research assistant jobs in dental public health

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• Research Training at NIDCR (Intramural Opportunities)
• Dental Public Health Research Fellowship

As dental public health and research fellows at NIDCR , Ishita Singh (left) and Leah Leinbach (right) will gain field experience, conduct research projects, and learn about the core disciplines of public health.

About the Program

The National Institute of Dental and Craniofacial Research (NIDCR) sponsors a three-year fellowship program in Dental Public Health Research. This fellowship includes a 12-month full-time residency in Dental Public Health (DPH) followed by a 24-month full-time postdoctoral fellowship with a strong focus on oral health research.

A stipend is available to support Dental Public Health Research fellows during the three-year program. This training opportunity requires a full-time commitment, and those selected cannot be enrolled in other training programs.

Individuals successfully completing the 12-month DPH residency component will receive a certificate of completion and are qualified educationally to apply for examination by the American Board of Dental Public Health (ABDPH) for specialty certification.

Equal consideration is given to all applicants without regard to race, religion, color, national origin, sex, sexual orientation, political affiliation, or age. 

While emphasizing research training during the three-year fellowship, the program provides experiences in other areas of dental public health, i.e., public health administration and management, the organization and financing of dental care programs, oral health promotion, and the development of resources.

The training program will be tailored to meet the particular interests and previous experience of each individual selected. However, a typical fellow's effort will require that time be spent during the first year in each of the following areas: Research Methods in Dental Public Health; Health Policy, Program Management, and Administration; Oral Disease Prevention and Oral Health Promotion; and Oral Health Services and Delivery Systems.

The content of the curriculum and the fellow’s training plan are designed to ensure that fellows receive the foundational knowledge and experiences necessary for core competencies in dental public health.

The educational structure of the fellowship program is based on:

• Site visits to public health organizations at the state, federal, and international levels;
• Field experience for applied public health practice;
• Seminars and lectures providing instruction in the core disciplines of public health (epidemiology, biostatistics, environmental health, behavioral health science, and health management and policy) with an oral health focus;
• Critical thinking and scholarship.

In addition, fellows will receive expert guidance in the origination and conduct of oral health research.

Eligibility Criteria

Applicants must be graduates of a school of dentistry accredited by the Commission on Dental Accreditation of the United States (CODA) or the Commission on Dental Accreditation of Canada (CDAC). Applicants who are graduates of a school of dentistry not accredited by CODA or CDAC must have acquired an equivalent education to a doctoral-level dental degree received in the U.S.

All applicants must also hold a graduate degree in public health (MPH or equivalent) from an accredited U.S. academic institution that is recognized by the U.S. Department of Education (e.g., the Council on Education for Public Health (CEPH)). Examples of an equivalent public health degree are a MHS, DrPH, or PhD in Epidemiology.

In general, graduate public health degrees (MPH or equivalent) should, at a minimum, include instruction in biostatistics, epidemiology, health care policy and management, environmental health and behavioral sciences.

Advanced graduate degrees in public health obtained outside of the U.S. do not meet the program's eligibility requirements.

Meet the Program Leader

Hosam Alraqiq BDS, MSD, MA, EdD, CHES is a Health Science Analyst at the NIDCR Office of Science Policy and Analysis. He previously worked at Columbia University College of Dental Medicine where he acted as Project Leader on HRSA-sponsored programs, including those that enhance HIV training and service, as well as postdoctoral and predoctoral training in dental public health, population oral health, health communication, community engagement, and inter-professional practice.

Meet Our Research Fellows

How to apply.

Applications will be accepted until Tuesday, January 16, 2024 . Applications submitted after that date will not be accepted, and incomplete applications will not be reviewed by the selection committee. All applicants are REQUIRED to submit a complete application package by email.

Applicants will be notified within 6 weeks after the submission deadline if they are selected for an interview.

The following items are to be included for review by the selection committee ( A Submission Checklist (PDF - 117 KB) ) is provided for your convenience):

• Application Form (PDF - 449 KB) and Current CV (Please note: these are to be combined together into one Adobe PDF document and sent electronically by email - no paper copies will be accepted).
• Submit an official translation for non-English transcripts via email.
• Submit Course-by-Course Evaluation Report electronically. Use the World Education Services  or Educational Credential Evaluators and list Yu-Ling Huang ( [email protected] ) as the recipient of your evaluation.
• Official transcripts from Accredited Graduate Education in Public Health (to be sent directly from the U.S. schools and transmitted electronically).
• Three Letters of Recommendation, including at least one from a faculty/administrator from your academic institution (letters of recommendation must be sent by email directly from persons who have agreed to serve as references).

Email: [email protected]

Application Coordinator Yu-Ling Huang NIHBC 31 BG RM 5B55 31 Center Drive Bethesda MD 20892

The tentative start date for the program is Monday, July 01, 2024 .

Have additional questions about the program, curriculum, or eligibility criteria? Visit our Frequently Asked Questions page .

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When many people think about working in the field of public health, their minds immediately jump to community health workers and health educators who directly interact with members of the community to improve health outcomes.

But the truth is public health is an extremely varied field of work, with multiple potential career paths. One such career path that many people overlook is public health research—which ultimately goes on to inform and impact the public health projects performed by others.

Want to learn more about Public Health Careers? Download Our Free Guide!

Are you interested in potentially pursuing a career as a public health research assistant? Here’s an overview of what the job entails, where these professionals work, and the specific steps you’ll need to take to make your goal a reality.

What Does a Public Health Research Assistant Do?

A public health research assistant is an entry-level researcher who works on public health projects. They perform a range of different tasks, primarily related to the collection, organization, and analysis of data that informs various public health initiatives in the communities they serve.

Usually, these data will be related to analyzing health trends within a certain community, and then using those trends to:

• Inform policy
• Develop health assessment reports
• Disseminate findings through meetings, conferences, and research publications
• Design public health programs

At entry level, public health research assistants will typically begin by performing administrative tasks as they are trained on the processes that they will eventually be responsible for. Depending on the specific position, researchers may also take on a secondary role as health educators who use their findings to inform the public. Writing and oral communication skills are vital, as are computer literacy and math/statistics. Courses such as research methods and epidemiology can also help.

Other job titles that you might find on job postings for public health research assistants include:

• Public Health Researcher (I)
• Public Health Research Coordinator
• Public Health Data Analyst (I)

Where Do Public Health Research Assistants Work?

Public health research assistants can be employed by any organization that engages in public health projects or initiatives. This can include:

• Long-term care facilities
• Community health clinics
• Specialized clinics (such as cardiac centers)
• Senior centers
• Eldercare services
• Women's health centers
• Breastfeeding clinics
• Universities
• Government agencies at the state and local level

How Much Do Public Health Research Assistants Make?

Public health research assistants tend to earn an average of $38,433 per year according to Zippia. This figure is a good representation of the entry-level salary that you can expect in this field.

As researchers gain experience and further their skills, however, pay tends to increase and reflect this. PayScale.com notes that the more senior-level researchers can earn $68,000 or more per year .

Three Steps to Becoming a Public Health Research Assistant

If you’re interested in becoming a public health research assistant, it’s important to be aware of the educational and experience requirements. Here are three steps to becoming a public health research assistant.

1. Earn a Bachelor’s Degree in Public Health

Most employers that hire public health research assistants require applicants to hold at least a bachelor’s degree in public health or a related field. This degree is specifically designed to provide exposure to research practices, which will form the foundation of any research-focused career.

If you choose not to earn a degree in public health but are interested in a career as a research assistant, it will be important for your degree to provide at least some training and exposure to basic research practices.

2. Gain Research Experience

As mentioned above, you should take every opportunity during your studies to gain research experience, as this will directly translate over into the job. Some excellent options include:

• Internships
• Independent research with a faculty member

With this in mind, when evaluating programs, it’s important to consider the research opportunities that the program will provide.

In the BA in Public Health program at Regis College, for example, students complete an average of 240 hours of hands-on field experience through internship placements at hospitals, community agencies, health care organizations, and nonprofit organizations where research opportunities are available.

In addition, nearly all courses in the public health curriculum incorporate research skills through readings, assignments, and discussions. Faculty are also actively engaged in research efforts that can include students.

Additionally, you should look for a program that offers courses and curriculum related to research. It can be very beneficial, for example, to complete courses that involve survey building and data analytics.

If it’s not possible to gain any research experience as you complete your degree, consider finding an entry-level position as a community health worker or public health educator, that will allow you to conduct some research-related tasks. If you express interest to your employer, many will find a way to help you explore it.

3. Consider Advancement

While you should be able to get an entry-level research position with just your bachelor’s degree in public health, more senior-level research positions will typically require additional training and education. Most commonly, this will involve earning a master’s in public health (MPH) .

