Forced displacement in Yugoslavia: A meta-analysis of psychological consequences and their moderators

Journal of Traumatic Stress. Vol. 14. NO. 4, 2001

Forced Displacement in Yugoslavia: A Meta-Analysis of Psychological Consequences and Their Moderators

Matt Porter' and Nick Haslam'.*

A meta-analysis was conducted to synthesize what is known about differences in mental health between refugees and nonrefugees from the former Yugoslavia. The analysis focused on moderating effects of a variety of enduring, contextual stressors. Results indicated that refugees suffer significantly more mental health impairment than nonrefugees. The psychological consequences of forced displacement were found to vary significantly as a function of chronic stressors (e.g., locus of displacement and type of accommodation in exile) and were also associated with other factors (e.g., degree of war exposure in the nondisplaced groups, participant age, and time of data collection as rejected in year of publication). Implications for the study of refrigee mental health are discussed. KEY WORDS: refugee; mental health; psychopathology; former Yugoslavia; meta-analysis.

Introduction

Over the last 60 years, organized political violence has increasingly targeted civilian populations. Frighteningly, it has been estimated that nearly one in a hun- dred of the world's population has been war-displaced (Summerfield, 1996b). The demise of the former Yugoslavia had by the end of 1998 produced an estimated 992,200 refugees and 1,203,000 internally displaced people (United States Committee for Refugees, 1999). The recent escalation of the global refugee crisis has made investigating and documenting the mental health consequences of forced displacement a top priority for professionals interested in a scientific, research- based formulation of public policy.

'Department of Psychology, New School University, New York, New York. 'To whom correspondence should be addressed at Department of Psychology, New School University,

65 Fifth Avenue, New York, New York 10003: e-mail: [email protected].

817

0894-9867/011100-0817$19.5011 0 21WI lnlernnlional Socicly 1orTmumatic Stms Studies

818 Porter and Haslam

Stress and the Refugee Experience: The Impact of Chronic Factors

Unlike survivors of certain types of natural disaster, freak accident or vio- lent incident, after the acute, life-threatening stress of the preflight period, and the flight itself, refugees experience an ongoing accumulation of losses, challenges, life changes, and adaptational pressures during the exile/acculturation and reset- tlementhepatriation periods (Martin, 1994; see also Surtees, 1989, for theoretical implications). The role of chronic stressors or enduring undesirable living conditions in the aftermath of the flight cannot be ignored if we are to approach a clear understanding of the psychological experience of refugee^.^

Refugees lose everything-their homes, professions, loved ones, communities, culture, and nation-and are forced to reevaluate assumptions about their social roles, lives, and core identities. The too-often paternalistic context of emer- gency relief projects can further disenfranchise displaced people. Fear, mistrust, or simple lack of resources can provoke host communities or aid organizations to circumscribe refugees’ rights to self-determination and self-governance. This can lead to development of a “dependency syndrome” (Von Buchwald, 1994) that fits the learned helplessness model (Seligman, 1975). A disheartening picture of the effects of long-term accommodation in refugee camps is painted by Rangaraj ( 1988), who studied Southeast Asian refugees:

Refugees who have been in the camps for a long time-five, six or seven years sometimes- seem to die internally. Outwardly. they have losteverything-family, country, culture. . . and suddenly they are nobody. Everything is done for them; and there is no future for them- nobody wants them.. . Decay seems to set in and they seem to disintegrate day-by-day.

The importance of chronic sources of stress has been documented in the refugee literature. Arcel, Folnegovif-Smalf, Kozarif-KovaEif, and MaruSif ( 1995) observed eight risk factors for psychiatric onset during their experience running the BOSWOFAM relief program for Bosnian refugee women and their families in Croatia. Of those eight risk factors, seven were chronic stressors: marginalization and minority status: socioeconomic (SES) disadvantage; poor physical health; star- vation or malnutrition; head trauma and injuries; collapse of social supports; and difficulties adapting to the host culture. Jablensky, Marsella, Ekblad et al. (1994) observed the following seven buffering factors for refugee mental health: presence

(p.41)

-‘It is important here to be clear about working definitions, because, as in the purest sense, specifying an event by its effect (e.g., “chronic stressor”) and then studying the relationship between them is equivalent to correlating the two sides of a tautology. Traditional life events research has long recognized this inherent logical overlap. Selye warned, “the stressor effects depend not so much upon what we do or what happens to us but on the way we take it” (1956. p. 370). Nonetheless, a pragmatic tradition of“event specificity” (Brown, 1989) has arisen as a way of looking at the relationship between various types of life events and illness. With the same utilitarian approach in the present work we used the terms “chronic stress,’’ “chronic stressor,” or “chronic sources of stress” to refer to conditions associated with living in exile that were assumed to represent an increased need for personal or cultural adaptation or effort.

