Trauma Experiences of African Men from a Refugee Background in Western Australia: A Cross-Sectional Study

As people from the African continent continue to settle in Australia, exposure of men from African refugee backgrounds to potentially traumatic events not only impact negatively on their settlement but have also been linked to increased mental health issues and family and domestic violence. This study aims to describe the prevalence and dominant forms of potentially traumatic experiences of African men from a refuge background in Western Australia. Survey data from 421 African men from Eritrea, Ethiopia, Rwanda, Republic of Congo–Brazzaville, Sierra Leone, Democratic Republic of Congo, Liberia, Sudan and South Sudan, Burundi and Somalia were analysed using descriptive statistics. Results The study showed that 81% of the participants experienced at least one potentially traumatic event either in their home country or in a refugee country. However, the prevalence of potentially traumatic events in their home country ranged from 45% (Somalia) to 95% (Democratic Republic of Congo) while in refuge countries, the potentially traumatic experience prevalence ranged from 17% (Somalia) to 51% (Sudan and South Sudan). The majority of the participants (64%) experienced "War at close quarter" in their home country. In comparison, the dominant potentially traumatic experience in refuge countries was "Forced Separation" (28%). The study showed that 53% of the participants who experienced one or more potentially traumatic events in their home country also experienced one or more potentially traumatic events in the refugee country. impact of should non-government agencies.

in terms of the number of counselling sessions and focus that will restore trust to the trauma victims and help them live a normal life free of fear and anxiety [26]. Understanding the prevalence and pervasive impact of war-related potential traumatic events, therefore, is crucial to enable the formulation and implementation of appropriate trauma-informed interventions and treatments for those exposed [27]. This evidence is currently lacking.
There have been studies on experiences of Africans from refugee backgrounds in Western Australia (WA) such as the impact of their visa status and Medicare eligibility [28], the sexual health of Africans in WA and their settlement [26,28]; and family and domestic violence [10] after they migrated to Australia. However, there appears to be no research about the exposure of African men to potential traumatic events before they migrated to Australia. Such research has the potential to inform the development of appropriate interventions for African men who have experienced war trauma. The current study lls this gap in knowledge by examining the trauma experiences of African men from a refugee background in WA.

Methods
The approval for this study was obtained from Human Ethics of The University of WA (reference -RA/4/20/5653).

Aim
The overall aim of this study was to investigate the prevalence and dominant forms of traumatic experiences of refugee men in WA, from the top ten WA migrant African countries of birth whose wars ended between 1990 and 2009 [29][30][31][32][33][34][35][36][37]. The secondary aim of the research was to identify differences in traumatic experiences for men from the different countries.

Study design
This study is a component of a broader mixed-methods study examining the association between a culture of masculinity, traumatic experiences, and attitudes towards family and domestic violence. Reported in this paper are the results of the rst phase of the study, which examines the potentially traumatic events experienced by African refugee men before their settlement in Australia. For the purpose of this study, the United Nation's de nition of refugee [4] was used and a "traumatic event" was de ned as an occurrence in which a person felt, witnessed or faced actual or threatened death or serious injury or a threat to the physical integrity of one's self or others [38]. A traumatic event is not limited solely to the traumatic situation, but it involves socio-psychological processes [39].
This study phase incorporated a cross-sectional quantitative design [40]. A validated survey instrument, the Refugee Trauma History Checklist (RTHC) questionnaire [41] was incorporated and modi ed for this study. The modi ed RTHC is appropriate in this study as it provides self-report data on refugee trauma history [45] and consists of two sets of eight items concerning potentially traumatic events that occurred in the Country of Birth and/or the Refugee Country, such as: 1) War at close quarters, 2) Forced separation from family or close friends, 3) Loss or disappearance of loved one(s), 4) Physical violence or assault, 5) Witnessing physical violence or assault, 6) Torture, 7) Sexual violence, and 8) Other frightening situation(s) where the participant felt his life was in danger. The questionnaire was available in English, French and Swahili, which are the languages commonly spoken by potential participants [44].

Study population
This study was carried out in Perth, WA, a city with a population of over two million [42]. In 2017, there were approximately 6,538 African refugees in Western Status, Highest Education, Profession and Length of Time in Australia). Prevalence of Repeat Potentially Traumatic Event was calculated as proportion (%) of potentially traumatic events in refugee country and potentially traumatic events in country of birth.

