Associations between different forms of intimate partner violence and posttraumatic stress among women who use drugs and alcohol in Kyrgyzstan.

Survivors of intimate partner violence (IPV) have an increased risk of experiencing posttraumatic stress, and the subsequently associated symptoms can vary by form of IPV exposure (i.e., physical, sexual, or psychological IPV). Related research among socially marginalized populations, however, is limited, including among women who use and misuse substances. Drawing on baseline data from a pilot study conducted among 213 women in Kyrgyzstan who reported using drugs or engaging in hazardous alcohol use, we examined the associations between different forms of IPV and severe posttraumatic stress symptoms (PTSS). The vast majority of participants reported lifetime (93.9%, n = 200) and past 3-month (65.3%, n = 139) IPV, and two thirds of participants (65.3%, n = 139) reported experiencing PTSS in the prior month. Multivariable logistic regression analyses indicated statistically significant associations between only some forms of IPV and PTSS, including physical IPV, adjusted odds ratio (aOR) = 3.24, 95% confidence interval (CI) [1.15, 9.14], and injurious IPV, aOR = 2.71, 95% CI [1.10, 6.65]. Additionally, experiencing any form of IPV was associated with 4.95 higher odds of reporting PTSS, 95% CI [1.16, 21.15]; no other results were significant. These results not only underscore the need for future research on the mechanisms that might explain the unique associations between different forms of IPV and posttraumatic stress, but also highlight an urgent need for trauma-informed mental health and psychosocial support interventions for women who use drugs and alcohol.

Suubi4Stigma study protocol: a pilot cluster randomized controlled trial to address HIV-associated stigma among adolescents living with HIV in Uganda.

BACKGROUND: Sub-Saharan Africa (SSA) is heavily burdened by HIV, with 85% of the global new infections among adolescents happening in the region. With advances in medication and national policies promoting antiretroviral therapy (ART), children < 15 years living with HIV (CLWH) continue to grow with a chronic, highly stigmatized disease. Unfortunately, the stigma they experience results in much lower quality of life, including poor mental health and treatment outcomes. Family members also experience stigma and shame by virtue of their association with an HIV-infected family member. Yet, stigma-reduction interventions targeting CLWH and their families are very limited. The goal of this study is to address HIV-associated stigma among CLWH and their caregivers in Uganda. METHODS: This three-arm cluster randomized control trial, known as Suubi4Stigma, will evaluate the feasibility, acceptability, and preliminary impact of two evidence-based interventions: (1) group cognitive behavioral therapy (G-CBT) focused on cognitive restructuring and strengthening coping skills at the individual level and (2) a multiple family group (MFG) intervention that strengthens family relationships to address stigma among CLWH (N = 90, 10-14 years) and their families (dyads) in Uganda. Nine clinics will be randomized to one of three study arms (n = 3 clinics, 30 child-caregiver dyads each): (1) usual care; (2) G-CBT + usual care; and (3) MFG + usual care. Both treatment and control conditions  will be delivered over a 3-month period. Data will be collected at baseline (pre-intervention) and at 3 months and 6 months post-intervention initiation. CONCLUSION: The primary aim of the proposed project is to address the urgent need for theoretically and empirically informed interventions that seek to reduce HIV-associated stigma and its negative impact on adolescent health and psychosocial well-being. As several countries in SSA grapple with care and support for CLWH, this study will lay the foundation for a larger intervention study investigating how HIV-associated stigma can be reduced to foster healthy child development-especially for CLWH as they transition through adolescence. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04528732 ; Registered August 27, 2020.

Validation of the Brief Symptom Inventory-18 Among Low-Income African American Adolescents Exposed to Community Violence.

African American youth, especially those who reside in low resourced communities, are exposed to higher levels of exposure to community violence relative to their counterparts from other race/ethnic groups. However, appropriate measures for assessing psychological stress related to such exposures are underresearched in the extant literature for this population. The aim of the current study was to examine the reliability and validity of the Brief Symptom Inventory (BSI-18) scale among African American youth exposed to community violence through classical test theory and item response theory methods. Internal reliability and construct validity were examined. Results indicated good internal reliability (α = .93). Construct validity of the BSI-18 was established through confirmatory factor analysis with the three-factor somatic, depression, and anxiety model. Construct validity was also determined with all items indicating adequate fit. Our study indicates good reliability and validity of the BSI-18 to assess psychological distress among African American youth exposed to community violence.