Refugee Mental Health 819

of extended family; gainful employment; presence of human rights organizations; availability of self-help groups; small camps; opportunities to engage in traditional cultural practices; and situational transcendence. Although these were originally framed as protective factors, in their frequent absence they can be similarly understood as chronic sources of stress associated with living in exile.

Although the severity and serious mental health consequences of the refugee experience have been widely acknowledged, existing approaches to understanding this form of life stress have significant limitations. Life events research studies relationships between diagnoses of mental illness and discrete events occurring in an individual’s life (see Brown & Hams, 1989). The application of such models to war trauma has been increasingly criticized as narrowly psychiatric or medical and lacking emphasis on the larger sociopolitical context of the events and situ- ations themselves (e.g., Bracken, Giller, & Summerfield, 1995; Higginbotham & Marsella, 1988; Summerfield, 1997). These critics have suggested a biopsychoso- cia1 reformulation of the refugee experience that would move away from a narrow medical model and shift emphasis to the impact of contextual (e.g.; situational, social, political, or historical) variables on symptom manifestation. Empirical evidence supporting the advantages of this perspective has begun to amass (e.g., Bryce, Walker;& Peterson, 1989; Curran, 1988; see also Bracken et al., 1995). This “biopsychosocial” approach also accommodates theories concerning the dele- terious effects of cultural bereavement. Vygotsky wrote, “Place sets the conditions for human consciousness” (1978). Part of the refugee experience is partial or total destruction of a meaningful cultural framework within which the joy and pain of life are understood. It has been proposed that this loss might be even more traumatic than the events per se (Eisenbruch, 1991). Such an understanding directs emphasis towards the social wounds of war-whole communities and ways of life are destroyed-and suggests that psychological functioning might not improve until some sort of satisfactory social or cultural context is rebuilt (Summerfield, 1996a). Little systematic work has been done to quantify the effects on refugee mental health of the particular challenges associated with living in exile. We conducted the first meta-analysis of the mental health consequences of displacement in the former Yugoslavia, focusing on the role that chronic stressors might play in moderating the size of these consequences.

Investigation of the Mental Health of Refigees in the Former Yugoslavia

A modest quantity of research has been conducted on the mental health of this population. These studies differ on important variables that have yet to be investigated. In most studies, sample constituency was determined not randomly, but in part by systematic influence of geographic or demographic factors. This weak- ened the ecological validity of the primary studies. Because the population of the former Yugoslavia is pluralistic, the representativeness of samples drawn from


specific locations was affected by whatever heterogenous social, economic, and historical factors determined the local population. Moreover, these geographic and demographic constraints limited the types of moderators that could be effectively studied by individual primary researchers. Any factors that were tied to specific local characteristics could not be studied without sampling from more than one location-a luxury not readily available under suboptimal war and postwar conditions. So, primary studies were mostly unable to address such potentially important issues as the effect of locus of displacement (i.e., inside or outside of the displaced person’s country of origin), type of accommodation during exile (i.e, private or institutionalized), or differences in degree of exposure to war trauma between different samples of nondisplaced comparison participants. Primary research also largely failed to address the impact on the displacedhondisplaced comparison of participant age, stage of the war in which data were gathered, and time elapsed since displacement. Furthermore, for obvious reasons primary studies were unable to test for the effect of researcher ethnicity on effect size.

This study aimed to remedy some of these limitations by meta-analyzing appropriate studies to investigate the relationship between forced displacement and mental health. First, we aimed to estimate the magnitude of the difference between. displaced and nondisplaced people on measures of mental health. Given a putative dose-response relationship, it was predicted that displaced people would manifest more suffering or impairment on such measures than would nondisplaced people. Second, we aimed to investigate the moderating effect of several potentially important variables that varied only across studies, and so not yet examined. Some of these moderators are assumed to represent chronic sources of stress associated with living in exile. Moderators that we investigated follow.

Three of the variables we investigated-locus of displacement, type of accommodation in exile, and degree of exposure to war events in the nondisplaced group (or control group “contamination”)-were assumed to correspond to ranges of relative stressfulness. As such, they were used to operationalize the dose-response relationship thought to exist in reactive psychopathology (i.e., the more stress in- flicted, the more impairment manifested). Furthermore, in contrast to the acute, stressful event of the flight itself, locus of displacement, and type of accommodation during exile also represent enduring (or chronic), external stressors associated with evolving postflight social and economic contexts. Additionally, to the degree that a study’s year of publication reflected the time that its data were collected, it operationalizes the influence on mental health in both groups of the developing social and political context over the course of the war. It was expected that these variables would be found to contribute significantly to the magnitude of effects of forced displacement, lending support to both existence of a dose-response relationship and the impact ‘of chronic stress on refugee mental health. Time elapsed since displacement was predicted to be negatively associated with effect size (see Surtees, 1989). The effect of researcher ethnicity on effect size was examined as


a potential source of bias. Participant mean age and the type of outcome variable (i.e., categorical or continuous) used by the primary researchers were also identified as potential moderators.

