Health and Quality of Life Outcomes BioMed Central

Background: The Medical Outcomes General Health Survey (SF-36) is a widely used health status measure; however, limited evidence is available for its performance in orthopedic settings. The aim of this study was to examine the magnitude and meaningfulness of change and sensitivity of SF-36 subscales following orthopedic surgery. Methods: Longitudinal data on outcomes of total hip replacement (THR, n = 255), total knee replacement (TKR, n = 103), arthroscopic partial meniscectomy (APM, n = 74) and anterior cruciate ligament reconstruction (ACL, n = 62) were used to estimate the effect sizes (ES, magnitude of change) and minimal detectable change (sensitivity) at the group and individual level. To provide context for interpreting the magnitude of changes in SF36 scores, we also compared patients' scores with age and sex-matched population norms. The studies were conducted in Sweden. Follow-up was five years in THR and TKR studies, two years in ACL, and three months in APM. Results: On average, large effect sizes (ES≥0.80) were found after orthopedic surgery in SF-36 subscales measuring physical aspects (physical functioning, role physical, and bodily pain). Small (0.20–0.49) to moderate (0.50–0.79) effect sizes were found in subscales measuring mental and social aspects (role emotional, vitality, social functioning, and mental health). General health scores remained relatively unchanged during the follow-up. Despite improvements, post-surgery mean scores of patients were still below the age and sex matched population norms on physical subscales. Patients' scores on mental and social subscales approached population norms following the surgery. At the individual level, scores of a large proportion of patients were affected by floor or ceiling effects on several subscales and the sensitivity to individual change was very low. Conclusion: Large to moderate meaningful changes in group scores were observed in all SF-36 subscales except General Health across the intervention groups. Therefore, in orthopedic settings, the SF-36 can be used to show changes for groups in physical, mental, and social dimensions and in comparison with population norms. However, SF-36 subscales have low sensitivity to individual change and so we caution against using SF-36 to monitor the health status of individual patients undergoing orthopedic surgery. Published: 31 July 2008 Health and Quality of Life Outcomes 2008, 6:55 doi:10.1186/1477-7525-6-55 Received: 28 January 2008 Accepted: 31 July 2008 This article is available from: http://www.hqlo.com/content/6/1/55 © 2008 Busija et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Background
In the period following wars and other forms of armed conflict, health and quality of life of mothers is a major concern as they have the closest contact with children. The effects of war trauma on the civilian population have more widely reported among women than among men [1,2].
Women in Afghanistan have lived with armed conflict for more than 20 years. Followed by a peaceful life by 1978, Afghanistan experienced an unstable period with armed conflict with factions fighting which continued to the end of 2001 when a military intervention of the international community was made [3]. Although now it is termed 'post-conflict', civilians still face fragile conditions and are still at risk to armed conflicts [4].
While the influence of exposure to traumatic events on the prevalence of stress disorders is widely known [5][6][7], there has still been relatively little discussion regarding means to restore the quality of life of people who were incapable of fleeing from long periods of conflict.
The objectives of this study were to examine the associations between exposure to armed conflict-related events and prevalence of posttraumatic stress disorder (PTSD) symptoms among women raising children, and to identify factors that may alleviate the negative consequences of exposure to traumatic events.

Subjects
The subjects in the present study were 1400 mothers of children less than 5 years old selected randomly from households in Kabul Province, Afghanistan. Random sampling was conducted based on the list developed with the cooperation and supervision of the Expanded Programme on Immunization Section.

Procedures
Study teams visited each household to conduct structured interviews in March 2006. Taking into consideration the cultural sensitivity of women in Afghanistan who generally refrain from communicating with males who are not relatives, each study team consisted of one male and one female interviewer, both of whom were trained to administer the interviews. Experience of armed conflict-related events, PTSD symptoms, hardships with regard to basic needs, support seeking resources for mental health, and socioeconomic variables were evaluated.
The protocol of this study was approved by the Ethical Review Board Committee of the Ministry of Public Health, Afghanistan. Informed consent was obtained from all of the subjects.

