in Sierra Leone
Psychosocial Questionnaire: Freetown Survey
by Kaz de Jong, Maureen Mulham, and Saskia van der Kam
January 11, 2000
This report is the product of close
cooperation and hard work by a multinational team motivated to bear
witness to the anguish suffered by the Sierra Leone population.
Warm thanks to MSF-Holland’s medical
coordinator in Freetown, Maureen Mulham, for skillfully guiding the
survey process. Lo van Beers was instrumental during the data entry
process. Special thanks go to the group of Sierra Leonian interviewers
and their respondents for the difficult and often painful work of asking
and answering the survey questions. For reasons of security, the names
of the interviewers/interviewees cannot be given.
— Kaz de Jong, Mental
Health Advisor, MSF-Holland (January 2000)
This report is based on a mental health
survey of persons in Freetown, Sierra Leone in May 1999. Several months
earlier the city saw fierce fighting that left more than 6000 people
dead, an untold number injured and mutilated, and tens of thousands
homeless. Many of those affected had gone through similar experiences
before, and had fled to Freetown for its relative safety.
The findings only touch on the
sufferings of the country’s population. The civil war in Sierra Leone
began in 1991 and no region has been spared. The residents of Freetown
were not alone in their trauma: the country’s town and village dwellers
too, have often been repeated victims of war, displaced time and again
from their homes and subjected to terrible and long-lasting hardships.
Although fighting in the country has
largely ceased since the Lome Peace Accord of July 1999, the effects of
that war will be with the population for a long time. As this survey
makes clear, few escaped the mental trauma of the war zone that Freetown
became for more than three weeks in January 1999.
Doctors Without Borders found, among
other things, that 99% of those surveyed suffered some degree of
starvation, 90% witnessed people being wounded or killed, and at least
50% lost someone close to them. The intensity of the fighting is
indicated by the numbers: 65% endured shelling, 62% the burning of their
property, and 73% the destruction of their homes. Physical harm was also
great: 7% had been amputated (typically a limb, hand, foot or ear), 16%
had been tortured by a warring faction, 33% had been held hostage, and
39% had been maltreated in some way or another.
The psychological impact of actually
witnessing horrific events imposes a serious psychological stress.
Deliberately or not, witnessing at least once events such as torture
(54%), execution (41%), (attempted) amputations (32%), people being
burnt in their houses (28%) and public rape (14%) often results in
traumatic stress or even Post-Traumatic Stress Disorder (PTSD). Almost
all respondents reported to have seen wounded people at least once
Doctors Without Borders also found,
through a technique called the Impact of Event Scale, that the
population showed very high levels of traumatic stress. Traumatic stress
associated with physical complaints like headaches (38%) and body pains
(12%) is reported most frequently.
The psychosocial and mental health
consequences of war on civilians are all too often neglected. Even after
hostilities cease, the war may continue in people’s minds for years,
decades, perhaps even generations. To address only the material
restoration and physical needs of the population denies the shattered
emotional worlds, ignores the broken basic assumptions of trust and
benevolence of human beings, and leaves unaddressed the shattered moral
and spiritual consequences of war.
After severe conflicts, people seek to
forget or deny what happened to avoid painful memories of the past and
to escape the sense of hopelessness, humiliation, and anger. But for the
direct survivors of violence, acknowledgement of the suffering is a
crucial element for making sense of and addressing traumatic
experiences. To help a traumatized person there is a need to restore the
bonds between the individual and their surrounding system of family,
friends, community, and society. Overcoming the extreme stress and
sometimes even severe mental health problems associated with mass
traumatization such as occurred in Sierra Leone, tests the healing
capacity of family and community.
1. Political Context
In May 1997, military officers of the
self-proclaimed Armed Forces Revolutionary Council (AFRC) overthrew the
democratically elected government of President Ahmed Tejan Kabbah and
formed a junta with the insurgent Revolutionary United Front (RUF). In
February 1998, the West African peacekeeping force ECOMOG ousted the
combined AFRC/RUF forces, whose remaining fighters fled to the
countryside. President Kabbah was reinstated in office on March 10,
1998. In December 1998 the combined RUF/AFRC forces launched a massive
offensive that brought the fighting into the capital, Freetown.