Earning a master’s degree in public health will be particularly important if you would like to lead research projects and actually design studies. It can also increase your earning potential, and help you stand out in job applications.

How to Make an Impact in Public Health

Public health research assistants play a crucial role in the field of public health. The projects that they work on and the data they collect and analyze form the bedrock of the entire profession. This means that by pursuing a career in public health research, you’ll have the opportunity to have a real impact in the communities that you serve.

If you’re ready to begin your public health journey, the first step is to complete a relevant undergraduate degree, such as Regis College’s Bachelor of Arts in Public Health . This program will provide the knowledge and skills you need to pursue a career in public health, as well as real-world experience through community engagement and service opportunities.

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Discover unique public health career paths that extend beyond traditional clinical roles and make a meaningful impact on global health.

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Research jobs in Medicine and Dentistry

Universities are in fierce competition to attract visionary researchers to contribute to the latest breakthroughs in medical science.

If you are interested in academic dentistry jobs or a clinical career in medicine that is more research-oriented, there is a wide range of roles available for practising doctors and dentists or aspiring non-clinical medical researchers.

There are two types of academic research jobs in medicine and dentistry:

• Clinical research jobs: you must already be medically qualified and registered with the General Medical Council (GMC) or General Dental Council (GDC) to be a clinical researcher. Depending on the role, you might already be a practising doctor or dentist.
• Non-clinical research jobs: research roles that require candidates to be experts in their medicine or dentistry field but do not need to be practising clinicians.

Job descriptions

Clinical Researcher/Clinical Research Fellow

• Research Fellow (non-clinical)
• Research Associate (non-clinical)
• Research Assistant (non-clinical)

Clinical researchers and fellows are fully qualified doctors or dentists who carry out or lead clinical trials and research in their specialist field of medicine and dentistry.

Clinical research roles or fellowships are project-led and are available when funding is acquired for a specific area of medicine or dentistry research. These roles can be available in universities, research foundations/institutes or charitable foundations.

• Planning and conducting high-quality research, working alongside a team of researchers
• Facilitating and monitoring clinical trials involving patients and volunteers
• Collecting data and disseminating results in peer-reviewed journals
• Supervising junior researchers (senior clinical researcher/fellow)

What qualifications and experience do you need?

Most clinical research posts require candidates to have a full medicine or dentistry qualification, full GMC/GND registration and to have completed at least two years post-graduation training (Foundation 2 or above).

Depending on the role, you might also need significant clinical and research experience in your field.

What’s the pay?

Most clinical research jobs in medicine and dentistry are offered on a fixed-term basis (they end on a fixed date on completion of a specific research project) and can be either full or part-time. Clinical research jobs are generally marketed with a salary between £34,563 and £52,090 but can be higher, depending on the research project and specialism.

What can it lead to?

Career progression in clinical research is dependent on the success and quality of your research projects. With experience, you might progress to clinical research lead or manager, senior clinical research fellow or professor.

Where can I find clinical research jobs?

Clinical research jobs are project-driven and funding dependent, therefore the roles tend to be quite niche. In the UK, a high percentage of these roles are based in London, as the Imperial College London and UCL clinical trials units are based there.

Find clinical researcher jobs here

Research Fellow (Non-clinical)

Medicine and dentistry research fellows are those who have taken an academic route into the sector and are not practising clinicians. They work as part of a wider research team in universities, research institutes or charitable foundations, carrying out research in a specific field, such as cancer or dementia studies.

• Carrying out high-level research activities
• Day-to-day planning and management of a research project
• Undertaking laboratory research
• Advising and supervising junior researchers (senior research fellow)
• Producing high-quality research papers and outcomes
• Assisting in the preparation of grant proposals

A PhD in a relevant or related discipline is essential for research fellowships in medicine and dentistry. Candidates also need to demonstrate a proven track record of previous research outcomes.

Most medical and dentistry research fellowships are offered on a fixed-term basis and are dependent on funding and outcome. Research fellowships usually command a salary of between £36,770 to £50,296, higher for senior research fellowships.

Research fellowships in medicine and dentistry are senior research roles and, as well as gaining higher research skills, they also help you to gain management and leadership skills. Depending on the success of your research activities, a research fellowship can lead to more permanent and senior academic jobs within a higher education setting.

Where can I find research fellow jobs?

Owing to the project-based nature of research work, most of these roles are contracted. The busiest time for recruitment is in June and July.

Find research fellow jobs here

Research Associate

Research associate jobs tend to be the first step on a postdoctoral research career across the spectrum of medicine and dentistry specialisms. Most research associates will have just finished their PhD and are looking to continue their research in a related area.

• Developing and contributing to a research project in a specific area of medicine and dentistry
• Supporting on-going research projects and writing grant proposals
• Disseminating research activities and producing high-quality research papers
• Supporting junior researchers in the laboratory
• Undertaking some one-off teaching duties related to a research project

A PhD in a relevant area is essential for research associate jobs in medicine and dentistry. Previous experience on other research projects in the specific area being studied is desirable but not always necessary.

Most research associate positions are offered on a fixed-term basis and have a salary range of £31,406 to £40,927, depending on qualifications and experience.

A research associate role is an excellent opportunity for those just finishing their PhD to embark on an academic research career in medicine or dentistry.

The research skills you gain can enable you to apply for more senior, research fellowship jobs and look towards permanent academic roles in higher education.

Where can I find research associate jobs?

Research associate jobs tend to be highly specific and may be advertised for one element of one specialism. Therefore, you may have a wait for jobs in your specific area of expertise to become available.

Find research associate jobs here

Research Assistant

Research assistants are the most junior research roles you might find in a university medical or dental school.

Research assistant roles in medicine and dentistry offer those starting out on an academic career to hone their research skills and learn from senior academic staff across a variety of specialist areas.

If you are thinking about taking an academic research route, rather than clinical route into medicine and dentistry, a research assistant job would be an ideal first step.

• Supporting senior researchers in a variety of research tasks
• Gathering, analysing and presenting data
• Contributing to reports, lab meetings and seminars
• Administrative duties

An undergraduate degree (First class or Upper second class) in a related field is essential for research assistant roles in medicine and dentistry. Some organisations may also require other postgraduate training, such as a Master’s degree. Having already completed your PhD will give you a significant advantage.

Most research assistant roles in medicine and dentistry are offered on a fixed-term basis with a salary in the range of around £27,924 to £32,344, depending on qualifications and experience.

These are the most junior research roles and can be a springboard to doctoral studies or more senior research roles, such as research associate in medicine and dentistry (on completion of your PhD).

Where can I find research assistant jobs?  

Research assistant jobs in medicine and dentistry are more widely available than more senior, niche medical research roles.

Find research assistant jobs here

Further information:

• Jobs in Medicine
• Jobs in Dentistry
• Lecturing jobs in medicine and dentistry
• Senior Level Academic Jobs in Medicine and Dentistry

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Research assistant.

The Center for Indigenous Health (CIH) at Johns Hopkins Bloomberg School of Public Health is seeking a motivated individual interested in working on public health research projects. This work is focused on participant recruitment, retention, data collection and cross-site communication to improve health outcomes in Native communities.

We are seeking a  Research Assistant  who will primarily assist in the day-to-day logistical and operational tasks for various research studies at the site. The Research Assistant will interact with the investigators, collaborators, and participants in a research environment. This person will assist in carrying out research in accordance with good clinical practices in such activities as obtaining informed consent, data and specimen collection, and patient follow-up over time.

Specific Duties & Responsibilities

• This description is a general statement of required duties and responsibilities performed on a regular and continuous basis. It does not exclude other duties as assigned.

Serve as a Research Assistant for the Center’s field-based projects. Specific responsibilities may include, but are not limited to,

• Maintain a good working knowledge of all assigned protocols and reporting requirements.
• Run routine and ad hoc reports from databases.
• Adhere to all protocol requirements to ensure validity of clinical research data.
• Interact with clinicians and other stakeholders to access the participant population.
• Recruit research participants.
• Verify participant eligibility for studies.
• Interview participants.
• Schedule follow-up visits.
• Perform data collection.
• Enter data into a computer database.
• Generate and summarize data into reports to share with PIs and Study Physicians.
• Maintain paper and computerized research files.
• Assist with facilitation of site staff meetings.
• Prepare for and participate in audits and monitoring of studies.
• Assist in preparation of IRB protocols and related documents.
• Meet regularly with research staff and site manager to review data accuracy, enrollment reports, and overall study progress.
• Communicate study findings and updates to tribal leaders and community stakeholders.

This description is a general statement of required duties and responsibilities performed on a regular and continuous basis; the Research Assistant will perform other related duties as assigned.

