Assessment of mental health in adults of the northern part of the city of Kosovska Mitrovica Procena mentalnog zdravlja odraslih stanovnika severne Kosovske Mitrovice

Background/Aim. Mental health disorders lead to disorder of effective functioning of people and deterioration of quality of life. Early detection of individuals at risk of mental health disorders is extremely important from the aspect of mental health disorders prevention. The aim of the research was to determine the frequency of mental health problems among adult residents of northern Kosovska Mitrovica and to examine the association between frequency of mental health problems and socio-demographic and other characteristics of the population obtained by the questionnaire. Methods. The cross-sectional study on the representative sample of adult residents of northern Kosovska Mitrovica was performed in October 2009. To obtain information about the characteristics of mental health the Goldberg’s General Health Questionnaire (GHQ-28) was used. For performing survey at site the method of rapid epidemiological assessment was chosen. Statistical analysis included the methods of descriptive statistics, multivariate regression analysis and calculation of the Cronbach’s alpha coefficient of internal consistency of the questionnaire. Results. Mental health problems (total score) were present in almost half of the respondents (49.2%). Psychosomatic problems were present in more than half of the respondents (55.4%), while anxiety and insomnia were present in almost half of the respondents (49.2%). Social dysfunction had more than three fifths of the respondents (63.1%) and depression more than a quarter of the respondents (28.5%). More positive responses in the questionnaire were statistically significantly associated with older age, poor financial situation, abuse and assessing of the current political-security situation as high risk. The value of Cronbach’s alpha coefficient was 0.705. Conclusions. Almost half of the respondents (49.2%) of North Kosovska Mitrovica had mental health problems. Mental health problems were associated with older age, poor financial situation, abuse and considering the current politicalsecurity situation as high-risk factor.


Introduction
According to the definition of the World Health Organization, which is an integral part of the Constitution of this organization 1 , mental health is a component of health.The World Health Organization points out that mental health is not merely the absence of mental illness, but it is "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" 2 .Mental health disorders lead to disorders of functioning and significantly affect the quality of life.In addition, mental health disorders are associated with physical health disorders, particularly with chronic diseases from which many people die and suffer, such as cardiovascular disease, diabetes, and etc. 3,4 .
Early detection of people at risk of mental disorders developing is extremely important in prevention of mental disorders 5 .So far, a few questionnaires have been created that can help to detect people at risk of mental disorders developing, but the Goldberg`s General Health Questionnaire is one of the most commonly used for this purpose 6 .This questionnaire has been used in various investigations.This questionnaire has been used to examine mental health of users of primary health care 7 , workpeople 8 , patients with ischemic heart disease and patients with gastrostoma 9,10 , and to investigate mental health of survivors of the tsunami in Indonesia 11 .
Within the last decade of the 20th century, Serbia faced many stressful events, such as disintegration of the former state, the United Nations economic sanctions that lasted three and a half years, conflicts in Kosovo, the bombing by NATO in 1999.All this had an effect on mental health of the population, so that the prevalence of mental disorders increased by 13.5% in the period 1999-2002 12 .In a study on burden of disease and injury in Serbia in 2002 depression is ranked fourth (third for women, and sixth for men) 13 .After the bombing, in June 1999, the Autonomous Province of Kosovo and Metohia came under UN administration 14 , and stressful events continued, especially for non-Albanian population.More than half of Serbs fled the Province, and those who remained were subjected to daily attacks.Many of them were kidnapped or killed 15 .Living in such an unstable political and security area affects mental health, but the data on this component of health are deficient.In September and October 1999 Salama et al. 16 were carried out the study on mental health of the population of Gnjilane and Priština using the Goldberg`s a questionnaire.In 2006 under the Health Survey the residents of northern Kosovska Mitrovica were investigated and some aspects of their mental health 17 .According to this survey, more than half of the respondents had problems with some of the aspects of mental health, urging to conduct a survey with on instrument adapted to assess mental health.
The aim of this research was to determine the prevalence of mental health problems in adult residents of North Kosovska Mitrovica and to study the relationship between mental health problems and the basic characteristics of adult residents of northern Kosovska Mitrovica obtained by the questionnaire (gender, age, marital status, number of family members, education, employment, self-rated financial situation, whether a person is displaced, the existence of mental disorders in the family, social support, abuse, assessment of current and future political and security situation).
We hypothesized that mental health was worse in females, adults, residents with lower education, unemployments, poor, displaced persons, abused and with poor social support.Also, we hypothesized that mental health could be worse in those people who take the political-security situation as high-risk factor.