In sum, it was hoped that the increased statistical power, ecological validity, and investigatory scope afforded by meta-analysis would serve to clarify the expectable degree of mental health consequences of war displacement, elucidate determinants of more severe responses, and document psychological sequelae of a particular historical catastrophe.

Method

Sample

Inclusion criteria. Meta-analysis is only appropriate for studies with com- mensurate effects. As such, only empirical, quantitative studies measuring refugee mental health in the former Yugoslavia in comparison with a nondisplaced control group were included in this project. To locate all such studies, exhaustive searches were conducted in early 1999 on a comprehensive mainstream psychological database (PsychLit) and a more specialized trauma literature database (PILOTS). Together, PILOTS and PsychLit returned 95 publications dealing with the issue of refugee mental health in the former Yugoslavia. Of these, 62 were quantitative studies, but only 10 fully operationalized the comparison of interest by including a nondisplaced control group. One of these studies was excluded because it compared two groups of grossly psychotic psychiatric inpatients rather than normals (KerepEiC et al., 1992). One additional study meeting all inclusion criteria was identified by searching bibliographies of these publications.

The first author, who had served in the United Nations Peace-keeping Oper- ation in the former Yugoslavia in 1996 and 1997, attempted to obtain unpublished manuscripts and data from former colleagues from Croatia and Yugoslavia and from prominent figures in the literature. Two additional reports meeting all inclusion criteria for the meta-analysis were obtained in this manner, yielding a total sample of 12 studies for the meta-analysis.

It would have been technically possible to drop the control-group inclusion criterion and include in the meta-analysis all studies using instruments for which normative data were available. However, norms developed for American populations could be dramatically different than for a Central European population, potentially invalidating cross-cultural comparisons. The increased statistical power that would have followed from including the additional studies was judged not to be worth this possible threat to validity.

Determination of independent findings. The 12 research reports included in the meta-analysis were statistically independent. Three of the studies were


conducted at the KliniEka Bolnica Dubrava in Zagreb with Dr. Kocijan-Hercigonja as the principal investigator. These studies all used nonoverlapping, independent samples, and each addressed the comparison between displaced and nondisplaced mental health from a different angle.

Two of the research reports were multiple treatment studies, comparing each of two independent samples to a third independent sample (Kocijan-Hercigonja, RijaveC, Marusid, & Hercigonja, 1998; Kuterovac. Dyregrov, & Stuvland, 1994). Following established procedures these four comparisons themselves were considered statistically independent for present purposes (Cooper, 1998). This brought the total number of independent effect size estimates included in the meta-analysis to 14.

Many of the studies presenting continuous data were multiple endpoint studies, taking separate measures on more than one dimension of mental health (e.g., depression, anxiety, somatization, etc.). However, since these measures were taken on the same displaced and nondisplaced groups, they could not be considered statistically independent. Instead, all nonindependent effects were averaged to obtain a single mean effect size, d, for each multiple endpoint comparison.

Collapsing various types of psychopathology into one measure of disorder in this way could obscure real relationships (Depue & Monroe, 1986). Ideally, separate meta-analyses would have been performed for the various outcome variables, but sample size made such an approach impossible. Rather, the present work is situated in the vein of Rubonis and Bickman’s meta-analysis on the disaster- psychopathology relationship (Rubonis & Bickman, 199 I ) , where psychopathology type was undifferentiated in the overall effect size estimate.

Methods used in primary research. Methods used by primary researchers were fairly homogenous. All, quite clearly, were quasiexperimental, as inclusion in the displaced or nondisplaced groups was predetermined by an individual’s experiences rather than by random experimental assignment. Our ability to make causal inferences was severely constrained by the posttest-only design of the primary studies.

The primary studies reported only minimal details about the derivation and composition of their samples. Presumably because of infrastructure constraints, all but 4 of the 14 comparisons explicitly stated that their displaced samples were drawn from particular client or outreach program populations (e.g., refugee camps, asylum centers, clinics, etc.). Although the other four comparisons did not explicitly report this, undoubtedly the core issue-the accessibility of the refugees to the research groups-influenced their samples, as well. Ostensibly randomized studies are representative only of the population of accessible refugees. Even future work is unlikely to address this problem. Only one of the studies reported participant response rate (Thulesius & Hakansson, 1999). In that case, 87% of the sampled refugees and 92% of the controls responded. Additionally, none of the primary studies reported information on the SES of their samples.


