There has recently been a growth of interest in mental health research, particularly in relation to the improvement of policy and practice across sectors (1-4). Most studies have involved descriptive data on mental disorders at the population level and have used large-scale survey methods, notably in work on the global burden of disease and disability-adjusted life years (5). Policy and practice in the field of mental health have traditionally been based on evidence obtained from such disease-centred studies. There is, however, growing interest in person-centred approaches to mental health policy, particularly in connection with such factors as stigma and social exclusion (6, 7). Interdisciplinary salutogenic (as opposed to pathogenic) perspectives on human ecology, coping mechanisms, strategies or adaptation, stress management and resilience have become increasingly relevant (8, 9).
Mental health studies in settings of complex humanitarian emergency fall into either the category of epidemiological psychiatry (10) or that of psychosocial psychiatry, often incorporating anthropology and/or sociology (11, 12). The present study focuses on the psychosocial well-being of women during pregnancy, childbirth, and the postpartum period in complex emergency settings in Eritrea associated with the 1998-2000 war with Ethiopia. Women, especially mothers of infants and young children, bear the brunt of economic, social, cultural and health burdens in societies affected by war. Moreover, the morale and mental well-being of mothers are important determinants of infant health in wartime (13). Consequently, this study is also of relevance to infant and child health policy and practice in complex emergency settings.
Eritrea has a population of about 4 million and has frontiers with Djibouti, Ethiopia, and the Sudan. In the highlands, staple crops and cash crops are grown (taff, wheat, barley, maize and, in the green belt of Semenawi Bahri, coffee) and there is dairy farming and goat, sheep, and poultry production. In the lowlands and middle altitudes, agropastoralism and transhumance are practised. There are nine ethnic groups with marked linguistic and sociocultural differences: predominantly Tigrinya-speaking orthodox Christians in the highlands; mostly Moslem societies consisting of Afar, Bilein, Hidareb, Nara, Rashaida, Saho and Tigre, ethnic groups in mid-altitude and lowland areas; along with Kunama Christians and followers of traditional religion.
The following questions are considered in this paper: What are the local perceptions of available statutory and non-statutory health services? What factors are believed to mitigate the effects of war-induced anxiety and mental distress? How do women and men differ in their perceptions of mental well-being?
Fieldwork was conducted in December 2001 and January, August and September 2002 in seven locations of Eritrea selected to include a range of geoclimatic zones and modes of subsistence (Table 1). The western lowland and mid-altitude provinces of Zoba Anseba and Zoba Gash-Barka and the southern highland provinces of Zoba Debub were the areas worst affected by the war because of their proximity to the Ethiopian border. Word-of-mouth invitations resulted in the recruitment of 104 women and 124 men to the study. All the ethnic groups except the Afar and Rashaida were represented.
Participatory methods and tools of investigation and onsite analysis were employed. They had been extensively field-tested, evaluated and validated in various countries, including Eritrea (14, 15). The study team carefully questioned and listened to the participants and kept written records. The quality and reliability of the data were established as follows: feedback sessions held at each study site in order to allow the participants to review and interpret, and, if necessary, correct the findings, and to enable the study team to follow up incomplete data; checks on the accuracy of factual or objective (as opposed to subjective) data relating to historical events, involving the use of published material where available and other secondary sources; and data triangulation by methods and sources. …