• Bachelor's Degree in related discipline.
• Additional related experience may substitute for required education, to the extent permitted by the JHU equivalency formula.
• Native language speaker.
• Knowledge of the community geography, ability to locate participant homes and navigate rural roads effectively and safely.
• Current driver’s license issued by the state of residence and good driving record required.
• Ability to travel with overnight stays required as needed. Some evening, weekend and holiday work may be required.
• May be required to float to other sites. Guidelines regarding travel time and project vehicle use will be clarified based on specific site needs.
• This position will maintain background clearance as required by the employer and any collaborating agencies.

Special Knowledge, Skills & Abilities

• Must be comfortable collecting saliva, urine, or blood samples from participants.
• Proficiency in the use of computers, including software applications, databases, spreadsheets, and word processing; excellent organizational and time management skills.
• Independent and self-motivated.
• Highly organized and detail oriented.
• Ability to manage multiple and competing priorities.
• Excellent oral and written communication skills.
• Demonstrated strong, positive interpersonal skills.
• Ability to communicate effectively across disciplines and within a variety of cultures.

Classified Title: Research Assistant  Job Posting Title (Working Title): Research Assistant    Role/Level/Range: ACRO40/E/03/CD   Starting Salary Range: $17.20 - $30.30 HRLY (Commensurate with experience)  Employee group: Full Time  Schedule: Monday to Friday: 8:00 am – 5:00 pm  Exempt Status: Non-Exempt  Location: MD - Other Location  Department name: 10001145-Center for Indigenous Health  Personnel area: School of Public Health 

Total Rewards The referenced base salary range represents the low and high end of Johns Hopkins University’s salary range for this position. Not all candidates will be eligible for the upper end of the salary range. Exact salary will ultimately depend on multiple factors, which may include the successful candidate's geographic location, skills, work experience, market conditions, education/training and other qualifications. Johns Hopkins offers a total rewards package that supports our employees' health, life, career and retirement. More information can be found here: https://hr.jhu.edu/benefits-worklife/ .

Education and Experience Equivalency Please refer to the job description above to see which forms of equivalency are permitted for this position. If permitted, equivalencies will follow these guidelines: JHU Equivalency Formula: 30 undergraduate degree credits (semester hours) or 18 graduate degree credits may substitute for one year of experience. Additional related experience may substitute for required education on the same basis. For jobs where equivalency is permitted, up to two years of non-related college course work may be applied towards the total minimum education/experience required for the respective job.

Applicants Completing Studies Applicants who do not meet the posted requirements but are completing their final academic semester/quarter will be considered eligible for employment and may be asked to provide additional information confirming their academic completion date.

Background Checks The successful candidate(s) for this position will be subject to a pre-employment background check. Johns Hopkins is committed to hiring individuals with a justice-involved background, consistent with applicable policies and current practice. A prior criminal history does not automatically preclude candidates from employment at Johns Hopkins University. In accordance with applicable law, the university will review, on an individual basis, the date of a candidate's conviction, the nature of the conviction and how the conviction relates to an essential job-related qualification or function.

Diversity and Inclusion The Johns Hopkins University values diversity, equity and inclusion and advances these through our key strategic framework, the JHU Roadmap on Diversity and Inclusion .

Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

EEO is the Law https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf

Accommodation Information If you are interested in applying for employment with The Johns Hopkins University and require special assistance or accommodation during any part of the pre-employment process, please contact the Talent Acquisition Office at [email protected] . For TTY users, call via Maryland Relay or dial 711. For more information about workplace accommodations or accessibility at Johns Hopkins University, please visit https://accessibility.jhu.edu/ .

Vaccine Requirements Johns Hopkins University strongly encourages, but no longer requires, at least one dose of the COVID-19 vaccine. The COVID-19 vaccine does not apply to positions located in the State of Florida. We still require all faculty, staff, and students to receive the seasonal flu vaccine . Exceptions to the COVID and flu vaccine requirements may be provided to individuals for religious beliefs or medical reasons. Requests for an exception must be submitted to the JHU vaccination registry.  This change does not apply to the School of Medicine (SOM). SOM hires must be fully vaccinated with an FDA COVID-19 vaccination and provide proof of vaccination status. For additional information, applicants for SOM positions should visit https://www.hopkinsmedicine.org/coronavirus/covid-19-vaccine/  and all other JHU applicants should visit https://covidinfo.jhu.edu/health-safety/covid-vaccination-information/ .

The following additional provisions may apply, depending upon campus. Your recruiter will advise accordingly. The pre-employment physical for positions in clinical areas, laboratories, working with research subjects, or involving community contact requires documentation of immune status against Rubella (German measles), Rubeola (Measles), Mumps, Varicella (chickenpox), Hepatitis B and documentation of having received the Tdap (Tetanus, diphtheria, pertussis) vaccination. This may include documentation of having two (2) MMR vaccines; two (2) Varicella vaccines; or antibody status to these diseases from laboratory testing. Blood tests for immunities to these diseases are ordinarily included in the pre-employment physical exam except for those employees who provide results of blood tests or immunization documentation from their own health care providers. Any vaccinations required for these diseases will be given at no cost in our Occupational Health office.

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5 Center for Refugee and Disaster Response, Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA

Judith Bass

A decade of conflict in Chechnya destroyed infrastructure and resulted in widespread exposure to violence. Amidst substantial reconstruction, periodic violence has contributed to an ongoing atmosphere of insecurity. We conducted a qualitative study to understand the mental health and psychosocial problems affecting adult Chechens in this context to inform development of assessment tools for an evaluation study related to individual counseling.

Data were collected in July 2014. A convenience sample of 59 Chechen adults was asked to Free List all problems affecting people in the area. Four problems were explored further in 19 Key Interviewee (KI) interviews, with respondents identified using snowball sampling. Data analysis was conducted in Russian by the Chechen interviewers.

Multiple mental health and psychosocial problems emerged, including ‘bad psychological health’, ‘depression’, ‘stress and nervous people’, and ‘problems in the family’. Aggression, ‘emotional blowing’, and ‘not adequate’ behavior were frequently reported indicators of these problems, with negative effects on the whole family. Chechens reported seeking help through informal social networks, psychiatric and psychological services, and Islamic Centers.

Chechens reported mental health and psychosocial problems similar to those experienced in other post-conflict settings. The description of ‘emotional blowing’ mirrored prior findings in Chechen asylum seekers and fits within a cluster of cultural concepts of distress featuring anger that has been identified in other conflict-affected populations. Further exploration of the nature and prevalence of this construct, as well as evaluations of interventions aimed at reducing these symptoms, is warranted.

The mental health impacts of conflict have been well-documented, with reviews consistently citing elevated rates of mental disorders in populations exposed to conflict and other mass violence [ 1 , 2 ]. Risk of disorder in a given context is influenced by both individual and situational factors, such as level of exposure to potentially traumatic events, time since conflict, and level of displacement [ 3 ]. Beyond the direct effects of mass violence, mental health is also affected through prolonged negative impacts of violence on economic development, social capital, human rights, and the availability of supportive resources [ 4 , 5 ]. Additionally, cultural factors influence mental health by impacting what is interpreted as a traumatic event, how community norms and practices elevate or protect against risks to mental health, and how mental distress itself is expressed [ 6 , 7 ]. Much of the research on mental health in conflict has focused predominantly on PTSD, thus we know less about other mental health problems that may be prominent in communities affected by long-term repercussions of conflict [ 8 ].

In the Republic of Chechnya in the North Caucasus, the mental health needs of the local population are not well understood. Chechnya is an autonomous region in Southern Russia with a population of approximately 1.2 million people, bordered by Russia and Ingushetia to the North and West, and Georgia and Dagestan to the South and East [ 9 ]. Ethnic Chechens comprise the majority of the population and are predominantly Sunni Muslims whose religious practices incorporate Sufism and pre- Islamic beliefs [ 10 ]. Society is patriarchal and structured around a clan system with a clear hierarchy within the family [ 10 ]. Chechens have a strong ethnic identity [ 11 ]; customs and traditions follow a social code, Nokhchallah , which is described as “Chechenness—the quality of being a Chechen” [10, p. 129]. The social code places high value on individual duty, family honor, respect for women, hospitality, friendship and brotherhood, and mutual help and charity [ 10 , 12 ].

Following its declaration of independence from the Soviet Union in 1991, Chechnya has experienced continued instability. From 1994–1996, and again in 1999, the population experienced repeated bombing, heavy fighting with widespread exposure to violence, displacement, and destruction of services and infrastructure [ 13 ]. The death toll from the two conflicts has been estimated at 160,000 people [ 14 ], and the humanitarian impact of these events have been well-documented [ 15 , 16 ]. While the region has undergone massive reconstruction and security has improved in recent years, periodic violence has sustained a general atmosphere of insecurity [ 9 ]. Health and social service systems remain overburdened and underequipped to meet the needs of the community [ 17 ]. The conflict disrupted education systems and resulted in massive brain-drain as many of the most educated left the republic [ 18 ]. The economy, which prior to the conflicts had been based on oil production and agriculture, has been bolstered by aid but has struggled to recover, resulting in an unemployment rate double that of the surrounding areas [ 18 ].

