Is war violence the only predictor of PTSD Symptom Severity among the Congolese refugees in Uganda

Structure of this presentation.• Conflicts in DR C• Refugee dimension• Purpose of the study• Tools• Results • Discussion and Conclusions

Conflicts in DRC:•1996 - 1997:

•Laurent-Desiré Kabila supported by different countries invaded Congo and ousted Mumbuto Seseko.

•1998 - 2003:•Laurent-Desiré Kabila fell out with his former allies•2001: Laurent-Desiré Kabila was ousted and Joseph Kabila became the president

Conflicts in DR

• Forces Armées de la Répuplique Démocratique du Congo (FARDC)

• Forces Démocratique de Libération du Rwanda (FDLR)

• Congrès National pour la Défense du Peuple (CNDP)

• Forces Rwandaises de Défense (FRD)

• lokale Bürgerwehren (Mai-Mai, Pareco etc.

• The March 23 Movement (Mouvement du 23-Mars)

Refugee Dimensions

①Pre flight: refugees experience hardships, persecution, constant alarm and fear, witnessing killings, looting, torture and threatened death, disappearance of a loved one, rape etc

②Flight: separation of family, loss of property, witnessing death of their loved ones on the way, survival on the wild food and fruits, walking unfamiliar distances etc

Post flight Rigorous hassle of registration

and fear of repatriation, refugee cultural clashes, living with perpetrators etc

The purpose of this study

• The purpose of this study was to establish the occurrence of different traumatic event types as well as relative contribution of war, family and community related violent events towards the development of PTSD Symptom severity among the Congolese refugees in Uganda.

War violence and associated atrocities in many regions of the world dominate every day's news. The protagonists’ armed forces often use fear, violent and aggressive behaviour to maintain control within the ranks and also to sustain the conflict. -Torture and mutilations of the victims are some of the common of tactics used to achieve these aims (Elbert et al., 2006). -The recent statistics of the UNHCR (2013) estimates 200,000 forcefully displaced refugees from the DRC in Uganda.

•This study was based on a dose response hypotheses, it assumes that the probability of developing PTSD, mainly depends on the severity of trauma based on exposure to a number of traumatic events (Mc Nally., 2003) Studies investing the objectivity of a single trauma and PTSD are restricted to a narrow variance of one traumatic event and miss out on the additional dose.

•Studies by Neuner et al. (2004) and Schauer et al. (2003) have reported a significant dose-response relationship between the number of traumatic event types experienced and the likelihood of suffering from PTSD symptom severity. This has been acknowledged as the “building block effect”

Tools• The checklist that included natural events, war, family and

community related violence was used to asses the number of traumatic event types.

• Posttraumatic

Continuous

Questions related to Natural

• Have you ever experienced a natural disaster (for example, flood, land slide, volcano outbreak, earthquake) in such a way, that your own life was in danger?

• Have you witnessed a serious accident? (e.g. car accident, bus, bicycle accident, tree falling on s.o.)?

• Have you witnessed a serious accident? (e.g. car accident, bus, bicycle accident, tree falling on s.o.)?

Some questions related to War related violence

• Have you been close to a combat situation?• Have you been very close to a crossfire or shootings?• Have you been very close to burning houses?• Have you been very close to a bomb/grenade attack?• Have you experienced a dangerous flight?• Have you been raped?• Have you witnessed the killing or murder of someone?• Have you seen people with mutilations or dead bodies?

Family violence

• Have you ever witnessed somebody being physically assaulted (for example, being attacked, hit, slapped, kicked, beaten up, includes beatings with sticks) by a family member?

• Have you ever been physically assaulted eg, attacked, hit, slapped, kicked, beaten up, includes beatings with sticks)

• Have you ever been assaulted with a weapon (a stick, stone, knife) by a family member?

• Have you ever witnessed a sexual assault (someone tried to touch someone’s private parts against his/her will, someone was raped, made to perform any type of sexual act through force or threat of harm, e.g. „given as wife“) by a family member?

Family related violence questions continued.• Have you ever experienced a sexual assault (someone tried to touch

your private parts against your will, rape, made to perform any type of sexual act through force or threat of harm, e.g. „given as wife“) by a family member?

