Depression, Post Traumatic Stress Disorder and Alcohol Misuse among Eritrean Refugees living in a camp in Ethiopia: Risk and Protective factors
Creators: name: Getnet, Berhanie(PhD)
Publisher: name: National Academic Digital Repository of Ethiopia
Year: 2019

description: Background By the year 2020, depression is projected to be the second leading cause of disability and the fourth leading contributor to the global burden of disease. Depression and post traumatic stress disorder (PTSD) are among the commonest mental health problems in refugee communities. Studies have shown that exposure to traumatic events refugees encountered in the pre-migration, during exile and post-migration periods are associated with symptoms of PTSD and depression in refugee populations. There were inconclusive findings from previous studies that have looked into the differential predictive significance of trauma related factors, particularly that of exposure to in pre-migration and post-migration traumatic experiences with symptoms of PTSD and depression among refugees. More importantly, there is no a rebust study that investigated the significance of association between trauma related and socio-demographic factors as predictors of psychological symptoms in Eritrean refugees living in Ethiopia. Despite the fact that there are several studies on detection of depression in the community using different measures, valid depression measure adapted in Eritrean culture for Eritrean community in humanitarian settings does not exist. In this regard, the latent factor structure (symptom presentation) for most measures of depression in many low income countries, particularly in almost all African countries, is not well understood Although there is abundant literature and theoretical basis on the co-morbidity of PTSD and depression in people affected by trauma, the extent of symptom co-variance and overlap between the two frequently reported forms of psychological symptoms by refugees (PTSD and depression) is not well known particularly in our study population. Mental health research is also increasingly focusing on the importance of investigating resilience in dealing with risk factors for mental health problems, such as personal coping styles and sense of coherence in people who are vulnerable for mental health problems in humanitarian crisis. Although extensive studies on the topic of resilience and sense of coherence were carried out among Eritreans in humanitarian settings, empirical adaptation studies on resilience measures and their validity were not given due attention. There is no quantitative evidence to confirm the psychometric properties of resilience measures in Eritrean refugees living in Ethiopia to date. There is also increasing concern on the co-morbidity of alcohol misuse with other mental health problems in refugee population in the context of humanitarian settings (refugee xiv camps). Indeed, the current study tried to investigate the relationship between theory driven risk and protective factors with mental health concerns of refugees (depression, PTSD and alcohol misuse) in Eritrean refugees living in Mai Aini refugee camp. Objectives: The objectives of this study are to: (a) identify which socio- demographic and trauma related factors are associated with PTSD and depression; (b) explore the direct, mediating and moderating effects of traumatic events on PTSD and depression; (c) determine the psychometric properties of measures employed in the study; (d) determine the structural relationship between exposure to cumulative trauma and poor mental health (indicated by co morbid symptoms of depression, PTSD and alcohol misuse). Methods: Cross-sectional study was conducted. In the survey, 562 adults were randomly selected from Eritrean refugees living in Mai Aini camp, Ethiopia. Center for Epidemilogic Studies Depression (CES-D) scale, Post-Migration Living Difficulties checklist, Primary Care PTSD screener (PC-PTSD), Oslo Social Support Scale (OSS-3), Sense of Coherence Scale (SoC-13), Coping Style scale and Fast Alcohol Screening Test (FAST) were administered concurrently. Data were analyzed using multiple linear regression modeling, path analysis and multivariable logistic regression model. In order to estimate the structural relationship between exposure to trauma, risk and protective factors (as mediating factors), and co morbid mental health outcomes (indicated by PTSD, depression and alcohol misuse), Structural Equation Modeling (SEM) was employed. SEM was also employed to identify the percentage of variance explaining common latent factors by the three outcomes of mental health concerns in refugees (PTSD, depression and alcohol misuse). It was also used to estimate symptom co-variance between symptoms of PTSD and depression. In order to test the factor structure of measures used in the present study, Confirmatory Factor Analysis (CFA) was carried out. Results PTSD and depression symptoms did not vary across major demographic variables with respect to gender, age and marital status. Exposure to pre-migration trauma was associated significantly both with increased symptoms of PTSD (β =0.11, p&lt;0.05) and depression (β =0.29, p&lt;0.001) after adjusting for demographic factors, sense of coherence and social support. Exposure to post-migration trauma was associated with increased symptoms of depression (β =0.21, p&lt;0.001), but not with PTSD symptoms. There was 85% co-variance between