Global Posttrauma Symptoms: A Systematic Review of Qualitative Literature.

Exposure to potentially traumatic events is a global health problem, especially in low- and middle-income countries. Assessments for symptoms resulting from trauma exposure rely heavily on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for post-traumatic stress disorder (PTSD), which may not be relevant in all regions of the globe. We examined posttrauma symptoms that were not limited to Western constructs of mental health (i.e., PTSD). In a systematic review, we searched nine databases to identify posttrauma symptoms arising in qualitative literature published before July 17, 2017. A total of 17,938 records were identified and 392 met inclusion criteria. The 392 studies represented data on 400 study populations from 71 different nationalities/ethnicities. The presence and frequency of posttrauma symptoms were examined across all regions. Fisher's exact tests were also conducted to compare frequencies in posttrauma symptoms across region and gender. Based on a weighted analysis across regions, a list of global posttrauma symptoms (N = 85) was compiled into an item bank. We found that the majority of DSM-5 PTSD symptoms were mentioned across regions (with the exception of inability to recall specific aspects of the trauma and blame of self or others for the event). Across all regions, we also found a number of symptoms mentioned that were not part of PTSD and its associated features. Findings suggest that assessing posttrauma symptoms solely based on PTSD may be limiting to global populations. Research, policy, and practice implications are discussed.

Adaptation and Validation of the Shame Questionnaire Among Ugandan Youth Living with HIV.

The purpose of this study was to adapt and validate a measure of HIV-related shame, the Shame Questionnaire (SQ), among Ugandan youth living with HIV. Culturally relevant, reliable and valid measurement is critical in the accurate assessment of HIV-related shame (a painful internalized emotion encompassing feelings that the self is damaged and defective) on psychosocial functioning, as well as the determination of the efficacy of interventions among youth living with HIV in sub-Saharan Africa. We utilized qualitative (i.e., cognitive interviews; N = 31) and quantitative (i.e., classical test theory and item response theory; N = 150) methods to establish, content, criterion and construct validity of the SQ. Cognitive interviews resulted in the revision in the wording of 2 out of 8 SQ items. Participants who endorsed having shame had statistically significant higher SQ scores than participants who did not endorse having shame (p < 0.001), suggesting criterion validity. We found a statistically significant positive relationship between SQ scores and average trauma symptom scores among participants (p < 0.001), also suggesting criterion validity. Finally, we found construct validity with discrimination parameters of the graded response IRT model all in the high range with a wide range of difficulty parameters across the 8 items of the SQ. Overall our results suggest that the SQ is a contextually relevant, valid and reliable assessment tool among Ugandan youth living with HIV. Findings provide support for the utilization of qualitative and quantitative methods in the adaptation of measures for cross-cultural use in order to maintain validity and contextual relevance.

Correction to: How Do Risk Environment Factors Influence Perpetration of Partner Violence among Male Migrant and Non-migrant Market Workers in Central Asia?

The surname of coauthor Lynn Michalopoulos was misspelled (as "Michalopolous") in this originally published. The original article has been corrected.

How Do Risk Environment Factors Influence Perpetration of Partner Violence among Male Migrant and Non-migrant Market Workers in Central Asia?

Intimate partner violence (IPV) has emerged as a serious public health issue in migrant communities in Central Asia and globally. To date, however, research on risk factors associated with male perpetration of IPV among migrants remains scant. This study aims to examine risk environment theory-driven factors associated with male perpetration of IPV in the prior 6 months. We recruited, enrolled, and surveyed a respondent-driven sample of 1342 male market workers in Almaty, Kazakhstan, that included 562 (42%) non-migrants defined as Kazakhstan citizens who reside in Almaty; 502 (37%) external migrants from Kyrgyzstan, Tajikistan, or Uzbekistan; and 278 (21%) internal migrants from other areas of Kazakhstan. We conducted multivariate logistic regressions to estimate the effects of physical, economic, and political risk environment factors on IPV perpetration by migration status after controlling for potentially confounding socio-demographic and psychosocial variables. A total of 170 participants (12.7%) reported ever perpetrating physical or sexual IPV and 6.7% perpetrated such IPV in the prior 6 months. Multiple logistic regression results suggest that the risk environment factors of poor living conditions, exposure to political violence, and deportation experiences are associated with IPV perpetration among external and internal migrants, but not among non-migrants. Food insecurity is associated with IPV perpetration among external migrants and non-migrants, but not among internal migrants. Homelessness and arrests by police are associated with IPV perpetration among internal migrants, but not among external migrants or non-migrants. These findings underscore the need to consider the unique combination of risk environment factors that contribute to male IPV perpetration in the design of programs and policies to address IPV perpetration among external and internal migrant and non-migrant men in Central Asia.