Most of what is known about the mental health and psychosocial needs of the Chechen people is based on a small number of studies conducted with refugees and internally displaced people at the height of the conflict. A 2004 study of 539 displaced Chechens showed that nearly all had been confronted with violence; a third had directly experienced war-related violence, and nearly a quarter had witnessed the killing of a person. Using a General Health Questionnaire cut-off score of 11, approximately 80 % of those interviewed were suffering from significant health complaints, including somatic complaints, symptoms of anxiety or depression, and social dysfunction; however, the GHQ cutoff was not validated in this context, so these findings must interpreted with caution [ 19 ]. In an evaluation of 50 Chechen asylum seekers located via convenience sampling in Austria, 62 % showed clinically significant trauma symptoms as assessed by clinicians [ 20 ]. A study of Chechen youth in temporary camps also reported higher internalizing problems when compared with non-conflict- affected Russian youth [ 21 ]. The same study of Chechen youth also reported a variety of physical and emotional stressors related to displacement, including worry about the future and feelings of humiliation [ 22 ]. Yet given the changing social context in Chechnya over the past decade and the potential differences between asylum seekers and those who stay, the above studies cannot be assumed to represent the current mental health needs of people in the Republic.

The international medical organization Médecins Sans Frontières (Doctors without Borders; MSF) has been providing individual mental health counseling in Chechnya since 2003. In preparation of an outcome evaluation of the MSF mental health program’s counseling approach, we undertook a brief qualitative study to improve our understanding of current mental health problems experienced by Chechen adults presently living in Chechnya, including the nature of the problems and locally relevant coping and help-seeking behaviors. The primary purpose of this study was to provide data to develop and adapt culturally valid assessment instruments for use in the outcome evaluation. These findings also have broader implications for improving our understanding of mental health needs in contexts of prolonged insecurity after the resolution of the acute phase of conflict.

Data were collected in the Chechen capital city of Grozny, Chechnya’s largest city and administrative center, over a three-week period in July 2014. The city was a site of heavy fighting and military bombardment during both Chechen conflicts, resulting in almost total destruction [ 23 ]. Grozny has also been a major focus of reconstruction efforts, including new roads, hospital and university buildings, a regional airport, and a new mosque. The study was undertaken by MSF in collaboration with Chechen State University.

Participants

Study participants included 78 Chechen adults from multiple sites in downtown Grozny, including hospital and community locations. Free List (FL) interviews (24, p. 32) were conducted with a convenience sample of three types of respondents: 1) MSF counseling clients ( n  = 12); 2) hospital patients receiving treatment (on either an in-patient or out-patient basis) for issues other than mental health problems ( n  = 14); and 3) general community members ( n  = 33). We purposively sampled to have gender balance for each respondent type and to capture a range of ages (18–67 years, mean  = 40 years). The rationale for including a small number of counseling and non-mental health hospital patients along with general community members was to ensure that perspectives of key MSF service groups were included in the study; this was deemed relevant because the key study aims focused on improving assessment of mental health problems patients were likely to seek treatment for at the MSF counseling program. No compensation was provided to FL respondents.

Following the FL interviews, in-depth interviews (24, p. 42) were conducted with 19 Key Interviewees (KIs) considered by community members to be knowledgeable about mental health problems. KIs were provided 450 rubles, the equivalent of 10 US dollars, as compensation for their time, with the expectation that they be available for two interview sessions lasting one hour each.

Data collection

Thirteen Chechen interviewers were trained by the study lead (AN) in research ethics, the two qualitative interviewing methods, and data analysis. These interviewers first conducted FL interviews to identify problems affecting people in the area. From the list of problems, potential mental health problems were identified (see analysis below) for further exploration using the KI interviews.

Interviewers worked in teams of two to conduct and record interviews verbatim in Russian, the official language used regularly in the public sphere. Many Chechens speak both Chechen and Russian, often mixed within a single conversation. In cases where a respondent preferred to provide an answer in Chechen the interview team recorded notes in Russian, as this is the written language used by most of the population. When the interview was conducted in Chechen, the Russian translation was confirmed by the interviewee. The study protocol was developed based on the Johns Hopkins University Applied Mental Health Research Group’s Design, Implementation, Monitoring, and Evaluation (DIME) research model, Module 1 [ 24 ]. Previous studies in diverse settings such as Haiti [ 25 ] and Georgia [ 26 ] have demonstrated the utility of this approach for identifying locally relevant mental health problems.

Adult men and women were recruited for FL interviews from MSF counseling services, hospital wards, and in public parks and markets, using convenience sampling. While there were no explicit exclusion criteria for the FL respondents, the nature of the locations required that respondents were reasonably mobile.

Free list interviews (24, p. 32) began with a single open-ended question designed to elicit responses in the form of a list. The purpose of these interviews was to gain a sense of the relative priorities of problems in the population and to identify problems – in the respondents’ own words - to be investigated in the KI interviews. Participants were asked: “What are all the problems affecting people in this area?” The interviewers probed until the respondent could list no more problems. Before ending the interview, the interviewers reviewed the problem list to identify potential mental health problems defined as problems related to thoughts , feelings or relationships . If any such problems were identified, they asked the respondent to suggest people in the community who were knowledgeable about this problem, or whom people would go to for help with this problem. If the respondent suggested someone, the interviewer asked permission to contact this person and recorded his or her name and contact information in a separate notebook. These names formed the initial list of potential Key Interviewees (KIs).

Following the analysis of the FL data (described below), KI interviews were undertaken to gain a deeper understanding of the selected problems (24, p. 42). The first seven KIs were those that were identified during the FL interviews, with subsequent KIs identified through snowball sampling. The initial inclusion criteria were that KIs were Chechens currently living in Chechnya and were identified by the FL respondents as being knowledgeable about the selected mental health problems. Most of the initial KIs were counselors or psychologists. After the first KIs were interviewed, we asked the KIs to refer us to additional KIs who were not counselors or psychologists, to ensure that respondents represented a wide set of experiences and backgrounds. KI roles and professions ranged from counseling, teaching, journalism, social services, and service users or family members. KIs were contacted by the study assistant, provided with a brief overview of the study, and invited to participate in an interview at Chechen State University, their home or their office.

For the KI interviews, the interviewer identified the first priority mental health problem from the FL results and asked the KI to describe everything he or she could about that problem. The KI was allowed to speak freely, without interruption, while the interviewers recorded responses verbatim. When the KI stopped, the interviewers asked follow-up questions regarding the nature of the problem, perceptions of causes, the effects of the problem on self and others, and current coping and help-seeking behaviors. After exhausting responses to the first mental health problem, the interviewer proceeded with the next priority problem, until all four selected mental health problems had been fully explored. The interviewers were instructed to end an interview session after one hour to avoid fatigue of the interviewers and KI. After each interview, the interviewers returned to the study office and immediately reviewed the transcript with the study supervisors (AN, CF) using a translator. The supervisors provided coaching and feedback, including specific items to follow-up on and additional questions to ask during a follow-up interview. The interviewers contacted the KIs to set up a second interview the following day. All KI interviews were conducted over a 4-day period and seven KIs (37 %) were available for a follow-up interview during that time.

Respondents were read a standard information sheet about the study and provided either written or verbal consent with a witness (if preferred) prior to being interviewed. A copy of the information sheet in Russian was also made available for respondents to take with them if they chose to do so, with contact information of the study staff. Participant names were not recorded for FL respondents; age, sex, and type of respondent were recorded and used to track the recruitment process. Names and contact information for potential KI respondents were recorded in a separate notebook solely for recruitment and scheduling purposes, and destroyed once interviews were completed. Potential KI respondents were contacted by the study assistant and informed that we had recently interviewed people in the area about problems affecting people here, and that the KI had been recommended as someone who was knowledgeable about a problem we were interested in learning more about. No information was provided about who had referred them.

Interviewers were all current medical students who received training on research ethics and qualitative interviewing methods. Because all questions asked about problems affecting Chechens in general rather than problems respondents had personally experienced, risk of emotional distress due to study participation was expected to be low. Interviewers were trained to redirect any discussion about personal problems or experiences back to problems as experienced by Chechens in general, and to stop an interview and consult their supervisor if a respondent became upset. Supervisors were present on site during FL interviews and available by phone during KI interviews, and met with the interview team following each interview to discuss any problems or concerns that arose. MSF counseling staff were also available to consult by phone if needed. The study protocol was approved by both the MSF and Chechen State University ethical review boards.

