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

doi:10.21203/rs.3.rs-3319331/v1

Background

Post-traumatic stress disorder places an enormous burden on conflict-affected society. People in conflict-affected areas have higher rates of mental disorders, in particular post-traumatic stress disorder, than those usually found in the non-conflict-affected general population. There is scarce evidence in Ethiopia regarding post-traumatic stress disorder in residents of conflict-affected areas. Therefore, the aim of this study is to assess the prevalence and associated factors of Post-Traumatic Stress Disorder among people in a post-conflict area, North Shoa, Ethiopia.

Methods

A community-based cross-sectional study design was employed from May 24-June 24, 2022, in the North Shoa Zone, Amhara, Ethiopia. The Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used to measure the symptoms of Post-Traumatic Stress Disorder, and the data was collected by direct interview. All collected data were entered into Epi Data version 4.6 and analyzed with SPSS version 25. Bivariable and multivariable regression models were used to determine the factors associated with Post-traumatic stress disorder symptoms. A p-value of less than 0.05 was considered statistically significant.

Result

A total of 830 participants were interviewed with a response rate of 96%. The estimated prevalence of Post-Traumatic Stress Disorder was found to be 63% (95% CI 60–66%). In the multivariable logistic regression, being female (AOR = 4.2, 95% CI (2.82, 6.27)), being unable to read and write (AOR = 3.08, 95% CI (1.67, 5.69)), witnessing the murder of loved ones (AOR = 3.28, 95% CI (1.58, 6.79)), witnessing the murder of strangers (AOR = 2.04, 95% CI (1.33, 3.11)), being verbally threatened or insulted (AOR = 4.09, 95% CI (2.69, 6.21)). Having poor and moderate social support (AOR = 5.26, 95% CI (3.35, 8.28)), (AOR = 1.89, 95% CI (1.15, 3.13)), respectively, was significantly associated with Post-Traumatic Stress Disorder.

Conclusion

More than half of the dwellers living in conflict-affected areas experienced post-traumatic stress disorder. Treating and using coping mechanisms regarding identified factors is a way to minimize the burden of post-traumatic stress disorder.

Post-traumatic stress disorder

traumatic events

post-conflict areas

Ethiopia

Post-traumatic stress disorder (PTSD) is one of the mental illnesses that can arise from exposure to a traumatic or stressful event in which the individual, witnessing the experience, faces actual or imagined loss of life or trauma that leads to a reaction of fear, helplessness, or terror. ^(1–3)

It occurs within a month of the event and can linger for months or years. Gender, IQ, family history, multiple neurobiological factors, type and duration of trauma exposure, coping mechanisms, and cognitive flexibility are potential risk factors for PTSD. ^{(1, 4)}

A traumatic events causes different mental and physical health consequences,⁽⁵⁾ especially PTSD.⁽⁶⁾

Post-traumatic stress disorder are among the leading contributors to the global disease burden, as researchers found that the lifetime prevalence of PTSD is 15.8–37.4% in post- conflict nations, in which PTSD affects between 1% and 5% of the general population.^{(7, 8)}

Its severity is linked to major repercussions such as decreased quality of life, increased usage of medical and social services, and impairments in work. ^{(9, 10)} It also has serious biological, psychological, behavioral, and social consequences that lead to substantial functional impairment.⁽⁷⁾ Across a conflict history spanning 1989 to 2019 (nearly entirely comprised of low and middle-income countries) (LMICs), a total of 3 million disability-adjusted life years were linked to PTSD, in conflict-affected areas.⁽⁷⁾

A study on Israelis aged 18 years and above and exposed to terrorism showed that the average prevalence of PTSD was 9.4%, 16.2% for women and 2.4% for men. ⁽¹¹⁾ In a population-based cross-sectional; post-conflict region of India's Kashmir Valley, the prevalence of PTSD was 19%.⁽¹²⁾ A cross-sectional study done among 558 randomly selected households among Albanians living in conflict-affected areas found that 17.1% reported symptoms of PTSD. ⁽¹³⁾ A study in Afghanistan revealed that post-conflict PTSD prevalence was 42.2%.⁽¹⁴⁾. A community-based cross-sectional study among Palestinians who have been subjected to political violence and unrest for a long time in the West Bank, Gaza, and East Jerusalem PTSD is estimated at 49.28%, 46.5%, and 35.8%, respectively, out of 1,196 study participants. ⁽¹⁵⁾