The Development of a Culturally Adapted Pilot Intervention for African American Family Members of Homicide Victims: A Preliminary Report.

African Americans are disproportionately impacted by homicide in the United States. Individuals who have lost a relative to homicide often experience symptoms of complicated grief. The objective of this study was to explore the impact of a culturally tailored psychoeducational pilot intervention whose development was informed by a conceptual model of coping for African American survivors of homicide victims and was designed to (a) educate participants about the manifestation of complicated grief and symptoms and (b) help participants develop ways to cope with their grief. Pre- and post-test results indicate preliminary support for this encouraging intervention in achieving its intended outcomes to help participants identify complicated grief symptoms, supports, and services to help them manage their grief. Implications for posthomicide research and practice are discussed.

The syndemic effect of injection drug use, intimate partner violence, and HIV on mental health among drug-involved women in Kazakhstan.

We examined the synergistic effect of substance use (injection drug use), intimate partner violence, and HIV (dubbed the "SAVA syndemic") on depression and suicidal thoughts among a sample of high-risk women in Kazakhstan, a country with a notably high prevalence of suicide and violence against women, and concentrated epidemics of HIV and injection drug use. Using baseline data from an intervention study conducted in Almaty, Kazakhstan among 364 drug-involved couples, multivariate logistic regression analyses were used to examine the relationship between the SAVA syndemic continuum and mental health. Compared to women reporting none of the SAVA conditions, women who experienced the full range of the SAVA syndemic continuum had a 15.5-fold odds (p < .05) of reporting depression and a 6-fold odds (p < .05) in reporting suicidal thought disturbances. Findings suggest the need for integrated screening assessments among practitioners and interventions designed to address multiple, commonly co-occurring conditions in Central Asia.

Traumatic Events and HIV Sexual Risk Behaviors Among Migrant and Non-Migrant Male Market Workers in Central Asia.

We examined potentially traumatic events (PTEs) and the relationship between PTEs and HIV risk behaviors among male market workers in Kazakhstan, comparing Kazakhstani to external migrants. Using respondent-driven sampling, participants were 1342 male marketplace workers in Almaty, Kazakhstan. Univariate, bivariate, and logistic regressions were conducted. We found high prevalence of PTEs among participants, and significant differences between PTEs and HIV risk by migrant status. Kazakhstanis reporting 1-2 or three-or-more traumatic events were more likely to report engaging in sex trading, compared to Kazakhstanis who reported no PTEs (OR = 3.65, CI 1.20-11.11, p = 0.022; OR = 8.17, 95% CI 2.66-25.09, p = 0.000, respectively). Kazakhstanis who reported three-or-more PTEs were more likely to report unprotected sex (OR = 2.17, CI 2.17-3.89, p = 0.009). Results did not support this relationship among external migrants. Findings underscore the need for attention on services that address trauma and HIV risk among this population and more research to understand differences by migrant status.

Exposure to Community Violence Among Low-Income African American Youth in Chicago: A Latent Class Analysis.

African American youth are exposed to some of the highest rates of exposure to community violence. However, few studies have explored factors related to exposures and various subtypes of exposures to community violence (i.e., no exposure, witnessing only and being a witness/victim). Among a matched sample of 129 African American youth and their caregivers, no exposure to community violence was correlated with being heterosexual versus being a lesbian, gay, bisexual, and transgender (LGBT) person, having parents who owned their homes versus rented, and having higher authoritarian parenting attitudes. In addition, being a witness/victim of community violence was correlated with any youth substance use, lower levels of school bonding, having less future orientation, less parental home ownership, and an adverse family history. Practice and programmatic considerations are discussed based on these findings.

"Life at the River is a Living Hell:" a qualitative study of trauma, mental health, substance use and HIV risk behavior among female fish traders from the Kafue Flatlands in Zambia.

