title: Association of combatant status and sexual violence with health and mental health outcomes in postconflict Liberia.
abstract: BACKGROUND
  Liberia's wars since 1989 have cost tens of thousands of lives and left many people mentally and physically traumatized.
  
  
  OBJECTIVE
  To assess the prevalence and impact of war-related psychosocial trauma, including information on participation in the Liberian civil wars, exposure to sexual violence, social functioning, and mental health.
  
  
  METHODS
  A cross-sectional, population-based, multistage random cluster survey of 1666 adults aged 18 years or older using structured interviews and questionnaires, conducted during a 3-week period in May 2008 in Liberia.
  
  
  METHODS
  Symptoms of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), social functioning, exposure to sexual violence, and health and mental health needs among Liberian adults who witnessed or participated in the conflicts during the last 2 decades.
  
  
  RESULTS
  In the Liberian adult household-based population, 40% (95% confidence interval [CI], 36%-45%; n = 672/1659) met symptom criteria for MDD, 44% (95% CI, 38%-49%; n = 718/1661) met symptom criteria for PTSD, and 8% (95% CI, 5%-10%; n = 133/1666) met criteria for social dysfunction. Thirty-three percent of respondents (549/1666) reported having served time with fighting forces, and 33.2% of former combatant respondents (182/549) were female. Former combatants experienced higher rates of exposure to sexual violence than noncombatants: among females, 42.3% (95% CI, 35.4%-49.1%) vs 9.2% (95% CI, 6.7%-11.7%), respectively; among males, 32.6% (95% CI, 27.6%-37.6%) vs 7.4% (95% CI, 4.5%-10.4%). The rates of symptoms of PTSD, MDD, and suicidal ideation were higher among former combatants than noncombatants and among those who experienced sexual violence vs those who did not. The prevalence of PTSD symptoms among female former combatants who experienced sexual violence (74%; 95% CI, 63%-84%) was higher than among those who did not experience sexual violence (44%; 95% CI, 33%-53%). The prevalence of PTSD symptoms among male former combatants who experienced sexual violence was higher (81%; 95% CI, 74%-87%) than among male former combatants who did not experience sexual violence (46%; 95% CI, 39%-52%). Male former combatants who experienced sexual violence also reported higher rates of symptoms of depression and suicidal ideation. Both former combatants and noncombatants experienced inadequate access to health care (33.0% [95% CI, 22.6%-43.4%] and 30.1% [95% CI, 18.7%-41.6%], respectively).
  
  
  CONCLUSIONS
  Former combatants in Liberia were not exclusively male. Both female and male former combatants who experienced sexual violence had worse mental health outcomes than noncombatants and other former combatants who did not experience exposure to sexual violence.
authors.affiliation: Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts, USA.
authors.forename: Kirsten
authors.initials: K
authors.lastname: Johnson
authors.forename: Jana
authors.initials: J
authors.lastname: Asher
authors.forename: Stephanie
authors.initials: S
authors.lastname: Rosborough
authors.forename: Amisha
authors.initials: A
authors.lastname: Raja
authors.forename: Rajesh
authors.initials: R
authors.lastname: Panjabi
authors.forename: Charles
authors.initials: C
authors.lastname: Beadling
authors.forename: Lynn
authors.initials: L
authors.lastname: Lawry
mesh_terms: D000328:Adult; D003130:Combat Disorders / Q000453:epidemiology*; D003430:Cross-Sectional Studies; D006304:Health Status; D006306:Health Surveys; D006801:Humans; D007988:Liberia / Q000453:epidemiology; D008603:Mental Health; D008875:Middle Aged; D008889:Military Personnel / Q000523:psychology / Q000706:statistics & numerical data*; D015995:Prevalence; D012742:Sex Offenses / Q000523:psychology / Q000706:statistics & numerical data*; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology*; D014728:Veterans / Q000523:psychology / Q000706:statistics & numerical data*; D014857:Warfare