Title: Ecacy of Psychosocial Group Treatment for Post-traumatic Stress Disorder among Genocide Survivors in Rwanda, 25 Years After 1994 Genocide Against Tutsi.

Background: Prior studies indicated that post-traumatic stress disorder is becoming a global health concern even though still poorly known and treated. In the aftermath of 1994 Genocide against Tutsi, studies found high rates of depressive and anxious symptoms along with PTSD among genocide survivors. Due to the highest cruelty in which the Genocide was committed, genocide survivors still need high special humanitarian services, of those including specialized health care services. The aim of this study was to assess the ecacy of psychosocial group therapies created by AVEGA Agahozo in reducing PTSD symptoms among Genocide survivors in Rwanda, 25 years after 1994 Genocide against Tutsi. Methods: We conducted a comparative cross-sectional study design with a sample of 98 genocide survivors who received group therapy by AVEGA Agahozo. We used a multi-stage random sampling method to select participants and 7 trained psychologists interviewed genocide survivors about their PTSD status before and after treatment using Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. The analysis was performed using SPSS version 17.1. Results: The results showed that women were 97.96% and men presented 2.04% of all participants because AVEGA Agahozo mainly focuses on helping women survivors who lost their husbands in Genocide and previous ndings also concluded that women are very prone to suffer from PTSD than men. Paired t-test results showed signicant differences between symptoms, before and after treatment (P<0.001 in all pairs). Cohen's d results also showed high effect sizes (d>0.5), only in pair 8 where the difference appears to be less signicant (d=0.28). The descriptive statistics showed that the severity of PTSD symptoms dramatically reduced after treatment. But this difference of severity is only statistically signicant among ve (5) PTSD symptoms.: (Marked physiological reactivity after exposure to trauma-related stimuli [P=0.045, x2=38.111]; inability to recall key features of the traumatic event [P<001, x2=56.309]; persistent negative trauma-related emotions [P=0.013, x2=43.184]; self-destructive or reckless behavior [P=0.041, x2=38.535]; hypervigilance [P=0.020,

treatment to help them recovering from PTSD. AVEGA Agahozo is one of the institutions in Rwanda which is trying to help genocide survivors to recover from PTSD by giving them PTSD group treatments. They have professional psychologists checking on them regularly and give them any psychosocial assistance they need to thrive. They also help them to x their personal issues including access to other health care services to those who have chronic diseases caused by Genocide. AVEGA Agahozo has created different group therapies in almost all districts of Rwanda. And many genocide survivors have profoundly con rmed that group therapies have helped them to recover from PTSD and regained hopes for living a better life. There were no previous studies that evaluated or analyzed the e cacy of these therapeutic groups in healing PTSD. The present study was designed to analyze the e cacy of these psychosocial group therapies created by AVEGA Agahozo in reducing PTSD symptoms and severity among Genocide survivors.

Research design
We used a comparative cross-sectional study design to analyze the e cacy 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 e cacy 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, con dentiality, 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 rstly 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 t 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, 5 th 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 identi ed before treatment and symptoms identi ed 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 certi ed 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 nd 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 ve 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 signi cance of differences between PTSD symptoms severity before and after treatment.

Paired t-test
Paired t-test was used to assess the e cacy of group therapy in reducing PTSD symptoms. Mean differences, standard deviations, standard error means, 95% con dence 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 1 st symptom severity before and after treatment, Pair2: represents 2 nd symptom severity before and after treatment, Pair3: represents 3 rd symptom severity before and after treatment, Pair 4: represents 4 th symptom severity before and after treatment, Pair 5: represents 5 th symptom severity before and after treatment, Pair6: represents 6 th symptom severity before and after treatment, Pair7: represents 7 th symptom severity before and after treatment, Pair8: represents 8 th symptom severity before and after treatment, Pair 9: represents 9 th symptom severity before and after treatment, Pair 10: represents 10 th symptom severity before and after treatment, Pair11: represents 11 st symptom severity before and after treatment, Pair12: represents 12 nd symptom severity before and after treatment, Pair13: represents 13 th symptom severity before and after treatment, Pair 14: represents 14 th symptom severity before and after treatment, Pair 15: represents 15 th symptom severity before and after treatment, Pair16: represents 16 th symptom severity before and after treatment, Pair17: represents 17 th symptom severity before and after treatment, Pair18: represents 18 th symptom severity before and after treatment, Pair19: represents 19 th symptom severity before and after treatment, and Pair 20: represents 20 th symptom severity before and after treatment (Table 5).

Cohen's d test
Cohen's d test was used to assess the signi cance 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.

E cacy of group therapy in reducing PTSD symptoms and severity
Descriptive statistics showed that the severity of PTSD symptoms was noticeably reduced after the treatment but chi-square results showed that the differences were statistically signi cant for only ve (5) PTSD symptoms:  (Table 5).