The fighting in Freetown in January
1999 was an intense, violent repetition of the brutality that has become
common in Sierra Leone. The rebel forces committed indiscriminate
attacks – thousands of executions, abductions, and rapes – on the
civilian population. Arson and looting were widespread. ECOMOG forces
were implicated in the summary execution of hundreds of suspected RUF
fighters. Altogether, some 6000 people died in Freetown over a
three-week period and some 150,000 were displaced from their homes. When
the rebels were forced to retreat, they cruelly amputated arms and legs
and ears of civilians in their custody.
On July 7, 1999 the various parties
signed a Peace Accord in Lome. Since then, armed clashes have been
sporadic, travel through most of the country is now possible, and
Freetown is being rebuilt. But insecurity remains. The inadequately
funded and ill-functioning Disarmament, Demobilisation, and
Reintegration program has meant that too many armed soldiers and
ex-soldiers roam the countryside. Too few of those abducted, including
hundreds of children, have been allowed to return home. And continued
lawlessness by the armed factions has sharply limited humanitarian
access in those regions, particularly in the north and east, where
assistance is most needed.
2. Medical Context
Since 1994, Doctors Without Borders has
provided medical and nutritional programs in Sierra Leone, including
surgery, primary health care support, and water and sanitation. At the
end of 1997, a psychosocial program was implemented around Magburaka in
central Sierra Leone, but because of the security situation, the program
was suspended. After the January 1999 events, Doctors Without Borders,
through trained local counselors, started psychosocial care to amputees
in the hospital in Freetown.
Until recently, emergency medical
programs have been dominated by a perspective emphasizing physical
health and immediate relief. Behavioral, mental, and social problems
were neglected. Since the genocide in Rwanda and the conflict in the
Former Yugoslavia, it has become recognized that mental health and
psychosocial programs can greatly contribute to the alleviation of the
suffering of people in war and disaster-stricken areas (e.g. Ajdukovic,
1997). Focused primarily on the effects of post-traumatic stress, these
programs have put the psychological consequences of massive man-made
violence on individuals and populations on the agenda of the
Research has shown that nearly all war
victims experience recurrent and intrusive recollections, dreams, and
sudden feelings of reliving the event (e.g. Bramsen, 1996). These
responses are combined with increased arousal, avoidance of stimuli
associated with the trauma, and numbing. Through the oscillation between
intrusions and avoidance, the psychological integration of the traumatic
experience is realized, which has been made clear in cognitive
processing models (e.g. Creamer, 1995). Physical symptoms such as
headaches, stomach pains, and back pains are often part of this process.
These physical symptoms frequently cause persons to seek medical
attention. The occurrence of mass PTSD can have a debilitating effect on
communities. Daily experience in the field demonstrates that traumatized
people impede the restoration of ordinary life and jeopardize conflict
Besides the mental and physical
suffering that people experience, on a spiritual level their fundamental
assumptions of control and certainty, as well as basic beliefs in the
future and in the benevolence of other people, are also shattered--often
beyond repair (Janoff-Bulman, 1992; Kleber & Brom, 1992). Research
indicates that the duration and the frequency of traumatic experiences
negatively influences physical, mental and spiritual coping mechanisms
(e.g. Kleber & Brom, 1992).
Post-Traumatic Stress Disorder (PTSD)
is frequently used in connection with traumatic events. The concept is
well fitted to describe the serious and prolonged disturbances of
individuals confronted with major life events. The distinctive criteria
of PTSD (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
(DSM-IV); APA, 1994) are (1) an extreme stress, (2) intrusive and
re-experiencing symptoms, (3) avoidance and numbing symptoms, (4)
symptoms of hyperarousal, and (5) symptoms of criteria 2, 3, and 4
should be present at least one month. The concept is also included in
the International Classification of Diseases (ICD-10) of the World
Health Organization (1992). PTSD is strongly associated with
dissociation and somatization (McFarlane, Atchinson, Rafalowicz & Papay,
1994; Van der Kolk et al., 1996).
The concept of PTSD should be
considered with care for several reasons. First, not all disorders after
traumatic events can be described in terms of PTSD. It is not the one
and only possible disorder after traumatic events, even according to the
DSM system. Co-morbidity has been found to be more prominent in trauma
patients than was originally assumed (Kleber, 1997). Second, whether
western conceptual frameworks on psychological stress and mental
disorders can be transferred to different areas of the world are
practical as well as theoretical and ethical questions (Kleber, Figley &
Gersons, 1995; Summerfield, 1996).