The measures used in each of the primary studies are shown in Table 1. Eight comparisons used combinations of translated versions of well-known standardized Western instruments such as the Beck Depression Inventory, the Child Depression Inventory, the Cornell Index 2, the General Health Questionnaire, the Impact of Event Scale, the Life Orientation Test, and the Post-traumatic Symptom Scale. Two comparisons used combinations of standardized instruments-some locally-developed and some translated. One comparison used only locally developed standardized instruments. Two comparisons used combinations of translated standardized instruments and clinical assessments. One comparison used clinical assessment alone. Some researchers went to lengths to ensure the validity of the translated instruments (e.g., Mooren & Kleber, 1998; Thulesius & Hakansson, 1999). others did not report these details.

Coding. The 14 independent comparisons were coded following sugges- tions contained in Cooper (1998). Drawing on a review of life stress theory and refugee trauma research as well as on the first author’s personal experience as a United Nations Peacekeeper in the former Yugoslavia, four broad areas of information were coded (i.e., study identification information, methodological and design characteristics, participant characteristics, and statistical outcome information). Although methodology was coded, the lack of variability in overall methodological quality of the primary studies-presumably because of postwar infrastructural deficiencies-as well as the dearth of detailed methodological information provided by most of the primary researchers made an investigation of the relationship between methodological quality and effect size impossible.

Statistical Procedures

The meta-analysis was conducted following the overall guidelines laid out by Cooper (1998)-a useful and widely used synthesis of standard procedures also elaborated elsewhere (e.g., Cohen, 1988; Cooper & Hedges, 1994; Glass, McGaw, & Smith, 1981; Hedges & Olkin, 1985; Rosenthal, 1991). The parameter under investigation was 6, the standardized mean difference in mental health between displaced and nondisplaced people in the former Yugoslavia. An effect size, d (Cohen, 1988), estimating this parameter was computed for each independent comparison. Effect sizes from studies using categorical dependent variables (e.g., diagnoses, presence or absence of disorder, etc.) were transformed first into 4 coefficients and then into d metrics (see Cooper, 1998). Where primary studies omitted sample means and standard deviations, d was estimated from published t-test values (Rosenthal, ‘1994) or p-values. Each independent effect size was weighted with the inverse of its variance (Cooper, 1998), so that studies were weighted roughly in proportion to their sample size.


Results

Descriptive Statistics

As described above, the meta-analysis included a total of 14 comparisons, two of which were derived from multiple treatment studies. Some characteristics of interest are summarized in Table 1. All but two studies were published in peer- reviewed journals. Of those not published in journals, one was published in a book (Carballo, Zen& & SmajkiC, 1996) and the other is unpublished (Mooren & Kleber, 1998). The relative paucity of unpublished data suggests that there may be a publication bias or “file-drawer problem” (Rosenthal, 1979). However, since the displacedhondisplaced comparison on dimensions of mental health was of only secondary interest to the primary researchers in 4 of the 14 comparisons, the likelihood of such bias in those studies is minimized (Cooper, 1998).

Ten of the 14 comparisons were conducted by Croatian researchers, the other 4 by internationals (Carballo et al., 1996; Herceg, Melamed, & Pregrad, 1996; Mooren & Kleber, 1998; Thulesius & Hakansson, 1999). Although there might have been political reasons why Serbian researchers did not examine refugee mental health, the absence of studies conducted by Serbian or Bosnian researchers and the relative overrepresentation of Croatian scholarship could have posed a threat to validity. This issue was explored empirically in the meta-analysis. Only two of the research reports appeared in a Croatian journal (Croarian Medical Journal). The rest of the journal articles appeared in American, British, German, and Norwegian journals, with no single nationality unduly represented.

Publications appeared as early as 1992 and as late as 1999; Mdn = 1996. Number of participants in each study ranged from 56 to 5242; M = 646.57, Mdn = 230. Gender was fairly equally balanced in all studies, except for one study on older adults, in which many of the men in the low portion of the age range had been mobilized by the Croatian Army and were not able to participate (FolnegoviC- SmalC et al., 1997). Studies comparing groups of children or adolescents were well represented in the sample (n = 7).