In a community-based cross-sectional study that was conducted in South Ethiopia after the civil conflict among 636 participants, the estimated prevalence of PTSD was 58.4%. ⁽³⁾

The burden of PTSD is poorly understood in post-conflict areas, particularly in Ethiopia. According to my knowledge and extensive search, no published studies have been conducted in the study area. Previous studies have been done on internally displaced persons (IDPs) and refugees who are in camps but not at the community level, but the current study was done at the community level by including comprehensive variables. The results of this study will help healthcare providers to promote evidence-based mental health care in the region. On the other hand, it also provides a good way for policy makers to help those suffering from the problem and develop mental health strategies that can raise great concerns for government agencies. It also served as a basis for further research in this area.

Study design and setting

A community-based cross-sectional study was conducted in the North Shoa Administrative Zone conflict-affected areas, Amhara National Regional State, Ethiopia from May 24-June 24, 2022. The North Shoa Zone is one of the Amhara regional state administrative zones where its head office is located in Debre Birhan, which is located 130 km north-east of Addis Ababa (the capital city of Ethiopia) and 682 km from the capital city of Amhara regional state, Bahir Dar. The total population of North Shoa estimated from the CSA 2007 projected in 2014 is 2,370,488. In the study area a mental health service delivered in the outpatient departments (OPDs) level for the community, with the exception of Debere Sina Hospital.

Study participants

The source population was all people who reside in conflict-affected areas of the North Shoa Zone, Amhara region, Ethiopia, whereas the study population was all people who were living in the selected districts of conflict-affected areas and available during the data collection time, North Shoa Zone, Amhara region, Ethiopia.

Inclusion criteria

All individuals who have permanently resided in the conflict-affected region for more than 6 months and age older than 18 years.

Exclusion criteria

Those who were not there at the time of conflict, those who were severely ill or had difficulty of communicating, and those who have been previously diagnosed as PTSD and on anxiolytic treatment.

Sample size determination and sampling technique

In this study, double population proportion formula using Epi Info version 7 was used to compute the sample size by bearing in mind the following assumptions: 95% confidence level, the margin of error of 5%, the % of outcome in exposed group (P1 = 62.3%) and % of outcome in unexposed group (P2 = 50.2%), the design effect of 1.5. Therefore, the overall sample size is N = 524. When we add 10% non-response, the working sample size is N = 865.

Data collection procedures

Data was collected by face-to-face interviews using structured questionnaire by four BSc nurses and was supervised by two psychiatric nurses. The questionnaire was designed in English and translated to Amharic and back to English to maintain consistency. Data collectors were trained on how to interview participants and explain unclear questions and the purpose of the study. Furthermore, they were aware of ethical principles, such as confidentiality /anonymity/ data management, and how to secure respondents’ informed consent for participation.

Measurements

PTSD was measured using the DSM5 (PCL5) post-traumatic stress disorder checklist. PCL5 is a standardized self-assessment tool and scale for assessing 20 DSM5 symptoms of PTSD. The total score is calculated by summing 20 items, and the possible scores range from 0 to 80 on the Likert scale of 5 points (0 = Not at all, 1 = A little bit, 2 = moderately, 3 = Quite a bit, 4 = extremely) with a cutoff point of ≥ 33. Validity and reliability of the PCL-5 had been tested and proven on displaced people and refugees in a number of countries and this tool was used on the study done in Ethiopia.^{(3, 16)} Reliability coefficient Cronbach’s α in this study for the DSM5 (PCL5) was 0.90 showing an excellent internal consistency of the items.

Social support was measured using the Oslo3 social support scale, which ranges from 3 to 14. Respondents with a score of 3–8 were considered to have poor social support, scores 9–11 were considered moderate social support, and scores 12–14 were considered strong social support. ⁽¹⁷⁾

An individual's stress level was measured using the Perceived Stress Scale (PSS-10). The questions on this scale asked about feelings and thoughts of last month. PSS was measured with a Likert type scale ranging from (0) "never" to (4) "very often". The four positively stated items (item 4, 5, 7, and 8) were reversed (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0) and then summed across all scale items. Individuals with a score of "0–13" were considered to have low perceived stress, "14–26" moderate perceived stress, and "27–40" higher perceived stress.⁽¹⁸⁾

To examine substance use history, respondents were asked: ‘Have you ever used any substance in the last three months or in your lifetime?’ and the responses were yes or no.

