Posttraumatic stress disorder and psychological distress in Rwandan refugees living in Zambia

Abstract

The present study investigated posttraumatic stress disorder and psychological distress among Rwandan refugees living in the townships of Lusaka, Zambia. Refugees are often exposed to trauma and violence which leads to a wide range of psychological distress and mental disorders. Two hundred and sixty-seven refugees participated in the study. The sample consisted of older and younger adult refugees, 128 (47.9%) males and 139 (52.1%) females, from Lusaka. The Impact of Event Scale–Revised and the General Health Questionnaire-28 were administered to all participants. The study found that a significant number of participants reported posttraumatic stress disorder and psychological distress. About 76.8% endorsed posttraumatic stress disorder symptoms. In addition, 31.8% reported somatic symptoms, 36.7% anxiety or insomnia, 27.3% social dysfunction, and 22.8% severe depression. Lower education (p < .01), larger family size (p < .001), lack of financial support (p < .05), and being unemployed (p < .001) were positively associated with posttraumatic stress disorder and psychological distress. Intervention strategies aimed at improving the lives of refugees should be ongoing and must encompass a well-articulated, structured refugee policy that emphasizes mental health and psychological needs.

Keywords

Depression genocide mental disorders psychological distress posttraumatic stress disorder refugees

It is estimated that there are about 25.4 million refugees and 3.1 million asylum-seekers globally (United Nations High Commissioner for Refugees [UNHCR], 2017). While the Holocaust is most reported, three lesser known genocides have also taken place in recent history: the Cambodian (Zahar & Sluiter, 2008), Rwandan (Hatzfeld, 2006), and the Bosnian (Kiernan, 2008) genocides. The 1994 Rwandan genocide led to about one million people being violently killed within 100 days, with more than two million people fleeing to different countries for refuge (Rieder & Elbert, 2013; Rutagengwa, 2012). In the context of the Southern African Development Community (SADC) region, during the years 1994–2010, Zambia hosted close to 11,000 Rwandan refugees (Simuchoba, 2014); they settled mainly in the urban areas, with the highest concentration in Lusaka, the capital city of Zambia (Commissioner for Refugees in Zambia, personal communication, June 14, 2018; Darwin, 2005).

Refugees are considered a vulnerable group; this is because they experience major disruptions in their social and economic networks resulting from fleeing their home countries (Molsa et al., 2017; Motti-Stefanidi & Salmela-Aro, 2018). When fleeing, the refugees’ entire social systems are lost or destroyed, including their family systems that provided livelihood and support (Jacobsen & Fratzke, 2016). These losses affect refugees’ mental health, resulting in many psychosocial problems, which are exacerbated by the extreme brutality many refugees may witness, or to which they are exposed (Turrini et al., 2017). The traumatic experiences of refugees lead to posttraumatic stress disorder (PTSD), which has a high comorbidity with other mental disorders, especially depression (Ullmann et al., 2015) and various psychiatric symptoms (Schwitzer et al., 2011). Compared to the general populace, studies show that asylum-seekers and refugees have higher prevalence rates of depression, somatoform disorders, psychosis and disorders, resulting from the stress they experience (Schwitzer et al., 2011; Turrini et al., 2017). PTSD remains the pre-eminent mental-health outcome studied among refugees; acculturation stress emerges among the factors that generate symptoms of PTSD, depression, and anxiety when refugees struggle with culture and identity (Hameed et al., 2018). It becomes difficult for refugees to integrate into their host country’s culture, thus creating mental stress.

Priebe et al. (2016) and Ullmann et al. (2015) report that trauma experienced by displaced people, refugees, and asylum-seekers has a different shape and span to that of other populations. Despite war-related traumatic events being the initial cause of their challenges, daily difficulties, such as acquiring material goods, account for further psychological distress (Rasmussen et al., 2010). In addition, many refugee populations encounter the effects of economic deprivation (Hynie, 2018; Jacobsen & Fratzke, 2016). The economic challenges also give rise to elevated levels of psychiatric sequelae, such as depression and PTSD symptoms (Rubanzana et al., 2015), and a high proportion of refugees are subjected to potentially traumatic and depressive experiences after arriving in their host country (Rieder & Elbert, 2013).

Reporting on the Rwandan refugees who settled in Lusaka, Bbaala and Mate (2016) highlight the challenges faced by refugees arising from the trauma experienced in their home country, as well as challenges faced in their hosting county, which are compounded by social and economic exclusion. The refugees from Rwanda who live in the compounds or townships of Lusaka have been the target of many xenophobic attacks, which have contributed to the heightened insecurity of the refugees. In their report on xenophobic attacks on refugees in South Africa, Misago et al. (2015) cited increasing urbanization of refugee populations as a factor that increases refugees’ vulnerability and exposes them to intolerant attitudes and practices among the hosting members of the country; these hostilities prevent refugees from securing their livelihoods and accessing the social welfare systems in an amicable manner. Similarly, the xenophobic attacks on refugees in Zambia have been a blatant intimidation which impacts negatively on refugees’ security and ability to freely access general public services (Bbaala & Mate, 2016). Often, there is a level of psychological distress in many refugees that is heightened by the harsh manner in which host citizens deal with them (Nickerson et al., 2011).

Nose et al. (2017) note that traumatic events, such as perceived stigma, discrimination, and resettlement stress encountered in the post-displacement era of refugees, are of paramount importance for understanding refugee stress and psychological distress. In addition, Roth et al. (2014) state that, at the family level, existing parental psychopathology emanating from the past traumatic experiences and current socioeconomic challenges have substantial psychological repercussions that affect the mental health of younger generations of refugees.

The recent cessation declaration clause by the UNHCR (2013), that Rwandan refugees should return home, has its own implications that have left many refugees stateless. The Refugee Convention of 1951 states that refugees can only return to their home countries on the return of peace. This clause leaves Rwandan refugees with two options, either to embrace repatriation or be naturalized as citizens in Zambia (Kagire, 2018). However, most of the Rwandan refugees have decided to remain in Zambia for fear of losing their already-established businesses and of being persecuted if they return to their home country. In addition, issues such as legal residency status have exacerbated uncertainty around security for the refugee communities, who live in fear and cannot freely attain or access public services, a situation that further increases their stress.

This study is guided by Bronfenbrenner’s (1977) ecological systems theory that recognizes the fact that multiple levels (individual, family, community and society) influence an individual’s development. Drawing on the insights of the ecological systems theory, this research emphasizes that PTSD and psychological distress among refugees emanate not only from past exposure to traumatic experiences but also from ongoing displacement-related stressors being encountered in their social ecology (Miller & Rasmussen, 2016). Therefore, the aim of this article was to determine the prevalence of PTSD and psychological distress in a sample of older and younger Rwandan refugees living in Lusaka and identify demographic factors associated with PTSD and psychological distress.

Method

Participants

Two hundred and sixty-seven participants were recruited to investigate PTSD and psychological distress among two generations of the Rwandan refugee population in Lusaka, Zambia. A quantitative cross-sectional design was utilized for this study. The data were collected over a 5-month period in Matero, Mutendere, Mandevu, