Posttraumatic stress disorder and its associated factors among people living in Dabat district, northwest Ethiopia

Background The conflict between the Ethiopian government and the Tigray People’s Liberation Front (TPLF) in the Dabat district of Ethiopia has led to significant civilian casualties, instances of rape, sexual abuse, and property theft. These traumatic events contribute to the development of post-traumatic stress disorder (PTSD) among local residents. However, there is currently no available data on the prevalence of PTSD and its associated factors in this region. This study seeks to fill this gap by assessing PTSD prevalence and identifying related factors among residents of the war-affected Dabat district in northwest Ethiopia. Method A community-based correctional study was conducted in the Woken and China kebeles of Dabat district, northwest Ethiopia, spanning from July 13 to September 19, 2023. A total of 410 participants were selected using systematic random sampling, making a 100% response rate. The study utilized an interviewer-administered questionnaire, which included the Post-Traumatic Stress Disorder Checklist (PCL-5) to assess PTSD. The research investigated the association between PTSD and various demographic and psychosocial characteristics using both bivariate and multivariable binary logistic regression analyses. Statistical significance was set at a P-value of 0.05. Results The majority of participants in the study were male (62%) with a mean age of 33 ( ± 1.67) years. The overall prevalence of PTSD was 30.7% (95% CI: 26.6–35.10). Multivariable logistic regression analysis identified several factors significantly associated with PTSD: symptoms of depression (AOR=3.5; 95% CI: 1.13-6.89), age between 45 and 67 years (AOR=1.68; 95% CI: 1.04-5.78), experiencing stressful life events (AOR=1.63; 95% CI: 1.05-7.86), experiencing sexual abuse or rape (AOR=1.53; 95% CI: 1.07-6.75), chewing khat (AOR=1.48; 95% CI: 1.08-4.56), being female (AOR=1.43; 95% CI: 1.13-3.67), and having an income of 34.6 USD (AOR=1.28; 95% CI: 1.07-4.67). Conclusion and recommendation This study reported that the prevalence of PTSD was high. As a result, the study suggested that governments and other stakeholders should be involved in implementing efficient interventions and quick measures to mitigate the effects of war on mental health following the conflict. The government and nongovernmental organizations were also advised by these studies to continue providing humanitarian assistance, which should include access to food, clean water, clothing, shelter, and education. This study also suggested that people living in conflict zones should be legally protected from rape, sexual abuse, arson, detention without cause, and kidnapping.


Introduction
The Tigray conflict in Ethiopia lasted from November 2020 to November 2022 and was mainly concentrated in the Tigray region (1).It involved the Ethiopian federal government and the Tigray People Liberation Front.The Ethiopian government declared war following accusations of Tigray forces attacking its northern command base (2).The conflict, which initially started in Tigray, later extended to neighbouring regions like Afar and Amhara, impacting over 20 million people, predominantly women and children.Approximately 5.5 million individuals were displaced, fleeing to other parts of Ethiopia (3).The situation, particularly in Dabat District in northwest Ethiopia, worsened displacement, exposing many to homelessness and various criminal acts, including murder, sexual abuse, rape, and abduction.This significantly increased the risk of posttraumatic stress disorder among those affected.
Posttraumatic stress disorder is a highly prevalent mental disorder in war-affected areas or natural disasters (4)(5)(6).Posttraumatic stress disorder can result from experiencing or witnessing distressing events such as murder, threats, kidnapping, loss of loved ones, displacement from one's home, and deprivation of basic needs such as food (7).It manifests symptoms such as nightmares and flashbacks, avoiding triggers connected to trauma, elevated alertness, and detrimental cognitive alterations (8).Post-war settings are frequently characterized by instability, peril, and a scarcity of humanitarian aid, factors that may contribute to the onset of posttraumatic symptoms (9, 10).In the absence of effective management, Posttraumatic stress disorder can lead to a deterioration in quality of life, disruptions in daily functioning, and, in severe cases, even mortality (11).
Posttraumatic stress disorder is more prevalent in low-and middle-income countries where mental health services are often less accessible (12).Worldwide, the documented prevalence of Posttraumatic stress disorder among global populations affected by war is 12.9% (13).There is significant regional variation in Posttraumatic stress disorder prevalence, ranging from 0.3% to 8.7% (14,15).A systematic review across 40 nations found that 30.6% of internally displaced individuals affected by war experienced Posttraumatic stress disorder (16).War-affected regions of sub-Saharan Africa also show high rates, with reported prevalence reaching up to 30% (17).In Uganda, Posttraumatic stress disorder prevalence is identified at 11.8% In Uganda (18), whereas in Kenya, it notably rises to 62.1% (18), South Sudan has reported a prevalence of 28% (19).Within Ethiopia, there is significant variation in Posttraumatic stress disorder rates: Addis Ababa reports a lower rate of 3.7% (20), while Dessie reports a higher prevalence of 34.5% (5).
Several factors contribute to the development of posttraumatic stress disorder following exposure to wartime trauma.These factors include age, gender, experiences of potentially traumatic events during and after the war, unemployment, lower educational levels, and the presence of chronic diseases (19,(21)(22)(23).
Limited information exists regarding the prevalence of mental disorders, particularly posttraumatic stress disorder, among individuals directly involved in armed conflicts in low-and middle-income countries such as Ethiopia.However, a substantial number of individuals in such contexts are vulnerable to various mental health challenges due to their exposure to conflict-related trauma (24, 25).In the Dabat district of Ethiopia, a substantial conflict involving the Ethiopian government and the TPLF erupted, leading to numerous civilian casualties, incidents of rape and sexual abuse, cessation of hostilities, and property theft.These traumatic events may have contributed to the development of posttraumatic stress disorder among the affected population.However, available data on the prevalence of posttraumatic stress disorder and its associated risk factors among individuals residing in conflictaffected areas post-war are lacking.Therefore, this study aimed to investigate the extent of posttraumatic stress disorder and identify factors associated with it.The findings from this research have the potential to inform the government and other stakeholders, guiding them in implementing interventions and appropriate actions to address the lingering issues following the war.

