Research design
We used a comparative cross-sectional study design to analyze the efficacy of psychosocial groupies created by AVEGA Agahozo. According to the DSM-5 criteria for PTSD (Table 1), 20 symptoms before and after treatment were compared to analyze the efficacy of psychosocial group therapy in reducing PTSD symptoms among genocide survivors. The genocide survivors were asked how they felt before joining the psychosocial group therapy and how they felt after treatment, then after the records were compared to assess the change in PTSD symptoms and severity before and after treatment. The severity of symptoms was measured by choosing the intensity of reoccurrence or re-experience of the symptoms. The intensity of PTSD symptoms severity was categorized into 6 levels (Not at all, very slightly, slightly, moderately, quite a bit and extremely) (Table 4).
Description of group therapy in this study
In this study, group therapies represent the psychosocial therapeutic groups created by AVEGA Agahozo to help genocide survivors to recover from PTSD. AVEGA Agahozo has several numbers of psychologists working in daily basis with genocide survivors. They are the staff of AVEGA Agahozo which is an association of the widows of Genocide. It is a Rwandan association formed to help widows, orphans and others who lost family members in the 1994 Genocide. AVEGA Agahozo was founded in October 1995 by women who had survived the killings but lost their husbands. As one of the mission of this association, AVEGA Agahozo generally helps genocide survivors who are suffering from different chronic health conditions. And that is where started the idea of creating group therapies to help widow genocide survivors to recover from PTSD. These group therapists teach genocide survivors new coping skills on how to manage their symptoms, reduce painful memories, overcome their sense of helplessness and hopelessness, develop healthy lifestyle habits, manage anxiety and anger, think positively, give a hand to others, and move on with their lives. The therapists ensure that every group therapy is secured with emotional safety, confidentiality, support, and a common goal (of recovering from PTSD), to help group members having a sense of belonging, acceptance and feel free to share their testimonies, strengths, and weaknesses throughout the healing journey. This makes genocide survivors feel less isolated knowing how to deal with the trauma. Each group therapy had 9 to 18 participants. All group therapies lasted for a period of 6 to 30 months depending on how long the members showed a tremendous recovery from PTSD. All group therapies included in this study were created and closed within the years from 2016 to 2019. The range of age mean of group members was 43-64 years. The group therapy sessions lasted usually for one to two hours, and they were repeatedly happening once to twice a week depending on how the group members needed the support to help them recover from PTSD.
Participants
Participants were 98 genocide survivors who were suffering from PTSD and who received psychosocial group treatment by AVEGA Agahozo. The age range of participants was 43 to 64 years. These group therapies were located in ten (10) districts of Rwanda (Bugesera, Gisagara, Huye, Gakenke, Rulindo, Musanze, Nyamasheke, Karongi, Kayonza, and Ngoma).
Inclusion criteria: (1) Participants were genocide survivors; (2) Participants were born prior to genocide, (3) Participants suffer from PTSD; (4) Participants were able to recall what happened to them during the Genocide (5) Participants experienced at least one traumatic event during the Genocide; (6) Participants had received PTSD group treatment under the supervision of AVEGA Agahozo within the years from 2016 to 2019, and (7) Participants were no longer receiving psychosocial group therapy.
Exclusion criteria: (1) Those people who are not genocide survivors; (2) who were born after Genocide, (3) who do not suffer from PTSD; (4) who did not experience traumatic events during the Genocide; and (5) who did not receive PTSD group treatment under the supervision of AVEGA Agahozo within the years from 2016 to 2019.
Subjects sampling and selection
We used a multi-stage random sampling method to select 98 participants. We firstly selected 10 districts (Bugesera, Gisagara, Huye, Gakenke, Rulindo, Musanze, Nyamasheke, Karongi, Kayonza and Ngoma) randomly among 14 districts which had graduated group therapies created and supervised by AVEGA Agahozo. In each selected district, one sector was selected, thereafter; in each selected sector one group therapy was selected. In each selected group therapy, ten genocide survivors precisely were randomly selected to participate in the study but if the members of group therapies were less than 10, all of the members were selected to participate in the study. All genocide survivors who met the inclusion criteria were given equal chance to participate in the study. Microsoft Excel was used to sort randomly the names of participants to participate in the study using a sampling frame containing all the names of genocide survivors in each psychotherapy group.