Methods
This cross-sectional study included the representative sample of adults in northern Kosovska Mitrovica, and was performed in October 2009.
The sample was selected by the list of polling units with the number of votes for each constituency and the list of streets that includes voting record.These data are the part of electoral roll for the parliamentary elections in the Republic of Serbia in 2008.A total number of voters in northern Kosovska Mitrovica was 17,876 residents.The required sample size for assessing the prevalence of mental disorders, with the assumption of their frequency in a population of 20%, with an accuracy of 0.7 (7%) and the confidence level of 95% was 126.
To obtain information about socio-demographic characteristics of respondents we used the questionnaire with questions about gender, age, education, occupation, selfrated financial situation, marital status, the presence of mental disorders in the family, social support, abuse and, considering the characteristics of the territory in which they lived, whether or not displaced and if take the current and future political and security situation as risky.
To obtain information about the characteristics of mental health we used the Goldberg`s General Health Questionnaire (GHQ-28) 7 .This questionnaire allows to estimate the prevalence of mental health problems and psychological distress in the target population 18 .
The questionnaire consisted of 28 questions divided into 4 groups with 7 questions related to psychosomatic problems, anxiety and insomnia, social functioning and depression.Of these questions, 7 were formulated in positive terms (eg: Do you feel perfectly well and in good health?questionsA1, C1, C3-C7), and the question 21 was formulated in the negative sense (eg.: Yes Do you feel sick?other questions).In cases of questions asked in positive way, we used the following response scale: 1 = better than usual, 2 = as usual, 3 = worse than usual, 4 = much worse than usual.For 18 questions asked in negative term the following responses were used: 1 = not at all, 2 = no more than usual, 3 = more than usual, 4 = much more than usual.For the question C2 the following response scale were used: 1 = less than usual, 2 = same as usual, 3 = more than usual, 4 = much more than usual.For the questions D4 and D7 the following response scale were used: 1 = definitely no, 2 = do not think I am, 3 = think I have it, 4 = definitely I am 18 .In this questionnaire respondents assessed their condition in the past few weeks as compared to normal.The classical way of scoring was as follows: the answers 1 and 2 were scored by 0 (zero), and the answers 3 and 4 scored by 1 (one).This scoring method seemed to be sensitive to temporary conditions and allowed detection of mental health deterioration 18 .The scoring in this way did not reveal long-term chronic problems with mental health 19 .To overcome this deficiency, a new scoring was proposed in 1985, that only the first answer was scored with 0, and the others with 1 19 .Since the tested territory political and security situation deteriorated for many years, we applied a new, modified scoring system proposed in 1985.The author of the questionnaire in 1998 suggested the best threshold to be arithmetic mean of all points of respondents 20 , which was used in this research.
Because of the source of information, for the sample of respondents at site the method of rapid epidemiological assessment was chosen 21 .For each constituency the number of respondents was determined and divided into the streets that made up the constituency.The number of respondents was pre-determined for each street to be interviewed and started from the first building or house on the right side of the start.If it was a building, we first surveyed the people from the first flat and then from every second.One flat was skipped.In case of not cooperating in the survey we skipped apartment, according to the ordinal numbers.In case of a house at the beginning of the street, the survey was performed in the first house and then in every second house.The survey in one street was considered finished when included as many respondents as possible.The surveyed people were older than 18 years.Due to the nature of the issues, the author insisted that the respondents complete the questionnaire independently, and only when they insisted the interviewer read questions and recorded answers, which was significantly less frequent, mainly for the elderly respondents.In this way, we surveyed 130 respondents in 40 households.In five households respondents refused to participate in the survey, which means that the rate of response was 89.0%.
The methods of statistical analysis included descriptive statistics and multivariate regression analysis (using the procedure step by step).To determine the reliability of research instrument we determined the Cronbach alpha coefficient of internal consistency of the questionnaire.