Doctors Without Borders has been
addressing the psychosocial problems of the survivors of violence in
Sierra Leone before, during and after the January 1999 events. Doctors
Without Borders is very concerned that neglect of the mental health and
psychosocial problems of the large number of people who are suffering
from prolonged traumatic experiences may cause serious problems for the
future of Sierra Leone. Simply ending the war does not eliminate the
Doctors Without Borders decided to
start a psychosocial program in Freetown. As part of its program, a
population survey was conducted in Freetown to learn what people
experienced, to what extent the events resulted in traumatic stress, and
what other medical needs the inhabitants had. In the absence of other
psychosocial surveys in emergency situations to serve as a model, the
survey instruments were composed and partly designed by Doctors Without
1. Target Population & Sample
The survey was conducted after
receiving the permission of the appropriate authorities, during the
first two weeks of May 1999, four months after the atrocities in
Freetown. Because everyone in Freetown had been subjected to traumatic
experiences, both Internally Displaced Persons (IDP’s) and residents
were included in the sample.
A two-stage cluster sampling method was
used, a methodology based on vaccination surveys. The methodology is
extensively described in the various handbooks of WHO. The sampling
method entails a first phase where 30 clusters are chosen. In the second
phase a pre-set number of individuals are chosen per cluster. The
sampling technique itself ensures that every individual has an equal
chance to be chosen. The result obtained through sampling techniques is
an approximation of the real value in the entire population. The real
population value is in a range around the value obtained by the sampling
method. The narrower the range, the more precise is the estimation. The
precision depends on the sample size and the inter-cluster variation and
the intra-cluster variation of the specific survey. The precision of the
results with this two-stage sampling technique is less than the
precision one would get with a random sampling technique.
The sample consisted of 30 clusters of
8 respondents, as the intra-cluster variation was thought to be
reasonably small, since most traumatic events take place on a community
level and not on an individual level. The sampling frame is based on the
1997 census of the Ministry of Health and UNICEF, which gives a
population of 600,000. The rural part of the Western area (encompassing
Freetown and its peninsula) was excluded because most of the area was
not accessible during the survey for security reasons.
The areas (clusters) were chosen with a
chance proportional to the population size. The teams went to the center
point of these areas; a pen was spun to determine the direction and
every tenth house to the right was selected until the eight necessary
for the cluster had been identified. The most senior member of the
household present was interviewed. Any refusals were noted and the
selection process continued to the next tenth house. There was a note
made on each questionnaire of the displaced or resident status of the
interviewee. Where the cluster was in a displaced camp one person from
each section of the camp was interviewed, depending on the layout of the
Four survey teams were selected. Each
team had to conduct eight interviews each day. All interviews were
scheduled in the first two weeks. Eight interviews per day per team were
the maximum due to the difficult nature of the information gathered.
The survey teams consisted of two
trained local counselors who did the interviews and a support team of
one expatriate staff member and a driver. The training consisted of the
following elements: introduction to Doctors Without Borders, the nature
and purpose of the survey, confidentiality of the data and information,
survey technique, data registration and task division among crews. Some
survey questions might have provoked strong emotions, so the counselors
received special training on how to deal with them. They were also
informed on referral possibilities for those in need of follow-up
Counselors practiced interviewing
skills on each other. The items of the questionnaire were discussed in
depth until a final interpretation was agreed on each question. A pilot
study of eight interviews was carried out by the teams in the National
Stadium IDP site, Kingtom area, Aberdeen Junction and Murray Town. After
the pilot interviews, problems of interviewing, sampling and approaching
people were discussed. Ambiguities in the questionnaire were addressed.
The training (including the pilot study) lasted two days.
3. The Interview
The counselors worked in pairs. After
the counselors introduced themselves and Doctors Without Borders, the
purpose of the survey was explained to the potential participant. In the
introduction it was clearly stated that the participant would not
receive any compensation, that the data were treated confidentially and
that the interview would last for a maximum of 40 minutes. After the
introduction the participant could decide whether to participate. The
timing of the interviews was crucial, since people had to be at home and
It was important that the participants
completed the survey. To avoid exceeding the interview time it was
explained that direct and short answers were necessary. Extra
discussions or conversations were avoided. However, the counselors were
permitted to stop or interrupt the interview when they deemed the
questions to be too emotionally upsetting for the participant. When the
counselor believed that the participant needed follow-up support,
referral to professional counselors was facilitated.