Socio-demographic, clinical, trauma event related, and medical-related factors were derived from a variety of relevant literature and used in questionnaires with "yes/no" answers that are adapted accordingly.

Data processing and Analysis

The data was thoroughly cleaned before entry. Then it was entered into Epi-data version 4.6 and analyzed by the statistical package for social sciences (SPSS) version 25. A bivariable and multivariable logistic regression analysis was used to see the significant association between the outcome and the independent variable/s. chi-square test was done. The model fitness was tested by the Hosmer and Lemshow test (0.30), and the model fitted for PTSD. The variance inflation factor (VIF) was < 3 for PTSD, which shows that there was no multicolinearity between the independent variables. Independent variables with a P value of less than 0.25 in the bivariable analysis and those considered important based on literature were entered into the multivariable analysis. In the final model, a significant association was declared at p < 0.05. The results were presented in text and tables with the adjusted odds ratio (AOR) and the corresponding 95% confidence interval, and also with figures.

Ethical consideration

The study was conducted after ethical clearance was obtained from the Institutional Review Board (IRB) of Debre Birhan University, Asrat Woldeys Health Sciences Campus. In this study the ethical approval was performed in accordance with relevant guidelines and declaration of Helsinki. A participant's written informed consent was taken regarding their willingness to participate in the study and even after starting the interview those who wanted to discontinue the interview had the permission to leave out from the participation. Participants that were found to be at risk of PTSD were referred for psychiatric evaluation in the psychiatric unit of the nearby hospital/clinic.

Socio-demographic characteristics of participants

A total of 830 participants were included in the study, with a response rate of 96%.The median age of the respondents was 34, with interquartile range of 29 – 44 years. Of the total study participants, 443 (53.4%) were female, and one-fifth of the respondents 171 (20.6%) were unable to read and write (see Table 1).

Table 1: Description of Socio-demographic characteristics of the respondents among conflict affected areas of North Shoa, Ethiopia, 2022 (n=830)

Note: Others *, Retired and private work

Clinical related factors of the study participants

Of 830 respondents, 184 (22.2%) had no access to health services. More than one-fifth of the study participants, 187 (22.5%), have a family member with a mental illness (see Table 2).

Table 2: Description of clinical related factors of the respondents among conflict-affected areas of North Shoa, Ethiopia, 2022 (n=830)

Variable

Category

Frequency

percentage

Previous Diagnosed mental illness

Yes

No

12

818

1.4%

98.6%

Diagnosed family mental illness

Yes

No

187

643

22.5%

77.5%

Co- morbid medical illness

Yes

No

109

721

13.1%

86.9%

Health service access for any illness

Yes

No

646

184

77.8%

22.2%

Psychosocial related factors of the respondents

With regard to the psychosocial characteristics of the respondents, around half of the participants 425(51.2%) have poor social support. Of the total study participants, more than two-in-five 375(45.2%) reported high perceived stress (see Table 3).

Table 3: Description of psychosocial related factors of the respondents among conflict-affected areas of North Shoa, Ethiopia, 2022 (n=830)

Variable

Category

Frequency

percentage

Social support

Poor

Moderate

Strong

425

207

198

51.2%

24.9%

23.9%

Perceived stress

Low

Moderate

High

153

302

375

18.4%

36.4%

45.2%

Food & water support

Yes

No

617

213

74.3%

25.7%

Immediate help when needed

Yes

No

340

490

41.0%

59.0%

Displacement

Yes

No

337

493

40.6%

59.4%

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 (see Figure 1).

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 (see Table 4).

