A decade after experiencing war-related events, widowed lone mothers reported significantly higher levels of somatic complaints, depression, anxiety, and post-traumatic stress than non-bereaved married mothers and bereaved married mothers even after adjusting for socio-demographic and war-related variables. Accordingly, widowed lone mothers reported significantly lower scores of subjective well-being than the two groups of married mothers. The groups did not differ with regard to utilization of health care services during the previous three months.
To our knowledge, this is the first study to make a direct comparison of levels of somatic and mental health distress and subjective well-being between war-related widowed lone mothers and married mothers, all of whom had experienced the war first hand. The results are strengthened by the fact that the comparison groups were recruited in exactly the same localities as widowed lone mothers. Yet, the study has a few limitations. The recruitment of participants in only one region limits the generalization of the findings to other populations with war-related bereavement. The cross-sectional design does not allow any conclusions on causal associations between the measured variables. Further, current findings on the differences and associations of the measured variables might still be subject to unobserved confounding war-related and postwar-related factors.
Of particular interest is the finding that widowed lone mothers reported higher levels of somatic and mental health complaints and lower levels of psychological well-being not only as compared to non-bereaved married mothers but also to bereaved married mothers. The finding that widowed lone mothers reported significantly higher levels of depression, somatization, anxiety, and posttraumatic stress than bereaved married mothers even after adjusting for relevant variables suggests that war-related killing of the husband and its accompanying consequences (first and foremost lone motherhood) might constitute a significant risk for psychopathology above and beyond other war-related traumatic events and bereavement following natural loss. This finding is strengthened by the fact that bereaved married mothers had experienced loss of first-degree relatives after the war. Thus, more time had passed since the killing of the husband of widowed lone mothers than since the loss of family members among bereaved married mothers, yet widowed lone mothers still reported higher rates of psychopathology. These findings are also in line with findings related to prevalence rates of major depressive episode, post-traumatic stress disorder, generalized anxiety disorder, and suicide risk resulting from this study that have been reported elsewhere [20
]. Widowed lone mothers reported significantly higher rates of posttraumatic stress disorder (82%), major depressive episode (71%), generalized anxiety disorder (48%) and suicide risk (45%) than non-bereaved (29.6%, 18.3%, 9.9% and 16.9%, respectively) and bereaved married mothers (25.7%, 25.7%, 25.7% and 22.9%, respectively).
Severity of psychopathology among widowed lone mothers is high in comparison to existing literature on survivors of war. For instance, in a recent study with war-related bereaved civilian survivors of war from Kosovo that included only ten percent widowed female war survivors and that used the same instrument to measure posttraumatic stress symptoms as in the current study (PDS), a mean score of posttraumatic stress symptoms of 18.08 was reported [8
] as compared to a mean score of 29.96 in the current study. The levels of somatic complaints among widowed lone mothers in this study are also very high in comparison to a recent study conducted in Kosovo with young adult war survivors with and without loss of father due to war-related violence (M
25.74 vs. 18.4 and 17.8, respectively) [9
]. Severity of prolonged grief was also higher in the current study (M
50.4) than in other studies with survivors of war that have used the same instrument. In the above mentioned study with Kosovar young adult war survivors with war-related loss of father [9
], a mean of 41.7 was reported. In another study [8
], a mean score of 28.7 was reported among war-related bereaved civilian survivors of war from Kosovo that had reported war-related loss of a first-degree relative. Similarly, the prevalence rate of prolonged grief disorder (69%, see [20
]) was higher than in the above mentioned studies conducted in Kosovo as well as in a recent study in survivors of the 1994 Rwandan genocide with loss of a parent or husband before, during, or after 1994 that reported a prevalence rate of prolonged grief disorder of 8% [10
The higher levels of severity of mental health and somatic distress among widowed lone mothers who remain lone mothers indicate that this population is particularly at risk for increased psychopathology. These findings are in line with results from bereavement research indicating that bereavement is associated with elevated general health distress as compared to non-bereaved groups [3
]. More importantly, however, the findings are supported by pilot studies among survivors of war indicating that bereaved survivors report higher prevalence rates of mental disorders than non-bereaved participants [9
]. Likely wise, our findings are consistent with pilot results from a recent study conducted in Kosovo indicating that war-related widows report higher psychiatric sequelae than other bereaved participants [8
]. Finally, the finding in our study that severity of prolonged grief was the only significant predictor of specialist physical health care further strengthens the relevance of research into prolonged grief, including war-related prolonged grief.