BACKGROUND: In Western settings, the relationship between trauma history, posttraumatic stress disorder, substance use, and HIV risk behavior, is well established. Although female fish traders in Zambia are affected by HIV at rates estimated to be 4-14 times higher than the national prevalence, no studies have examined the co-occurring issues of trauma, substance use and HIV risk behavior among this vulnerable population. The current study examined: 1) trauma history, trauma symptoms and HIV risk behaviors and 2) the relationship between these co-occurring issues among female fish traders from the Kafue Flatlands in Zambia. METHODS: Twenty individual semi-structured qualitative interviews and a focus group discussion (n = 12 participants) were conducted with female fish traders in the Kafue Flatlands of Zambia. Template analysis was used to examine the data. RESULTS: The findings indicate that female fish traders in Zambia are at risk of multiple and ongoing traumatic events and daily stressors, severe mental health symptoms (including western conceptualizations of disorders such as anxiety, depression, post-traumatic stress disorder (PTSD) and complicated grief, as well as local idioms of distress), substance abuse, and HIV sexual risk behaviors. The results suggest a relationship between trauma and HIV sexual risk behavior in this population. CONCLUSIONS: The indication of these co-occurring issues demonstrates the need for HIV prevention intervention efforts, which account for trauma, mobility, and psychosocial outcomes in order to reduce HIV sexual risk behavior among female fish traders in Zambia.

A qualitative study of migrant-related stressors, psychosocial outcomes and HIV risk behaviour among truck drivers in Zambia.

Truck drivers are part of mobile populations which have been noted as a key population at risk of HIV in Zambia. This study was aimed at: (1) determining potentially traumatic events (PTEs), labour migrant-related stressors, psychosocial problems and HIV risk behaviours among truck drivers in Zambia; and (2) examining the relationship between PTEs, migrant-related stressors, psychosocial outcomes and HIV sexual risk behaviour among truck drivers in Zambia. We conducted 15 semi-structured interviews with purposively sampled male truck drivers at trucking companies in Lusaka, Zambia. Findings indicate that truck drivers experience multiple stressors and potentially traumatic incidences, including delays and long waiting hours at borders, exposure to crime and violence, poverty, stress related to resisting temptation of sexual interactions with sex workers or migrant women, and job-related safety concerns. Multiple psychosocial problems such as intimate partner violence, loneliness, anxiety and depression-like symptoms were noted. Transactional sex, coupled with inconsistent condom use, were identified as HIV sexual risk behaviours. Findings suggest the critical need to develop HIV-prevention interventions which account for mobility, potentially traumatic events, psychosocial problems, and the extreme fear of HIV testing among this key population.

The association between psychosocial and structural-level stressors and HIV injection drug risk behavior among Malaysian fishermen: A cross-sectional study.

BACKGROUND: Malaysian fishermen have been identified as a key-affected HIV population with HIV rates 10 times higher than national rates. A number of studies have identified that psychosocial and structural-level stressors increase HIV injection drug risk behaviors. The purpose of this paper is to examine psychosocial and structural-level stressors of injection drug use and HIV injection drug risk behaviors among Malaysian fishermen. METHODS: The study employs a cross-sectional design using respondent driven sampling methods. The sample includes 406 fishermen from Pahang state, Malaysia. Using multivariate logistic regressions, we examined the relationship between individual (depression), social (adverse interactions with the police), and structural (poverty-related) stressors and injection drug use and risky injection drug use (e.g.., receptive and non-receptive needle sharing, frontloading and back-loading, or sharing drugs from a common container). RESULTS: Participants below the poverty line had significantly lower odds of injection drug use (OR 0.52, 95 % CI: 0.27-0.99, p = 0.047) and risky injection drug use behavior (OR 0.48, 95 % CI: 0.25-0.93, p = 0.030). In addition, participants with an arrest history had higher odds of injection use (OR 19.58, 95 % CI: 9.81-39.10, p < 0.001) and risky injection drug use (OR 16.25, 95 % CI: 4.73-55.85, p < 0.001). Participants with depression had significantly higher odds of engaging in risky injection drug use behavior (OR 3.26, 95 % 1.39-7.67, p = 0.007). Focusing on participants with a history of injection drug use, we found that participants with depression were significantly more likely to engage in risky drug use compared to participants below the depression cutoff (OR 3.45, 95 % CI: 1.23-9.66, p < 0.02). CONCLUSIONS: Findings underscore the need to address psychosocial and structural-level stressors among Malaysian fishermen to reduce HIV injection drug risk behaviors.