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

Types of traumatic events	Frequency	Percentage
Destruction of personal property	279	33.6%
Lack of housing and shelter	253	30.5%
Lack of food and water in the living area	282	34.0%
Witness murder of loved ones	88	10.6%
Witness murder of significant others	294	35.4%
Witness murder of strangers	363	43.7%
Ill health without medical care	156	18.8%
Forcefully isolated from community	282	34.0%
Made to accept ideas against will	148	17.8%
Imprisoned against will	70	8.4%
Being in a war fighting situation	160	19.3%
Being abducted or kidnapped	34	4.1%
Sexually abused or raped	31	3.7%
Physically abused	146	17.6%
Verbally threatened or insulted	611	73.6%
Forcefully separated from family	312	37.6%
Serious injury	241	29.0%
Past childhood physical abuse or neglected	68	8.2%

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)) (see 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)

Explanatory variables	PTSD	COR (95% CI)	AOR (95% CI)
	Yes No
Sex
Female	336 107	3.35 (2.50 – 4.51)	4.2 (2.82 – 6.27)***
Male	187 200	1	1
Educational status
Unable to read and write	142 29	4.84 (2.94 – 7.95)	3.08 (1.67 – 5.69)***
Able to read and write	177 101	1.73 (1.18 – 2.54)	1.13 (0.69 – 1.85)
Primary education	59 43	1.35 (0.83 – 2.21)	0.88 (0.47 – 1.63)
Secondary education	56 46	1.20 (0.73 – 1.96)	1.14 (0.61 – 2.12)
College and above	89 88	1	1
Witnessed murder of loved ones
yes	76 12	4.2 (2.23 – 7.82)	3.28 (1.58 – 6.79)**
No	447 295	1	1
Destruction of personal property
Yes	213 66	2.50 (1.81 – 3.46)	1.15 (0.62 – 2.15)
No	310 241	1	1
Being in a war fighting situation
Yes	114 46	1.58 (1.08 – 2.30)	1.00 (0.59 – 1.70)
No	409 261	1	1
Witnessed murder of strangers
Yes	277 86	2.89 (2.13 – 3.91)	2.04 (1.33 – 3.11)**
No	246 221	1	1
Lack of housing or shelter
Yes	194 59	2.47 (1.77 – 3.46 )	1.72 (0.92 – 3.21)
No	329 248	1	1
Verbally threated or insulted
Yes	448 163	5.27 (3.78 – 7.35)	4.09 (2.69 – 6.21)***
No	75 144	1	1
Family member with mental illness
Yes	136 51	1.76 (1.23 – 2.52)	1.23 (0.80 – 1.88)
No	387 256	1	1
Social support
Poor	350 75	8.72 (5.94 – 12.81)	5.26 (3.35 – 8.28)***
Moderate	104 103	1.88 (1.26 – 2.81)	1.89 (1.15 – 3.13)*
Strong	69 129	1	1

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.

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⁾.

Strength of the Study

The present study was done with a large sample size at the community level using a validated tool and good sampling techniques. Since there is no previous study done on PTSD among peoples resides in post-conflict areas, this research will serve as a getaway for other studies.

Limitations of the Study

Due to social desirability bias, sexual violence may be miscalculated.

More than half of the dwellers living in conflict-affected areas experienced post-traumatic stress disorder. The study showed that both psychopathologies were more prevalent in women. In this study, there were two variables that showed an association with PTSD but not in other studies (verbally threatened or insulted and witnessing the murder of loved ones). Being female, witnessing the murder of loved ones, and poor social support were the variables that were associated with PTSD. Inability to read and write, witnessing the murder of strangers, being verbally threatened or insulted, and having moderate social support were the explanatory variables that have an association with PTSD.

AOR: Adjusted Odds Ratio, CI: Confidence Interval, DALYs: Disability-Adjusted Life-Years, IQ: Intellectual Quality, LMICs: Low Middle Income Country’s, OR: Odds Ratio, SPSS: Statistical Package for Social Science, PCL-5: Post-Traumatic Stress Disorder Checklist for DSM-5, PI: Principal Investigators, PTSD: Post-Traumatic Stress Disorder, WHO: World Health Organization, USA: United State of America

Ethics approval and consent to participate:

The study was conducted after ethical clearance was obtained from the Institutional Review Board (IRB) of Debre Birhan University, Asrat Woldeys Health Sciences Campus. An ethical clearance letter was submitted to North Shoa’s health administration and management body and was permitted to conduct the research. The objectives of the study were clarified to the North Shoa health administrative body and an additional supportive letter from the North Shoa health administration was disseminated to the study Woredas and Kebeles. A participant's written informed consent was taken regarding their willingness to participate in the study. Participants that were found to be at risk of PTSD and depression were referred for psychiatric evaluation in the psychiatric unit of the nearby hospital/clinic.

