Department of Psychiatry, Upper Hill Medical Centre, Nairobi, Kenya
Departments of Medicine and of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
Upper Hill Medical Centre, Nairobi, Kenya
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
Correspondence: Dr Jonathan R. T. Davidson, Duke University Medical Center, Durham, North Carolina 27710, USA. Tel: +1 919 684 2880; fax: +1 919 684 8866; e-mail: jonathan.davidson{at}duke.edu
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To describe reactions following the US embassy bombing in Nairobi and the characteristic features of and risk factors for post-traumatic stress symptoms in a large, non-Western sample soon after the attack.
Method A self-report questionnaire which assessed potential risk factors and identified symptoms matching DSMIV criteria for post-traumatic stress disorder was answered by 2883 Kenyans, 13 months after the bombing.
Results Symptoms approximating to the criteria for post-traumatic stress disorder occurred in 35%. Factors associated with post-traumatic stress included female gender, unmarried status, lack of college education, seeing the blast, injury, not recovering from injury, not confiding in a friend, bereavement and financial difficulty since the blast. Many other factors were not significant.
Conclusions Specific factors often cited to predict marked short-term post-traumatic stress were confirmed in this large, non-Western sample.
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INTRODUCTION |
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METHOD |
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Instrument
The questionnaire was a nine-page, 57-item, English-language self-report
instrument and was administered by personnel trained to help respondents with
language or content comprehension (very few respondents required such
assistance). It was an unvalidated instrument constructed within the first
month after the attack with the assistance of international agencies and
trauma experts. There were five parts: the first (11 questions) dealt with
demographic factors, including age, gender, number of children and dependants,
educational level, religion and occupation. Part two determined the level of
exposure, with five questions relating to the persons location at the
time of the blast and whether the person had experienced it directly or first
heard about it through conversation or the media. Part three asked detailed
questions about injuries, initial treatment and pregnancy: injuries were
divided into body part affected (eyes, face, hearing, head and neck, limbs,
trunk and genitals) and further divided by severity (from minor cuts
and bruises to loss of body part; paralysis was handled
separately); ten questions were concerned with medical care (location of
treatment, method of transportation, assessment of care received and
continuing medical sequelae); pregnancy was addressed by six questions
detailing month of pregnancy, complications immediately succeeding the blast,
assistance received and outcome or current status of pregnancy. The fourth
part comprised a number of questions designed to assess PTSD symptoms; in
addition, it addressed substance misuse, attack-related conversation and
counselling, and bereavement. For this study, the PTSD symptomatology portion
of the questionnaire was rearranged into 21 yes/no questions
that matched most of the criteria specified by DSMIV
(American Psychiatric Association,
1994), although there was no question equivalent to criteria B5,
C3 or C7. For example, participants were asked whether since the bombing they
were having dreams of the bombing (criterion B2), finding
it harder to be with family/friends/workmates (criterion C5) and
sleeping less (criterion D1). A caseness algorithm
was used such that responses including at least one criterion B
(re-experiencing) symptom, three criterion C (avoidance/numbing) symptoms
(including at least one of criteria C1 and C2 and one of C4 to C6) and two
criterion D (hyperarousal) symptoms all together satisfied the criteria for
post-traumatic stress symptomatology (PTSS) our
approximation to the PTSD diagnosis. Criterion A symptoms (fear, helplessness
or horror in response to a significant trauma) were not part of the algorithm,
but were included in the analysis for validation; there was an 11% rise in the
prevalence of post-traumatic stress symptoms when criterion A symptoms were
excluded from the algorithm (see Results). Also not included in the algorithm
was a formal assessment of subsequent distress or functional impairment. The
questions relating to substance misuse asked about increased use of alcohol,
cigarettes and drugs (e.g. bhang). Six questions about
attack-related conversation and counselling specified the source of support,
e.g. friend/workmate, family, religious leader, psychologist. The three
bereavement questions asked about the relationship to the deceased and what
problems resulted from the loss loneliness, loss of financial support,
loss of professional support. The final nine questions addressed economic
concerns, such as financial difficulty unemployment due to injury,
loss of breadwinner, lost business and the source and type of
assistance received from the government, for a coffin, for example. A
space was left at the end of the questionnaire for comments.
