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Original research
Correlates of post-traumatic stress disorder among adult residents of conflict-affected communities in Cross River State, Nigeria: a cross-sectional study
  1. Theresa Mark Awa1,
  2. Ugbe Maurice-Joel Ugbe1,2,
  3. Obiageli Chiezey Onwusaka1,2,
  4. Eucheria Ekugeni Abua1,
  5. Ekpereonne Babatunde Esu1,2
  1. 1Department of Public Health, University of Calabar, Calabar, Nigeria
  2. 2Centre of Excellence for Research and Training in Human Resources for Health, University of Calabar, Calabar, Nigeria
  1. Correspondence to Dr Ugbe Maurice-Joel Ugbe; mauricejoelph{at}unical.edu.ng

Abstract

Background Conflict-affected communities in Nigeria experience a range of problems. These experiences have been associated with different types of mental disorders, most notably, post-traumatic stress disorder (PTSD).

Aim This study sought to assess PTSD and its associated factors among adults in conflict-affected communities in Odukpani Local Government Area (LGA), Cross River State, Nigeria.

Methods A cross-sectional study was conducted using non-probability and probability sampling techniques. The sample size for this study was 486 conflict-affected adults. The symptoms of PTSD were assessed using the Harvard Trauma Questionnaire and a semistructured questionnaire was employed to collect data on sociodemographic and trauma-related characteristics. Data were analysed using descriptive statistics, χ2 and multivariable logistic regression.

Results The prevalence of PTSD in conflict-affected communities in Odukpani LGA, Cross River State, Nigeria was 73.9%. The multivariate analysis revealed that higher educational attainment (AOR 5.66; p<0.001; 95% CI 2.37 to 13.54), family size >4 (AOR 1.72; p=0.03; 95% CI 1.06 to 2.77), discrimination because of present status (AOR 1.96; p=0.03; 95% CI 1.26 to 3.06) and family history of mental illnesses (AOR 2.08; p=0.002; 95% CI 1.31 to 3.31) showed statistically significant relationships with PTSD in the study population.

Conclusion A multisectoral approach for creating and routinely arranging mental health interventions and aid programmes aimed at improving social outcomes such as employment, living conditions and social networks for conflict-affected communities is recommended.

  • mental health
  • epidemiology
  • public health

Data availability statement

Data are available on reasonable request.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • By considering a wide range of factors associated with post-traumatic stress disorder (PTSD), including individual, interpersonal and contextual elements, this study provides a holistic understanding of the issue, which can inform both research and practice.

  • The collection of empirical data strengthens the credibility and validity of the findings, enhancing the relevance of the study.

  • A major limitation encompasses the fact that assessing PTSD and associated factors often relies on self-reported measures, which may be subject to response biases.

  • Also, because this is a cross-sectional design, we are limited in establishing causal relationships between variables.

Introduction

Anxiety disorders such as post-traumatic stress disorder (PTSD) are characterised by a syndrome that appears after a person witnesses, participates in, or learns about a severe traumatic stressor. The symptoms of this condition usually occur not less than 1 month after the stressful events have occurred.1 The individual experiences anxiety and powerlessness in response to this, repeatedly imagines what happened and attempts to forget about it.2 According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the psychological condition, PTSD, is characterised by intrusive thoughts, avoidance behaviours, changes in mood and cognition, and hyperarousal/alterations in arousal and reactivity.3 For a clinical diagnosis of PTSD to be made, these symptoms must persist for longer than 1 month.2 Witnessing a close relative suffer a catastrophic injury, illness, or assault, or losing a parent, child, or spouse are examples of traumatic stressors. Other examples include witnessing or being exposed to awful occurrences like murder, threats, kidnapping, losing one’s home and starving. PTSD is a documented major public health concern for a population affected by armed conflict because war and armed conflict increase poverty, unemployment, community violence, unstable living conditions and changes in social dynamics.4 PTSD can co-occur with other mental health disorders, such as depression and anxiety.4