Consent for publication: Not applicable

Availability of data and materials

The corresponding author can bring the datasets collected and analyzed for this study based on a reasonable request.

Competing interests

The authors assure that they have no competing interests.

Funding

Funding for data collection, entry, analysis, and write-ups were covered by Debre Berhan University

Authors’ contributions

BT, NA, AS and AD participated in the conception, developing the proposal, participating in data entry and analysis, interpretation, and manuscript preparation and revision. BT, NA, AS, AD, WA, EM, and BG, EA participated in proposal development, data analysis and interpretation, manuscript preparation, and revision. All authors read the final version of the manuscript and approved the manuscript to be considered for publication.

Acknowledgment

We would like to thank God for giving us the courage and wisdom to do this effective work. Moreover, we thank Debre Berhan University for funding this study. We Finally, I would like to acknowledge the North Shoa Zonal administration and selected district administrations for giving me a permission letter to do the research and assigning a community guider on my data collection process

Vahia VN. Diagnostic and statistical manual of mental disorders 5: A quick glance. Indian J psychiatry. 2013;55(3):220.
Asnakew S, Shumet S, Ginbare W, Legas G, Haile K. Prevalence of post-traumatic stress disorder and associated factors among Koshe landslide survivors, Addis Ababa, Ethiopia: a community-based, cross-sectional study. BMJ open. 2019;9(6):e028550.
Madoro D, Kerebih H, Habtamu Y. Post-traumatic stress disorder and associated factors among internally displaced people in south ethiopia: a cross-sectional study. Neuropsychiatr Dis Treat. 2020;16:2317.
Sadock B. Kaplan and Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry. Lippincott Williams & Wilkins; 2011.
Strachan H, Scheipers S. The changing character of war. OUP Oxford; 2011.
Priebe S, Bogic M, Ajdukovic D, Franciskovic T, Galeazzi GM, Kucukalic A, et al. Mental disorders following war in the Balkans: a study in 5 countries. Arch Gen Psychiatry. 2010;67(5):518–28.
Hoppen TH, Priebe S, Vetter I, Morina N. Global burden of post-traumatic stress disorder and major depression in countries affected by war between 1989 and 2019: a systematic review and meta-analysis. BMJ global health. 2021;6(7):e006303.
Atwoli L, Stein DJ, Koenen KC, McLaughlin KA. Epidemiology of posttraumatic stress disorder: prevalence, correlates and consequences. Curr Opin Psychiatry. 2015;28(4):307.
Dams J, Rimane E, Steil R, Renneberg B, Rosner R, König HH. Health-Related Quality of Life and Costs of Posttraumatic Stress Disorder in Adolescents and Young Adults in Germany. Front Psychiatry. 2020;11:697.
Bock JO, Luppa M, Brettschneider C, Riedel-Heller S, Bickel H, Fuchs A, et al. Impact of depression on health care utilization and costs among multimorbid patients–from the MultiCare Cohort Study. PLoS ONE. 2014;9(3):e91973.
Bleich A, Gelkopf M, Solomon Z. Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. JAMA. 2003;290(5):612–20.
Housen T, Lenglet A, Ariti C, Shah S, Shah H, Ara S, et al. Prevalence of anxiety, depression and post-traumatic stress disorder in the Kashmir Valley. BMJ global health. 2017;2(4):e000419.
Cardozo BL, Vergara A, Agani F, Gotway CA. Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. JAMA. 2000;284(5):569–77.
Cardozo BL, Bilukha OO, Crawford CAG, Shaikh I, Wolfe MI, Gerber ML, et al. Mental health, social functioning, and disability in postwar Afghanistan. JAMA. 2004;292(5):575–84.
Canetti D, Galea S, Hall BJ, Johnson RJ, Palmieri PA, Hobfoll SE. Exposure to prolonged socio-political conflict and the risk of PTSD and depression among Palestinians. Psychiatry: Interpersonal and Biological Processes. 2010;73(3):219 – 31.