A Systematic Review of HIV Risk Behaviors and Trauma Among Forced and Unforced Migrant Populations from Low and Middle-Income Countries: State of the Literature and Future Directions.

The aim of the current systematic review is to examine the relationship between trauma and HIV risk behaviors among both forced and unforced migrant populations from low and middle income countries (LMIC). We conducted a review of studies published from 1995 to 2014. Data were extracted related to (1) the relationship between trauma and HIV risk behaviors, (2) methodological approach, (3) assessment methods, and (4) differences noted between forced and unforced migrants. A total of 340 records were retrieved with 24 studies meeting inclusion criteria. Our review demonstrated an overall relationship between trauma and HIV risk behaviors among migrant populations in LMIC, specifically with sexual violence and sexual risk behavior. However, findings from 10 studies were not in full support of the relationship. Findings from the review suggest that additional research using more rigorous methods is critically needed to understand the nature of the relationship experienced by this key-affected population.

Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Clinical Trial.

IMPORTANCE: Orphans and vulnerable children (OVC) are at high risk for experiencing trauma and related psychosocial problems. Despite this, no randomized clinical trials have studied evidence-based treatments for OVC in low-resource settings. OBJECTIVE: To evaluate the effectiveness of lay counselor-provided trauma-focused cognitive behavioral therapy (TF-CBT) to address trauma and stress-related symptoms among OVC in Lusaka, Zambia. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial compared TF-CBT and treatment as usual (TAU) (varying by site) for children recruited from August 1, 2012, through July 31, 2013, and treated until December 31, 2013, for trauma-related symptoms from 5 community sites within Lusaka, Zambia. Children were aged 5 through 18 years and had experienced at least one traumatic event and reported significant trauma-related symptoms. Analysis was with intent to treat. INTERVENTIONS: The intervention group received 10 to 16 sessions of TF-CBT (n = 131). The TAU group (n = 126) received usual community services offered to OVC. MAIN OUTCOMES AND MEASURES: The primary outcome was mean item change in trauma and stress-related symptoms using a locally validated version of the UCLA Posttraumatic Stress Disorder Reaction Index (range, 0-4) and functional impairment using a locally developed measure (range, 0-4). Outcomes were measured at baseline and within 1 month after treatment completion or after a waiting period of approximately 4.5 months after baseline for TAU. RESULTS: At follow-up, the mean item change in trauma symptom score was -1.54 (95% CI, -1.81 to -1.27), a reduction of 81.9%, for the TF-CBT group and -0.37 (95% CI, -0.57 to -0.17), a reduction of 21.1%, for the TAU group. The mean item change for functioning was -0.76 (95% CI, -0.98 to -0.54), a reduction of 89.4%, and -0.54 (95% CI, -0.80 to -0.29), a reduction of 68.3%, for the TF-CBT and TAU groups, respectively. The difference in change between groups was statistically significant for both outcomes (P < .001). The effect size (Cohen d) was 2.39 for trauma symptoms and 0.34 for functioning. Lay counselors participated in supervision and assessed whether the intervention was provided with fidelity in all 5 community settings. CONCLUSIONS AND RELEVANCE: The TF-CBT adapted for Zambia substantially decreased trauma and stress-related symptoms and produced a smaller improvement in functional impairment among OVC having experienced high levels of trauma. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01624298.

Testing the validity and reliability of the shame questionnaire among sexually abused girls in Zambia.

PURPOSE: The aim of the current study is to test the validity and reliability of the Shame Questionnaire among traumatized girls in Lusaka, Zambia. METHODS: The Shame Questionnaire was validated through both classical test and item response theory methods. Internal reliability, criterion validity and construct validity were examined among a sample of 325 female children living in Zambia. Sub-analyses were conducted to examine differences in construct validity among girls who reported sexual abuse and girls who did not. RESULTS: All girls in the sample were sexually abused, but only 61.5% endorsed or reported that sexual abuse had occurred. Internal consistency was very good among the sample with alpha = .87. Criterion validity was demonstrated through a significant difference of mean Shame Questionnaire scores between girls who experienced 0-1 trauma events and more than one traumatic event, with higher mean Shame Questionnaire scores among girls who had more than one traumatic event (p = .004 for 0-1 compared to 2 and 3 events and p = .016 for 0-1 compared to 4+ events). Girls who reported a history of witnessing or experiencing physical abuse had a significantly higher mean Shame Questionnaire score than girls who did not report a history of witnessing or experiencing physical abuse (p<.0001). There was no significant difference in mean Shame Questionnaire score between girls who reported a sexual abuse history and girls who did not. Exploratory factor analysis indicated a two-factor model of the Shame Questionnaire, with an experience of shame dimension and an active outcomes of shame dimension. Item response theory analysis indicated adequate overall item fit. Results also indicate potential differences in construct validity between girls who did and did not endorse sexual abuse. CONCLUSIONS: This study suggests the general utility of the Shame Questionnaire among Zambian girls and demonstrates the need for more psychometric studies in low and middle income countries.