An estimated 354 million adult combat veterans worldwide suffer from PTSD and/or serious depression.5 Nearly 4% of the world’s population is thought to be affected by PTSD, which contributes significantly to the burden of disease on the planet.6 This can be inferred from the fact that studies have found that 70% of adults experience at least one traumatic event in their lifetime and 20% of people who experience a traumatic event will develop PTSD.7 8 According to Koenen et al6 in 50% of cases, PTSD lasts longer than a year and frequently results in significant impairments in functioning and production. disputes between communities over land or natural resources including oil deposits, solid minerals and water are the main causes of communal disputes in Nigeria.9 Conflicts can also develop when communities attempt to protect their honour, assets or members against the encroachment of other communities. Conflicts in Nigeria have caused the afflicted populace to lose loved ones, be uprooted, and suffer sexual assaults, injuries, and impairments, among other things.4 10 The most commonly reported conflict zones in Nigeria are the northeast, north-central and northwest geopolitical zones.11 Most recently, various factors including political unrest and secessionist protests have led to violence, killings and destruction of human lives and properties in the Southern zone of the country. A recent study4 in Ogoja, in the southern part of Nigeria, found high prevalence rates of anxiety and depression among internally displaced persons who were affected by conflicts. The United Nations High Commisioner for Refugees (UNHCR) also noted the unfavourable increase in household vulnerability in conflict-affected areas in all regions in Nigeria, as the vulnerability screening identified over 32 000 vulnerable families and over 36 000 vulnerable individuals; of these, 18.68%, 33.28% and 48.66% were identified as orphans, women-headed households and senior households, respectively.12

There is a dearth of mental health research among the people of Odukpani who have constantly experienced reoccurring intercommunal conflicts. Accordingly, this study was essential to add to existing studies of the plights of conflict-affected populations in Nigeria. The study engaged in a full-scale assessment of PTSD and sought to identify key predictors of this disorder among war-affected adults in Odukpani in line with theoretical assumptions. It is essential to note the widely acknowledged risk factors for PTSD in conflict-affected populations, including exposure to trauma, displacement, loss of loved ones and ongoing stressors associated with conflict.13 These factors have been extensively documented and serve as a foundational framework for understanding PTSD in such contexts.

Building on this foundation, our theoretical presumptions stem from a socioecological perspective, which emphasises the interplay between individual, interpersonal and contextual factors in shaping mental health outcomes.14 In conflict settings, this perspective suggests that not only direct exposure to violence but also broader sociocultural, economic and political factors influence the prevalence and severity of PTSD symptoms.15 Furthermore, research has highlighted the significance of social support networks, coping strategies and access to mental health services as protective factors against PTSD.15 Conversely, stigma surrounding mental health, limited resources and disruptions in community cohesion may exacerbate PTSD symptoms.16

This study aims to synthesise these findings and provide a comprehensive understanding of the factors contributing to PTSD in conflict-affected settings. By elucidating the complex interplay between individual experiences, social dynamics and structural factors, we strive to offer insights that can inform both research and interventions aimed at addressing PTSD in these contexts. This is timely because it offers the government and other humanitarian agencies relevant information to carry out a broad relief intervention for such communities. This, however, puts Odukpani on the humanitarian landscape. Operationally, two hypotheses were formulated to guide the study:

  1. Trauma-related factors do not statistically significantly predict the prevalence of PTSD among adults in conflict-affected communities in Odukpani Local Government Area (LGA), Cross River State, Nigeria.

  2. Sociodemographic factors do not statistically significantly predict the onset of PTSD among adults in conflict-affected communities in Odukpani LGA, Cross River State, Nigeria.

Methodology

Scope of the study

This study aimed to explore correlates of PTSD among conflict-affected adults 18 years or older in Odukpani LGA of Cross River State. The data for this research were collected only from indigenes of Odukpani who resided in the affected communities.

Study design

This cross-sectional descriptive study used a quantitative approach to determine the prevalence and associated factors of PTSD among adults in conflict-affected settings in Odukpani LGA of Cross River State.