Study area and period
This study was conducted in Woken and China Kebeles, which are located in the Dabat district of the Amhara regional state in Northwest Ethiopia, spanning from July 13 to September 19, 2023.The Dabat district is located approximately 775 kilometres away from Addis Ababa.These two kebeles comprise 2000 households with a total population of 8,000.Unfortunately, during the study period, China and Woken Kebeles became battlegrounds between the Tigray People's Liberation Front and Ethiopian government forces.The Amhara Media Corporation documented that China and Woken Kebeles witnessed the tragic loss of hundreds of civilians, either through massacres or shelling.Furthermore, many residents endured severe hardships, including instances of sexual abuse and rape.

Study design and population
A community-based cross-sectional study was carried out within war-affected regions of the Dabat district, specifically in China and Woken Kebeles.The source population consisted of adult residents aged 18 and above living in China and Woken Kebeles, who had been residing in the two kebeles for at least six months.However, the target population or study population included all adult individuals aged 18 years and above who presented themselves during the data collection period.

Sample size calculation
By applying a single proportion population formula, the sample size was determined using the estimated prevalence rate of PTSD, which was 58.4%, as identified in a study conducted in southern Ethiopia (26).With the 10% nonresponse rate added, the total sample size was 412 with a 5% margin of error, a 95% confidence level, and a 10% nonresponse rate.

Sampling technique and procedure
Participants for the study in both China and Woken Kebeles were recruited using a systematic random sampling technique.Initially, the number of households and the total population were determined for both kebeles.Then, 30% of households were selected from each kebele.Proportional allocation was applied to the selected households.Finally, the sampled population was chosen through a systematic random sampling technique after proportional allocation (refer to Figure 1).

Eligibility criteria and study variables
The inclusion criteria for this study included all adult individuals aged 18 years or older, residing in China and Woken Kebele for a minimum duration of 6 months.
Individuals who reported being severely ill and unable to participate in interviews for data collectors, those who provided a medical certificate or related document indicating their current illness, and those with observable verbal communication problems were excluded from the study.
Posttraumatic stress disorder: A 20-item post-traumatic checklist (PCL-5) was used to assess PTSD).A cumulative score was derived by summing the 20 items, with scores ranging from 0 to 80 on a five-point Likert scale (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely), Which means adults who score< 50 have no PTSD and ≥ 50 have PTSD (27).

Depression
Participants exhibiting depression were identified through their scores on the Patient Health Questionnaire (PHQ), specifically those individuals who scored 10 or more on the nine items (28).
Stressful life event.It was determined by the presence of one or more life-threatening events within the last six months, as indicated by the relevant questions (29).

Social support
Social support was assessed using the Social Support Scale (OSS-3), which consists of three items with scores ranging from 3 to 14.A score within the range of 3-8 indicates poor social support, while a score between 9-11 suggests intermediate social support.A score of 12-14 on the OSS-3 reflects strong social support (30).
Substance abuse was defined as the consumption of cigarettes, alcohol, or khat by individuals who met the criteria of (31,32).