Discussion
To the best of our knowledge, only a few studies examined the mental health status of the Rwandan population in the aftermath of the Genocide, however, all ndings showed that the percentages of those who suffer from mental health disorders, mainly depression and PTSD are very high [11][12] [13]. As a result of the inhumane atrocity in which the genocide was committed, genocide survivors still require special quality care services notably appropriate health care services [14]. The main objective of this study was to analyze the e cacy of psychosocial group therapies created by AVEGA Agahozo in reducing PTSD symptoms among Genocide Survivors. According to the results found after performing analysis, demographic statistics indicated that women were 97.96% (96) of all participants and men presented only 2.04% (2) ( Table 2). In terms of demographic variables, female gender is a commonly reported risk factor in the development of symptoms of depression and PTSD [15][16] [17]. Previous ndings consistently concluded that women are very prone to suffer from PTSD than men [18] [19] [20]. This difference in prevalence is also explained by how men were mostly targeted by perpetrators and were killed in Genocide than women. In 2004, Amnesty International showed that the widows were 10 times more than widowers, about 50,000 widows of the genocide [21]. A study conducted 25 years after the Genocide also found a very high prevalence rate of post-traumatic stress disorder among survivor mothers [9]. AVEGA Agahozo also mainly focuses on helping widows than widowers. 94.9% (93) of all participants are 41 year and above ( Table 2). That means that they were around 16 year old during the Genocide.
Previous studies found that genocide survivors who were between the ages of 11 and 20 during the genocide are at the highest risk for PTSD [22]. All participants witnessed different traumatizing events that they went through during 1994 Genocide perpetrated against Tutsi and most of them experienced more than one traumatic event. Descriptive statistics showed that the severity of PTSD symptoms was dramatically reduced after treatment. However, these severity differences were only statistically signi cant for 5 PTSD symptoms: (Marked physiological reactivity after exposure to trauma-related stimuli; inability to recall key features of the traumatic event; persistent negative trauma-related emotions; self-destructive or reckless behavior and hypervigilance (Table 5). Paired t-test and Cohen's d results showed signi cant differences between symptoms severity before and after treatment with p-values less than 0.001 (P<0.001) in all 20 pairs representing 20 PTSD symptoms (Table 5). According to the results mentioned above, the present study concluded that the group therapy is effective to reduce the severity and symptoms of PTSD among Genocide survivors. These group therapies helped the genocide survivors to relieve the PTSD symptoms and regain hopes for a bright future. These results support the previous studies that stated that trauma centered group therapy effectively heals PTSD among a large number of combat veterans and non-military trauma victims of cruel violence and other disasters (like earthquake and hurricane) [23]. Based on the existing research, group treatment for PTSD appears to be an effective approach, although meta-analytic ndings suggest that it is not as effective as individual therapy [24], thus further research should compare the effectiveness of group treatment and individual treatment. Most genocide survivors who suffer from PTSD do not go to the hospital to seek health care services and mental health disorder is one of the risks that might develop the complications of other diseases that can permanently harm the lives of genocide survivors. Prior study ndings revealed that post-traumatic stress disorder, major depression disorder, and traumatic brain injuries can have long-lasting, and surging consequences such as substance abuse, suicide attempts, unhealthy behaviors, physical health problems, mortality, diminished productivity, and unemployment [25]. Children of trauma victims suffering from PTSD symptoms are also more likely to develop PTSD [26]. Some research ndings consistently found that PTSD may persist longer after a traumatic event happened [

2][3][4][5][6]. Post-traumatic stress disorder is still a substantial public health concern
in Rwanda, and enabling people to have access to quality care for those who need it should be a national priority [22]. Thus, despite the great work made by the government of Rwanda to actively support reconciliation and reduce trauma, the magnitude of trauma among the Rwandan population remains essential over a decade after the Genocide [27]. Based on the ndings of this study, we strongly recommend the use of group therapy for helping genocide survivors to recover from PTSD and improving their mental health and quality of life.

Limitations
There were some limitations while conducting this study. Firstly, the study did not assess the effect of group therapy longevity in healing PTSD symptoms. Secondly, the study did not assess how the intensity of traumatic events was associated with PTSD severity. Thirdly, the study used a small sample size due to the absence of many group therapies meeting inclusion criteria. Fourthly, the study did not analyze the effect of gender in recovering from PTSD because the sample was not proportionally distributed by gender.

Strengths
The interviews with participants were conducted by quali ed psychologists and Diagnostic and Statistical This study has been approved by the research committee of Ningxia Medical University and AVEGA Agahozo after rigidly reviewed the design and intervention plan and evaluated the potential risks and possible harm to people involved in the research. All methods were performed in accordance with the relevant guidelines, regulations and principles of conducting research involving human subjects. All participants were allowed to withdraw from the study whenever they felt like they wanted to end the interview. Participation in this study was voluntary. All participants received informed consent before they participated in the study and the participation was approved by signing the consent form. All information was con dential and no names were mentioned in this study.

Consent for publication
Non-applicable Availability of data and materials The data analyzed and included in this study are accessible from the corresponding author after presenting a reasonable demand.

Competing interests
All authors declare no con ict of Interest

Funding
This study was partially supported by Ningxia Medical University. The funders did not participate in the conduct of the study, data collection, data entry, data analysis, preparedness of the manuscript and submission.      Table 5 shows mean, standard deviation, standard error mean, 95% con dence interval, t-test results, degree of freedom, p-values and Cohen'd effect sizes.