Coping with grief responses among African American family members of homicide victims.

Research relevant to coping with grief for African American family members of homicide victims is limited. This retrospective study was conducted to determine the effects of gender, length of time since death, the traumatic impact of experiencing the homicide of a loved one, and the use of coping strategies to current grief reactions of African American family members of homicide victims (N = 44). Multiple regression analysis results suggest that gender and level of traumatic stress, related to posttraumatic stress symptomatology, predict current symptoms of grief. Women reported higher levels of current grief symptoms than men. Family members of homicide victims who reported higher levels of posttraumatic stress symptomology reported higher levels of current grief. Implications for research and recommendations for practitioners are discussed.

Counselor and client perspectives of Trauma-focused Cognitive Behavioral Therapy for children in Zambia: a qualitative study.

This study examined Zambian counselors, children, and caregivers' perceptions of an evidence-based treatment (EBT) for trauma (Trauma-Focused Cognitive Behavioral Therapy [TF-CBT]) utilized in Zambia to address mental health problems in children. Semistructured interviews were conducted with local counselors trained in TF-CBT (N = 19; 90% of those trained; 12 female) and children/caregivers who had received TF-CBT in a small feasibility study (N = 18; 86% of the children and N = 16; 76% of the caregivers) who completed TF-CBT (total completed; N = 21). Each client was asked six open-ended questions, and domain analysis was used to explore the data. Counselors were positive about the program, liked the structure and flexibility, reported positive changes in their clients, and discussed the cultural adaptation around activities and language. Counselors stated the training was too short, and the supervision was necessary. Challenges included client engagement and attendance, availability of location, funding, and a lack of community understanding of "therapy." Children and caregivers stated multiple positive changes they attributed to TF-CBT, such as better family communication, reduction of problem behaviors, and ability to speak about the trauma. They recommended continuing the program. This study brings a critical examination of providers' and clients' perspectives of the implementation of an EBT for children in a low-resource setting. Clinical implications include changing implementation methods based on responses. Research implications include future study directions such as an effectiveness trial of TF-CBT and an examination of implementation factors.

The mental health and psychosocial problems of survivors of torture and genocide in Kurdistan, Northern Iraq: a brief qualitative study.

BACKGROUND: From 1986-9, the Kurdish population of Iraqi Kurdistan was subjected to an intense campaign of military action, and genocide by the central Iraq government. This campaign, referred to as the Anfal, included systematic attacks consisting of aerial bombings, mass deportation, imprisonment, torture, and chemical warfare. It has been estimated that around 200,000 Kurdish people disappeared. PURPOSE: To gain a better understanding of current priority mental health and psychosocial problems among Kurdish survivors of the Anfal, and to inform the subsequent design of culturally appropriate and relevant assessment instruments and services to address these problems. The study examined 1) the nature and cause of current problems of survivors of torture and/or civilian attacks and their families, 2) what survivors do to address these problems, and 3) what they felt should be done. METHODS: We used a grounded theory approach. Free list interviews with a convenience sample (n=42) explored the current problems of Kurdish persons affected by torture. Subsequent key informant interviews (n=21) gathered more detailed information on the priority mental health problem areas identified in the free list interviews. RESULTS: Major mental health problem areas emerging from the free list interviews (and explored in the key informant interviews) included 1) problems directly related to the torture, 2) problems related to the current situation, and 3) problems related to the perception and treatment by others in the community. Problems were similar, but not identical, to Western concepts of depression, anxiety, PTSD and related trauma, and traumatic grief. CONCLUSION: Iraqi Kurdish torture survivors in Iraq have many mental health and psychosocial problems found among torture survivors elsewhere. The findings suggest that the problems are a result of the trauma experienced as well as current stressors. Development of mental health assessment tools and interventions should therefore address both previous trauma and current stressors.