All teams had a daily technical and
emotional debriefing. Further emotional support for the counselors was
provided through the Doctors Without Borders psychosocial peer support
system for national staff, which was trained by the Doctors Without
Borders Amsterdam Public Health Department and Psychosocial Care Unit.
4. The Psychosocial Questionnaire
The structured interview was based on a
questionnaire consisting of 35 questions with subdivisions.
To control the time of the interview
most questions offered a limited number of alternatives from which the
participant could choose. Only two questions in the health section of
the questionnaire were open ended. To limit the emotional burden the
questions were put as factually and simply as possible. When unclear, a
short explanation was allowed. Participants were not allowed to fill the
questionnaire later nor were they permitted to study the questionnaire
in advance. Interviewers had to respect confidentiality at all times.
No trans-cultural tools to measure
traumatic stress are available. To assess the level of trauma, three
important indicators of traumatic stress were measured. The first
indicator is the presence of a potential traumatic event. The second
indicator is the impact of event scale, which expresses the extent of
traumatic stress response. The third indicator appraises physical
complaints, which likely are correlated to traumatic stress. When all
three indicators of traumatic stress were positive, at least strong
circumstantial evidence for the prevalence of traumatic stress was
The psychosocial questionnaire was
composed of four sections. The first section assessed the demographics
and personal background of the participant. A second section appraised
traumatic events such as exposure to violent situations, who was lost
and the traumatic events witnessed. Both the number of traumatic
experiences and their length are important risk factors in the
development of PTSD (Kleber & Brom, 1992).
The third section measured the impact
of these events. To measure the prevalence of traumatic stress responses
the Impact of Event Scale was used (Horowitz, Wilner & Alvarez, 1979).
This psychometric instrument assesses two central dimensions of coping
with drastic life events: intrusion and denial. It has been used
worldwide and generally consistent structures have been found across
samples and situations (Dyregrov, Kuterovac & Barath, 1996; Joseph,
Williams, Yule & Walker, 1992; Robbins & Hunt, 1996; Schwarzwald,
Solomon, Weisenberg & Mikulincer, 1987; Silver & Iacono, 1984; Zilberg,
Weiss & Horowitz, 1982). Despite its wide use, interpretations of the
outcomes should be done with appropriate care since the Impact of Event
Scale is not validated either for Western Africa or for Sierra Leone.
The final section of the questionnaire
evaluated current physical health complaints and needs. PTSD is
frequently associated with somatization. Physical symptoms like
headaches, stomach problems, general body pain, dizziness or
palpitations are often expressed by people suffering from traumatic
stress. A high prevalence indicates a possible high level of traumatic
stress or PTSD. Physicals are registered by means of open-ended
questions. The access to health care and the perceived health levels
were registered using the Lickerd scale.
5. Data registration
The forms were registered anonymously.
Data were entered in a spreadsheet in EXCEL, and data were analyzed by
EXCEL and EPIINFO-6.
All four teams contributed equally to
the survey (each 25%). The fixed number of interviews in each cluster
(n=80) was extended in four clusters (Old Warf, Aberdeen, Approved
School/Kuntoloh, National Workshop). The total number of respondents was
248 (n= 248), of which three respondents were excluded because they were
younger than 15 years.
1. Demographics (First section)
In total 91 (37%) respondents were
recently displaced; only 66 (27%) were residents. The others (37%) could
not be placed in one of these categories. A possible explanation is that
many people had been displaced in earlier years. About half (52%) of the
respondents were female (Confidence interval 95% level: 46.4 – 56.8).
The age of the respondents varies from
15 up to 81 years with a majority of the respondents in the middle age
group of 35-44 years (29%).
The majority has attended primary school, also in the older age groups;
on average 30% have not had formal education.
2. Appraisal of traumatic
experiences (Second section)
Graph 3 shows what situations the
respondents have faced. Incidents include: attack on village (84%),
exposed to cross fire (84%), explosion of mines (28%), aerial bombing
(83%), mortar fire (65%), burning of properties (62%) and destruction of
houses (73%), indicating that large groups of the population of Freetown
have been caught in direct war. In addition to the direct threats caused
by the hostilities, the lack of food and other commodities forced people
to take extra risks (74%). A smaller number of people (57%) had to walk
long distances to find a safer place. The risk of abduction was clearly
present since 43% of the respondents reported having been exposed to
abductions. Generally half of the respondents indicate that the event
had taken place more than three times.