Analysis
Descriptive statistics were applied to all non-PTSD variables and
chi-squared analysis was used to determine relatedness of those variables to
PTSD symptoms. As mentioned above, PTSS was determined using a straightforward
algorithm based on DSMIV symptom clusters B, C and D. For the few
symptoms that matched more than one question, a positive response to only one
such question could count towards caseness; for example, answering
yes to both Since the bombing are you...losing your
temper easily? (symptom D2) and ...feeling angry?
(symptom D2) would satisfy only one of the two cluster D symptoms required by
the algorithm.
Only the data for those individuals who responded to all 21 PTSS algorithm
questions were analysed. This narrowed the sample from 2883 to 2627. Some
questions addressed only a portion of the total sample (e.g. Were you
pregnant at the time of the blast? or After you were injured,
where were you treated?) and in such cases the 2
analysis was applied to the appropriate subset of the total sample (e.g. the
number of women or the number of people injured). Also, when there were four
or more multiple choice answers to a question (e.g. How many children
do you have? or What is your religious affiliation?) the
responses were usually grouped into two or three appropriate answer
bins in order to facilitate the analysis (e.g. 0, 16 and
712, or Christian and non-Christian).
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RESULTS |
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Exposure and injury
Table 1 outlines the
responses concerning the nature of exposure to the blast and resulting
injuries. In sum, nine-tenths of this sample were direct witnesses of the
tragedy; this was a highly physically traumatised sample; and the majority of
those injured rated their medical care favourably.
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Peritraumatic reactions and sequelae
Table 2 addresses the
emotional and behavioural reactions people had to the event and how it changed
their lives. A majority of respondents satisfied criterion A for PTSD, and
approximately half the sample had talked about their experience with a friend
or workmate. Nearly half of respondents reported currently experiencing
financial difficulties resulting from the attack.
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Time distribution of surveys
Ninety-five per cent of the surveys were completed between 20 days and 99
days after the bombing, most (65%) between days 53 and 95. The median
post-bombing day of survey completion was day 67.
Prevalence of PTSS and missing responses
Of the 2883 persons surveyed, 256 failed to answer enough of the PTSD
symptomatology questions to allow a determination of PTSS by the algorithm
described in the Method section, and this subsample was omitted from the
analysis. Of the 2627 remaining individuals, 35.4% (929) fulfilled PTSS
criteria. However, when the additional requirement of affirming any one of the
criterion A questions was added to the PTSS criteria, the prevalence of PTSS
decreased to 24.5% (643 of 2627). In terms of risk factors, when those left
out of the analysis were compared with those included, the former group
contained fewer women (41% (104/256) v. 47% (1229/2618),
P<0.05), fewer injured persons (45% (107/237) v. 64%
(1617/2546), P<0.001) and more among the injured who considered
themselves cured (46% (39/85) v. 31% (475/1514),
P<0.005). There was no other significant risk factor difference
between the two groups.
Risk factors for PTSS
Among the demographic factors, female gender (P<0.0001),
unmarried status (P<0.01) and less education
(P<0.0001) were associated with PTSD symptoms. Variables not found
significant in the current analysis were age, number of children (grouped 0,
15, 615), number of dependants (grouped 0, 110,
1137), pregnancy and religion (grouped Christians and non-Christians).
The exposure and injury variables that achieved significance were location
somewhere outside of a building (P<0.05), seeing the blast
(P<0.05), injury of any kind (P<0.0001) and not being
cured (based on the injured subsample, P<0.0001). No particular
type of injury was associated with PTSS by this analysis, and neither were
site of treatment (grouped hospital/clinic and other; analysis on injured
subset), assessment of hospital care (grouped very good/good and fair/poor;
injured subset) or immediate medical response (grouped very/fairly adequate
and inadequate; injured subset).
Peritraumatic reactions and sequelae that were significant risks for PTSS were feeling afraid (P<0.0001), helpless (P<0.0001) or threatened (P<0.0001); talking about the bomb, but not to a friend/co-worker (P<0.01), grouped friend/co-worker and other; and bereavement in general (P<0.05). The data concerning substance use were suspect and so were left out of the analysis. Variables not found to be harmful or benign in the present analysis were change in sexual relationship, having talked about the bombing at all, receiving reading materials or counselling, particular person mourned (grouped family and other; based on bereaved subsample) and type of problem resulting from losing a loved one (grouped loneliness/lack of companionship and other; based on bereaved subsample).