Data collection
Seven psychologists collected data in October, 2019 from 10 selected districts of Rwanda (Bugesera, Gisagara, Huye, Gakenke, Rulindo, Musanze, Nyamasheke, Karongi, Kayonza and Ngoma). One week before collecting data, we recruited 7 psychologists and trained them to have the same understanding of the study methodology and objectives. Twenty psychologists submitted their copies of degrees and CV, then after we reviewed their documents and chose those who were more closely to fit the requirements. Selected psychologists had experience of two years and more in conducting trauma focused therapies. The training was conducted online because the psychologists were located in different areas of the country. All data collection sites were nearby health centers that in case the interviewees re-experienced the occurrence of the traumatic events, they would have received emergency care services from the health centers. Each site was supervised by the psychologist who led the group therapy since when it was created. And the research team coordinated all the research work. The interviews included open ended and close questions. The psychologists explained clearly the objectives of the study to the participants before they started interviews, then after they carefully interviewed 98 genocide survivors who met the inclusion criteria using a questionnaire which was designed in reference of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. The interview lasted between 30-60 minutes. The participants had to sign a consent form before they participated in the study and they were allowed to stop or withdraw from the interview whenever they felt uncomfortable. We collected the information on demographic characteristics of participants, description of group therapy, symptoms identified before treatment and symptoms identified after treatment. To increase the quality control of the study, we involved the psychologists to conduct the interview and did piloting as to test and adjust the questionnaire before it was fully certified for use. The psychologists were mostly trusted by the participants and they knew how to handle any situation that might cause trauma reoccurrence during the interviews. This was not only demonstrated that the target population understood the questions in the same way as the researchers but also offered an opportunity to identify errors in the questionnaire. Then after, the questionnaire was given to the second reader to find out if it was well designed for the study.
Statistical analyses
We used SPSS 17.1 to enter the data into the database and performed analysis. We used the following five statistical methods to analyze the data:
Descriptive statistics
Descriptive statistics were used to compare PTSD symptoms severity before and after treatment. Percentages of participants in each category of severity intensity were calculated and compared before and after treatment to assess if there is any difference.
Chi-square test
Chi-square test was used to test the significance of differences between PTSD symptoms severity before and after treatment.
Paired t-test
Paired t-test was used to assess the efficacy of group therapy in reducing PTSD symptoms. Mean differences, standard deviations, standard error means, 95% confidence intervals, t-test results, p-values helped to identify the differences between PTSD symptoms severity before and after treatment. To calculate t-test results the means and standard deviations of twenty symptoms of PTSD (According to DSM5) were compared in pairs before and after treatment. Pair1: represents 1st symptom severity before and after treatment, Pair2: represents 2nd symptom severity before and after treatment, Pair3: represents 3rd symptom severity before and after treatment, Pair 4: represents 4th symptom severity before and after treatment, Pair 5: represents 5th symptom severity before and after treatment, Pair6: represents 6th symptom severity before and after treatment, Pair7: represents 7th symptom severity before and after treatment, Pair8: represents 8th symptom severity before and after treatment, Pair 9: represents 9th symptom severity before and after treatment, Pair 10: represents 10th symptom severity before and after treatment, Pair11: represents 11st symptom severity before and after treatment, Pair12: represents 12nd symptom severity before and after treatment, Pair13: represents 13th symptom severity before and after treatment, Pair 14: represents 14th symptom severity before and after treatment, Pair 15: represents 15th symptom severity before and after treatment, Pair16: represents 16th symptom severity before and after treatment, Pair17: represents 17th symptom severity before and after treatment, Pair18: represents 18th symptom severity before and after treatment, Pair19: represents 19th symptom severity before and after treatment, and Pair 20: represents 20th symptom severity before and after treatment (Table 5).
Cohen’s d test
Cohen’s d test was used to assess the significance of differences between symptoms severity before and after treatment by comparing the magnitude of effect sizes. The interpretation of these effect sizes refer to three categories based on benchmarks suggested by Cohen [10]. When d = 0.2, it means that effect size is small, when d = 0.5, it means that effect size is medium and when d = 0.8, it means that effect size is large). Cohen's d in between-subject designs can be readily interpreted as a percentage of the standard deviation, such that a Cohen's d of 0.5 means the difference equals half a standard deviation.
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