Overall Eflect Size

Primary effect sizes, given in Table 1, ranged from d = -.19 (Kocijan- Hercigonja et al., 1998) to d = 2.03 (KondiL & Mavar. 1992), with unweighted average of .64. All but one of the effect sizes were in the expected direction (i.e., more impairment in the displaced group than in the nondisplaced group). This exception was statistically insignificant. Nine of the 14 effect sizes were significant at p c .05, and 10 at p < .01. Effect sizes were combined for overall weighted average d = S O with 95% confidence interval .45 c 6 .c .55. That is, displaced individuals were on average about one half of a standard deviation

Tabl

e 1.

Cha

ract

eris

tics o

f St

udie

s Inc

lude

d in

the

Met

a-A

naly

sis

Dis

plac

ed

Non

disp

lace

d Ty

pe o

f C

ontro

l gro

up

Num

her

ethn

icity

et

hnic

ity

acco

mni

odat

ion

degr

ee of

of

yea

rs

Res

earc

her

(com

mun

ity (

com

mun

ity

Dis

plac

emen

t du

ring

expo

sure

to

Age

of

sinc

e Ef

fect

A

utho

r (ye

ar)

natio

nalit

y D

ata

type

N

type

) ty

pe)

Mea

sure

ty

pe

disp

lace

men

t w

ar e

vent

s"

sam

ple

fligh

t si

ze

Car

hallo

et

al. (

1996

) Fo

lneg

ovic

-Sm

alc

et a

l. (1

997)

Her

ceg

et a

l. (1

996)

Koc

ijan-

Her

cigo

nja

et a

l. ( 1

998)

Koc

ijan-

Her

cigo

nja

et sl. (

1998

)

Koc

ijan-

Her

cigo

nja.

R

ijave

c. h

rry-

Jone

s.

& R

eine

ta (1

996)

K

ocija

n-H

erci

gonj

s et

al.

(199

6)

Kon

dic

and

Mav

ar (

1994

)

Inte

rnat

iona

l C

ateg

oric

al 5

242

Bos

nian

(r

ural

) Lo

cal

Cat

egor

ical

107

6 C

roat

ion

(sam

e as

(rur

al)

parti

cipa

nts)

Inte

rnat

iona

l C

ontin

uous

Loca

l C

ontin

uous

(d

iffer

ent

from

pa

rtici

pant

s)

(sam

e as

pnrti

cipa

nts)

Loca

l C

ontin

uous

56 C

roat

ian,

B

osni

an

and

Serb

ian

(rur

al)

70 C

roat

ian

(rur

al)

70 C

roat

ian

(rur

al)

Loca

l C

ateg

oric

al

32 I

Cro

atia

n (s

ame a

s (r

ural

) pa

rtic

ipnt

s)

Lclca

l C

ateg

oric

al

62 C

roat

ian

(sam

e as

(rur

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parti

cipa

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Lo

cal

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tinuo

us

I34

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as

(rur

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nian

(r

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roat

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(urb

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n,

(rur

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batte

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sess

men

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loca

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deve

lope

d ba

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asse

ssm

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SCSl

&

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CO

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CD

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4

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itutio

nal

3

da

4

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nal

3

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5

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3

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3

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dle-

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2-

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and

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ld

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yo

unge

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Chi

ld

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nd

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ld

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nd

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tritt

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Tabl

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(Con

tinu

ed)

' D

ispl

aced

N

ondi

spla

ced

Type of

C

ontm

l gro

up

Num

ber

ethn

icity

ef

hnic

ify

acco

mni

odaf

ion

degr

ee of

of

yea

rs

Res

earc

her

(com

mun

ity

(com

mun

ity

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lace

men

f du

ring

expo

sure

to

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of

sinc

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fecf

A

utho

r (Y

ear)

na

tiona

lity

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a ty

pe

N ty

pe)

type

) M

easu

re

type

di

spla

cem

ent

war

eve

nts'

sam

ple

fligh

t si

ze

Kut

erov

ac

et a

l. ( 1

992)

Moo

rcn

and

Kle

ber (

1998

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bem

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kano

vic

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. (19

93)

Thul

esiu

s and

H

akan

sson

(199

9)

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ic (1

993)

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ic (1

993)

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l C

ontin

uous

142

(sam

e as

pani

cipa

nts)

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fern

atio

nal

Con

tinuo

us 400

Lnca

l C

onfin

uous

88

(s

ame a

s pa

rtici

pant

s)

Inte

rnat

iona

l C

onfin

uous

593

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l C

ontin

uous

480

(sam

e as

parti

cipa

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l C

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3 I8

(s

ame a

s oa

rtici

nant

s)

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atia

n (r

ural

)

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nian

(r

ural

) C

roat

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(rur

al)

Bos

nian

(r

ural

)

Cro

atia

n (r

ural

)

Cro

atia

n (r

ural

)

Cor

afia

n IE

S (r

ural

)

