This is the first 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 findings 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 findings are important for public health and to aid understanding the experiences of African refugees in WA. Three crucial findings 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 findings 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 potentially traumatic events experienced by the participants have been associated with difficulties of settling in Australia resulting in many African refugees taking time to develop trust with Australians and Australian government agencies as shown in previous study on Sudanese refugees in Australia [54]. Repeated potentially traumatic experiences are also associated with feelings of insecurity, self-blame, disappointment and disenfranchisement [55]. Furthermore, health professionals “who work with survivors of more extreme or prolonged and repeated traumatisation (e.g., sustained childhood sexual abuse, confinement 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 five (Liberia, Rwanda, Congo Brazzaville, Burundi and Eritrea), moderate number of potentially traumatic events with median number of three to five (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.
Some specific potentially traumatic events such as Torture, Physical Violence and Sexual Violence experienced by refugee men in the study have important implications. In their country of birth, approximately 50% of participants experienced Torture, over 50% experienced Physical Violence and approximately 23% experienced Sexual Violence. Survivors of torture and other organised violence are usually overwhelmed by feelings of guilt, shame, mistrust; and commonly complain of symptoms, such as sleeplessness, nightmares, weakness, lethargy, headaches and abdominal pain [58]. In addition, a study by Stepakoff et al indicated that Liberian and Sierra Leonean refugees in Guinea who experienced war torture were left with deep psychological scars such as depression, lethargy, hopelessness, anxiety, and posttraumatic stress and were unable to make meaningful contributions to their families and communities [18].
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 [59]. Research suggests that Sudanese refugees in Australia who experienced physical violence such as beating, gunshot wounds, and brutal interrogations reported feelings of insecure and perpetual fear both of the violence itself and of the possibility that it would lead to their death as they continually thought about death and never felt safe [54].
Our findings on the prevalence of sexual violence show that approximately 35% of men experienced sexual violence in Rwanda, Congo Brazzaville, and Burundi. This finding aligns with a previous review that indicated that 32.6% of Liberian former male combatants and 7.4% of non-combatant males experienced sexual violence [60]. Previous studies have suggested that sexual violence inflicts negative social and psychological consequences on the survivors, their families and communities [60]. Sexual violence against men poses serious public health consequences which need to be taken into consideration when designing any impactful intervention for men. For instance research on sexual violence against men and boys suggested that it has both physical (sexually transmitted infections, incontinence, genital and rectal impairment, infertility, sexual dysfunction) and mental health (depression, anxiety, PTSD, suicidal ideation) impact on the victims [61].
For agencies involved in developing and delivering counselling and other interventions to African men from a refugee background, the results of the current study highlight the importance of considering incorporating therapeutic treatments for potentially traumatic exposures in their interventions. The findings also highlight the need for deliberate policies to address the impact of potentially traumatic exposures experienced by African refugee men. Current short-term torture and trauma counselling in Australia provided for new arrivals under the Humanitarian Settlement Strategy (HSS) programme does not specifically address their potentially traumatic exposures. To facilitate the settlement of African refugees in Australia, this program should be modified to provide sufficient counselling sessions addressing the intensity of war-related repeated potentially traumatic events they experienced.