Study population

Adults (18 years and above) who are living in conflict-affected communities (Odukpani Central, Ekori/Anaku, Ikoneto, Ediong/Obomitiat/Mbiabo, etc in Odukpani LGA, Cross River State) will be considered as the study population.

Sample size determination

Embedded Image

where; n=desired sample size.

Z=1.96 (95% CI).

p=24.7% (0.247) previous proportion of PTSD among adults of conflict-affected communities in south-east Nigeria (Onyebueke, Okwaraji, & Obiechina, 2018).

q=probability of the event not occurring, that is, (1−P)=0.753.

d=acceptable margin of error for proportion being estimated=4% (0.04).

Therefore;

Embedded Image

n=446.

However, to account for a non-response rate of 10%, the sample size was increased by 10%

Embedded Image

The final sample size was rounded up to 500. This implies that 500 adults aged 18 years and above from the study population were randomly selected for the study.

Sampling procedure

Multistaged sampling procedure was employed in the selection of study participants with the following procedures:

Stage 1: selection of wards

The study setting has 13 wards; purposive sampling was used to select all 4 wards majorly housing conflict communities in Odukpani.

Stage 2: selection of communities

Odukpani Central ward consists of eight communities; Ekori/Anaku ward consists of eight communities, Ikoneto ward is made up of seven communities while Ediong/Obomitiat/Mbiabo has six major communities. Purposive sampling was used to select all 29 communities of the 4 wards.

Stage 3: selection of households

A systematic random sampling technique was used to select 17 households each from the (29 communities (500/29=17). This was done using the fixed interval and a random starting point to select households from the 29 communities. The households in each community were counted and assigned numbers. At the end of the counting, 17 households each were sampled from the 29 selected communities in the study area. The interval was determined by dividing the total number of households in each community by the desired households to be sampled per community.

Stage 4: selection of respondents

From each selected household, only one adult within the age bracket of 18 years and above who consents to participate in the study was recruited. In households where there is more than one such targeted population, a simple random sampling technique by balloting without replacement was used to select one respondent.

Instruments for data collection

A semistructured questionnaire was used to collect information on the sociodemographic characteristics of respondents and factors associated with PTSD in the study setting between 15 June and 17 July 2023. Harvard Trauma Questionnaire (HTQ-5 DSM-5) which has been identified by Berthold et al,17 to have demonstrated higher diagnostic accuracy than other instruments and excellent external validity for use as a diagnostic aid is a 25-item questionnaire that covers symptoms and signs generally associated with PTSD. The HTQ is the most widely used screening measure for trauma-related symptoms in clinical and research work for people in conflict settings and among refugees worldwide. Each question on the HTQ is rated on a 4-point Likert scale of distress with responses ranging from ‘not at all’ to ‘extremely’.1–4 17

Method of data collection

Data were collected with the aid of research assistants, who were medical and health professionals due to the nature of this research. A semistructured questionnaire was also used. Section A contained the sociodemographic/socioeconomic characteristics; section B contained the 25-item HTQ to identify the diagnostic symptoms of PTSD and section C contained questions on trauma-related factors of PTSD. Using the Open Data Kit (ODK) data collection software, the aforementioned questionnaire was administered by an interviewer. To teach research assistants how to use the programme and submit the data once it has been collected, ODK training was conducted. For data gathering and processing, ODK is a portable data-collecting tool that may be connected to an electronic database. The required linkage with ODK collect was made using the internet database known as Kobo toolbox.