Osorio FL, SILVA TDAD, SANTOS RGD, Chagas MHN, Chagas NMS, Sanches RF, et al. Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): transcultural adaptation of the Brazilian version. Archives of Clinical Psychiatry (São Paulo). 2017;44:10–9.
Kocalevent R-D, Berg L, Beutel ME, Hinz A, Zenger M, Härter M, et al. Social support in the general population: standardization of the Oslo social support scale (OSSS-3). BMC Psychol. 2018;6(1):1–8.
Chan SF, La Greca AM. Perceived stress scale (PSS). Encyclopedia of Behavioral Medicine: Springer; 2020. 1646–8.
Johnson H, Thompson A. The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A review. Clin Psychol Rev. 2008;28(1):36–47.
Ikin JF, Creamer MC, Sim MR, McKenzie DP. Comorbidity of PTSD and depression in Korean War veterans: Prevalence, predictors, and impairment. J Affect Disord. 2010;125(1–3):279–86.
Roberts B, Damundu EY, Lomoro O, Sondorp E. Post-conflict mental health needs: a cross-sectional survey of trauma, depression and associated factors in Juba, Southern Sudan. BMC Psychiatry. 2009;9(1):1–10.
Santarnecchi E, Sprugnoli G, Tatti E, Mencarelli L, Neri F, Momi D, et al. Brain functional connectivity correlates of coping styles. Cogn Affect Behav Neurosci. 2018;18(3):495–508.
De Jong JT, Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. The lancet. 2003;361(9375):2128–30.
Carmassi C, Dell'Osso L, Manni C, Candini V, Dagani J, Iozzino L, et al. Frequency of trauma exposure and post-traumatic stress disorder in Italy: analysis from the World Mental Health Survey Initiative. J Psychiatr Res. 2014;59:77–84.
Olff M. Sex and gender differences in post-traumatic stress disorder: an update. Eur J psychotraumatology. 2017;8(sup4):1351204.
Chivers-Wilson KA. Sexual assault and posttraumatic stress disorder: a review of the biological, psychological and sociological factors and treatments. McGill J medicine: MJM : Int forum advancement Med Sci students. 2006;9(2):111–8.
Letica-Crepulja M, Salcioglu E, Francisković T, Basoglu M. Factors associated with posttraumatic stress disorder and depression in war-survivors displaced in Croatia. Croatian Med J. 2011;52(6):709–17.
Zinzow HM, Rheingold AA, Hawkins AO, Saunders BE, Kilpatrick DG. Losing a loved one to homicide: prevalence and mental health correlates in a national sample of young adults. J Trauma Stress. 2009;22(1):20–7.
Elklit A, Kurdahl S. The psychological reactions after witnessing a killing in public in a Danish high school. Eur J psychotraumatology. 2013;4.
Mugisha J, Muyinda H, Wandiembe P, Kinyanda E. Prevalence and factors associated with posttraumatic stress disorder seven years after the conflict in three districts in northern Uganda (The Wayo-Nero Study). BMC Psychiatry. 2015;15(1):1–12.
Khamis V. Impact of war, religiosity and ideology on PTSD and psychiatric disorders in adolescents from Gaza Strip and South Lebanon. Soc Sci Med. 2012;74(12):2005–11.
Eagleman D. The brain on trial. The Atlantic. 2011;7:112–23.
Giotakos O. Neurobiology of emotional trauma. Psychiatrike = Psychiatriki. 2020;31(2):162–71.
Rebecca Valdez M. RDN Can Emotional Abuse Cause PTSD? verywell health. 2021.

No competing interests reported.

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

Status:

Version 1

Abstract

Background

Methods

Result

Conclusion

Figures

Background

Methods

Study design and setting

Sample size determination and sampling technique

Data collection procedures

Measurements

Data processing and Analysis

Ethical consideration

Result

Socio-demographic characteristics of participants

Substance use related factors of the study participants

Traumatic event related factors of the study participants

Factors associated with PTSD

Discussion

Limitations of the Study

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1