Coping with traumatic events is more
difficult when people themselves experience immediate life-threatening
circumstances (Kleber, Brom; 1992). Graph 4 shows what life-threatening
traumatic experiences some of the respondents survived.
The respondents were allowed to report
on all items. The percentages are related to the number of people having
experienced that event as a proportion of the total number of
respondents. Several people suffered from multiple life-threatening
A high percentage of respondents
directly experienced at least once an event threatening their physical
integrity, either by maltreatment (39%) torture (16%) or amputations
(7%). 40% of the respondents have seen their houses burned down; 33%
were taken hostage. The percentage of people reporting abduction is, in
contrast to the above, relatively low (7%). The relatively low report on
rape (2%) should not be misinterpreted. Rape is, as in most other
countries, a taboo topic. Rape victims usually do not report this crime
to avoid serious repercussion from their family or to evade the stigma
communities and society impose on these victims.
The dire food situation is by far the
highest life threatening experience, as it was reported by almost all
the respondents (99%).
2.2 Loss and witnessing
Conflict and violence are closely
related to loss. Loss of loved ones and witnessing their violent death
might be one of the most serious risk factors for PTSD. Graph 5 gives an
overview of both.
The percentage of people lost increases
with the number available. The loss in the nuclear family (partner (5%),
father (5%), mother (7%), child(ren) (9%) and siblings (16%)) is
reported less then the loss of more "distant" family members (aunt,
uncles (14%)). The percentages reported on death of neighbors (53%) and
friends (50%), is clearly higher, since there are more of them. These
data indicate that at least 50% of the respondents lost someone they
knew very closely. Many respondents witnessed the death of a close
person: 30% witnessed the death of a friend, 41% that of a neighbor.
Additionally 7% witnessed the death of their child.
To create terror a perpetrator often
demands others to witness the atrocities. The psychological impact of
actually witnessing horrific events imposes a serious psychological
stress. Deliberately or not, witnessing at least once events such as
torture (54%), execution (41%), (attempted) amputations (32%), people
being burnt in their houses (28%) and public rape (14%) often results in
traumatic stress or even PTSD. Almost all respondents reported to have
seen wounded people at least once (90%). Graph 6 gives an overview.
3. Impact of Event Scale (Third
The inhabitants experienced horrific
events. The third section measures the prevalence of traumatic stress
responses through the Impact of Event Scale questionnaire (Horowitz,
Wilier & Alvarez, 1979). The PTSD score as outcome of the Impact of
Event Scale (I.E.S.), is constructed around two clusters of reactions.
Intrusions such as flashbacks, nightmares and reliving the event are
indicators of the preoccupation with the events that often characterize
survivors of violence. Complaints like "I can't stop thinking about it"
combined with the unpredictable occurrence of flashbacks often provoke
feelings of having lost control or becoming crazy. To compensate for the
agony of ongoing intrusions, survivors try to avoid situations, places,
conversations or people that remind them of the events. The avoidance as
well as the intrusions has a debilitating effect on the survivors'
social life. Social withdrawal and a life obsessed by fear and avoidance
may be the destiny of those that suffer from severe, chronic PTSD.
The overall PTSD scores registered on
the I.E.S. are high. When the cut of scores (no problem: 0-10, at risk:
11-25, PTSD: 26-75) for Western Europe are applied, no one reports to
having "no problem." Two people have scores indicating a risk for
developing PTSD. All other respondents (99%) have scores on the I.E.S.
that are associated with PTSD in a Western European setting. In the
current survey most people (111, 27%) have scores between 36 and 45,
which is similar to the number of people having scores between 46 and
55. Graph 7 shows the scores on the I.E.S. No significant differences
were found between the contribution of intrusions and avoidance on the
overall PTSD score. There were 16 respondents who were not able to give
a clear answer on one of the questions composing the PTSD scale; these
respondents are excluded from the total PTSD score. The average score on
the PTSD scale was 47.6, with a confidence interval of 45.6-49.6 (95%
confidence level). This result shows good precision.
The results on the I.E.S. are
consistent with the conclusions on the appraisal of traumatic
experiences. The reported high numbers of traumatic experiences may
explain the high scores on the I.E.S. However, this conclusion has to be
read with care. The I.E.S. is not validated in Sierra Leone and may
therefore be subject to differences in understanding some questions.
