outcomes including appropriate help-seeking, perceived social support and levels of psychological distress were measured 2 months after intervention delivery. Results The prevalence of psychological distress (SRQ score =&gt;9) was 38.1%. Psychological distress was positively associated with four or more traumatic events and there was a dose-response relationship, with levels of psychological distress increasing with an increase in the number of traumatic events [4 events (OR=2.80, 95% CI: 1.18 to 6.65), 5 (OR=2.85, 95% CI: 1.04 to 7.79) and 6 or more (OR=4.62, 95% CI: 1.59 to 13.44)]. Psychological distress was also independently associated with three or more stressful life events in the post-conflict year. Family support and living in a joint family was protective, as was being primi gravida. There was very low level of recognition of psychological distress in the trial participants at the baseline. Following intervention, more women sought assistance for their distress from their community health worker in the intervention arm, compared to women in the control arm (71% intervention arm vs 46% control arm P= 0.036). There was no difference in the levels of perceived social support or severity of symptoms although mean reduction of SRQ score from baseline was significantly more in the intervention arm compared to control arm. There was a high response rate, and attrition rates were low. Conclusions This study is one of the first epidemiological studies to assess the prevalence of psychological distress during pregnancy in an area affected by conflict. The study shows that over a third of all women show evidence of significant psychological distress, and are likely to be suffering from a common mental disorder. A psychoeducational intervention to improve awareness and appropriate help seeking showed promising results in the context of this rural post-conflict setting.