Method of data analysis

Data were downloaded into Microsoft Excel after being extracted from the Kobo toolbox. Using Microsoft Excel, all data were cleaned, inputted and reviewed for accuracy. V.23 of the SPSS was used to transfer and analyse the data. The HTQ convenient scoring template was used to assess 486 respondents. A total score of >2.0 on the HTQ depicts that respondents were symptomatic for PTSD in the community setting with a sensitivity of 78% and specificity of 65%.17

The sociodemographic characteristics of respondents and factors associated with PTSD were analysed using descriptive statistics (frequencies and percentages). Descriptive statistics were also used to determine the general prevalence of PTSD and examine the distribution of specific symptoms of PTSD. Pearson’s χ2 of independence was used to test bivariate association in the outcome (PTSD) across sociodemographic characteristics. Multivariate logistic regression analysis was used to estimate the odds of developing the outcome (PTSD) with trauma-related factors while controlling for statistically significant sociodemographic characteristics. The elements connected to PTSD were predetermined based on data from the literature that has already been published and our theoretical presumptions that these aspects will be pertinent in researching PTSD in the target demographic. Other life stressors not included in the model such as general health status and individuals’ general quality of life would be subject to further research. To reduce the likely danger of overadjusting without compromising the identification of the predictors for the outcome, only components that were linked with the outcome of interest in the χ2 procedures were included in the equivalent multivariate method. ORs were used to determine the strength of association in the model. The significance threshold was set at α=0.05.

Patient and public involvement

None.

Results

The sociodemographic characteristics of the respondents are presented in table 1. A total of 486 respondents (accounting for a 97% response rate) out of the total sample size of 500 consented to participate in this study and they were interviewed (figure 1). Slightly over half of the respondents (53.3%) were females. The mean age of participants was 36.95 years±11.3 (with a range of 18–59). Most respondents (36.4%) aged between 31 and 45 years while older adults aged 45 and above made up the least number of respondents (27.6%). Most respondents identified themselves as being married (49.6%) or single (31.5%). Most of the respondents had attained either secondary (37.2%) or tertiary education (33.1%). In terms of occupation, the majority of the respondents were predominantly business owners (34.4%) and farmers (27.8%) while 20.4% were public servants.

Figure 1

Flow diagram for the study on correlates of PTSD among conflict-affected adults in Odukpani Local Government Area, Cross River State Nigeria. PTSD, post-traumatic stress disorder.

Table 1

Sociodemographic characteristics of respondents

Most of the respondents (50.4%) had less than four members living in the same household. Among the income earners, almost half of the respondents (49.9%) earned below minimum wage (₦1 and ₦29 999), and a quarter of respondents (23.8%) earned no monthly income.

The study, however, found that there were 359 respondents (73.9%) who were positive for PTSD symptoms in the study area.

Table 2 indicates the distribution of χ2 p values to establish the relationship between conflict-related factors and PTSD. The conflict-related factors significantly associated with PTSD in the study population include loss of loved ones due to crises, χ2=9.48, df=1, p=0.04; discrimination, χ2=11.6, df=1, p=0.001; family member suffering from a mental illness or has had a family history of mental illness, χ2=3.67, df=1, p=0.04 and financial strain, χ2=14.0, df=1, p<0.001. In each of the above scenarios, we, however, reject the null hypothesis of no statistically significant relationship between conflict-related factors and PTSD in the study population.

Table 2

Association between trauma-related factors and PTSD

Table 3 presents the relationship between sociodemographic characteristics and PTSD. There is a statistically significant relationship between respondents’ level of education and PTSD, χ2=28.8, df=3, p<0.001. There is also a statistically significant relationship between the family size of respondents and PTSD, χ2=5.14, df=1, p=0.023. Furthermore, the χ2 analysis showed that there is a statistically significant relationship between monthly individual income and positive PTSD diagnosis, χ2=7.12, df=3, p=0.045.