Bos

nian

GHQ-28 &

(rur

al)

IES

Cro

atia

n BD

I &

(urb

an)

clin

ical

Swed

ish

PTSS-10-70

asse

ssm

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(urb

an)

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DI &

(u

rban

) Em

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n Sc

ale

(loca

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roat

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I (u

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ages

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ln

stifu

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l 4

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ages

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nl

a 3

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dle-

aged

an

d ol

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stitu

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8and

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(18

and

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Eve

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SI: S

choo

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opin

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rate

gies

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ntor

y. C

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NEX

2: C

orne

ll In

dex

2, B

DI:

Beck

Dep

ress

ion

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ntor

y, C

DI:

Chi

ld D

epre

ssio

n In

vent

ory,

GH

Q: G

ener

al H

ealth

Que

stio

nnai

re, a

nd PTSS: Po

sttra

umat

ic S

ympt

om S

cale

. 'T

he

num

bers

repr

esen

t the

follo

win

g de

gree

s of

nonr

efug

ee e

xpos

ure:

I -

No

exp

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! a

// (f

orei

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st co

untry

), 2 -

No

dire

ct e

xpos

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(par

t of

the

coun

try

that

did

not

exp

erie

nce w

ar e

vent

s). 3

-Ind

irec

t o

r in

frequ

ent

expo

sure

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c air

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4 -

War

-tor

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nd 5

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exp

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more disturbed than nondisplaced controls. Because this confidence interval did not include 0, it confirmed the prediction that the mental health of displaced people is more impaired than that of nondisplaced people. Another way of understanding this relationship is that 50% of the displaced participants were more impaired than 69% of the nondisplaced participants; U3 = 69.1% (Cohen, 1988). This effect is of medium magnitude (Cohen, 1988) but not as large as might have been expected, suggesting that general war stress exacts a heavy toll on everyone involved, displaced or not.

Moderator Effects

An overall homogeneity analysis revealed significant heterogeneity in the effect size distribution, ~ ~ ( 1 3 , N = 14) = 154.42, p < .001. All eight potential moderating variables discussed in the introduction were examined following Hedges and Olkin (1985) to identify those having significant effects on overall effect size variance. The results of this procedure are summarized in Table 2. Vari- ables meeting a p c .05 criterion for significance were systematically analyzed for patterns. Standardized mean weighted effect sizes and, where possible, 95% confidence intervals were calculated for all values of each of these variables. The results of this analysis are summarized in Table 3.

As expected, when the variables locus of displacement and type of accommodation during exile assumed more "stressful" values, displaced participants manifested significantly more symptoms relative to the nondisplaced control participants than when locus of displacement and type of accommodation did not represent as much additional adaptationd pressure. Furthermore, the difference between the two groups decreased as control group contamination (i.e., degree of exposure to war events in the nondisplaced control group) increased. Also as expected, effect sizes were in general smaller in comparisons using categorical dependent variables, reflecting the definitional insensitivity of that type of analysis

Table 2. Analysis of Heterogeneity in Overall Effect Size Variance and Its Potential Contributors

df X 2

Overall Year of publication Degree of exposure to war in the

nondisplaced group Locus of displacement Type of dependent variable Type of accommodation during exile Age of participants Researcher nationality Number of years since flight

13 6 4

1 I 1 3 I 2

154.42". 61 20"' 33.15***

13.40"' 8.85" 7.01" 8.99' I .02 0.80

* p < .05. * * p < .01. ***p < .001.


Table 3. Effect Sizes, Ranges, and Confidence Intervals Associated With Significant Moderators of the Disdaced/Nondisolaced Comparison

95% confidence interval

Lower Upper Variable n Minimum bound M bound Maximum

Year of publication 1992 1993 1994 1996 1997 I998 1999

in the nondisplaced groupa Degree of exposure to war

I 2 3 4 5

Internal External.

Categorical Continuous

Private Institutional

Child Adult Older Wide range (approx. 7-85)

Locus of displacement

Type of dependent variable

Accommodation during exile

Age of participants

1 3 I 4 1 3 I

1 2 6 3 1

10

4 10

5 7

7 3 2 2

.29

.42

-.I9

.32

.I6 -.I9

-.I9 .I6

.42 -.I9

.29 -. 19

-.I9 .42 .53 .I6

.2 I

.37

.oo

.52

.44

.34

.42

.60

.40

.53

-39 .5 I

.25

.46

.42

.45

2.03 .35 .67 .43 .53 . I8

1.15

1.15 .69 .55 .40 .42

.47

.73

.45

.61

.45

.59

.36

.52

.54

.64

.49 .74

S O 1.16

.36 .69

.86 2.03 -65 1.16 -46 .so

.52 2.03

.87 1.15

.5 I 1.16

.70 2.03

.5 I 2.03

.68 1.16

.47 .69

.58 1.16

.66 .74

.82 2.03

“The numbers represent the following degrees of nonrefugee exposure: I -No exposure ar all (foreign host country), 2 - No direct exposure (part of the country that did not experience war events). 3 - Indirect or infrequent exposure (sporadic air raids, etc.), 4 - War-torn area. and 5 - Some direct exposure to violence.

to subdromal impairment. Effects on children were smaller than effects on adults. A possible interpretation of the curvilinear pattern of effect sizes across year of publication is given in the next section.

