Abstract
Aims:
There is a scarcity of data on mental health problems among Sudanese internally displaced persons (IDPs). This study aims to assess the prevalence of mental disorders of IDPs in Sudan, and to determine and compare the association between mental disorders and socio-demographic variables between the rural and urban long-term IDP populations.
Methods:
This cross-sectional study was implemented in two IDP areas in Central Sudan. Data were collected during face-to-face interviews using structured questionnaires to assess socio-demographic factors and the Mini International Neuropsychiatric Interview (MINI) to determine psychiatric diagnoses. A total of 1,876 adults were enrolled from both study areas.
Results:
The overall prevalence of having any mental health disorder in the IDP population was 52.9%. The most common disorders were major depressive disorder (24.3%), generalized anxiety disorder (23.6%), social phobia (14.2%) and post-traumatic stress disorder (12.3%). Years of displacement and education were associated with different mental disorders between the two areas, and there were no gender differences in prevalence of mental disorders in either area.
Conclusion:
This study shows high prevalence rates of mental disorders in both urban and rural IDP populations in Sudan, indicating a need to explore the circumstances for these high rates and to develop appropriate responses.
Introduction
Globally, the number of internally displaced persons (IDPs) has steadily increased from 17 million in 1997 to 27.5 million at the end of 2010, while the number of refugees has remained fairly stable, fluctuating between 13 million and 16 million in the same period (Ghanem, Gadallah, Meky, Mourad & El-Kholy, 2009). Most IDPs live in low-income, war-torn countries, and their psychosocial health has not been well addressed (Thapa & Hauff, 2005). As of 2009, the Internal Displacement Monitoring Centre (IDMC) reported that Sudan continued to have the largest internally displaced population in the world, with an estimated five million, about 13% of the total Sudanese population (Gureje, Lasebikan, Kola & Makanjuola, 2006). The limited and existing IDP-specific health data suggest that in more than half the countries affected by internal displacement, IDPs and often the population at large have no access to adequate health care (Internal Displacement, 2011). IDPs have found to be a high-risk group for mental health disorders, and they scored lower on mental health indices than externally displaced refugees, thus further studies are needed to establish the magnitude of mental health consequences of forced displacement and the variables that moderate these consequences (Porter & Haslam, 2005). The paucity of research on the situation of displaced people living in urban areas of sub-Saharan Africa is frequently discussed in refugee studies, and it reflects a wider dearth of surveys of populations affected by conflict (Kagee & Garcia del Soto, 2003).
IDPs often find themselves in particularly ambiguous legal positions. It has long been acknowledged that IDPs lack the legal status of refugees and thus miss out on the special protection and support afforded to the latter. Furthermore, despite being citizens resident in their own country, they are commonly marginalized socially and politically (Kagee & Garcia del Soto, 2003). Unlike refugees, IDPs have not crossed an international border to find sanctuary but have remained inside their home countries. Even if they have fled for similar reasons as refugees (armed conflict, generalized violence, human rights violations), IDPs legally remain under the protection of their own government – even though that government might be the cause of their flight (UNHCR, n.d.). In this context of legal invisibility, little attention is directed at their mental health and psychosocial well-being, and mostly their needs go unacknowledged by relief agencies (IDMC, 2009).
Sudan is a multiethnic, multicultural country that links the Arab world to sub-Saharan Africa. The Sudanese population at the time of the study in 2009 consisted of 597 ethnicities who speak over 400 different languages and dialects (Kim, Torbay & Lawry, 2007). Sudan has experienced one of the worst population displacements in the world as a result of the world’s longest-running civil war (US Committee for Refugees, 2004). During the war the cities have doubled in size due to a huge influx from rural areas. In the capital Khartoum alone, an estimated two million persons have fled the southern part of the country during the civil war, and recently more have fled during the ongoing conflict in Darfur. The IDMC (2010) study (in collaboration with Tufts) states that the pattern of displacement into Khartoum arises from the combination of conflict, drought and famine that has afflicted the south and west of Sudan since the 1980s. Most IDPs in Khartoum live outside officially designated camps and formal resettlement areas. Although Khartoum had enjoyed strong economic growth in recent years, the impact of the growth has been uneven, and areas with internally displaced populations generally offer poor living conditions, few sustainable livelihood opportunities, or basic services (IDMC, 2010). IDPs from different regions of Sudan left their area of origin due to different reasons and over long time intervals after the 1983 civil war.