1) Sample characteristics.
A total of 432 men completed the questionnaire. Hardcopy questionnaires were completed by 279 participants and online by 153. Eleven questionnaires were not completed in entirety and thereby rendered invalid (total valid questionnaires: 421). As shown in Table 1, the minimum time spent in Australia by the participants was approximately one year and the maximum was 32 years with a median of 12 years. The median number of potentially traumatic events experienced by the participants was ve (inter-quartile range: 2 to 8). Demographic descriptive statistics are displayed in Table 1 indicating Countries of Birth tabulated against: Age Group, Relationship Status, Highest Education and Profession. The prevalence of participants' exposure to potentially traumatic events in their country of birth their refugee country) and repeat potentially traumatic events [1] are presented in Table 2.
While experience of potentially traumatic events was common amongst the participants (81.0% had experienced at least one potentially traumatic event), the extent of traumatic exposure was associated with their country of birth. Although the participants left their country of birth to seek safety, this study shows that, overall, more than half of the participants who experienced potentially traumatic events in their country of birth also experienced at least one potentially traumatic event in their refugee country (denoted as Repeat Potentially Traumatic Event).
Country variations in the extent of potentially traumatic events were observed. For example as shown in Table 2, participants from Sudan/South Sudan had the highest Repeat Potentially Traumatic Event prevalence: 67.1% of the participants who were traumatised in their country of birth were also exposed to repeated potentially traumatic events in their refugee country. Participants from Congo (DRC) had the lowest Repeat Potential traumatic events (32.6%).
Participants born in Congo (DRC) had the highest prevalence of potentially traumatic events in their country of birth with nearly all (95%) exposed to at least one potentially traumatic event. The participants from Somalia, however, were least exposed to potentially traumatic events in their country of birth as 45% of the participants were exposed to at least one potentially traumatic event. In their refugee country, participants from Eritrea had the highest prevalence of potentially traumatic events as half of the participants were exposed to at least one. Participants from Somalia had the lowest potentially traumatic event exposure in their refugee country with 17% of the men exposed to at least one potentially traumatic event.  The prevalence of participants' exposure to potentially traumatic events in their country of birth, refugee country and repeat potentially traumatic events by Age Group is shown in Table 3. Participants aged between 45 and 54 years old had the highest potentially traumatic events prevalence in their country of birth as 89% were exposed to at least one potentially traumatic event. Participants aged between 18 and 24 years had the lowest prevalence as 63% were exposed to at least one potentially traumatic event in their country of birth. In the refugee country, participants aged between 65 and 70 years had the highest prevalence of potentially traumatic events as 73% were exposed to at least one potentially traumatic event. Participants aged 18 and 24 years had the lowest prevalence in the refugee country as 36% were exposed to at least one potentially traumatic event.
Participants aged between 65 and 70 years had the highest prevalence of repeat potentially traumatic events at 89%. In contrast, participants aged between 55 and 64 years had the lowest prevalence of repeat potential traumatic events at44.2%.
Participants in the age groups 35 -44, 45 -54, 55 -64 and 65 -70 each had a median number of ve potentially traumatic events as shown in table 3. While participants in age group 25 -34 had a median number of four potentially traumatic events, those aged between 18 and 24 had a median number of only one potentially traumatic event. These results show that older participants were exposed to more potentially traumatic events compared to the younger ones.   Discussion This is the rst study to our knowledge to identify the prevalence of potentially traumatic events experienced by African men from a refugee background in Australia. Congruent with studies of East African Refugees in the United States [49] and Sierra Leonean refugees in Gambia [50], the prevalence of potentially traumatic experiences was high, with more than 81% of the participants exposed to at least one potentially traumatic event. A unique aspect of this investigation's ndings is that participants were not only exposed to potentially traumatic events in their country of birth, but also that 43% of them were further exposed in their refugee country.
The ndings are important for public health and to aid understanding the experiences of African refugees in WA. Three crucial ndings from this study with public health implications include the high prevalence of potentially traumatic experiences, high prevalence of repeated potentially traumatic experiences in refugee countries and, the heterogeneous prevalence of potentially traumatic events across countries and different age groups.
Our ndings noted a high prevalence of potentially traumatic events with 340 (81%) men from war-torn African countries now living in WA being exposed to at least one potentially traumatic event prior to their settlement in Australia. This result is consistent with a study by Fox and Tang (2000) examining Sierra Leonean refugee experiences which found that more than 90% of participants experienced potentially traumatic events [50]. A study on pre-migration trauma experiences of East African refugees in the US found that potentially traumatic events were experienced by at least 75% of male and female participants [51].
Furthermore, a state-wide survey conducted in WA using a structured questionnaire showed that potentially traumatic events are among the factors that contribute to a person being mentally unhealthy or vulnerable to mental health problems [52]. Similarly, a study of the mental health of African, South-Eastern Asian, and Western/Southern Asian refugee adults in WA shows that potentially traumatic events are associated with probable PTSD, and high Kessler Psychological Distress Scale (K10) mean scores [53].
Our study demonstrates that more than half of African male refugees in WA who have experienced potentially traumatic events in their country of birth also experience one or more additional potentially traumatic events in their refugee countries. This high prevalence of potentially traumatic exposure, both in their country of birth and, more disturbingly, repeated exposure in their refugee country has some serious public health implications. For instance, repeated Furthermore, health professionals "who work with survivors of more extreme or prolonged and repeated traumatisation (e.g., sustained childhood sexual abuse, con nement in a concentration camp, extended domestic violence, war, torture) have noted that the symptom patterns observed are more complex than those encompassed by the PTSD category" [56 p.19]. Therefore, it can be suggested that identifying and responding to the cumulative impact of potentially traumatic events experienced in both their country of birth and refugee country could reduce the risk of behavioural, mental health and other psychiatric issues in future.
The prevalence of potentially traumatic events in participants' country of birth ranged from 45.0% (Somalia) to 95.0% (Congo (DRC)) demonstrating the magnitude and intensity of the potentially traumatic events the participants were exposed to varied between the countries of origin. The implications for public health of the impact of these potentially traumatic events indicate that there may be a lack of homogeneity and, rather, experiences vary depending on the country of descent. The impact of these events may also manifest differently. This, therefore, suggests that any one intervention may not be effective for all refugees from all African countries.
There is evidence that heterogeneous traumatic exposures are associated with high comorbid disorders suggesting that impact of traumatic exposures affecting population subgroups could manifest underlying unobserved characteristics [57]. The distribution of potentially traumatic events shows three severity groupings: severe potentially traumatic events with median number greater than ve (Liberia, Rwanda, Congo Brazzaville, Burundi and Eritrea), moderate number of potentially traumatic events with median number of three to ve (Ethiopia, Sierra Leone, Congo DRC and Sudan/South Sudan) and low number of potentially traumatic events with median number less than three (Somalia).
There was also variation in prevalence of potentially traumatic events experienced in country of birth among the Age Groups ranging from 63% (18-24 years) to 89% (45-54 years). The lower prevalence among men aged between 18 and 24 years is likely due to many being too young or not yet born to be exposed to the wars that ended between 1990 and 2009. Conversely, it is likely that men currently aged between 45 and 54 years had the highest prevalence of potentially traumatic events because they would have been adults during the war years and hence, had a higher likelihood of exposure to war and potentially traumatic events.
Our study established that about one half of the participants experienced physical violence in their country of birth and 21.1% in their refugee countries. The public health implications of physical violence may include effects on the brain, neuroendocrine system, and immune response which may result in increased incidences of depression, anxiety, posttraumatic stress disorder, and suicide; increased risk of cardiovascular disease; and premature mortality