latent factors of depression and PTSD, which shows the likelihood of symptom overlap between the two constructs. Pre-migration living difficulties were directly associated with symptoms of PTSD (β=0.09, p &lt;0.05), and indirectly associated with PTSD through paths of duration of stay in camp, sense of coherence, post-migration living difficulties, task-oriented coping style and depression (standardized indirect coefficient=0.26, p&lt; 0.01). Depression was directly associated with pre-migration (β=0.35, p &lt;0.001) and post-migration (β=0.23, p &lt; 0.05) living difficulties. Post-migration living difficulties were indirectly associated with PTSD through paths of sense of coherence, task-oriented coping style and depression (standardized indirect coefficient=0.13, p&lt;0.01). Social support moderated the effect of post-migration living difficulties on depression (β = -0.106, P&lt;0.05). Emotion-oriented coping style moderated the effect of pre-migration threat for abuse on PTSD (β = -0.18, p&lt;0.001) and depression (β = 0.12, p&lt;0.01). It also moderated threat for life on PTSD (β = -0.13, p&lt;0.001). With respect to the measure of depression, first-order two factors with second-order single factor model of CES-D (correlated error terms) yielded the best fit to the data [CFI= 0.975; RMSEA=0.040 (90%CI=0.032, 0.047)]. The 16 items defining depressive affect were internally consistent (Cronbach"s alpha = 0.932) and internal consistency of the four items defining Positive Affect was medium (Cronbach"s alpha = 0.703). CES-D has acceptable convergent validity with pre-migration living difficulties checklist (r= 0.545, p&lt;0.001), postmigration living difficulties checklist (r= 0.47, p&lt;0.001), PC-PTSD (r= 0.538, p&lt;0.001) and FAST (r=0.197, p&lt;0.001). It has acceptable divergent validity with SoC-13 (r= -0.597, p&lt;0.001) and OSS-3 (r= -0.319, p&lt;0.001). Key findings regarding the validity of the measure for sense of coherence (SoC-13) demonstrated that the one factor model of SoC-13 with twelve items best fitted the present data (CFA=0.982, RMSEA=0.035), with good internal consistency (Cronbach"s Alpha= 0.75). The negative association between SoC-13 and PC-PTSD (r= -0.433, p&lt;0.001), CES-D (r= -0.597, p&lt;0.001), pre-migration and post-migration living difficulties checklist subscales ((r= -0.265, p&lt; 0.001 and r= -0.249, p&lt;0.001 respectively), and FAST (r= -0.105, p&lt; 0.001) provided sufficient evidence for its divergent validity. SoC-13 has positive association with Oslo Social Support scale (OSS-3) (r= 0.363 p&lt; 0.001) and task oriented coping style sub-scale(r=0.089, p&lt;0.001), demonstrating acceptable convergent validity of this measure. Multivariable logistic regression analysis indicated that exposure to pre-migration living difficulties (Adj. OR = 1.09 [95%, CI =1.03, 1.08] p˂ 0.001) and use of emotion-orientecoping (Adj. OR=1.63 [95% CI=1.15, 2.32], p˂ 0.01) were positively associated withrefugees" alcohol misuse. Bi-variate analysis of perarson"s correlation also indicate that refugees" alcohol misuse is positively associeted with depression (r=0.197, p˂0.01). Iaddition, in the multivariable logistic model, being a female (Adj. OR = 0.30[95%, CI= 0.170.55], p&lt; 0.001) is associated with decreased odds of alcohol misuse compared to maleParticipants aged 25-34 (Adj. OR = 0.40 [95%, CI =0.20, 0.80], p&lt; 0.05) and those withiage group of 45-54 (Adj. OR =0.14 [95% CI=0.02, 0.78], p&lt; 0.05) were less likely exposedfor alcohol misuse compared to the younger refugees aged 18-24. Increased frequency oprayer was negatively associated with probable alcohol misuse (Adj. OR = 0.51 [95%, CI0.37, 0.70], p&lt; 0.001). Furthermore, findings from the SEM analysis demonstrated thalcohol misuse has significantly loaded onto the second-order common factor (β =0.21,p&lt;0.001) with symptoms of PTSD and depression; which means 21% of variance for thsecond-order common factor (co-morbid problem) is accounted for by alcohol misuse in structural model which demonstrated close acceptance of fit to the current data (χ /df =2.508,CFI=0.868; TLI=0.855, RMSEA= 0.052(90%:0.055 0.066). Conclusions Fostering sense of coherence, social support, task-oriented and emotion-oriented coping styles and preventing post-migration abuses, especially for female refugees, need to be given particular consideration when planning an intervention. The current finding regarding significant positive correlates of alcohol misuse (such as pre-migration trauma, depression,emotion-oriented coping, and younger age) and significant negative correlates (such as beingfemale in gender, sense of coherence and frequency of prayer) provide useful information specific to intervention of alcohol misuse in Eritrean refugees. Inferences from co-variances of latent factors indicate that there is a strong co-morbidity between the two mental health concerns in Eritrean refugees (PTSD and depression). The evidence regarding modest co morbidity between alcohol misuse and psychological symptoms strongly suggests the importance of considering alcohol misuse as an integral part of intervention in the mental health care endeavors for Eritrean refugees. The findings regarding" refugees" longer duration of stay in the camp for mediating the effect of exposure to pre-migration traumatic experiences on PTSD informs the need for their acceleration of repatriation, resettlement or integration with the host society. 2