Throughout the history of long-term displacement of Sudanese IDPs and their squatter settlements in both rural and urban settings, the mental health problems and needs of those IDPs have not been properly addressed. There is a scarcity of data on the mental health problems among IDPs after the civil war in Sudan in 1983, and most of these studies were conducted among Sudanese refugees in neighbouring countries or in refugee camps in Darfur. A selective review of studies of Sudanese refugees on mental health and psychosocial well-being, coping strategies and interventions reported high rates of psychopathology, particularly post-traumatic stress disorder (PTSD) and depression (Tempany, 2009). Most of these studies focused on persons who had recently been displaced. Moreover, internationally there is very limited knowledge of the mental health consequences of long-term internal displacement. Globally, IDPs have resettled in very different locations, but little is known about the difference in mental health status between IDPs living in an urban and those in a rural location.
In this article we use data from an ongoing study of the need for mental health services in Sudan to address the following research questions:
What is the prevalence of mental disorders in two distinct IDP areas in Sudan: the urban Mayo IDP area in Khartoum and the rural Mobi IDP area in Gezira State?
What is the association between mental disorders and socio-demographic characteristics in the rural and urban IDP populations and how do they compare?
Methods
Participants
The sample frame was two IDP settlement areas that were randomly selected from all IDP settlement areas in Central Sudan. We wrote the names of each IDP settlement area – listed on the official registry – on a small piece paper, put all the names together in a bucket and randomly picked two: Mayo, an urban area in the outskirts of the Sudanese capital Khartoum; and Mobi, in a rural area in Gezira in Central Sudan.
The IDPs in both study areas are impoverished people from different regions of Sudan who left their areas of origin for various reasons during the last 30 years after the civil war started in 1983. Estimates of the number of IDPs in the greater Khartoum area varied in 2010 between 1.3 and 1.7 million (Gureje, Lasebikan, Kola & Makanjuola, 2006). Housing in both areas consists of temporary shelters built from cardboard, tin, sacks and mud. Near the urban Mayo area in Khartoum, there is a local hospital, in contrast to the rural area Mobi belonging to the Gezira agricultural scheme, where there is a small health centre.
The target population included all adults aged 18 years and over living in these areas. Written informed consent was obtained from all participants, and persons with severe intellectual disabilities or who did not speak Arabic were excluded.
Measures
The research questionnaires included socio-demographic data (age, gender, area of origin in Sudan, education, marital status, family size, employment and income), measures of history of migration, exposure to trauma, subjective health, somatic illness, stigma, and the use of traditional healers and public health services. The instrument used to determine psychiatric diagnoses was the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998). MINI is a short, structured diagnostic interview developed jointly by researchers and clinicians in the USA and Europe according to criteria for both the Diagnostic and Statistical Manual – 4th Edition (DSM-IV) and the International Classification of Diseases – 10th Edition (ICD-10) (Sheehan et al., 1998). It was designed to meet the need for a short but accurately structured psychiatric interview for clinical trials and epidemiological studies. It consists of standardized, structured, closed-ended questions throughout its diagnostic procedure. The DSM-IV and ICD-10 criteria were re-framed into standardized questions in MINI. Psychiatric diagnoses were made according to the number of affirmative replies to the specific questions. Studies have shown that MINI is a valid and reliable diagnostic tool, and it has been widely used in different cultural settings. Validation and reliability studies have compared MINI to the Structured Clinical Interview for DSM-IV disorders (SCID) and the Composite International Diagnostic Interview (CIDI), the two most widely used instruments. MINI has acceptably high validity and reliability scores, and can be administered in a short period of time (M = 18.7 minutes (SD = 11.6)) compared to the one to two hours required for the other two instruments (Sheehan et al., 1998).
Procedures
This cross-sectional study is part of the Sudan Mental Health Project, a longitudinal community-based study collecting interview-based mental health data before and after the implementation of a primary health care personnel training and health education programme. Baseline data were collected from October to December 2008 and were used for the current analysis. A pilot study was carried out among 100 university students in Khartoum City to test the applicability of the instruments, and the resulting suggestions regarding clarity of language used and logistics required were taken into account. Data were collected in face-to-face interviews using a structured questionnaire by qualified psychologists under the supervision of a research team from the University of Oslo and the University of Khartoum. All members of the research team underwent a one-week intensive training programme in research interview techniques. All houses in the study areas were contacted with the help of the local social contacts, and the list of houses and names of adult residents were checked and compared with the local registry lists obtained from each settlement to ensure that all households were selected. The research team asked all individuals over 18 years in all houses in the study areas to participate and if anyone was absent at the time of the first visit, the house was revisited at an arranged time when he/she was available. The response rate was 97% and a total of 1,876 adults from Mayo, Khartoum and Mobi, Gezira IDP areas were included. Individuals identified in need of special mental health services were informed about available health services in the area and those who were in need of urgent psychiatric help were referred immediately to the emergency psychiatric units in both areas. Ethical committees in Norway and Sudan approved the research protocol.