• Have you been threatened to be killed by a family member

• In addition, the most frightening event in this checklist, also required description that called for qualitative data.

PTSD Symptom severity

The symptoms severity of PTSD was determined using the PTSD Symptom Scale-Interview (PSS-I); Foa, Riggs, Dancu, & Rothbaum, 1993).

PSS-I is a semi-structured interview designed to assess current symptoms of PTSD. It assesses the 17 DSM-IV symptom criteria for PTSD basing on the most traumatic event.

Each of the items was answered on a 4-point scale ranging from 0 (not at all or only once) to 3 (five or more times per week or almost always). If a symptom was scored as 1 or above in the past month, the symptom was considered to be present in the respondent

Results• Using systematic sampling, 325 Congolese refugees who

arrived in Nakivale refugee settlement after 2012 were interviewed.

• Out of this number,182 were female and 143 were male participants with average mean age of 31.0 (SD = 8.7, ranging from 18 – 59 years.

Prevalence of different types of traumatic events

• Majority of the refugee’s endured extreme atrocities with nearly100% participants experiencing or witnessing most of the events.

• Almost all participants 324 (99%) experienced/witnessed war related events. for example (97.0%) Reported to have been close to gun fire or shootings.

• One twenty five participants (38.5%) reported to have been raped out of this number, 22(6.8) were men and 105 (31.7) were females.

Prevalence continued

• Three hundred and eighteen participants (97.9%) reported to have experienced or witnessed community related events ever in their life.

• Two hundred and thirty four participants (84.7%) reported to have experienced or witnessed community violence within the last four weeks prior to the interview.

• Three hundred and nineteen participants (98.2%) reported to have experienced family related violence ever in their life and 186 (57.7%) with in the past month respectively.

Correlation between different traumatic event types and PTSD Symptom severity.

• Natural events r=0.268,p<.001 • Community related violent events ever, r=0.570,p<.001• Family related violent events r=0.407, p=<.001• Number of traumatic event types, r =0.132, p=.018

Variables

PTSD Symptom Severity

t pB S E of B βStep 1 Sex in gender 4.968 1.321 .204 3.762 <.001 Time spent in the camp .071 .143 .026 .492 .623 Somatic complaints .275 .321 .047 .857 .392 Natural events 2.557 .589 .234 4.342 <.001Step 2 Sex in gender 4.464 1.121 .184 3.982 <.001 Time spent in a camp .127 .121 .047 1.054 .293 Somatic complaints -.015 .271 -.003 -.057 .955 Natural events -.354 .565 -.032 -.626 .532 War related ever 1.489 .165 .486 9.001 <.001 Community violence ever .297 .269 .065 1.103 .271

Family violence ever .582 .277 .120 2.099 .037

• The regression model with sex in gender, time spent in the camp, somatic complaints and natural traumatic events as control variables explained 13% of the variability of PTSD symptom severity,

• Adding number of war, family and community events improved the model significantly with 37% of the variability of PTD symptom severity. Sex in gender significant, war and family events positively correlated with PTSD symptom severity.

• The building block effect was replicated for only the number of war and family related traumatic events respectively.

• Its is possible to argue that repeated exposure to a number of traumatic events acts as a building block one after another to create a house of misery for soul.

• When we arrived here, we were allocated this village. Soon as we started building our houses, “nationals” chased us with machetes and spears, claiming we were digging their land” we also fought back and most of us were wounded and decided to relocate to Rwamwanja in Kamwengye.

• The Prime Minister’s office intervened and we now have some relative peace, however, I am still distressed, I am an elected leader of this community, one day an officer from the OPM asked me to lie down when we had a community meeting, “ He looks down and begins to cry” He gave me five lashes. All this was before my children, wife and all the people I lead. This was an act of humiliation for me and I have not yet overcome it, I felt like I was back in Congo.

