Prevalence of Post-Traumatic Stress Disorder, Depression and Associated Factors in Post-Conflict Areas of North Shoa Zone, Ethiopia: A Community-Based Cross-Sectional Study

Substance use related factors of the study participants

This study result showed that about two-thirds of the respondents 501 (60.4%) had current alcohol use. Of the 830 study participants, 130 (15.7%) reported current use of khat (Figure 1).

 Figure 1: Description of substance use related factors of the respondents among conflict-affected areas of North Shoa, Ethiopia, 2022 (n=830).

Traumatic event related factors of the study participants 

Regarding individual trauma types, the most frequent type of trauma experienced by the community was verbally threatened or insulted 611 (73.6%) and witnessed murder of strangers 363 (43.7%), respectively. More than one-third of the respondents 279 (33.6%) had destruction of personal property. Of the respondents, 146 (17.6%) were physically abused. Among the 830 study participants, 88 (10.6%) had witnessed the murder of loved ones. In addition, more than one-third of the participants 282 (34.0%) reported a lack of food and water in the living area (Table 4).

Table 4: Description of traumatic event related factors of the respondents among conflict-affected areas of North Shoa, Ethiopia, 2022 (n=830).

Factors associated with PTSD

A bi-variable analysis was done for each explanatory variable. Socio-demographic variables including female sex and educational status (being unable to read and write and being able to read and write) fulfilled the minimum requirement. The following traumatic event factors: witnessing the murder of loved ones, lack of housing and shelter, being in a war fighting situation, witnessing the murder of strangers, and destruction of personal property also fulfilled the minimum criterion. Clinical and psychosocial factors like family members with mental illness, poor and moderate social support were variables that satisfied the minimum requirement (p < 0.25 significance level) for further multivariable logistic analysis in PTSD. In the multivariable analysis, being female, being unable to read and write, witnessing the murder of loved ones, witnessing the murder of strangers, being verbally threatened, poor and moderate social support were significantly associated with PTSD (p<0.05).

Females were four times higher in odds to develop PTSD than males (AOR=4.2, 95% CI (2.82-6.27)). From the study participants those who are unable to read and write were three times higher in odds to develop PTSD than those who are college and above (AOR=3.08, 95% CI (1.67-5.69)). The odds of developing PTSD among participants who had witnessed the murder of loved ones and witnessed the murder of strangers were three times and two times higher as compared to those participants who had not witnessed or experienced these traumatic events (AOR = 3.28, 95% CI (1.58-6.79)) and (AOR = 2.04, 95% CI (1.33-3.11)) respectively. With regard to those who were verbally threatened or insulted, the likelihood of developing PTSD was four times higher (AOR=4.09, 95% CI (2.69–6.21)) as compared to those who were not verbally threatened or insulted. Individuals who had poor social support were five times more likely to develop PTSD than those who had strong social support (AOR = 5.26, 95% CI (3.35-8.28)). The odds of developing PTSD symptoms among participants who had moderate social support were nearly two times higher as compared to those who had strong social support (AOR = 1.89, 95% CI (1.15-3.13)) (Table 5).

Table 5: Bi-variable and multivariable binary logistic regression analysis showing an association between factors and PTSD in post- conflict areas, North Shoa -zone, Ethiopia 2022 (n=830)

Key: *p<0.05, **p<0.01, ***p<0.001

Abbreviations: COR= Crude Odds Ratio, AOR=Adjusted Odds Ratio, PTSD=Post-Traumatic Stress Disorder, n= Sample Size.

DISCUSSION

The findings from the current study revealed that the estimated prevalence of PTSD was 63% with a 95% CI (60%–66%). The estimated prevalence of PTSD in the current study was higher as the study compared to Palestinians (west bank 49.28%, Gaza 46.5%, and East Jerusalem 35.8%) [15]. This discrepancy might be due to the analysis and reporting technique, in which the other studies analyzed and reported for the 3 states separately, while in the current study the result was reported as a total of 4 districts. Similarly, the current study was higher than the studies carried out in Albania (17%) [13], India (19%) [12], Liberia (44%) [19], Afghanistan (42.2%) [14], Korea (15%) [20], and South Sudan (36.2%) [21].