Results
The study included 130 respondents.More than half (56.2%) of them were female.The average age was 45.5 ± 17.3 years.Half of the respondents had secondary level of education, and most of them were married (58.5%).More than half of the respondents (56.9%) were employed.Most of them (42.3%)described their financial condition as middle (Table 1).Table 2 shows the values of arithmetic means of the results obtained by the Goldberg`s General Health Questionnaire -28 (GHQ-28), as the threshold for determining whether a respondent is in good or poor mental health as well as the proportion of respondents who scored below or above the mean value.Thus, the psychosomatic problems of all respondents with 5 or more positive answers were classified as positive, and they were more than half of the respondents (55.4%).The same result of arithmetic mean was for anxiety and insomnia, that were present in almost half of the respondents (49.2%).There were 6 positive responses for social dysfunction threshold, present in more than three-fifths (63.1%) of the respodents.The threshold for depression was 2, which was marked by more than a quarter of respondents (28.5%).The threshold for the total score was 16 positive responses, which was given by almost half of the respondents (49.2%).
Table 3 shows the results of multiple linear regression for total score related to mental health.There is a highly statistically significant positive correlation between mental health problems and age, which means that these problems are more frequent in the elderly.Problems with mental health were significantly negatively associated with financial state and abuse, showing that mental health problems are more frequent in patients with poor financial situation and abuse.A statistically significant positive correlation was found between mental health problems and assessment of the current political and security situation showing that those who consider it as high risk are in worse mental health.
Table 4 presents the results of multiple linear regression for psychosomatic problems, anxiety and insomnia, social functioning and depression.Psychosomatic problems were significantly positively associated with age, social support and assessment of future political and security situation and negatively with their financial situation, implying that these problems were more frequent in the elderly, those without social support, who consider future political and security situation as high risk and those who were in worse financial situation.Social functioning was significantly positively correlated with age, implying that older people had more frequent problems with social functioning.Anxiety and insomnia were significantly positively associated with age and assessment of the current political and security situation, showing they were more frequent in the elderly and those who considered current political and security situation as high risk.Depression was statistically significantly positively associated with age and marital status, and negatively with their financial situation, that was more frequent in the elderly, widowed and divorced, those with poor financial condition and in people suffering from abuse.The value of Cronbah alpha coefficient of internal consistency of the questionnaire was 0.705 (95% confidence interval: 0.612 to 0.780), indicating satisfactory reliability of the questionnaire, as the values higher than 0.7 are interpreted as acceptable 22 .

Discussion
This research examined the prevalence of mental health problems of residents in northern Kosovska Mitrovica, and the association of mental health problems with demographic, socio-economic and other characteristics of the population, resulting from the characteristics of the territory.The applied questionnaire -GHQ-28, for mental health assessment in previous research showed to have acceptable reliability and validity for use for adult population in different countries.It has been used as a screening test by the World Health Organization in one of multicenter studies 6 .The applied scoring results proved satisfactory for the detection of chronic problems with mental health 23 .
The results showed that the average score of positive answers in the questionnaire was 15.54, taken as the threshold for determining the presence of mental health problems, so that each respondent with 16 or more positive answers was indicated as positive.These respondents were nearly half (49.2%).In a similar research for the rankings, which was done for the region of Montreal in Canada, the limit value was 11.45, a positive was 44.5% respondents 5 .This shows that all respondents in northern Kosovska Mitrovica had poorer mental health as a whole, and in addition, higher proportion of respondents had mental health problems.Salama et al. 16 have come to the conclusion that the average score of positive answers for the Serbs from Kosovo and Metohija is greater than all the population in Europe or in other parts of the world.This result coincides with the results of studies that have shown deterioration in mental health of residents living in areas affected by war and unstable political-security situation [24][25][26] .
The study also found that mental health problems were related to older age, poor financial situation, abuse and assessment of the current political-security situation as high risk.This result coincides with the evidence from literature 2, 27 , which states that these characteristics are among the most important determinants of mental health.A connection between mental health problems and an assessment of the current politicalsecurity situation as high risk is particularly interesting, indicating that the fear of evidently deteriorated political and security situation affect mental health so to cause psychologi-cal distress.This result makes the research itself justified, given that the data about mental health of residents of this territory, especially on its determinants, is deficient.In addition, the Serbian Government in its Strategy for the Development Care for Mental Health points out that it is necessary to support research in all areas of mental health in our community and that epidemiological studies on this subject are extremely rare 28 .Determination of residents with mental health problems, but not to the extend of illness, and to define risk groups is very important in prevention of mental disorders.Preventive strategies are maximally effective if applied before the onset of the disorder and if directed to the groups at higher risk of suffering 29 .By establishing that, nearly half the population of the area have mental health problems highlights the importance of this problem, implying the need to implement preventive strategies.
Possible limitations of this study come from the type of study, which examines the relationship between variables in a defined point in time, so it could lead to call in question a variables causality, since there is no information on their relationship in the long time.The average score of positive answers used as a threshold or borderline between good and poor mental health was higher than in other studies.Increasing the threshold in the interpretation of the results leads to a decrease in sensitivity and increase in specificity of instrument 30 , which also could be a limitation of the study.However, data about sensitivity and specificity in this case are not known, since we do not use another instrument, so the results could not be compared.The hypothesis of the research is partly confirmed, a restriction may be the sample size, because the biger sample allows to detect more discrete association as statistically significant.Finally, the data could be generalized only to the area of northern Kosovska Mitrovica, with respect to the method used for sampling.

Conclusion
The obtained results show that almost half (49.2%) of the residents of northern Kosovska Mitrovica have mental health problems.Mental health problems are associated with older age, poor financial condition, abuse and taking the current political-security situation as high risk.Theses results partially confirm the hypothesis of the study, but determining the frequency of mental health problems and risk groups is important for planning and implementing prevention strategies for preservation, enhancement and improvement of mental health.

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