Table 3

Association between sociodemographic characteristics and PTSD

Table 4 shows the multivariate logistic regression analysis of the conflict-related factors and sociodemographic characteristics of PTSD after adjusting for all potential covariates that were found significant in the bivariate χ2 analysis. However, regardless of their significant status for each of the outcome variables, age and sex were included in the multivariate model due to their biological relevance. Tertiary educational attainment was a positive and significant correlate of PTSD in the study population, b=1.73, p<0.001, AOR 5.66 (95% CI 2.37 to 13.54). This implies that conflict-affected persons who had attained tertiary education were 5.66 times more likely to develop PTSD in the study area. Family size also showed a positive and significant relationship with PTSD in the study population, b=0.54, p=0.03, AOR 1.72 (95% CI 1.06 to 2.77). In other words, conflict-affected persons residing in households with a greater number of persons (four and above) in the study area were 1.72 times more likely to develop PTSD. Discrimination because of present status showed a positive and significant relationship with the development of PTSD, b=0.67, p=0.03, AOR 1.96 (95% CI 1.26 to 3.06). Hence, those who were discriminated against because of their living status were almost two times more likely to develop PTSD in the study population. Lastly, a family history of mental illnesses showed a positive and significant relationship with PTSD, b=0.73, p=0.002, AOR 2.08 (95% CI 1.31 to 3.31) meaning that those who have lived or are living with persons with mental illness were over two times more likely to develop PTSD.

Table 4

Multivariate analysis of conflict-related factors, sociodemographic characteristics and PTSD

Discussion

Overall, the results of this present study show a high prevalence of PTSD in the study population. We found a 73.9% prevalence of PTSD, which is similar to the rates reported among conflict-affected communities and victims of armed conflicts in Nigeria and other African countries. In Nigeria for instance, Taru et al18 and Tagurum et al19 found a 63.7% and 46.1% prevalence of PTSD, respectively, among total samples of victims of Boko-haram terrorism and victims exposed to ethnoreligious conflict/armed-conflict in North-Central and North-eastern Nigeria. This high prevalence is also reflected among internally displaced victims of war in Northern Uganda (54%).20 Thus, our findings, as well as previous findings in Nigeria and other studies suggest that exposure to traumatic events is associated with an increased prevalence of PTSD. The prevalence of PTSD in the current study was also higher compared with studies carried out by Sheikh et al21 in Nigeria with a PTSD prevalence of 42%; Georgia with 23.3%,22 Iraq with 20.8%23 and Central Sudan with 12.3% prevalence.24 These disparities in prevalence among the various studies may be influenced by variations in methodology, standard instruments employed and cases under research. Additionally, this difference might have been influenced by the use of various study samples. However, it is important to stress the difficulty in comparing research of various populations exposed to armed conflict because of the heterogeneity in parameters including the degree of trauma exposure, the amount of time between exposure and diagnosis, other methodological distinctions and cultural considerations. For instance, we reasoned that the higher prevalence of PTSD in our study and that of Kenya in comparison to earlier surveys in Nigeria, Uganda and South Sudan may be attributed to the variations in the population studied as well as the higher level of trauma in the various home countries at various times. Research examining the prevalence and risk factors associated with PTSD suggests that it is associated with a range of sociodemographic characteristics.25

Discrimination because of present status, loss of loved ones, a family member suffering from mental illness and financial strain were the most reported trauma-related factors significantly associated with being symptomatic of PTSD in this population. The finding on the death of a family member is consistent with the study26 which found that sudden death of a loved one is significantly associated with the development of PTSD, particularly if the loss was tragic and unexpected. Similarly, a previous study27 on war-related PTSD documented the following as some of the common risk factors: the number of negative life exposure to a traumatic event, absence of basic social goods and services such as food, having a family history of mental illness and type of traumatic event, among other factors. However, no previous studies have established a relationship between discrimination and PTSD specifically as a mental health condition in postconflict settings. Discrimination and unfair treatment can cause PTSD symptoms in many different ways, especially for Africans. Discrimination may act as a persistent stressor that can cause unpleasant emotional states, unhealthy behaviours, the depletion of protective psychological resources and an exaggerated stress response, according to certain theories. There is some scientific support for the idea that PTSD symptoms are linked to unfair treatment in specific marginalised and minority populations, like those in disadvantaged communities who have lost their means of livelihood. There is proof, for instance, that discrimination based on socioeconomic status, can lead to undesirable mental effects.28

Respondents’ sex, age, marital status, level of education, monthly income and family size were factored into this present study to test for the relationship with the outcome. The multivariate analysis revealed that females were more likely than males to develop this condition. This is consistent with a study29 which found that females were 2.4 times more likely to have PTSD compared with males. Birkeland et al30 also identified more female participants suffering from PTSD symptoms than their male counterparts. Similarly, a study by Shalev et al31 found PTSD to be more commonly reported among women. This might be as a result of women’s poorer tolerance for exposure to psychotrauma than men do. Indirect psychological effects of rape or sexual abuse, the violent death of a partner, children and becoming a single parent or widow are other potential causes.32 33 Another factor might be that females react to stress more emotionally and ruminatively than males do.

