Trauma-related mental health problems among national humanitarian staff: a systematic review of the literature

Figures & data

Table 1 Overview of studies included in this review

Author identification number	First author, year	Methodology, method, time frame	Total number of study participants/number or percentage of national staff (sex national staff), subjects and place	Outcome studied (measure)	Prevalence rate national staff (prevalence rate reference group)	Results on sex/gender	Results on organization type	Presented limitations of study	Other relevant information
Quantitative studies
1	Ager, 2012	Quantitative study; cross-sectional; self-administered survey; during service	N=376/N=376 (64% male, 36% female) National staff from Uganda	PTSD (Los Angeles Symptom Checklist) Depression (Hopkins Symptom Checklist) Anxiety (Hopkins Symptom Checklist) Burnout (Maslach Burnout Index Human Services Survey)	26% 68% (45 and 67%)* *These rates refer to Ugandan IDPs 53% 5%	Women reported significantly more symptoms of anxiety, depression, PTSD, and emotional exhaustion than men	Working with internat. NGO (compared with working with a UN and related agency) risk factor for depression and anxiety. Proportion of staff of nat. NGOs reporting clinically concerning levels of depression symptoms similar to that of staff of internat. NGOs, but significantly above that of staff of UN and related orgs. Org. type no significant variable to predict PTSD symptoms	Only staff working in organizations with at least 20 national staff participated in survey; cross-sectional design; findings are based upon self-report of symptoms	Increasing exposure to chronic stress associated with increased anxiety symptoms, with most prevalent chronic stressor organizationally related: economic/financial problems, asked to perform duties outside of professional training, lack of recognition for work accomplished by management, tension due to inequality of treatment between expatriate and national staff
2	Ehring, 2011	Quantitative study; cross-sectional; self-report questionnaires; during service	N=267 / N=267 (83.9% male, 16.1% female) National staff from Pakistan	PTSD (Impact of Event Scale-Revised) Depression (Pakistan Anxiety and Depression Questionnaire and Bradford Somatic Inventory) Anxiety (Pakistan Anxiety and Depression Questionnaire and Bradford Somatic Inventory) Burnout (Maslach Burnout Inventory)	42.6% 23.3% (PADQ) 18.8% (PADQ) 7.8%	Women showed significantly higher levels of PTSD, mixed anxiety, and depression on the PADQ, somatic symptoms on the BSI, and burnout. No significant differences were found for depression	n/a (all staff from same organization)	Cross-sectional; no use of structured clinical interviews; questionnaires assessing burnout and social support were problematic from an intercultural perspective	Greater levels of social support associated with lower symptom severities for majority of outcomes measured
3	Eriksson, 2013	Quantitative study; cross-sectional; group-administered survey; during service	N=255/N=165 (26.4% male, 73.6% female) National staff from Jordan and Iraqi refugee volunteers	PTSD (Los Angeles Symptom Checklist)	19.2%	Women were 4.3 times more likely than men to report clinical levels of anxiety	Organization type as variable was included but not significant	Sample may not be representative; stressors were limited by the predetermined list of stressors; in-depth interviews would have provided more nuanced understanding of well-being of staff; time and	Important resilience factors for occupational burnout and mental health outcomes: social support and team cohesion
								financial constrains; cross-sectional design
				Depression (Hopkins Symptom Checklist)	48.3%* (31%)** **This rate refers to a random sample of Jordanian women in a primary care setting
				Anxiety (Hopkins Symptom Checklist)	43.3%* *These rates refer to Jordanian national staff only.