Moreover the cut-off scores may prove to be quite different then the
ones used by us. Despite these considerations, high levels of traumatic
stress are evident, since even when the cut of score is raised to 55
(more then doubled), 63 people (25%) still suffer from severe traumatic
stress or even PTSD.
4. Physical health (Section 4)
People suffering from traumatic stress
and PTSD often have physical complaints like headache, stomach problems,
body pain, dizziness or palpitations. Frequently the complaints cannot
be related to a physical disease or disorder. Nevertheless, the physical
complaints are expressed in frequent visits to the overburdened health
care settings. People continue to search for a physical cure to
alleviate their emotional problems. Medical people are not aware of or
feel powerless against the somatizing patient and offer medication.
Despite the costs both to the patient and the health system, this
situation is frequently found in health settings in violent contexts.
Some indicators of physical health and medical needs are described
Since the onset of the violence, the
majority of the respondents (85%) perceived their health to be worse
than before. Consistent with this finding is the occurrence of unclear
physical symptoms reported by the majority of the respondents (78%). As
a result, 42% of the respondents visited the health post or clinic at
least twice in the four weeks prior to the survey.
NOT AT ALL
HEALTH POST VISIT
The table above is an overview of
perceived health, the occurrence of unclear symptoms and the number of
health post/clinic visits (Rarely = 1; Sometimes= 2.3; Often= 4+).
The results of the fourth section
(physical health) confirm the tendencies reported earlier. Traumatic
stress associated with physical complaints (like headache (39%) and body
pains (12%)) is reported most frequently. The visits to health
facilities are relatively high (42%). The majority takes medication
(e.g. paracetamol, panadol, vitamins, chloroquine).
The survey among respondents from all
suburbs of Freetown indicates high levels of traumatic stress among the
population surveyed. Every indicator (experienced events, Impact of
Event Scale and Physical Health) points in the same direction. The
indicators are discussed below.
The responses on the second section
appraise the traumatic experiences of the respondents. The high
percentages of certain events (starvation (99%), witnessing wounded
people (90%), having lost someone close (at least 50%)) result in a
clear conclusion that most respondents living in all parts of Freetown
have experienced at least one traumatic experience. It is likely they
have been subjected to many more.
The Impact of Event Scale (Horowitz,
Wilner & Alvarez, 1979) indicates high levels of traumatic stress and
PTSD in the survey population (99%). The final score on the I.E.S. is
constructed around two clusters of reactions: intrusions (e.g.
flashbacks, reliving of events) and avoidance (e.g. evasion of
situations, amnesia). Neither of them contributed significantly more to
the overall PTSD score.
The outcome of the Impact of Event
Scale (I.E.S.) is not conclusive and should be considered with care
since the I.E.S. questionnaire is not validated for Sierra Leone and the
cut-off scores applied in this report are based on Western European
data. The outcomes on the I.E.S. should not lead to the conclusion that
almost everybody in Sierra Leone is traumatized and suffers from PTSD or
other mental health problems. However, the high scores on the I.E.S. are
supported by the outcomes on the appraisal of traumatic experiences
The results of the last section
(physical health) confirm the tendencies reported earlier. Traumatic
stress associated with physical complaints (like headache (39%) and body
pains (12%)) is reported most frequently. The visits to health
facilities are relatively high (42%).
The high levels of traumatic stress or
even PTSD indicate a clear need for psychosocial or mental health
interventions to address the needs of the survivors of violence in
Freetown. To focus humanitarian aid only on material restoration and
physical needs denies the shattered emotional worlds of the population,
and ignores the ruined basic assumptions of trust and the benevolence of
human beings. It leaves unaddressed the broken morale of the survivors
and the spiritual consequences of war.
A population that is in general
psychologically healthy can prosper and overcome the burdens of the
past. Psychologically healthy people can also solve their disagreements
in less violent ways. Helping traumatized people is a matter of
restoring the bond between the individual and the surrounding system of
family, friends, community and society. To overcome mass traumatization
as in the case of Sierra Leone, the healing capacity of family and
community systems must support people in their coping with extreme
stress and more severe mental health problems. Psychosocial and mental
health programs are evident tools in this process and should not be
overlooked. The involvement of Sierra Leoneans in these programs is of
ESTIMATED TOTAL POPULATION
NO. OF CLUSTERS PER SECTION
106459 - 219368
219369 - 255116
255117 - 282658
282659 - 335528
335529 - 408786
408787 - 521758
521759 - 602558
Table 1: Key areas and cluster
KROO TOWN ROAD