All the variables dealing with financial sequelae of the explosion were found significant for PTSD symptoms: currently experiencing financial difficulties (P<0.0001), anticipating financial difficulties (P<0.0001), inability to work owing to injury (P<0.01; type of difficulty grouped cannot work and other, analysed on subset with current financial difficulty) and receiving assistance (P<0.05).
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DISCUSSION |
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Notably, there was no significant association with PTSD symptoms for age, number of children or religion; assessment of hospital care or immediate medical response; receiving counselling; or the relationship to the person mourned.
Advantages in context
Non-Western sample
Terrorism is now a global concern. Every day there are headlines reporting
terrorist activities in industrialised Western nations and elsewhere,
including Africa and Asia. Despite the magnitude of this threat to worldwide
mental health, there are few published studies that systematically determine
the prevalence of and risk factors for PTSD following a
terrorist attack. One relevant paper
(Pfefferbaum et al,
2001) showed a close relationship between injury and
post-traumatic stress in a directly exposed group of 21 individuals 8 months
following the simultaneous US embassy bombing in Dar es Salaam, Tanzania, in
which 11 people were killed and 80 wounded. As in our study, the people
surveyed in this convenience sample were highly exposed to the traumatic
event: a mean score of 6.7 (s.d.=1.9) out of a possible 8 on their measure of
hearing and feeling the explosion, and a 31% (6 of 21) injury rate, with one
individual rating his/her injury 3 (some injury) out of 4 and
five others rating theirs 2 (a little injury) out of 4. Initial
reactions, such as nervous or afraid, felt
helpless and thought I would die, were rated on a scale
of 1 to 5. There was also a battery of questions on post-traumatic stress
symptoms, e.g. I had dreams about it, I tried not to talk
about it and I felt watchful and on guard. In this
traumatised sample, injury significantly predicted post-traumatic stress
symptoms (R2=0.21) in general as well as intrusion and
arousal symptom clusters in particular; however, injury did not predict
avoidance/numbing symptoms at 8 months. The measures of hearing and feeling
the explosion and initial reaction did not predict post-traumatic stress
symptoms or symptom clusters. In our larger sample, however, presence of
injury, witnessing the explosion and peritraumatic reactions of fear,
helplessness and feeling threatened all significantly predicted PTSS within 3
months of the incident.
The DSMIV criteria for PTSD have not been fully validated in developing countries. Despite the growing literature on post-traumatic morbidity in Africa, which describes results similar to those in Western studies, it is possible that a different set of symptoms would better represent psychiatric impairment after trauma among, for instance, middle-class Kenyans. Jenkins (1996), after finding certain PTSD criteria inapplicable among Salvadoran women, suggested some criterion modifications for different cultures. In the case of African populations, somatic symptoms such as intense heat (central heat; Ifabumuyi, 1981) or the social repercussions of numbing might be more salient indicators of PTSD. The roles of dreams, ancestors, witches and fate may need to be assessed with appropriate terminology. Alternatively, the concept of PTSD could be a cultural category fallacy (cf. Kleinman, 1977), in the sense that no such diagnostic entity, as configured in DSMIV, for example, exists outside of Western industrialised nations. Although by no means conclusive, the similarity between findings in Western and non-Western studies of PTSD argues against this, and suggests that the DSMIV criteria at least approximate a universal phenomenon.
Sample size
In addition to its short-term, non-Western focus, the current study is
unique for its large sample size (n=2627). Even in this age of
telephone interviews and web-based surveys neither of which were
feasible in this investigation there are only three other studies of
terrorist-related PTSD with populations exceeding 2000: Pfefferbaum et
al (2002) on
childrens response to the Oklahoma City tragedy; Silver et al
(2002) on the reactions to the
disaster of 11 September 2001 of Americans living outside of New York; and
Schlenger et al
(2002) on the reactions to the
latter tragedy of a US national sample including New Yorkers.
