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Measuring Trauma and Health Status in Refugees
A Critical Review
Michael Hollifield, MD;
Teddy D. Warner, PhD;
Nityamo Lian, DOM,(NM);
Barry Krakow, MD;
Janis H. Jenkins, PhD;
James Kesler, MD;
Jayne Stevenson, MD;
Joseph Westermeyer, MD,PhD
JAMA. 2002;288:611-621.
Context Refugees experience multiple traumatic events and have significant associated health problems, but data about refugee trauma and health status are often conflicting and difficult to interpret.
Objectives To assess the characteristics of the literature on refugee trauma and health, to identify and evaluate instruments used to measure refugee trauma and health status, and to recommend improvements.
Data Sources MEDLINE, PsychInfo, Health and PsychoSocial Instruments, CINAHL, and Cochrane Systematic Reviews (searched through OVID from the inception of each database to October 2001), and the New Mexico Refugee Project database.
Study Selection Key terms and combination operators were applied to identify English-language publications evaluating measurement of refugee trauma and/or health status.
Data Extraction Information extracted for each article included author; year of publication; primary focus; type (empirical, review, or descriptive); and type/name and properties of instrument(s) included. Articles were excluded from further analyses if they were review or descriptive, were not primarily about refugee health status or trauma, or were only about infectious diseases. Instruments were then evaluated according to 5 criteria (purpose, construct definition, design, developmental process, reliability and validity) as described in the published literature.
Data Synthesis Of 394 publications identified, 183 were included for further analyses of their characteristics; 91 (49.7%) included quantitative data but did not evaluate measurement properties of instruments used in refugee research, 78 (42.6%) reported on statistical relationships between measures (presuming validity), and 14 (7.7%) were only about statistical properties of instruments. In these 183 publications, 125 different instruments were used; of these, 12 were developed in refugee research. None of these instruments fully met all 5 evaluation criteria, 3 met 4 criteria, and 5 met only 1 of the criteria. Another 8 standard instruments were designed and developed in nonrefugee populations but adapted for use in refugee research; of these, 2 met all 5 criteria and 6 met 4 criteria.
Conclusions The majority of articles about refugee trauma or health are either descriptive or include quantitative data from instruments that have limited or untested validity and reliability in refugees. Primary limitations to accurate measurement in refugee research are the lack of theoretical bases to instruments and inattention to using and reporting sound measurement principles.
Author Affiliations: Departments of Family and Community Medicine (Dr Hollifield) and Psychiatry (Drs Hollifield, Warner, Lian, and Stevenson), University of New Mexico Health Sciences Center, Albuquerque; Sleep and Human Health Institute, Albuquerque, NM (Dr Krakow); Departments of Anthropology and Psychiatry, Case Western Reserve University, Cleveland, Ohio (Dr Jenkins); Northern Colorado Family Practice Center, Greeley (Dr Kesler); University of Minnesota and the Minneapolis Veterans Affairs Center, Minneapolis, Minn (Dr Westermeyer).
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