Measurements
Exposure to armed conflicts-related events Traumatic events specifically related to armed conflict in Afghanistan over the past decades were assessed. Respondents were asked whether they had experienced shelling or rocket attacks, bomb explosions, murder of family members or relatives, missing or lost of family members, family member becoming disabled because of the conflict, and other events related to armed conflict.
Cases of PTSD PTSD symptoms were assessed according to a scoring algorithm based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) criteria for PTSD [8]. The subjects that satisfied all of the three following conditions were defined as subjects with PTSD: reactions on at least 1 of 4 re-experiencing symptoms, at least 3 of 7 avoidance symptoms, and at least 2 of 7 arousal symptoms.

Hardships with regard to basic needs
Experience of hardships over the last decade consisted of lack of food, water and shelter was assessed.

Resources seeking for mental health support
To examine the coping mechanism for PTSD symptoms, we assessed resources sought by women in Afghanistan for mental health support. The respondents chose multiple resources from among the following listed resources: health facility, religious leader, spiritual healer, friends, reading Quran or praying, holy place, and other.

Demographics and socioeconomic variables
Age, number of household member, monthly household income, education, and occupation were examined.

Analysis
The prevalence of re-experiencing, avoidance, and arousal were calculated as the percentage of the subjects with individual PTSD symptom clusters among the subjects studied in this survey. Prevalence of PTSD was calculated as the percentage of the subjects satisfying all three PTSD symptom cluster criteria among the subjects. The associations between PTSD symptoms and experience of armed-conflict related events, hardships with regard to basic needs, resources sought as mental health support, and socioeconomic variables were examined by logistic regression.

Results
A total of 1,172 women completed the study (83.7% response rate). Of the respondents, 555 women (47.4%) reported that they experienced at least one traumatic events related to armed conflict. Table 1 shows experienced armed conflict-related events.
Demographics and socioeconomic characteristics of the subjects are presented in Table 2. The participants were 21.7 ± 3.6 years old, and among those who had received any education, the mean ± SD educational period was 9.7 ± 3.7 years. Table 3 shows the association between PTSD symptoms and armed conflict-related traumatic events. Experience of conflict-related traumatic events showed a significant association with higher prevalence of PTSD symptoms (p < 0.01). Table 4 shows the association between PTSD and both material deprivation and resources sought for mental health support. Food shortage showed a significant association with PTSD among both subjects who reported having experienced armed conflict-related events and those who reported having not experienced such events. Seeking for mental health support was inversely associated with the prevalence of psychological symptoms among those who reported no experience of armed conflict-related events. There was no statistically significant association with seeking for mental health support and PTSD among those reported having experienced armed conflict-related events. There was no statistically significant association between demographic and socioeconomic variables and PTSD.

Discussion
The results of the present study revealed the prevalence of PTSD symptoms and associated factors with PTSD among women raising children in Kabul Province, Afghanistan. PTSD was significantly associated with exposure to traumatic event related to armed conflict and food shortage. Support seeking for mental health resources showed a mitigating influence on armed conflict-related distress among those who reported having no experience of armed conflict-related events.
This study provided evidence from subjects representing a community of Afghanistan that has experienced decades of conflicts with regard to a wide range of determinants of mental well-being. The achieved response rate of 83.7% was attributable to consideration of cultural gender sensitivity in Afghanistan and a full communication with the authorities throughout the research process.
The prevalence rates of PTSD symptoms were relatively high in the present study population in comparison to studies performed in other areas [9][10][11][12] both among those who reported having experienced traumatic events related to armed conflict and those who reported having no such experiences. This was considered due to the impact of traumatic events directly related to armed conflict and the exposure to the long-term exposure to the conflicts even among those reporting having no direct experience of armed conflict-related traumatic events.
Material deprivation of food is one of the common traumatic experiences during periods of conflict related to high prevalence of PTSD [13,14]. The independent association between hardship due to lack of food and PTSD symptoms regardless of experience of traumatic events related to armed conflict demonstrated in this study indi-  cates that food security alleviate the negative influence of traumatic events on the occurrence of PTSD symptoms.
Seeking psychosocial support had been identified an effective coping strategy in dealing with traumatic distress [15,16]. Support seeking from health facilities, spiritual healer, and visiting friends tended to show a positive effect on PTSD among subjects who reported direct experience of armed conflict-related traumatic events, although the association was not statistically significant.
Considering the significant alleviating influence of seeking support from any resource on PTSD symptoms, these observations indicated the existence of various mental health support resources in Afghanistan society, and their marginal functioning in coping with severe traumatic experiences.