All FL and KI transcripts were coded and analyzed in Russian by the Chechen interviewers, with technical assistance from the English-speaking supervisors (AN, CF). FL analysis involved combining all individual FLs into a single master list of problems, ranked by frequency of reporting (Table  1 ). Decisions as to whether two differently worded items referred to the same problem were made by group consensus. If the interviewers agreed that two items were the same, they selected the better (i.e. more descriptive or representative) of the two wordings to include on the list; if the interviewers could not agree, the items were listed as separate problems. After all lists were combined, the group reviewed the resulting composite list to determine if any items on the list could be combined further, again by consensus. The final master list was reviewed by the study team for potential mental health problems to explore further in the KI interviews. Selection of which problems to select was based on those that were identified by multiple respondents and were also most likely to be addressed by the available MSF counseling program.

FL problems mentioned by at least three respondents ( n  = 59)

a Priority problem explored in KI interviews

KI interviews were analyzed similarly to the FL interviews. Interviewer teams reviewed each interview transcript, creating lists of all symptoms, positive and negative effects, and positive and negative coping strategies reported for each of the priority problems. The lists from each KI interview were combined into master lists for each problem.

A number of mental health related problems emerged from the free list interviews, including: (a) bad psychological health; (b) drug addiction; (c) problems in the family; (d) drunkenness; (e) depression; and (f) stress and nervous people. Commonly reported non-mental health problems represented categories of: (a) service and infrastructure problems such as unemployment and the quality of medical care; and (b) social and relational problems such as changes in culture and communication (see Table  1 ).

Key interviewee interviews

Four problems were explored in the KI interviews: 1) bad psychological health was selected in order to understand whether this constituted a distinct local syndrome or was a summary term of multiple problems; 2) depression and 3) stress and nervous people were selected as these are mental health problems the MSF psychosocial counseling program aims to address and intended to evaluate in the subsequent outcome evaluation study; and 4) problems in the family was selected to further understand the nature and consequences of these problems. The frequently reported issue of drug and alcohol problems was not selected because substance use was not intended to be assessed as a primary outcome in the subsequent evaluation; however, this problem was often discussed by KIs in the course of their interviews. Below we summarize the features frequently reported for each of the selected problems.

Bad psychological health (Table  2 ) appeared to be a summary term encompassing general distress and an inability to cope with daily stressors: “ For example we have many emotions that we’re not expressing, and one day we can do something bad because of these emotions”. KIs described this problem as manifesting in verbal and physical aggression (often toward children and family), physical health problems (e.g. “constant headaches due to nervousness” ), and social withdrawal. A number of KIs talked also about problems with communication: “people keep everything inside, and this is the tremendous psychological pressure”, and emphasized that bad psychological health was experienced differently for men and women due to Chechen norms that restrict men from talking about their problems: “men experience more difficulties than women because they have no place to spill out their emotions…withholding affects mental and physical health, correlate[ing] with poor physical health in Chechen society ” .While some KIs explained that bad psychological health was similar to depression or that depression was a part of bad psychological health, many respondents distinguished this problem from specific disorders. For example, one KI explained, “a person with bad psychological health can be normal but the emotions will blow up from time to time…if a person just sometimes in the past was inadequate, had emotions blow up, it doesn’t mean he’s sick”.

KI descriptions of ”bad psychological health” (n = 19)

Depression (Table  3 ) was characterized by social withdrawal, functional impairment, and difficulties in communication. One respondent described it as being “…despondent, when your body refuses to act. Depression is unwillingness of the body to organize something .” And another: “It is a hard disease, a heavy disease.” KIs described people with depression as being indifferent toward themselves and their families, with subsequent effects on personal health and family relationships, saying:

It’s difficult for such people to find mutual language with other people. When he’s at the peak of disease, he’s irritated by his wife, family, children. He’s afraid to go out because he’s afraid he will say something, otherwise he’s afraid of the community. He’s afraid that people will start talking about his disease.

KI descriptions of “Depression” ( n  = 19)

They described hopelessness and “not adequate” behavior that failed to meet Chechen social norms, including aggression and an inability to look beyond their own problems. One KI illustrated the cognitive and mood components, describing “ Depression is when a person sees in an ugly way everything, in an emotional way.” Others highlighted the risk of suicide, (e.g.: “ people are doing away with their own lives. Officially it is not recognized, but this is how it is”. ), noting that suicide was viewed as a sin and stigmatized as un-Chechen: “This is difficult for me to understand – my mentality is Chechen and I still don’t know how that could happen”.

Stress and nervous people (Table  4 ) featured symptoms of irritability, aggressiveness, and psychological pressure. As one respondent described, “he is aggressive, irritable, if you tell him something he’s responding in an unethical way. Something has led him to this situation – this is not out of the great life that he became like that”. KIs also listed a number of associated health problems implicated in prolonged hyper arousal, such as strokes, heart attacks, insomnia, headaches, sweating, and rapid breathing. They repeatedly linked this problem with “not adequate” behavior, “emotional blowing”, and verbal and physical aggression toward themselves and others: “If a person closes up and doesn’t share, then aggression and depression appear…It’s the form of defense and mentality meaning that people don’t want to be seen as morally weak”. These concepts were described as being highly associated: “Particularly in our society, as opposed to the other places, this aggressive behavior is very visible—aggressiveness, tension, nervousness”.

KI descriptions of “Stress and nervous people” ( n  = 19)

Problems in the family (Table  5 ) were described as a cluster of problems including bad family relations, conflicts, jealously, bad communication, divorce, no attention paid toward family, and physical and verbal aggression toward the children and family. Changing gender roles and generational gaps were highlighted, such as: “a generation grew up abroad, losing tradition and language”. Problems in the family were also said to impact the community, with increasing criminality and behavior ‘not adequate’ to Chechen norms: “Problem in the family is bad psychological and physical health of the nation. And the level of criminality and drug addiction increases. And all this comes from the family”.

KI descriptions of “Problems in the Family” ( n  = 19)

In addition to exploring the presentation and description of the selected problems, KIs reported on their perception of the causes of the problems and what people did to help themselves cope or deal with them when they arise. Different problems were not attributed to different causes; rather, multiple causes were discussed as a source of all the explored problems. Among the causes frequently discussed by the KIs were the war and ongoing stressors, changing social norms, and general insecurity. For example: “ people, they are scared of dangerous situations, they always take care of something that they think will happen someday, they explain that they are afraid for their families…they are scared after war that the war will begin again”. Multiple KIs described an interaction between conflict-related traumatic experiences and proximal stressors that impacted people’s ability to cope: “Few people receive psychological rehabilitation. A lot of values are lost. And now the reason is social factors, alcoholism and drug addiction.” As one KI summarized, “ The nature of mankind is so it’s difficult to live under constant tension”, while others explained: “Many people suffer. Youth suffer due to lack of self- realization. In the republic, the situation is changing rapidly…So people could not get oriented in their station and build up their life”. ; and:

Any country who had war, after reconstruction people took out many problems, everything that we cannot explain. So all the things that we can’t explain make us worry about it. We had serious changes after war in religion, in culture…so very sharp changes comparing to the situation before war and after war.

These changing social structures were also said to impact men and women differently:

After the war, because of the devastated economy men had no places to work, so women have taken the role of breadwinner. So men being unemployed, losing previous role in the family, falling into depression, start drinking, and then show aggression to the other members of the society.

First and foremost, there’s a shift in role between men and women. For instance, the woman is working and she is earning, while the man, for instance, is not working or working with inconsistent income. In such a way there’s a matriarchal society being formed up…in this situation all these things are being changed and there’s a conflict between them, and this is reflected on children.

In addition to the context of ongoing stress, two KIs talked about the importance of spiritual forces. For example, one KI indicated “ When they have some jinx the symptoms are the same as person that has depression…very weak, no interest to life”. However, the KIs who spoke about spiritual forces did not appear to view the problems as the same, but rather as separate problems with similar symptom presentation, explaining that there should be a distinction between the two: “ many appeal for help to Islamic centers…but it is not always the case that this is the result of external spirits. These things should be divided, mental health and external forces ”.

Negative impacts

A common theme across the described problems – particularly the problems of “bad psychological health” and “stress and nervous people” - was that of aggression, ‘emotional blowing’, and ‘not adequate’ behavior, described as behavior, often aggressive, that deviated from Chechen norms: “I’m talking about the behavior of people who have stress. It shows up in aggression.” “People become unbalanced and they are spinning off their anger on their children and they beat up their children and shout/yell at them.” Aggression was also linked to depression, although to a lesser extent:

“When a person has depression he stops being the person he used to be and spoils relations with friends. And his friends demand from him to be the same as he used to be, but the person is not able to be the same. And here starts aggression. This person needs help but he has only demands from other people. In such case a person turns inside or he starts to be aggressive”.