In the multivariate analysis, tertiary educational attainment was also found to be significantly associated with symptoms/development of PTSD. This may be because respondents who had attained tertiary education were the working population and so when there is communal conflict, there is a disruption in their means of livelihood. In this present study, although financial strain was not found to be a statistically significant predictor of PTSD prevalence, respondents who were strained financially were 1.51 times more likely to experience PTSD. This contradicts a finding by Tang et al34 which found that Individuals with higher education levels were less likely to experience/develop PTSD. Low socioeconomic status generally plays a major role in the development and persistence of PTSD symptoms. This could be because victims of communal conflicts lack the recourses to cushion the various effects of trauma and therefore continue to face daily stressors like overcrowding, diseases outbreak, famine and rape among other vulnerabilities. Higher family size was a significant predictor of PTSD. However, no previous studies have been found to establish the relationship between PTSD and family size. A possible reason for our finding may be the effects of intrahousehold conflicts as well as the pressure to cater to larger numbers of family members despite the difficult economic realities.

Limitations

Due to the likelihood of responder bias in a cross-sectional study, it is important to interpret predictors of the study’s outcomes cautiously. Although recall bias might have occurred given that the study was conducted a few years after the conflict, the psychological issues the displaced people were dealing with made it easy for them to recall their experiences with ease. Other variables that have not been considered in the model could confound this study’s findings. However, future research should address this limitation.

Implications

Implementing wide public health measures will require a collaborative effort from all socioecological niches to address the pervasive consequences of mental health issues among Internally Displaced Persons (IDPs). To ensure that the responders’ welfare is given first attention while also ensuring that other community members stop inflicting hostility on these vulnerable groups, reintegration efforts and promoting tolerance are required.

Conclusion

The study found that adults living in conflict-affected areas of Odukpani LGA, Cross River State, had a prevalence of PTSD of 73.9%. The results imply that the high frequency of PTSD symptoms in the research population may be linked to numerous trauma caused by interpersonal conflicts and negative life experiences. In other words, according to the data, rates of PTSD symptoms are much higher than they were in earlier research conducted globally. Conflicts have a heavy psychological toll, which is likely related to the lack of political will that has prevented the most vulnerable populations from getting the necessary mental healthcare.

However, the results of this study have important implications for those who are impacted by armed violence. The implications of the findings underscore the complex aetiology of PTSD. According to epidemiological data, the burden on mental health is greater in conflict-affected and post-conflict-affected regions of the world than it is in non-conflict-affected places. This covers regions that have seen ethnic conflict and targeted violence as a result of civil upheaval and political unrest.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involved human participants and was approved by the Department of Public Health, University of Calabar, Calabar, who sent an introduction letter to the Ministry of Health. The Cross River State Research Ethics Committee, Ministry of Health Headquarters, Calabar, was contacted through the letter to acquire their ethical consent (CRS/MH/HREC/2021/VOL.V/216). Additionally, advocacy visits were made to community leaders in the host villages to inform them of the goals, importance and advantages of the study and to reassure them of the confidentiality and anonymity of the respondents’ information. Participants received guarantees of complete secrecy about their information. They were also told that they might choose not to be recruited at any time and that they were not required to do so. Participants gave informed consent to participate in the study before taking part.

References

Footnotes

  • Contributors TMA conceived the study and was involved in all the development and conclusive processes. UM-JU completed the analysis. OO developed the manuscript, EEA and EE reviewed all the contents of the manuscript. UM-JU is the guarantor and accepts full responsibilty for the work, had access to the data, and controlled the decision to publish.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.