				Burnout (Maslach Burnout Inventory-Human Services Survey)	5.8%
4	Hagh-Shenas, 2005	Quantitative study; cross-sectional;	N=154/N=18 (n/a) Red Crescent workers (=national staff), fire	PTSD (Civilian Mississippi Scale, Persian Version	1 out of 18 (1 out of 36 fire fighters;	n/a	n/a	n/a	Students without affiliation to any org. and formal training had worse psychological
		questionnaires; 90 days after earthquake	fighters, and student volunteers from Iran	ESHEL)	34 out of 100 students)				effects than Red Cross workers and fire fighters
				Different aspects (General Health Questionnaire)	n/a (means of all subscales greater for students than for Red Crescent workers and fire fighters)
				Anxiety (Anxiety Sensitivity Index)	n/a (students scored
					significantly higher than Red Crescent workers and fire fighters)
5	Lopes Cardozo, 2013	Quantitative study; cross-sectional; group-administered survey; during service	N=398/N=398 (44.3% male, 55.7% female) National staff from Sri Lanka	PTSD (Harvard Trauma Questionnaire) Depression (Hopkins Symptom Checklist) Anxiety (Hopkins Symptom Checklist)	19% (7%)* 58% (22%)* 53% (32%)* *These rates refer to Jaffna district residents	No statistically significant gender differences were found for the outcomes studied	Staff working for nat. NGOs, the Red Cross, or a UN org. less likely to suffer depression symptoms than staff working for an internat. NGO. Org. type not significantly correlated with PTSD or anxiety	Cross-sectional design; Findings based on self-reported symptoms; screening instruments not specifically validated for Vanni region; findings limited to specific population only	Participants who received less social support more likely to experience probable PTSD than those who received more social support. Probable PTSD significantly more likely among those who experienced greater numbers of conflicts and misunderstandings with co-workers
6	Lopes Cardozo, 2005	Quantitative study; cross-sectional; self-administered survey; during service	N=610/N=325 (70.5% male, 29.5% female) Expatriates and Kosovar Albanians (=national staff)	PTSD (Harvard Trauma Questionnaire) Depression (Hopkins Symptom Checklist-25)	6.15% (17.1%)* (1.1%)** 16.92% (17.19%)**	Women had substantially more depression and worse NSPM than	n/a	No clinical interviews; timeframe for symptoms of PTSD was only 1 week; qualitative component could have generated	Occupational factors may have different relevance for national staff and expatriates: lack of access to org. support services not associated with adverse mental health
			working in Kosovo	Non-specific psychiatric morbidity (General Health Questionnaire-28) Hazardous alcohol consumption (3 or more standard alcoholic drinks/day)	11.5% (23.9%)** 2.52% (16.2%)** *This rate refers to a population-based sample of Kosovar Albanians **These rates refer to expatriate staff working in Kosovo	men		important information; response rate was high but non-response bias cannot be ruled out; cross-sectional survey; lack of baseline data and information on mental health prior to recruitment; retrospective studies involving recollection of trauma events may be limited by inaccurate recall; situation in Kosovo was relatively stable and results are not generalizable to relief workers operating in more acute emergencies	outcomes among national staff. For national staff, access to regular social support may have been more relevant than org. support
7	Musa, 2008	Quantitative study; cross-sectional; self-report questionnaires; during service	N=53/60% (n/a) Expatriates and Sudanese people (=national staff) working in Sudan	Secondary traumatic stress (Professional Quality of Life Questionnaire) Burnout (Worker Burnout Questionnaire) Nonpsychotic psychiatric disorders (General Health Questionnaire)	25%* 16%* 50%* *These rates refer to expatriate and national staff. Results showed that national staff suffered	Women scored higher levels of burnout than men	n/a	n/a	Study recommends that org. managers and directors should create a positive work climate through the provision of training, psychological support offers, and cultural orientation
					significantly more burnout and STS
8	Shah, 2007	Quantitative study; cross-sectional; survey administered face-to-face in group fashion; 5 months after mass violence in which staff served	N=76/N=76 (n/a) National staff from India	PTSD (Secondary Traumatic Stress Scale) Symptoms of secondary traumatic stress (Secondary Traumatic Stress Scale)	8% 100%	n/a (no demographic data collected)	n/a (all staff worked for NGOs)	STSS not validated for this population; possible respondent pool mismatch due to cultural factors; no comparison group and no baseline data available; one NGO received psychotherapy during study and impacts on STSS scoring are unclear; primary traumatic stress as confounder for measuring STS; primary and secondary trauma intermingle and inform each other; survivor guilt may play a part in magnifying STS; DSM-IV valid in some cultures but may be strained in others	Significant differences in PTSD between staff from different NGOs: mean STS score for NGOs recruiting staff with lower socio-economic status significantly higher than that of NGOs with more privileged staff. Distance to epicenter of violence not significant