Contrary to our expectations, neither researcher ethnicity nor time elapsed since displacement was found to have a significant moderating effect on the overall effect size distribution.

Discussion

S ynthesis-generated evidence supported the existence of the dose-response relationship thought to underlie reactive psychopathology. For all three directly


relevant variables (i.e., locus of displacement, type of accommodation during exile and nondisplaced degree of exposure) meta-analysis revealed significant associations in the expected directions. As the hypothesized difference between the two groups in amount of experienced stress or adaptational pressure increased, the difference between their levels of mental health impairment also increased. Ex- ternally displaced people were more impaired relative to nondisplaced people, d = .73, than were internally displaced people, d = .47. Displaced people living in institutionalized accommodation (e-g., refugee camps) were more impaired relative to nondisplaced people, d = .59, than were displaced people living in private accommodation. Additionally, as control group contamination (i.e., different degrees of exposure to war stress in the nondisplaced group) increased, the effect size decreased from a maximum of d = 1.15 to a minimum of d = .40. In other words, the more serious the exposure the nondisplaced people had had to war events, the less different their levels of mental health impairment were from those of displaced people.

The representation of various degrees of control group contamination within our sample afforded a more detailed look at the dose-response relationship. Analy- sis of the pattern of variance across the five levels of this factor generated evidence in support of an additive dose-response model. Effect size decreased smoothly as control group contamination increased, shrinking from d = -69 where controls had had no direct exposure to war events, to d = .55 where they had had indirect or infrequent exposure, to d = .40 where they had had some direct exposure to violence. The relative smoothness of this progression gainsaid the existence of any obvious threshold effect.

However, there was a 40% reduction in effect size from the condition where the control group was Swedish, d = 1.15, and where the control groups were from local populations that had had no direct exposure to war events, d = .69. Even without displacement or direct exposure to war events, living in a country at war was associated with greater relative mental health impairment in controls. Although the design of the primary studies precluded outright causal inferences, meta-analysis suggests that a direct comparison of residents of nonaffected areas of the former Yugoslavia with foreign controls might find a sizable difference in mental health. No primary studies have yet specifically addressed this issue.

On the other end, even when controls had endured considerable war stress and were suffering demonstrable mental health consequences, displacement was associated with an additional, significant increase in suffering and impairment. In the two conditions where the controls had had more severe exposure (i.e., had lived in war-torn areas or been directly subjected to violence), the displaced groups were still almost a half of a standard deviation more impaired than the nondisplaced groups (i.e., d = .40 and d = .42).

Analysis of the moderator variables points to the limitations of the "medical" approach to stress research and to the importance of context and chronic stress associated with exile in the study of refugee mental health. The relatively smooth

Porter and Haslam 830

increase in effect size across the five degrees of control group contamination suggests that a strictly categorical theoretical stance on stress-induced mental health impairment may have limited explanatory power. Although design limitations of the primary studies preclude ruling out the potential confounds, the significant moderating effect of the dependent variable type (categorical vs. continuous) suggests that diagnosis-driven comparisons may be insensitive to real, symp- tomatic differences between displaced and nondisplaced people. The significantly lower d for comparisons made using categorical variables (i.e., d = .45 compared to d = .61) may indicate that much of the difference between displaced and nondisplaced mental health occurs subdromally, below the diagnostic cut- points. Differently designed research could clarify this issue by reducing potential confounds and applying both types of measures to the same samples.

It was assumed that a study's year of publication partially reflected the stage of the ongoing war during which its data were collected. To the extent that this was true, the changing social, economic, and political context over the course of the war was alsoassociated with refugee mental health. For instance, from 1996 to 1998 studies exhibited a marked drop in mean intergroup difference (i.e., from d = .43 in 1996 to d = .18 in 1998). The posttest-only design of the primary studies makesit impossible to rule out all potential confounds, but a renewed sense of hope among refugees and displaced persons given the actions of NATO and the UN subsequent to the signing of the Dayton Peace Accords in early 1996 is a possible reason for this drop. Unfortunately, such a specific hypothesis would be impossible to verify retroactively.

