Women's mental health, reproductive health, and agency in humanitarian crises by Susan A. Bell A ...

201 Pages·2014·0.54 MB·English

Women’s mental health, reproductive health, and agency in humanitarian crises

by

Susan A. Bell

A dissertation submitted in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
(Nursing)
in The University of Michigan
2014

Doctoral Committee:
Associate Professor Julia S. Seng, Chair
Professor Timothy R.B. Johnson
Associate Professor Jody R. Lori
Professor Richard W. Redman
© Susan A. Bell 2014
DEDICATION
This dissertation is dedicated to my one-person support team for the past twenty
years. Thank you for always having the highest of expectations for me and also for the
many sacrifices you have made so that we can both follow our dreams. Also to my girls,
Madison, Megan, and Meredith (M3). My family is my reason for being. Thank you for
supporting me unconditionally.

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ACKNOWLEDGMENTS

I would like to thank the School of Nursing and Rackham Graduate School for
providing support to make this dissertation research possible. I am humbled to
represent both schools through support from a Rackham Merit Fellowship as well as an
NIH T32 pre-doctoral fellowship. I am also grateful to Global REACH, African Studies
Center and the Institute for Research on Women and Gender for conference and small
grant funding.
I am extremely fortunate to have such a supportive dissertation committee who
has put up with me in good times and bad. I often describe my committee by saying that
I won the mentor jackpot. This is undoubtably true, as I cannot imagine a more
encouraging group of world-renowned scholars who are also patient and kind. I am
forever grateful to you all.
Thank you very much to Stacy DeJesus of the Centers for Disease Control for
consistent advice, and for connecting me with numerous people along the way. Thanks
to Katie Anfison, formerly of the American Refugee Committee and now of Population
Services International for providing me with this dataset and others as I sought to
answer my research questions. Thank you to the Seng Lab Group. Two hours per week
to present my research, get feedback and be with my tribe was essential to keeping me
on track. Thank you to Michelle Munro, Meghan Eagen-Torkko and others who have
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provided an enormous amount of input, support and guidance.
I am grateful to the women who participated in this survey. I hope they will
someday benefit from this research, and will know the gift they have given me in return.

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TABLE OF CONTENTS

DEDICATION ii

ACKNOWLEDGMENTS iii

LIST OF FIGURES vi

LIST OF TABLES vii

LIST OF ABBREVIATIONS ix

ABSTRACT xi

INTRODUCTION 1

CHAPTER

1. Women’s Mental Health, Reproductive Health and Agency in 6
Humanitarian Crises: Literature and Theoretical Support

2. Psychometric Validation and Comparison of the SRQ-20 75
and SRQ-SIB among Congolese Refugee Women

3. Understanding the Effects of Mental Health on Reproductive 107
Health Post-Crisis: A Mixed Methods Approach

4. Development of a Brief Screening Tool for Mental Health 147
Assessment in Refugee Settings

5. Closing and Summary 178

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LIST OF FIGURES
FIGURE
1.1 Conceptual Model of Trauma Informed Disaster System Response 53
2.1 Dose response relationship of the SRQ-SIB with mean scores
on SRQ-SIB with SIB items removed 99

4.1 Dose response relationship of the SRQ-SIB with mean scores
on SRQ-SIB with SIB items removed 170

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LIST OF TABLES
TABLE
1.1 Simplified Evidence Table 54
1.2 Carper's Four Ways of Knowing Applied to this Research 57
1.3 Selected Stakeholders 58
1.4 Current Standards for Health Care in Emergency Situations (selected) 59

1.5 Table of Evidence 60
2.1 SRQ-SIB 88
2.2 Sample Characteristics of Sample 90
2.3 Comparison of SRQ-20 and SRQ-SIB 91
2.4 Item Total Statistics 92
2.5 Mean Comparison between Women who Experienced Forced Sex during 93
Conflict and Those Who Did Not on SRQ-SIB and SRQ-20

2.6 Comparison of SRQ-SIB and SRQ-20 in MPlus 94
2.7 Oblique Rotated Loadings for the SRQ-SIB and SRQ- 20 95
2.8 SRQ-SIB Three Factor Model 97
2.9 Logistic Regression of SRQ-20 and SRQ-SIB Total Scores and Subscales 98
as Predictors of Being in the Group of Women who Experienced Forced Sex
during the Conflict

3.1 SRQ-SIB 130
3.2 Operationalization of Reproductive Health Service Use Variables 132
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3.3 Explanation of Participants Included in Each Analysis 133
3.4 Sample Characteristics 134
3.5 SRQ-SIB Results by Total Sample and By Camp 136
3.6 Logistic Regression Models for the Four Main Outcomes with the

Mental Health Scale entered as a Whole and with Three Subscales 138

4.1 SRQ-SIB 164
4.2 Comparison of Demographic and Trauma Exposure Profiles by Training
and Testing Samples 166

4.3 Descriptive Information About the 22 items in Training Versus Testing
Samples and for the Total Sample 167

4.4 Cross-Validation Results of Two-Item and Four-Item Screening Tools 168

4.5 SRQ-5 Screening Tool with Single Item Suicide Screener 169

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LIST OF ABBREVIATIONS
AIDS- acquired immunodeficiency syndrome
ANOVA- Analysis of variance
ARC- American Refugee Committee
CDC- Centers for Disease Control
CMD- Common mental health disorders
DMAT- Disaster Medical Assistance Team
DSM-IV – Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
HC- Humanitarian Crisis
HIV- Human Immunodeficiency Virus
IDP- Internally displaced person
IASC-Inter-Agency Standing Committee
IAWG- Inter-agency Working Group
MISP- Minimum Initial Service Package for Reproductive Health
mhGAP-Mental Health Gap Action Project
MGD- Millennium development goal
PRIME-Program for Improving Mental Health Care
PTSD- Posttraumatic Stress Disorder
RAISE -Reproductive Health Access, Information, and Services in Emergencies
SD- Standard deviation
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