Data collection tools
Data collection was conducted by psychiatric professionals with Bachelor of Science (BSc) degrees, trained in data collection techniques and ethical principles.The questionnaire was initially developed in English and translated into Amharic, with a backtranslation into English to ensure accuracy.Training was provided to study participants about the study's objectives, handling ambiguous questions, and adhering to ethical standards, including informed consent, confidentiality, anonymity, and data management.PTSD was assessed using the 20-item self-report Post-Traumatic Stress Disorder Checklist (PCL-5), which measures the 20 DSM-5 PTSD symptoms.We validated this assessment tool internally, achieving a Cronbach's alpha reliability coefficient of 0.78.It has been previously utilized in Ethiopia (5,20).The Validity and reliability of the PCL-5 had been tested and proven in a different country, for example, Zimbabwe (Cronbach's alpha = 0.92) with sensitivity and specificity of 74.5% and 70.6% respectively (33), (5).We validated this assessment tool, achieving a Cronbach's alpha reliability coefficient of 0.78.Depression was measured using the Patient Health Questionnaire-9 (PHQ-9), where a person is considered depressed if their score is 10 or higher on the nine items.The PHQ-9 has 4 items with corresponding scores: not at all (0), several days (34), more than half a day (15), nearly every day (35), and over the last week (28).

Data processing and statistical analysis
The collected data was coded and entered into Epi-Data version 4.6, followed by analysis using IBM SPSS Statistics version 25.0 software.Summary statistics, including proportions and frequencies, were utilized to summarize the results in tables.Bivariable and multivariable logistic regression models was fitted to identify factors associated with the outcome variable.In the bivariable logistic regression, variables with a p value ≤ 0.2 were considered candidates for inclusion in the multivariable logistic regression.Binary logistic regression was employed.Adjusted odds ratios (ORs) was used to determine the relationships between PTSD and associated variables at a significance level of p ≤ 0.05.The normality of continuous data was assessed using the Shapiro−Wilk test, and the model's fitness was checked using the Hosmer-Lemshow goodness-of-fit test.

Ethics approval and consent to participate
We obtained ethical approval from the Institutional Review Board of the University of Gondar, School of Medicine, College of Medicine, and Health Sciences Ethical Review Committee, with reference number IRB/373/2023, subsequent to the review of our research proposal.After adequately briefing the educated study participants about the study, written informed consent was obtained from each individual.Conversely, during data collection from illiterate study participants, the data collectors began by reading aloud the consent form, providing a thorough explanation of the study's objectives and procedures.Upon participants' voluntary agreement to participate, the data collectors marked "Yes" on the consent form.Subsequently, participants confirmed their consent by providing their signature using a "thumbprint" as acknowledgment.This approach was approved by the Institutional Review Board (IRB) of the University of Gondar.To uphold confidentiality and privacy, participants' names and other personal identifiers were excluded from the documentation.To maintain confidentiality, potential identifiers were omitted from the questionnaire, and all collected data were securely stored.Our procedures adhered to the relevant rules and guidelines outlined in the Helsinki Declaration (36).

Background characteristics of the study participants
In this study, a total of 410 study participants were included, making 100% response rate.The majority of participants were male (62%).The mean age of the study participants was 33 years ( ± 1.67).Approximately 45% of the participants were married, and 43% had completed elementary school.Nearly 63% of participants resided in rural areas, and approximately 45% were employed as farmers.Majority the participants reported a monthly income ranging from 34.6 USD (see Table 1).

Clinical and behavioural characteristics of the study participants
In the present study, 17% of all participants reported a family history of mental illness.Approximately one-third of the participants (32%) had a known diagnosis of a chronic medical condition, 43% of whom were specifically diagnosed with diabetes.Symptoms of depression and morbidity were exhibited by approximately thirty percent of the research participants.More than thirty percent of the participants had engaged in khat chewing at some point in their lifetime.Additionally, one-third of the study participants reported experiencing sexual abuse or rape during the war (refer to Table 2).