In our sample, adaptational pressure associated with living in exile was associated with refugee mental health impairment. People forced into exile outside their country of origin were found to be significantly more impaired than people displaced internally. Likewise, people accommodated in refugee camps were found to be significantly more impaired than those in private accommodations during exile. Although the former observation has not been previously addressed, the latter is congruent with the literature. Various refugee research groups and theo- rists have indicated that living in institutionalized refugee camps is more disruptive and requires more adjustment than does living temporarily in private accommodation or with friends or relatives during exile (Arcel et al., 1995; Jablensky et al., 1994; Martin, 1994; Rangaraj, 1988). For both locus of displacement and type of accommodation, the more adjustment, uncertainty, or disruption inherent in the postflight experience, the more difference was observed between the displaced and nondisplaced groups.

The significant association of these chronic, contextual, exile/acculturation factors with refugee mental health is especially important in light of the finding of no significant moderating effect of number of years since flight. Although decay of stress over time may have had its proposed effect (see Surtees, 1989), any such mitigating effect in our sample was obscured by other variables, perhaps including ongoing adaptational pressures.


Perhaps the most significant limitation of this study is that the inferences that can be made on the basis of our results are limited by the quasiexperimental, posttest-only design of the primary studies. Although observable patterns in effect size variance demonstrated associations, those associations could potentially have resulted from variables that were not controlled by the primary researchers. For example, none of the studies reported information about the SES of their samples. Because high prewar SES may have an association with private accommodation during exile (Arcel et al., 1995), it may function as an indirect buffering factor. Brody (1994) suggested that, in general, SES and the chronic stress of adjustment in the exile/acculturation setting may be more predictive of psychopathology than severity of acute stress during the war. Clearly, future work should examine the impact of SES on refugee mental health. Although refugee research will thankfully never be truly experimental, more careful empirical control of theoretically important variables such as SES will potentiate the development of more precise causal conceptualizations of the psychological consequences of forced displacement. Of course, this will require more and more diverse primary studies.

Other methodological problems affected all of the primary studies and also limited our work. As mentioned above, the derivation of all primary samples was constrained by the influence of systematic prewar and wartime demographic factors. Additionally, none of the primary researchers reported blind testing of participants. Clearly, the grossly deficient social, economic, and political infrastructure during and following the war made these rather idealistic experimental c&ditions understandably difficult for primary researchers. It will be important, however, for future work to move in this direction. Another limitation of the study was the sample size, which precluded differentiation between the various possible stress-related symptoms and disorders. With more primary studies future work may be able to investigate more specific relationships. Further, given the variable onset and course of posttraumatic stress disorder, future studies of mental health in this population would ideally have longitudinal designs to capture the changing picture of a the mental health of a traumatized population over time.

In additional to quantifying the expectable degree of mental health consequences of war displacement, the present study demonstrates the impact of chronic, contextual, postflight, and adaptational pressures on the mental health of displaced people. These are the types of factors that standard analyses of coping with discrete stressors have difficulty modeling. Our findings suggest that to be maximally effective, models of refugee mental health must accommodate the impact of the larger social, economic, political, and situational contexts that an individual experiences as she copes with the various phases of the refugee experience. This calls for a move away from traditional life events research paradigms towards a more comprehensive, multidisciplinary approach.

Moreover, since the displacement process, although clearly forced, is nonetheless goal-directed, a richer understanding of context will emphasize its interactivity-"forced displacement can be conceptualized as a form of migration,

a32 Porter and Haslam

essentially a proactive way of coping with serious threats to security. During the flight and postflight periods, refugees’ options are severely limited, not eliminated. The kinds of decisions refugees make during migration partially shape another problematic situation-the circumstances of living in migration-that in turn requires other coping solutions. In this way, refugees cocreate their experiences and are partial agents of their own future mental health.

Our work has begun to build on the ideas of Eisenbruch (1991) by isolating two factors associated with living in migration whose levels were assumed to represent different degrees of “cultural bereavement:’ or cultural loss, change, and need for adaptation (i.e., type of accommodation during exile and locus of displacement). Future work will be able to flesh out these findings by investigating these and other domains in which refugees decide-under duress-to undergo cultural change and adaptation, and how their specific coping decisions impact their future mental health. Such work will move away from emphasizing refugee passivity, and toward emphasizing partial agency of refugees in creating, through appraisal as well as through action, their experience. Rather than .“blaming the victim,” this line of work will have important policy implications for refugee aid organizations, where establishing and enhancing refugee agency is fast becoming a primary focus.

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Documents

Forced displacement in Yugoslavia: A meta-analysis of psychological consequences and their moderators