KIs repeatedly raised concerns about the effects of this aggression on children, families, and community: “…a ggression and anxiety. If a woman is beaten, children are afraid, and in the future they take it as a model of behavior and it leads to violence in the family”. They spoke of aggression displaced onto children: “ a woman who was beating her children, she was very angry at her husband and mother in law but she was beating her children because of that”. And referred to patterns of behavior affecting their families:

“The family is about constant relationships. Mentally unhealthy people are breaching this system of the relationships. Mentally unhealthy person is changing his behavior, he becomes passive aggressive, inadequate. He cannot provide any assistance, any help in the solution of the problems of his relatives. If someone is ill in the family, that is being transmitted onto children, directly. As a consequence there are problems with children. There is a family wellbeing that is breached”.

KIs also identified the impact of this aggression on the community, including the loss of relationships with those manifesting aggression:

“ The aggression of a person will affect everyone who is around him…So we have people who are destroying themselves but it also affects people around because we have really close relationships between relatives. Community lost the part of it faced by this person ”.

Coping and help-seeking

Common coping and help-seeking behaviors were similar for all four of the problems explored.

Formal help-seeking behaviors included seeing a psychologist, going to the Islamic center, and seeking medical treatments. Some suggested people suffering from mental health problems would first seek help in primary care: “Firstly they go to the hospital. If they have a headache, they will go to the doctor and he will think that they have some disease”. One KI reported women were more likely than men to seek counseling and would present with problems in the family: “in general, they are women. They go with their home problems, with the problems of gender violence, and with problems of their children”. Others were said to seek help from religious authorities because “it’s familiar, that’s why it’s not so scary”. However, these help-seeking behaviors were not mutually exclusive, and referrals could be made between them. One KI explained, “ When the medicine is helpless people apply to Islamic center. In the Islamic center there are also psychologists.” KIs reported that the Islamic healers would also refer cases to doctors or psychologists that they were unable to treat using traditional methods, and suggested, “ it is not correct to deny one of these supports, they should work together…Mullah usually gives decisions, but also there should be a way to cope with the problem. And psychologists are giving this opportunity to cope with the problem”.

Psychologists were described as taking case histories and “ looking for the reasons not applying to the spiritual side”. Islamic center treatments were described as lectures that support relaxation, treatments using holy water, reading from the Koran, and using oils and herbal treatments. Medical treatments involved body therapy, medication, rehabilitation centers, and respites at sanatoriums abroad: “v ery frequently people are traveling abroad, because here the treatment is not effective”. KIs also described that people suffering these problems would seek guidance from the Muftiat , or Islamic legal counsel, particularly in the case of family problems. Religion was discussed as a protective factor, including against suicide: “if not religion, which is the factor that holds people, the quantity of suicides would increase”.

The most frequently described informal help-seeking strategies involved talking with friends and relatives, or doing self-care activities. One popular activity was going outside to rest; this referred not only to the outdoors but also, in some cases, leaving the Republic either permanently or for holiday: “going out somewhere for rest is also an important factor.” Discussing high emigration, some respondents raised concerns about the impact of this on Chechen culture: “some are trying to go abroad thinking everything is good there, which is not the case. And children growing up there, they cease to be Chechens”. Negative coping strategies included social withdrawal or refusing help, plunging into work, giving up, antisocial behavior, and substance use. For example, “Maybe the depression will lead to disability itself. And it leads to drug addiction and to taking psychoactive pills. And the community suffers…and decreases the health of the nation. People are not emotionally resistant”. The latter not only included mention of alcohol and drugs, but also energy drinks, the use of which is frowned upon in Chechen culture.

In the current study respondents described syndromes similar to depression and a cluster of anxiety/trauma-related symptoms with high levels of aggression and irritability. They also described a more general concept of “bad psychological health,” which appeared to be not only an umbrella term including other symptoms and syndromes but also a psychosocial state that fell somewhere between illness and wellbeing. Although it was not surprising that these syndromes emerged in the FL interviews, the purpose of beginning with free listing was not only to confirm that these were problems of concern but to gain some sense of the relative priorities of problems in the population, and to include the words used by individuals to describe these problems as we explored them further in KI interviews. This approach allowed us to explore syndromes as conceptualized from the local perspective rather than imposing preconceived distinctions between symptoms.

The frequent reports of irritability, aggression, and emotional outbursts associated with mental health problems are similar to findings in a study of asylum seekers from a variety of countries conducted in Austria in the mid-2000s. In that study, conflict-affected Chechens reported higher levels of irritability and aggression compared to West African or Afghan asylum seekers [ 20 , 27 ]. That these symptoms were also reported by Chechens in the current study suggest that they are not only an immediate response to trauma but perhaps are more typical of the Chechen response regardless of time. Similar accounts of explosive anger and aggression have also been reported in diverse cultures with recent histories of conflict and trauma, such as among East Timorese adults in Southeast Asia, where the symptoms were frequently discussed amidst concerns of violence toward children and families [ 28 ]. This suggests that while Chechens may differ from Africans in this response it is not specific to Chechens. Rasmussen and colleagues’ 2014 review of the literature on cultural concepts of distress (CCDs) in trauma-affected populations outside of Europe and North America identified a cluster of concepts distinguished by negative moods and cognitions featuring anger [ 29 ]. The prominence of such symptoms in the current study may suggest a relevant cross-cultural (but perhaps not universal) syndrome that fits well within this cluster of CCDs.

The mental health problems identified in our study appeared to be highly interconnected. This is expected in a population that has experienced war with its combination of trauma during hostilities and subsequent deprivations and upheaval, resulting in a wide range of co-occurring mental health problems. Given this, it is not surprising that there was little distinction between problems in terms of the causes that were described. Previous research from multiple trauma-affected populations has suggested that whereas war-related stressors are more closely associated with PTSD-like syndromes, depression and anxiety-like symptoms are often viewed as the result of both past events and current stressors [ 5 , 30 ] such as those reported in the current study. That we did not identify intrusion and avoidance symptoms characteristic of a PTSD-type syndrome may be because these symptoms are less prominent among Chechens, or not readily reported. Alternatively, it could be that we used a largely community-based sample of respondents, rather than a specifically trauma-affected sample. However, our findings are similar to those of the Rasmussen CCD review [ 29 ]. Specifically, they reported that depression-like syndromes emerge much more commonly than PTSD-like syndromes in emic research, that avoidance symptoms are rarely reported, and that across the literature there was no clear distinction between CCDs caused by trauma symptoms rather than chronic stressors [ 29 ].

In Chechnya, our findings suggest many of the described proximal causes of current mental health problems are social pressures and chronic stressors rather than explicit trauma exposure. As such, trauma- informed treatment programs targeted at symptom reduction, mood regulation, and improved coping may be more appropriate than programs over-emphasizing a history of trauma exposure or the processing of a particular traumatic event. A recent analysis of data from 18 MSF non-specialized counselling programs (including the Chechnya program) demonstrates the relative strength of a flexible, trauma-informed treatment approach. Researchers found that although the MSF programs are originally designed for those affected by conflict and violence and appear to be effective in reducing symptoms, fewer than 20 % of cases were focused on trauma-related symptoms and a quarter of those seeking treatment did not link any traumatic event to their main presenting complaint, whereas 25 % identified domestic discord or violence as the underlying event triggering their main complaint [ 31 ].

Frequent reports of aggression and irritability symptoms across mental health problems further suggest that counseling programs, regardless of the intended focus or target population, should be prepared to address problems related to explosive anger and aggression. Given the potential bidirectional relationship between these emotional problems and problems in the family, early identification and prevention programs aimed at strengthening family supports are warranted.

As formative research for the MSF outcome evaluation, this study led us to develop a number of Chechen-specific items for inclusion in the MSF mental health assessment tool regarding being “out of temper”, emotional load, “emotional blowing”, and physical and verbal aggressiveness. Previous research validating assessment instruments with Chechen asylum seekers also noted these symptoms and concluded that standard diagnostic tools were likely to underestimate post-trauma related symptomatology relative to clinical interviews in this population [ 20 ], highlighting the importance of culturally adapting measures. Findings from the MSF outcome evaluation will provide additional information about the importance of these symptoms in a treatment-seeking sample, and the effectiveness of the existing treatment program in reducing these symptoms.

The current study identified approaches to help-seeking for mental health problems in Chechnya that inform where people with mental health problems may enter the system of care. First, we observed a greater awareness of the psychiatry model than has been observed in similar studies elsewhere [ 25 , 32 ], reflected in the tendency for free list respondents to recommend predominantly counselors and psychologists as KIs. While this is likely due in part to our sampling approach, the finding is not entirely surprising given a relatively well-established history of specialist psychiatry in former Soviet countries [ 33 , 34 ]. Second, we identified the Islamic center as an important parallel system of care alongside psychiatric and psychological services, with an apparent potential for collaboration and referrals between mental health professional and Islamic healing services. It seems that while some people may choose to initially seek help from one service or the other, if that service proves to be ineffective they are likely to look to an alternative option. The information provided by KIs reflects the perspective that Islamic healing is not in opposition to a biomedical model [ 35 ], and that understanding Islamic teachings on illness can also inform care provided in other settings [ 36 ].