Several factors such as emotional, functional, and economic difficulties are assumed to play a role in elevated levels of psychopathology. Widowed lone mothers must cope with their own experiences of war, killing of the husband during the war, being a lone mother, and raising children on their own. Loss of the husband due to war-related violence might contribute to psychopathology in different ways, such as the loss of the husband with whom the widow had a strong emotional relationship as a partner, the traumatic circumstances under which the loss of the husband took place, or the loss of the father of the children of the widow. In post-war Kosovar society, loss of the husband meant also loss of the main breadwinner and was accordingly associated to economic difficulties. This is also reflected by the reported unemployment rate of 89% among widowed lone mothers. Although the survey did not differentiate between those who were seeking employment and were unable to find it and those who did not want to work, this extremely high unemployment rate still revealed that 89% of widowed lone mothers did not have a wage-earning job. While war-related widowed women in Kosovo receive social welfare benefits and often also immaterial help from relatives, the total monthly income of the bereaved families in this study was significantly lower than that of married participants. The accepted norm in Kosovar society that a widowed mother should not remarry, resulting into forced lone motherhood, is likely to negatively affect coping mechanisms following exposure to war-related events and the killing of the husband and to hamper attempts at mastering socioeconomic circumstances. Thus, lone motherhood is likely to constitute a significant factor in the elevated rates of psychopathology. In fact, research in Western countries has indicated that lone motherhood is associated with poorer psychological health and higher risk of mortality as compared to partnered motherhood [39
]. Further factors that might influence mental health among this population are on-going societal instability, political uncertainty, and unsatisfactory health and social care. This notion is in line with findings from studies conducted with survivors of war living in the countries of former conflict [17
] as well as among refugees revealing that post-migration living stressors contribute to psychopathology in addition to war- or torture related events [42
]. Yet, the interaction between exposure to war-related events, post-war practical difficulties, and mental health status among war survivors living in the areas of former conflict is still only poorly understood and needs further examination. Additionally, the impact of the traumatic circumstances under which the husband was killed on psychopathology needs further empirical investigation.
The fact that widowed lone mothers reported higher number of war-related traumatic events than non-bereaved married mothers needs further explanation. Checklists of traumatic events such as the one used in this study pose a limitation with regard to comparing number of traumatic events among groups exposed to several traumatic events. The very nature of single traumatic events cannot be captured with the existing checklists of traumatic events. This indicates that even after controlling for number of traumatic events in the current study, health distress differences between widowed lone mothers and the comparison groups might exist not only due to the consequences of losing the husband and being a lone mother but also due to the experience of other war-related events. Furthermore, 16% of widowed lone mothers reported war-related loss of first-degree relatives other than the husband as compared to none in the control groups. Although we recruited both bereaved and non-bereaved participants in the same localities, killing of the husband seemed to have increased the likelihood of being exposed to more traumatic events and also losing other family members as compared to participants whose husbands were not killed during war. Our findings should be seen as preliminary and need replication.
Civilian war survivors experience a wide array of potentially traumatic events that may have diverse consequences in terms of morbid psychiatric outcomes [46
]. Therefore, future studies need to further investigate the associated psychological consequences of single war events and mental well-being. For example, research has shown that torture and rape are also associated with more general health distress as compared to other war experiences [47
]. War-related death of the husband is another case in point worth of further study.
More than 50% of participants in all groups reported any use of health care services during the last three months. However, the majority of participants reported primary health care utilization only and barely a tiny proportion of participants reported utilization of mental health services during the last three months. Participants were not asked about reasons for seeking and especially not seeking health care services. Furthermore, they were also only asked about utilization of health care during the last three months. However, given the high levels of mental and physical distress especially in the widowed group, it is likely that participants had little or no hope in finding any useful mental health care. This corresponds with reports that in Kosovo primary health care was given special focus following the war in 1998/1999 and that specific interventions for treating mental disorders have only rarely been available [49
]. Further possible reasons for low rates of mental health care use might be related to stigmatization of seeking mental health care or fear of recalling painful experiences.
Recent research with survivors of war seeking mental health treatment in the Balkans [50
], including Kosovo [51
], has shown that utilization of mental health services in these countries is not associated with improved levels of mental health. These findings might further explain why a very small proportion of our participants reported use of mental health services despite elevated levels of mental health and somatic distress. Given the fact that utilization of mental health care services is an interplay of availability of resources, need for those resources as well as individual and social characteristics [52
], an advancement of mental health services for survivors of war as well as a better understanding of possible barriers for seeking mental health needs seem obligatory. Recent research in Kosovo has also found that posttraumatic stress disorder and major depression were not significantly associated with medical visits or hospitalization in the past 12