Statistical analyses
All data analyses were conducted using SPSS, version 16. Descriptive statistics are reported as frequencies and percentages for categorical variables, means (SD) for normally distributed continuous variables and medians (SD) for non-parametric variables. The data were stratified by interview location, and bivariate associations between socio-demographic factors and mental disorders were estimated using the χ 2 test for independence, taking the Yate’s continuity correction p value where appropriate.
Results
Table 1 presents the socio-demographic characteristics from both study areas. Just over half (52.8%) of the respondents were from Khartoum and 55.7% were women. Overall, 69.5% were married and 51.5% were originally from Western Sudan. The majority of the respondents (63.3%) moved from their original area in the last 20 years and the age of the study subjects ranged between 18 and 85 years, with a median of 35 years. The 18–30 years group made up 42.7% of the total sample. Over a fifth (21.6%) had no formal education, only 2.3% had a university degree and 53.6% had only up to six years of school education. Over half (53.4%) were unemployed. Of the 15.1% with permanent jobs, 47.7% had an income of less than US$100 per month. Compared with the urban area in Khartoum, the people from the rural area in Gezira had fewer years of education, larger family size and more people were displaced due to war problems. IDPs in Gezira also had higher employment and family income. Overall, 52.9% of respondents had a psychiatric disorder and 34.4% were identified as having two or more current mental disorders.
Socio-demographics characteristics of adults in two IDP areas in Central Sudan.
Sudanese pound.
Table 2 presents the prevalence of MINI-assessed mental disorders by location. In total, the most common disorders detected in the sample were major depressive disorder (24.3%), generalized anxiety disorder (23.6%), social phobia (14.2%) and PTSD (12.3%). The least common disorders were antisocial personality disorder (0.9%) and psychotic disorders (1.0%). IDPs from Khartoum had higher prevalence rates of hypomanic episode, PTSD, suicidality and alcohol and substance dependence than those from Gezira, who had a higher prevalence rate of social phobia.
Prevalence of MINI-assessed mental disorders by location among adult IDPs in Sudan.
Yate’s continuity correction, * p < .05.
Tables 3 and 4 present the associations between the socio-demographic characteristics and the most common MINI-assessed mental disorders in both study areas. No statistically significant differences between men and women were observed when comparing participants with a psychiatric disorder and those without
Socio-demographics by selected MINI-assessed mental disorders among adult IDPs in Mayo, Khartoum area.
p < .05; p values are about comparisons between those with and those without a mental disorder on the corresponding socio-demographic, not between the different disorders.
Sudanese pound.
Socio-demographics by selected MINI-assessed mental disorders among adult IDPs in Mobi, Gezira area.
p < .05; p values are about comparisons between those with and those without a mental disorder on the corresponding socio-demographic, not between the different disorders.
Sudanese pound.
Discussion
This study is the first census survey of rates of mental disorders in IDPs in Sudan. The study showed high prevalence rates of mental disorders in a sample of poor and long-term displaced people living in squatter settlements in both rural and urban areas of Sudan. More than half (52.9%) of the respondents fulfilled the diagnostic criteria of the MINI for any mental disorder. Almost a quarter (24.3%) had major depressive illness and over one fifth (23.6%) had generalized anxiety disorder, while 14.2% had social phobia and 12.3% had PTSD.
In relation to specific disorders, our study showed that social phobia and PTSD were significantly more common in the urban Khartoum area than the rural Gezira area, while the other disorders were found at similar rates in both areas. Years of displacement and education were key risk factors associated with the different rates of social phobia and PTSD in the two areas. Overall, few demographics were associated with any mental disorder in either area.
There are no epidemiological studies of the general adult population in Sudan with which to compare these IDP prevalence rates, apart from an old epidemiological study of mental disorders in a stable sample of young adults of an urbanized area in Khartoum, which found much lower prevalence rates of disorder (Mogga, 2006), and it is likely that a representative sample of the general adult population in Sudan would show lower prevalence rates than our study of IDPs.
It is therefore of interest to compare our IDP findings with epidemiological studies of general populations in other countries in the Middle East and in sub-Saharan Africa. Our findings were higher than the representative National Survey of the Prevalence of Mental Disorders in Egypt, using the MINI-Plus, which reported an overall prevalence of mental, mood and anxiety disorders as 16.9%, 6.4% and 4.75%, respectively (Karunakara et al., 2004), but similar to rates found in Ethiopia in a general population sample, using a different instrument, the CIDI (Steel et al., 2006).