Discussion
The observed prevalence of PTSD among people living in waraffected areas in Dabat district, was determined to be 30.7%(95% CI 26.6-35.1).These finding suggest a higher prevalence of PTSD among residents of war-affected regions in the study settings, this result is similar to findings from studies conducted in Dessie, Ethiopia (34.5%) (5), Israel (27%) (37), Servia (32.3%) (38) and South Sudan (28%) (19).However, this result is lower than those of studies conducted in Kenya, which reported a prevalence of 62.1% (39); in South Sudan Juba, which reported a prevalence of 37.6% (40); and in Croatia, which reported a prevalence of 56.7% (41).On the other hand, this prevalence is higher than that reported in studies conducted in Uganda, 18% (21), and in Libya 25.23% (42).In the Dabat district of Ethiopia, cultural beliefs profoundly influence responses to war-related atrocities such as rape, torture, murder, and abduction.Stigma often prevents victims from seeking justice or support services due to fears of social ostracization and This study revealed that PTSD was positively associated with having symptoms of depression, ages 45-67, experiencing stressful life events, enduring sexual abuse or rape, chewing khat, being female, and having an income of less than 34.60 USD.
Symptoms of depression were the strongest predictor, showing that individuals with depression symptoms were more likely to develop PTSD compared to those without.This study is supported by a study performed in Nigeria (46), northeaster Ethiopia (5), the Maikadra massacre in Ethiopia (47),.This is because people with depression may have heightened sensitivity to stress and trauma, impaired coping mechanisms, and neurobiological changes that increase their vulnerability to developing PTSD (48).Elderly study participants were more prone to developing PTSD than their male counterparts were.This result is in line with research conducted in Netherland (49).This could be attributed to the greater prevalence of chronic health conditions such as heart disease, hypertension, and diabetes among elderly people, coupled with challenges such as sleep disturbances, insomnia, physical and mental fatigue, changes in appetite, muscle tension, pain, chest discomfort, an upset stomach, and other issues more commonly experienced in the elderly population.All these factors may contribute to the development of posttraumatic stress disorder (50,51).
According to the results of this study, women were more likely to develop PTSD than men were.These findings align with research conducted in northeast Ethiopia (5) and Uganda (52).This could be attributed to the greater vulnerability of females to sexual abuse or rape during times of war, making them more susceptible to developing PTSD than men are (53).
A potential explanation could be the influence of sex hormones and neuro-steroids on emotional learning and memory formation, coupled with disparities in brain anatomy and activation in response to traumatic stress (54).Contrary to current findings, research conducted in the US found no significant difference in PTSD rates between men and women, even after adjusting for demographic factors and lifetime trauma exposure (55).Hence, it is reasonable to deduce that when males and females experience similar types and levels of traumatic stressors, disparities in PTSD rates between the genders may not be as pronounced (53).Individuals with lower incomes were more likely to develop PTSD than their higher-income counterparts were.This study aligns with the study conducted in lowincome countries (56).This can be attributed to the vulnerability of individuals with low incomes, who are more prone to experiencing depression, anxiety, and increased levels of the hormone cortisol.These factors collectively contribute to heightened stress levels (57).Compared with no chewers, study participants who chewed khat had greater odds of developing PTSD.This study is supported by a study performed in Somali (58).A possible explanation is that chewing khat can result in side effects such as headaches, vertigo, decreased cognitive function, fine tremors, sleeplessness, heightened alertness, dependence, tolerance, and anxiety.All these effects could contribute to the development of posttraumatic stress disorder (59).
Compared to study participants who were not sexually abused or raped, those who suffered these events had a greater chance of developing PTSD.This study is in line with previous findings in the Balkans (4).This correlation may be attributed to the impact of depression, which influences susceptibility to trauma and contributes to the development of posttraumatic stress disorder by elevating steroid hormones such as cortisol (60).Finally, participants who experienced stressful life events exhibited a greater likelihood of developing posttraumatic stress disorder (PTSD) than did those who had not experienced such events.This study consistent with findings from a prior investigation conducted in southern Sudan (40) and northeast Ethiopia (5).This can be explained by the fact that

Strengths and limitations of the study
The strength of this study was its use of primary or original data, which increased its relevance.This study and this study had certain limitations, including social desirability bias, as participants might be hesitant to provide socially acceptable responses to sensitive questions concerning sexual abuse and substance use.Additionally, there was a recall bias due to the limitations of the study design.

Conclusion and recommendation
The results of this study showed that a significant proportion of people living in war-affected areas had PTSD.As a result, the study suggested that governments and other stakeholders should be involved in implementing efficient interventions and quick measures to mitigate the effects of war on mental health following the conflict.The government and nongovernmental organizations were also advised by these studies to continue providing humanitarian assistance, which should include access to food, clean water, clothing, shelter, and education.This study also suggested that people living in conflict zones should be legally protected from rape, sexual abuse, arson, detention without cause, and kidnapping.This study recommends that scholars employ a combination of qualitative and quantitative approaches to gain a comprehensive understanding of PTSD in war-affected areas.Furthermore, it highlights the critical role of cohort studies in establishing causal relationships between exposure to war and the development of PTSD.

FIGURE 1 sampling
FIGURE 1sampling procedure for the war-affected area in the Dabat district, northwest Ethiopia, 2023.

TABLE 2
Clinical and behavioural factors among study participants who reside in the ware-affected area in the Dabat district, northwest Ethiopia, in 2023.

TABLE 1
background characteristics of study participants who reside in the ware affected area in the Dabat district, northwest Ethiopia, 2023.

TABLE 2 Continued
TABLE 3 factors associated with PTSD among study participants who reside in the ware-affected area in the Dabat district, northwest Ethiopia, 2023.