Strengths And Limitations
This study has several strengths. The robust sample size exceeded the sample size necessary to estimate the prevalence of potentially traumatic events of men of African descent in WA. This assists with neutralising erroneous responses from the participants [62]. The data used in the study were collected using a validated instrument. Analysis of the response rate and demographic pro le of participants from each country indicates that the results are reasonably representative of the populations studied.
The study also has some limitations. As non-probability sampling was used, the opportunity to participate was not equal for all quali ed participants in the target population, and the study results are thus not necessarily generalisable to all African refugee men in WA [63]. The researchers acknowledge the potential for selection bias. It is possible that participants in the research are from only those who attended the community events, those who accessed community organisations online and those who received information from OMI. Furthermore, as this study is a cross-sectional study, the ndings do not establish causality. Whilst the questionnaire was also available in Swahili, literacy issues may have prevented or discouraged some men from participating in the research.

Conclusion
A remarkable deduction to be drawn from this paper is that potentially traumatic event exposures are far from rare amongst men of African refugee background. This study shows the heterogeneity of these potentially traumatic experiences and highlights the importance of designing and implementing appropriate trauma-informed interventions and treatments for African men exposed to potentially war traumatic events. The study also underscores the need to prioritise interventions for those from countries with high potentially traumatic events exposures. Further studies are needed to explore the impact of potentially traumatic events on refugee populations, particularly in terms of their mental health.

Declarations
Ethics approval and consent to participate: The approval for this study was obtained from Human Ethics of The University of Western Australia ( le reference -RA/4/20/5653). All the respondents gave consent to participate in the survey.

Consent for publication: Not applicable
Availability of data and material: All data generated or analysed during this study are included in this published article Competing interests: The authors declare that they have no competing interests Funding: This study was part of a PhD thesis and was supported by The University of Western Australia.
Authors' contributions: EON conducted data collection, analysis and interpretation of the results, and drafted the manuscript. CF assisted in data collection, guided data analysis and interpretation and critically revised the document before submission. LS and KM guided data analysis and interpretation and critically revised the document before submission