In relation to other studies of IDPs, as expected, the prevalence rates in our IDP populations have been found to be similar to the study done by the International Medical Corps (2005) among IDP households in Darfur camps, where 31% of IDPs were found to be suffering from major depressive disorders, assessed using the Patient Health Questionnaire (PHQ-9) (Bolton, Wilk & Ndogoni, 2004).
In the present study 12.3% of the sample was reported to have PTSD, which is lower than the 46% reported among refugees from Southern Sudan living in Uganda (Jenkins, Mbatia, Singleton & White, 2010) and also lower than the 36.2% reported recently in the population of Juba Town in South Sudan (Roberts, Damundu, Lomoro & Sondorp, 2009). Both these populations have been exposed to forced migration recently, in addition to other recent traumatization by war and other events. Furthermore, different measures might account for those different findings since the study from South Sudan used a symptom scale to assess the levels of depression (Hopkins Symptom Checklist-25; Roberts et al., 2009) and not a diagnostic measure as we did in our study.
This study also explored the association of mental disorders with the socio-demographics of IDPs from two regions in Sudan, settled in both urban and rural areas. Compared with the urban area in Khartoum, the people from the rural area in Gezira had fewer years of education, larger family size and more people were displaced due to war problems. IDPs in Gezira had higher employment and family income. This may be due to the opportunity for some of the IDPs in Gezira to work on the farms in the rural area, while IDPs around Khartoum had difficulties finding jobs because of their low level of education and job scarcity. The similarities in prevalence rates between Mayo, Khartoum as an urban area and Mobi, Gezira as a rural area may be explained by the fact that the populations in the two areas were very similar in that they were both displaced from their original areas, had low education and suffered from lack of jobs, low income and crowded living conditions. Although the reported numbers were small, IDPs from the study area in Khartoum had higher prevalence rates of PTSD, alcohol and substance dependence and suicidality. The social desirability and religious effects may have led to under-reporting of alcohol and substance dependence. Those from the study area in Gezira had higher prevalence rate of social phobia, which may indicate the nature of the rural and somewhat isolated life in Gezira compared tothe open life in the urban area near the capital Khartoum. The study findings highlighted the fact that there were no marked gender differences in most common psychiatric disorders in our sample, which is consistent with other studies from Africa (Bechtold, 1990; Evans, 2007; Rahim & Cederblad, 1989).
The findings also shed light on the high morbidity in our sample in spite of the long duration since forced migration. This is in accordance with other studies, where poor integration into society has been suggested as one of several possible explanations for the increased prevalence of mental disease among refugees (IDMC, n.d.). However, studies of refugees living in less deprived and more secure situations like Norway and Australia have showed markedly lower prevalence rates after many years in the resettlement country (Sundquist & Johansson, 1996; Vaage et al., 2010).
Strengths and limitations
The strengths of this study were that it adopted a full psychiatric diagnostic assessment of IDP populations from various regions in Sudan while other studies have just assessed distress symptomatology of IDPs, as in the camps in Darfur area. The study was conducted by qualified and well-trained psychologists under the supervision of expert psychiatrists from University of Oslo and University of Khartoum and used a valid and reliable psychiatry interview questionnaire (MINI). The cross-sectional data presented here yield restrictions with regards to going beyond associations in the interpretation of the results. Another limitation of the study is that the research was conducted in two IDP areas in Central Sudan only. Thus, the findings cannot be generalized to all IDPs or host populations in other regions of Sudan; however, the similarity of the findings in the two areas indicates that the results may also be valid for other disadvantaged settlements of forced migrants in other areas of Sudan. It is likely that the prevalence rates of the non-migrant Sudanese population may be lower than the rates reported for the two IDP areas in our study, but to answer this question necessitates a representative epidemiological study of the prevalence rates of mental disorders in the Sudanese population.
Conclusion
In conclusion, this study revealed high prevalence rates of mental disorders among IDPs living in two IDP resettlement areas of Sudan with limited urban/rural differences. The socio-demographic characteristics and the high prevalence of mental disorders found in both study areas emphasize the vulnerability of those long-term IDP populations to the triad of poverty, illiteracy and disease, and that creates a considerable burden at both the national and international level. In order to explore these findings further and develop appropriate responses, there is thus a great need for further research focusing on mental disorders in general and not only on trauma-related disorders of these populations. It is likely that more systematic intervention studies aiming at increasing public awareness, human resource capacity building and developing low-cost community mental health services will have a positive impact on the health care system and subsequently contribute to reduce the high prevalence rates of mental disorders in these areas.