The possible explanation for the observed differences might be due to different instruments and cut-off points to measure PTSD and exposure to multiple traumas. All the studies used the Harvard Trauma Questionnaire (HTQ) and the General Health Questionnaire (GHQ-28), except the study carried out in Korea. The other cause of discrepancies could be due to the methods they used to collect the data. In Albanian and Korea, they used a self-administered technique (where the difference in individual understanding of the question might affect the magnitude) in which this study used an interview that had a high chance of common understanding. The study conducted in Liberia was conducted after 10 years of conflict, but the current study was conducted less than 1 year after the conflict. Therefore, the increased duration was more likely to reduce magnitude due to recall bias. Variation in the type of sampling technique, exposure to trauma, sample size and socio-cultural difference might also contribute to this discrepancy.

Regarding the socio-demographic characteristics of the respondents, this study showed that the education level of participants (those who are unable to read and write) has a significant association with PTSD. This finding is supported by a study done in the Kashmir valley [12]. This might be due to people who are unable to read and write may have less ability to cope with a stressful situation than those of college and above [22].

Also, being female has a significant association with PTSD. This finding is also supported by other studies carried out in the Kashmir valley, Italy, South Sudan, Afghanistan, and Palestine [12,14,19,23,24]. Biological and psychosocial factors may contribute to women's increased risk of having PTSD. Women appear to have a more sensitized hypothalamus–pituitary–axis than men due to the effect of oxytocin, which results in excessive fear, stress, and needs for social support [25]. Psychological consequences of rape, sexual abuse, violently losing a partner and being widowed (single parent) might also be a risk factor. Another reason could be that females tend to show a more emotional and ruminative response to stress [12,26].

The significant association between witnessing murder of loved ones with PTSD is consistent with report of other study in Italy and Croatia [24,27]. The strongest relationships with the people we love have the capacity to positively or negatively change us and contribute to our sense of identity. As a result, witnessing the murder of loved ones resembles an irreversible negative life-changing effect and altered thinking ability. The anguish, the repeated memory of the event, negative intrusive thoughts (For example thoughts of revenge), has a significant impact on emotional well-being and could also interfere in everyday living activities [28,29].

The current finding showed that, witnessing the murder of strangers was associated with PTSD. But it was not associated with other studies. The possible reason might be the number of individuals exposed to this traumatic event was high in the current study and this variable was not included in some of the other studies [30,31]. This traumatic event trapped the person in a constant state of strong emotional reactivity [29]. The three areas of the brain (amygdala, hippocampus, and prefrontal cortex) all play a role in regulating emotions and responding to fear. When there is strong emotional reactivity, these areas may perform and function differently than before. The amygdala becomes hyperactive; the hippocampus affects the ability to recall some memories; and the prefrontal cortex will have a hard time regulating fear and other emotions. All of this emotional instability, irritation, and stress make the person vulnerable to PTSD [32,33].

Furthermore, participants who experienced verbal threats or insults are more likely to acquire PTSD; this finding was not supported by previous studies. This might be due to, in the current study this traumatic event is the highest frequency that was experienced by the community. Words are instruments for managing human bodies. A person's mental and physical health might be negatively impacted by aggressive words. As kind words make us feel calmer stronger and loved. Verbally threatened or insulted shatters a person’s self-esteem and self-respect. This nonphysical act harms another person's overall ability to function, their mental well-being, and makes the person constantly afraid, ashamed, guilty, unwanted, powerless, and hopeless. These cumulative emotions lead to symptoms of trauma, making them susceptible to different mental disorder, including PTSD [34].

Strengths and Limitations

Strengths

The study used standardized and validated instruments for assessing PTSD and depression. It was conducted at the community level and included a large sample size from multiple conflict-affected districts.

Limitations

Due to the cross-sectional design, causal relationships could not be established. Recall bias may have occurred because participants were asked to report past traumatic experiences.

CONCLUSION

The prevalence of PTSD and depression among adults living in conflict-affected areas of North Shoa Zone was remarkably high. Female sex, traumatic experiences, poor social support, and perceived stress were important determinants of mental health outcomes. Strengthening mental health services and community-based psychosocial interventions is essential in post-conflict settings.

Declarations

Ethical Approval and Consent to Participate

Ethical approval was obtained from the Institutional Review Board of Debre Berhan University, Asrat Woldeyes Health Science Campus. Written informed consent was obtained from all participants.

Consent for Publication

Not applicable.

Availability of Data and Materials

Data are available from the corresponding author upon reasonable request.

Competing Interests

The authors declare no competing interests.

Funding

No external funding was received.

Authors' Contributions

All authors contributed to the conception, design, data collection, analysis, interpretation, and manuscript preparation.

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