Limitations

The placement of our study in the capital city was relevant for programmatic purposes, as it is one of the two main sites, together with mountain villages, where the MSF counseling program is implemented in Chechnya. Because Grozny was at the center of conflict during both Chechen wars, it is unlikely that our respondents were sheltered from the impact of the conflict. However, Grozny is also now the center for reconstruction and development, meaning that people living in this area may experience daily life and psychosocial stressors differently from those in more rural areas less impacted by the reconstruction efforts. We cannot presume that this research is generalizable to people in other parts of the Chechnya.

As is the case with much qualitative research, this study was conducted with a convenience sample of adult men and women representing key stakeholder perspectives. In particular, inclusion of a hospital-based participants is likely to produce results that over-emphasize medical complaints, which were frequently reported in the FL interviews. We felt that this was appropriate given that the aim of the study was to identify and explore mental health problems in the Chechen context within a limited scope of study, and that it was likely that people seeking medical care would reference mental health problems in free listing. Because of this convenience sampling approach, the frequency of responses cannot be assumed to represent the prevalence of a given problem within the larger population. Rather than emphasizing absolute frequency, we highlighted instead items that were reported repeatedly versus those that were only reported by one or two people.

Another limitation was the small number of follow-up KI interviews we were able to conduct due to scheduling issues and the short time frame for data collection. Because this study was primarily intended to provide data relevant to the design of an outcome evaluation, we do not assume that we have identified all the issues affecting this population, or that we have obtained a truly nuanced understanding of them, but rather that we have established a foundation on which to build future research. For example, the frequently discussed problem of substance use was beyond the scope of our study to examine in more detail as this problem had not been a primary focus of the counseling program and therefore was not a priority problem for inclusion in the outcome evaluation. Yet the frequent discussion of this problem may highlight a need to develop relevant interventions and indicates the benefit of future research to better understand these problems in the Chechen context. Finally, we were not able to include KI interviews with representatives from the Islamic center. In future studies it would be helpful to include perspectives from those who provide services at these centers.

The aim of this study was to gain a better understanding of mental health and psychosocial problems currently affecting people in Grozny, Chechnya, from their own perspective. This included understanding the nature of these problems, the effects of these problems on individuals, families, and communities, as well as coping and help seeking behavior. The purpose of gathering this information was to inform the development of assessment instruments for an outcome evaluation study of the MSF counseling approach. By conducting a relatively brief qualitative study, we were able to use the acquired data to adjust question wording and examples, and also to add questions to assess locally relevant symptoms to assess aggression and “not adequate” behavior. We believe this as important example of good practice in using qualitative methods to help develop tools for mental health care evaluations. This process also produced data regarding daily functioning of Chechen adults for the creation of a local functioning assessment; a description of this work will be included in the publication of the outcome evaluation.

Because of the dearth of literature on mental health problems in Chechnya, we believe our findings, although limited, also have broader utility for informing research and programming in this context. Given the consistent reports of high levels of irritability, aggression, “emotional blowing”, and “not adequate” behavior, future research exploring the relationship between these symptoms of distress and relevant syndromes is warranted. Additionally, research should further explore the relative role of conflict-related exposures and proximal social stressors in contributing to mental health of the population in this setting, particularly focusing on chronic stressors that could be addressed through individual and community-level programs to improve population health.

Abbreviations

CCD, cultural concepts of distress; DIME, design, implementation, monitoring, and evaluation; FL, free list; KI, key interviewee; MSF, Médecins Sans Frontières (Doctors without Borders); PTSD, post-traumatic stress disorder

Acknowledgements

The authors give special thanks to Hamzat Molamusov (translator), who provided critical project support during data collection and analysis. We also acknowledge the wonderful team of interviewers provided by Chechen State University. Lastly, we thank the MSF OCA Medical Coordinator and Head of Mission for their multiple rounds of draft review and feedback. All funding for the MSF Russia mission comes from private donors – no institutional or governmental funding is accepted. AN is funded through the NIMH Child Mental Health Services and Service Systems Research Training Grant (5T32MH019545-23). CF, ZT, GP, and AL are funded by MSF. KI is funded by Chechen State University. PB and JB are funded through a variety of grants and contracts.

Authors’ contributions

All authors contributed to study design. AN, CF and ZT led the field team to conduct data collection and analysis, with technical support and oversight from GP, AL, PB, and JB. KI provided institutional support for acquisition of data, and KI and ZT provided critical cultural insight and interpretation of results. AN drafted the manuscript, with all authors contributing important intellectual content and revisions. All authors read and approved the final manuscript and are responsible for its content.

Authors’ information

AN is a current doctoral student in the Applied Mental Health Research (AMHR) group at Johns Hopkins Bloomberg School of Public Health. CF is a licensed mental health counselor in Italy and served as study coordinator of this study and a subsequent RCT of the MSF counseling approach in Chechnya. ZT was the study assistant. GP is the Mental Health Advisor, and AL the Epidemiology Advisor, at MSF OCA. KI is a psychiatrist and Chair of the Department of Psychiatry at Chechen State University. PB and JB are faculty at the Johns Hopkins Bloomberg School of Public Health and are founding members of AMHR.

Competing interests

The authors declare that they have no competing interests.

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Expert Commentary

Understanding the Chechen conflict: Research and reading list

2013 review of Chechnya-related scholarship and the conflict and political grievances there that continue to reverberate.

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by Alexandra Raphel, The Journalist's Resource April 22, 2013

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News that the primary suspects in the April 15 Boston Marathon bombings are of Chechen heritage resurrected interest in historically troubled Chechnya, an autonomous republic in Russia’s North Caucasus Region. Suspects Dzhokhar and Tamerlan Tsarnaev’s motive has yet to be confirmed, but questions abound about what role the ongoing violence between Russia and Chechen separatists might have played.

Of course, precise connections are speculative, and the media has already been criticized for making too quick a leap — and for perpetuating stereotypes about Chechens and Muslims in general . Charles King’s article in Foreign Affairs , “Not Your Average Chechen Jihadis,” provides further insights on these points.  London School of Economics scholar Jim Hughes offers compelling perspective .

Fiona Hill, director of the Center on the United States and Europe at the Brookings Institution , writes , “Chechnya and Russia have spent centuries at war and it isn’t surprising that this conflict, which has spanned generations, would provide fertile ground to incite and radicalize sympathizers wherever they happen to live.” Hill also provides an overview of the conflict in an interview titled “The Troubled History of Chechnya.”

Although the region has, for the most part, stayed out of the Western media headlines in recent years, reverberations of the conflict are still being felt both in the region and among the global diaspora. Thomas de Waal, a Russia expert at the Carnegie Endowment for International Peace, notes in a recent article that “a low-level Islamist insurgency continues in and around Chechnya that takes dozens of lives each year.” For a sense of recent activity in the region, see “Islam, Islamism, and Politics in Eurasia Report,” published in March 2013 by Center for Strategic and International Studies.

The ongoing animosity between the largely Muslim ethnic Chechens and the Russian government dates back to Russo-Persian War (1804-1813), when Persia transferred the territory to Russian control. After years of attempted revolt by the Chechens, in 1944 Soviet Leader Josef Stalin deported the entire population of the North Caucasus — people in the republics of Ingushetia, Chechnya and North Ossetia — to Central Asia, claiming that they were collaborating with Nazi Germany.

After the fall of the Soviet Union in 1991, Chechen separatists called for independence from Moscow and two bloody wars followed during the following decade. The second ended in 2000 when Russian forces captured the Chechen capital of Grozny. Since then, Chechen separatists have continued to engage in acts of terrorism, including the 2002 hostage drama at a Moscow theater, capture of a school in 2004 and the 2010 bombing of a Moscow metro station .

For more information on the Chechen conflict and recent Russian history, see the Council on Foreign Relations’ “Backgrounder on Chechen Terrorism” and the article “What to Read on Russian Politics” in Foreign Affairs .

Below is a selection of papers, reports and articles that can provide further context on the conflict:

“The Rise of Radical and Nonofficial Islamic Groups in Russia’s Volga Region” Markedonov, Sergey. Center for Strategic and International Studies, January 2013.