Risk factor significance
Another advantage of our investigation is its clear findings on risk
factors for attack-related PTSD symptoms, concerning which other research
findings are not always consistent. Most importantly, the Nairobi data show a
strong link between injury and PTSS (P<0.0001). Other studies
showing the importance of injury severity include those of Pfefferbaum et
al (2001), described
above; Abenheim et al
(1992), on 254 survivors of
terrorist attacks in France; and Wilson et al
(1997), on police officers in
Ireland who witnessed terrorist acts. On the other hand, Curran et al
(1990) demonstrated an inverse
relationship between injury severity and PTSD for 26 people involved in the
1987 Enniskillen bombing in Northern Ireland, and Tucker et al
(2000), studying 85
individuals after the Oklahoma City bombing, showed a significant association
between injury and PTSD in a univariate analysis that was not significant in
the multivariate analysis. Several factors consistently reported to be
associated with PTSD were further confirmed in our analysis. For example,
measures of proximity to the event (in our study, being outside v.
inside a nearby building) have predicted PTSD in several studies of terrorist
attacks: Galea et al
(2002a,b),
in a telephone survey of 988 Manhattanites, demonstrated the significance of
residence below Canal Street on 11 September; and Bernard et al
(2002) showed higher PTSD rates
among staff at two schools near the World Trade Center site compared with
staff at two New York City schools over 8 km away. Other variables found to be
significant in our study that typically correlate with PTSD after terrorist
attacks include female gender, not being married and various negative
long-term sequelae such as increased financial difficulty or losing
possessions in the attack (Easton &
Turner, 1991; Galea et al,
2002a,b).
Some risk factor variables were interrelated: for example, there was an
association between financial loss and both anticipating financial difficulty
and receiving assistance.
Prevalence
The prevalence of PTSS in this recently traumatised civilian cohort
35% (or 24%, when peritraumatic feelings are included in the analysis)
is comparable with data from other terrorist incidents. In his evidence-based
review prior to the 11 September disaster in the USA, Gidron
(2002) showed a mean
post-attack PTSD prevalence of 28%; this value was derived from six US studies
and was unduly affected by one study of police officers (PTSD prevalence 5%),
small samples, and variability in sampling, timing and assessment. Estimates
of PTSD prevalence following the 11 September disaster in large samples of US
populations have been reported as 7.5% in Manhattan and 20% below Canal Street
in New York at 12 months (Galea
et al, 2002a); 7.5% in Manhattan, as well as 24%
with increased smoking and 36% with increased marijuana use at 12
months (Vlahov et al,
2002); 9% in Manhattan at 12 months
(Galea et al,
2002b); 11% in New York City and 4% in the rest of the
USA at 12 months (Schlenger et
al, 2002); 17% at 2 months and 6% at 6 months in the US
population outside New York City (Silver
et al, 2002); and 1523% near the site and
68% over 8 km away at 46 months
(Bernard et al, 2002). Hence, it is not surprising that our group composed primarily of directly
exposed civilians assessed at 13 months had a PTSS prevalence of
roughly 35%.
Limitations
Convenience sample
One of the shortcomings of our study is its lack of randomisation.
Operation Recoverys primary objective in the months following the
incident was service delivery and there was no opportunity to form randomised
groups. Participants were recruited at nearby businesses, at a clinic devoted
to people affected by the blast and at public gatherings such as the annual
agricultural exposition. The profile of the resulting cohort was skewed
towards highly exposed, educated professionals. Respondents might have been
seeking help for high levels of distress, and a bias towards increased trauma
in a sample would naturally inflate the prevalence of PTSD. However, this
shortcoming is shared by many studies: with the exception of the investigation
of the responses of 2000 schoolchildren to the Oklahoma bombing
(Pfefferbaum et al,
2002), no large, randomised study of PTSD after a terrorist attack
had been conducted until the telephone and internet surveys conducted after
the New York 11 September tragedy. Notably, the results of these surveys agree
in many ways with the data from our Kenyan sample. Also, we made a concerted
attempt to include everyone who had been near to the blast, by contacting
every office in the surrounding city blocks and inviting workers who were
present during the blast to participate in the study. Although this
predisposed to a large proportion of educated professionals in the sample, it
provided an accurate reflection of the population present on a weekday morning
in the centre of the business district. These middle-class participants were
local Black Kenyans.