• Participant 031

We were in the garden with my friends around 12:00 PM, rebels came and took three of us to the forest, they raped us, after a while, I never saw my friends again. I was raped every other time, sometimes gang raped, I got pregnant and delivered “this baby boy” when I look at him he reminds me of my time with the rebels for the whole year. I was later abandoned in the forest which led to my escape. In Nakivale, no one wants to associate with me, but I have tried hard to also get a man to be with since I could not build a house on my own and be in the garden alone. He too doesn’t like my child. Participant 016

It was around 3.00 am in the morning, I heard a knock on my door “my wife has been killed by the Congolese. This family was relatively new in the camp, the gentleman had come with two wives and now one of them was dead.

We called on the police and the camp commandant and as he was questioned further, we observed that together with his new wife were responsible for the death of this woman.

Later on we learnt that he had been fighting in the combat alongside M23. Chairman new Congo in Nakivale.

Stories from some of the participant • It was around 10 PM when the rebels broke into our house, asked us

for money and all that we had.• They forced me to have sex with my son, he refused and he was

threatened to be killed, they immediately put me down and forced him to have sex with me, my son agreed to their demands, and when he'd finished they killed him.

• They raped me in front of my husband after which they killed him and took away my daughter who I have not heard from since that time.

• In Nakivale, I asked someone to help me build a house, he refused

that I should first be his second wife, I agreed so that I can be accorded help.

• When we arrived here, we were allocated this village. Soon as we started building our houses, “nationals” chased us with machetes and spears, claiming we were digging their land” we also fought back and most of us were wounded and decided to relocate to Rwamwanja in Kamwengye.

• The Prime Minister’s office intervened and we now have some relative peace, however, I am still distressed, I am an elected leader of this community, one day an officer from the OPM asked me to lie down when we had a community meeting, “ He looks down and begins to cry” He gave me five lashes. All this was before my children, wife and all the people I lead. This was an act of humiliation for me and I have not yet overcome it, I felt like I was back in Congo.

• Participant 031

Discussion • By looking closely at the relative contribution of different

traumatic events and their association with PTSD symptomatology among the Congolese refugees, we found that both war and family related traumatic events positively correlated with PTSD symptom severity.

• Consistent with prior research (Neuner et al., 200; Annan, Brier & Aryemo, 2009; Ertl., 2011)., our results confirmed the building block effect in a sample of the Congolese refugees for only war and family violence.

• Repeated exposure to different types of traumatic experiences cumulatively heightens the risk for PTSD symptom severity.

Discussion continued

• Evidence from the current data indicates that the Congolese refugees investigated in the present study on average each experienced 35 number of traumatic events.

• Following Neuner et al. (2004) for this sample, PTSD rates between 50 and 60% would be expected. However, PTSD diagnosis in the current sample was not assessed. Therefore the prevalence could not be determined.

Discussion continued

• While exposure to the number of war related traumatic events remained the strongest predictor of PTSD symptoms severity within the current sample of the refugees, the results of this study reveal a significant relationship between exposure to family related traumatic events and PTSD symptoms even after controlling for other confounders.

• This implies that even amidst exposure to number of traumatic events of war, exposure to the number of family related events, maintains its association with PTSD symptom severity.

• This is supported by previous studies that have documented prevalence of high rates of domestic and family violence (UNHCR, IRBC, 2006, Olema et al 2014

Conclusions

The present study revealed high rates of exposure traumatic event types of war, community and family for both ever and current. Future studies should continue to look into the occurrences of community and family related traumatic events with in the refugee camps

• In line with replicating the building block effects, similar studies should be done among refugee communities to provide further evidence where interventions geared towards reduction of the prevalence of different traumatic events and PTSD symptom severity can be based.

• Refugees are exposed to life threatening events during periods of preflight and flight.

• Refugees are not immune from exposure to violence even after arriving in the refugee settlements. They continue experiencing more violence from the natives, their fellow refugees as well as their own family members. There is a likelihood of increased violence in the refugee settlements perpetuated by both the neighboring native communities and the refugees themselves.

• Therefore peaceful programs designed to settle conflicts between the refugees themselves as well as natives are recommended.

Recommendations continue

• Psychologists, social workers and human rights activists should advocate for such vulnerable communities and design therapeutic programs and Trauma focused cognitive therapy. This may encourage safety among the refugees and enhance cognitive re-structuring that is able to help the refugee communities.

• The same group can provide hope to the hopeless refugee communities as well as mediating between the refugees and international communities for the plight of these refugees.