Summary: “In the two decades since the dissolution of the USSR, Russian and Western experts, human rights activists, and journalists have become accustomed to the political violence of the North Caucasus. Terrorist bombings and acts of sabotage in Dagestan, Ingushetia, and Chechnya are perceived as somehow intrinsic to the region. But a recent tragedy in the Volga region suggests that this sort of violence — and the Islamist terrorists who perpetrate it — may not be confined to the Caucasus. To examine this increasingly serious situation, this report sheds light on the ideological sources and resources of radicalism in the Volga region, nonofficial Islamic movements’ support among the regional population, and opportunities for the potential growth of different forms of Islamist activities. It describes the origins of different nonofficial Islamic movements, as well as their post-Soviet development, ideology, and relationship with the authorities and official Muslim clergy. The report also offers practical approaches both for Russian domestic policy and for the U.S.-Russia security cooperation agenda.”

“Russia’s Homegrown Insurgency: Jihad in the North Caucasus” Blank, Stephen J. Strategic Studies Institute, October 2012.

Summary: “The three papers offered in this monograph provide a detailed analysis of the insurgency and counterinsurgency campaigns being conducted by Islamist rebels against Russia in the North Caucasus. This conflict is Russia’s primary security threat, but it has barely registered on Western minds and is hardly reported in the West as well. To overcome this neglect, these three papers go into great detail concerning the nature of the Islamist challenge, the Russian response, and the implications of this conflict. This monograph, in keeping with SSI’s objectives, provides a basis for dialogue among U.S., European, and Russian experts concerning insurgency and counterinsurgency, which will certainly prove useful to all of these nations, since they will continue to be challenged by such wars well into the future. It is important for us to learn from the insurgency in the North Caucasus, because the issues raised by this conflict will not easily go away, even for the United States as it leaves Afghanistan.”

“Prisoners of the Caucasus: Russia’s Invisible Civil War” King, Charles; Menon, Rajan. Foreign Affairs , July/August 2010.

Summary: “A pernicious mix of heavy-handed rule, corrupt governance, high unemployment, and militant Islam has reignited the Russian North Caucasus. Today, it is not only the old conflict zone of Chechnya but also its neighboring republics that are bordering on open civil war.”

“The New Chechen Jihad: Militant Wahhabism as a Radical Movement and a Source of Suicide Terrorism in Post-War Chechen Society” Speckhard, Anne; Akhmedova, Khapta. Democracy and Security , Vol. 2, Issue 1, 2006.

Abstract: The first act of Chechen suicide terrorism occurred on June 7, 2000, and was carried out by two young women. This inaugurated the migration of suicide terrorism from other conflict zones, into the Chechen conflict. How suicide terrorism as a tactic made its way into Chechnya is the topic of this paper, which provides an analysis of the events concerning the importation of militant ideologies and radical terrorist movements taking place since the Chechen declaration of independence as well as an empirical and theoretical analysis of Chechen suicide terrorism based on psycho-social interviews that were collected in Chechnya over a two-year time period from March 2003 to March 2005. We report data about suicide terrorism and the radicalization process from 32 interviews with family members and close associates of thirty-four Chechen suicide terrorists, inquiring about the terrorists’ backgrounds, experiences, religious, and psychological reasons leading up to their suicidal acts.

“Russia’s Ruinous Chechen War” Menon, Rajan; Fuller, Graham. Foreign Affairs , March/April 2000.

Summary: “The Russian Federation is unraveling, and its war against Chechnya shows why. Moscow blames Islamist terrorists for the trouble there. But in doing so, it ignores Russia’s deeper afflictions. Russia has forced disparate ethnic groups to live together for decades but has proven inept at governing its wobbly empire. Now the fighting in Chechnya is leading dissatisfied nationalities to rethink their options — and their dependence on Russia. Chechnya was the first to rebel. It will not be the last.”

“Russia’s Invasion of Chechnya: A Preliminary Assessment” Blank, Stephen J.; Tilford, Earl H. Jr. Strategic Studies Institute, January 1995.

Brief Synopsis: “On December 11, 1994, Russia invaded the secessionist republic of Chechnya in the North Caucasus. The aim was to suppress the republic’s government, led by General Dzhokar Dudayev, compel it to accept Moscow’s authority, and to force it to renounce its bid for independence and sovereignty. This invasion, which quickly turned into a military quagmire for Russia’s troops, triggered a firestorm of domestic opposition, even within the higher levels of the Ministry of Defense. As a result, the invasion has the most profound and troubling possible consequences for the stability of the Russian government, Russian democracy, and the future political-military relationship. This special report, based on what is already known, attempts to assess the discernible consequences of this invasion and provide a framework within which future developments can be assessed.”

“The North Caucasus: Russia’s Volatile Frontier” Kuchins, Andrew C.; Markedonov, Sergey. Center for Strategic and International Studies, March 2011.

Synopsis: “Continued violence and unrest in the North Caucasus have created a major area of instability for the Russian Federation. Although Chechnya is relatively more stable, for now, under the brutal dictatorship of Ramzan Kadyrov, neighboring republics including Ingushetia, Dagestan, and others have experienced significant increases in the frequency of violence. The entire region is plagued by extreme poverty, high unemployment, and corrupt and often incompetent governance. Additionally, the prevalence of radical Islamic influences as well as growing competitive nationalist identities further increases the challenges for governance and stability. The Russian federal government seeks to insulate the rest of the country from the overflow of violence in this volatile region, but terrorist attacks in the past year on the Moscow Metro and again on the train between Moscow and St. Petersburg demonstrate how hard this is to manage. Kuchins, Malarkey, and Markedonov examine the socioeconomic trends in the region, the role of Islam and rise of radicalism throughout the Caucasus, nationalism and growing ethnic tensions, and the external factors influencing the North Caucasus.”

“Radical Islam in the North Caucasus: Evolving Threats, Challenges, and Prospects” Markedonov, Sergey. Center for Strategic and International Studies, November 2010.

Synopsis: “As Kyrgyzstan plunges into crisis and the threat of a second Afghanistan in Central Asia looms large, the situation in the “Big Caucasus” seems less pressing and thus overshadowed. The worst scenarios predicted by analysts and politicians for the period of the 2008 August war have not been realized. The Russian attempt to “replace the regime” of Mikhail Saakashvili or apply the Georgian pattern in Ukraine, expected by many in the West, has not taken place. Neither have the attempts from the West (the United States, NATO, and others) to “nudge Georgia into a rematch,” which were expected in Moscow. Nonetheless, the Caucasus region remains one of the most vulnerable spaces in Eurasia. What challenges have turned the North Caucasus into a primary issue for Russia? Could we paint the political, ideological, and psychological portrait of the North Caucasus militant resistance? What resources do they have, and why has radicalism becomes popular? What external and internal factors determine their approaches? What mistakes did Russia, its society, and the Western observers make? And, finally, could the rise of Islamist militancy in the North Caucasus bring Moscow and Washington closer, regardless of the numerous foreign policy disputes existing between the two countries? This report is an attempt to answer these questions. It is based on open sources and interviews made during several trips to the North Caucasus republics, and it aims to promote more practical approaches to the situation there.”

“Conflicts in the Caucasus: Prospects for Resolution” Testimony by Fiona Hill before the U.S. Helsinki Commission, December 2011.

Excerpt: “The Helsinki Commission has an important role to play in advancing peace and democracy throughout the world. Unfortunately today, even in what might be considered an enlightened time, many people still face war and oppression in their homes. One of the regions that still witnesses much conflict is the Caucasus, with disputes in Georgia, Russia, Chechnya and others. The quest for peace is ongoing and certainly a worthwhile goal. Today, I hope to hear from the witnesses about the latest developments in the Caucasus. I would like to hear about what actions the countries within the region are taking to ease tensions. I’d also like to learn what the other Helsinki Commission countries are doing to help, as well as what the role the witnesses believe that us here in the United States House of Representatives, where we could be helpful.”

“Connectedness, Social Support and Internalising Emotional and Behavioural Problems in Adolescents Displaced by the Chechen conflict” Betancourt, Theresa S. et al. Disasters , 36(4), 2012.

Abstract: “ The study investigated factors associated with internalising emotional and behavioural problems among adolescents displaced during the most recent Chechen conflict. A cross-sectional survey (N=183) examined relationships between social support and connectedness with family, peers and community in relation to internalising problems. Levels of internalising were higher in displaced Chechen youth compared to published norms among non-referred youth in the United States and among Russian children not affected by conflict. Girls demonstrated higher problem scores compared to boys. Significant inverse correlations were observed between family, peer and community connectedness and internalising problems. In multivariate analyses, family connectedness was indicated as a significant predictor of internalising problems, independent of age, gender, housing status and other forms of support evaluated. Sub-analyses by gender indicated stronger protective relationships between family connectedness and internalising problems in boys. Results indicate that family connectedness is an important protective factor requiring further exploration by gender in war-affected adolescents.”

Tags: terrorism, research roundup

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Alexandra Raphel