Questionnaire
A second weakness of our study is its use of an unvalidated psychometric
instrument. The questionnaire was constructed in the first month following the
embassy bombing with the help of international trauma experts and it went
through many revisions before it was used to collect data. Incidentally,
virtually no one required assistance with comprehending the English-language
questionnaire. Nevertheless, an opportunity was lost to use a more standard
trauma scale or some other tool based on DSMIV. It should be noted,
however, that the reported studies on this topic have made use of a wide
variety of non-standard measures of post-traumatic stress, and that commonly
used standard instruments for assessing PTSD have not yet been validated in
African populations. The unvalidated self-report instrument in this study,
then, allowed only an approximation of PTSD caseness and not a diagnosis.
Questions in one section of the survey did roughly correspond to the
DSMIV criteria and so a PTSS algorithm (one or more re-experiencing
symptoms, three or more avoidance/numbing symptoms and two or more arousal
symptoms) was plausible. This algorithm did not include retrospectively
reported criterion A (exposure and peritraumatic reaction) symptoms, nor did
it address decline in function, overall subjective distress or (unequivocally)
duration of symptoms. However, our procedure was somewhat validated by the
fact that there was a strongly significant association (P<0.0001)
between PTSS and each of the criterion A reaction questions (feeling afraid,
helpless or threatened during the event). Furthermore, 91% of this sample
experienced the explosion directly, which addresses the exposure aspect of
DSMIV criterion A. Regarding decline in function or increased distress,
many respondents were seeking mental health treatment either at a clinic or at
their workplace. Sequelae such as bereavement, financial difficulties and
receiving assistance were closely aligned with PTSS. Once again, the small
amount of published research on this subject includes several examples of the
use of similar methods to measure post-traumatic stress. Last, although other
anxiety and depressive disorders are important sequelae of trauma, appropriate
testing for these disorders would have made the (already long) questionnaire
impracticably lengthy, and this might have led to an underestimation of
post-traumatic morbidity.
Missing responses
A third problem with our study is the unfavourable response rate. Lower
levels of trauma exposure and of serious injury characterised the 256 people
who were omitted, thereby possibly raising the actual prevalence of PTSS above
that observed. A few important variables were removed from the analysis owing
to poor response (e.g. changes in sexual relationship). Some interesting
results presented above had upwards of one-third non-response (e.g. having
felt afraid, helpless or threatened; numbers of children and dependants) and
so are difficult to interpret. Related to the issue of non-response in surveys
is the problem of accuracy. This was most pronounced in our sample in the
responses on substance use. Vlahov et al
(2002) in a telephone survey
of 988 Manhattan residents confirmed the intuitive notion that cigarette,
alcohol and marijuana use increased after the World Trade Center attacks and
their use was linked to cases of PTSD and depression. Our investigation
with only about 15% missing data on this subject showed not
only low rates of increased use (alcohol 5%, smoking 3%, illicit drugs 1%) but
also unusually high rates of reported abstinence (alcohol 61%, smoking 73%,
illicit drugs 78%). If the tendency of this population was to underreport
symptoms in other potentially stigmatising areas such as post-traumatic stress
criteria, then the already highly traumatised people in this sample may be
more troubled than the descriptive statistics indicate.
The 35% prevalence of significant PTSD symptoms in this highly exposed sample a few months after the Nairobi bombing is comparable with the prevalence found in studies of Western populations affected by terrorism. Likewise, frequently reported predictors of PTSD such as female gender, injury, peritraumatic response and financial sequelae were confirmed in this large non-Western sample. It will be important to learn more from this cohort, and from the unfortunately growing number of similar groups, so that we can further refine our diagnoses, identify those at greatest risk and effectively treat the victims of terrorism.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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J.R.T.D. and F.G.N. were funded by GlaxoSmithKline, who supported analysis of the data; J.R.T.D. is a consultant to GlaxoSmithKline, for whom he serves as a speaker and from whom he has received research grant support.
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Received for publication September 5, 2003. Revision received May 24, 2004. Accepted for publication May 31, 2004.
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