9	Thormar, 2013	Quantitative study; longitudinal; self-report questionnaires; 6, 12, and 18 months post-earthquake	N=506/N=506 (74% male, 26% female) National staff from Indonesia	PTSD (Impact of Event Scale-Revised) Anxiety (Hospital Anxiety and Depression Scale) Depression (Hospital Anxiety and Depression Scale)	23% clinical levels* 58% mild cases, 8% moderate levels* 4% moderate levels* *These rates	Gender had a significant effect on depression, and being male was predictive of higher depressive	n/a (all staff worked for Red Cross)	n/a	Feeling of safety: one of the most important variables in context of PTSD and anxiety: lack of safety measures facilitated development of PTSD and anxiety symptoms
					refer to the third assessment at 18 months post-disaster	syndromes
10	Wang, Yip, 2013	Quantitative study; retrospective cohort design; self-administered survey; 11 months after earthquake	N=70/N=70 (70% male, 25.7% female) National staff from China	Suicidal ideation (single item, binary response format)	21.4% (7.1%)* *This rate refers to suicidal ideation in the same national staff asked about suicidal ideation prior to the earthquake	Sex was excluded from the study as it was not significantly related to any variable	n/a	Cross-sectional; possible recall-bias	Study emphasizes the importance of disaster management's awareness of mental health risks for staff and the relevance of supportive work climate
				Depression (Chinese version of Center for Epidemiological Studies Depression Scale)	n/a
				Posttraumatic Stress (15-item Chinese version of Impact of Event Scale)	n/a
				Job burnout (16-item Maslach Burnout Scale)	n/a
11	Zhen, 2012	Quantitative study; cross-sectional; self-administered questionnaires; within one year after earthquake	N=446/N=210 (100% female) National staff and disaster-unexposed nurses from China	PTSD (Traumatic Stress Symptom Checklist) Depression (Traumatic Stress Symptom Checklist)	30% (10.2%)* 27.1% (9.7%)* *These rates refer to disaster-	n/a (100% female participants)	n/a (all participants from same organization)	Potential cohort effects, such as difference in level of education between national staff and unexposed nurses	In exposed staff, psychological distress associated with the difficulty of task performed, for example, proximity to the center of the earthquake resulted in greater distress
					unexposed nurses.
Qualitative studies
12	Bilal, 2007	Qualitative study; case report; after service	N=1/N=1 (100%m) National staff from Pakistan	Vicarious traumatization (psychiatric examination)	Diagnosed as suffering from depression and secondary trauma	n/a (only one participant)	n/a (only one participant)	n/a	Case report emphasizes importance of recognizing and managing mental health issues of staff at org. level
13	Wang, Chan, 2013	Qualitative study; semi structured interviews; 10 months after earthquake	N=25 / N=25 (13 males, 12 females) National staff from China	Stress and coping experiences (semi-structured interviews, thematic analysis)	Results categorized by two general themes: perceived sources of stress and coping experiences	n/a	n/a (all government officials)	Interpretation of results is bound to specific sample	Staff experienced strong feeling of fulfilment, purpose, and meaningfulness of relief work, which may help in handling loss and trauma. Atmosphere at work often more positive than at home
Mixed method study
14	Putman, 2009	Study 1: Qualitative study; focus group discussions; during service	Study 1: N=26/N=26 (35% male, 65% female) National staff from Guatemala	Study 1: Sources of stress related to work and motivators and rewards that help stay engaged in service	Study 1: Most frequently recurring theme was exposure to direct and indirect violence during work; key problems were lack of training, lack of governmental support, lack of emotional support, lack of financial resources to carry out work; key motivators for work were compassion, gods calling, giving back; most rewarding experiences were seeing growth in community, spiritual benefits	Study 1: n/a	Study 1: n/a (all participants from NGOs)	Studies 1 and 2: No random sample; cross-sectional; self-selection to attend traumatic stress management workshops offered prior to survey: possible bias in that those with more distress may have elected to come or found it difficult to attend; self-report questionnaires; work-related support needs, motivators and rewards were not included in survey: these variables are not directly comparable to the survey results due to differences in method and sample; translation of focus groups may have led to losing some nuances of meaning in qualitative data	Study recommends orgs. should protect their staff through specific safety services, specifically in contexts of high exposure to community violence
		Study 2: Quantitative study; cross-sectional; survey; during service	Study 2: N=135/N=1 35 (36% male, 64% female) National staff from Guatemala and student volunteers	Study 2 PTSD (LA Symptom Checklist)	Study 2: 17%* *This rate refers to national staff and students. The rate is higher than that found among returned international aid workers from five humanitarian	Study 2: n/a	Study 2: n/a
					agencies and Guatemalan refugees living in camps in Mexico
				Exposure to community violence (Survey of Children's Exposure to Community Violence)	Average number of events: 13
				Burnout (Maslach Burnout Inventory)	n/a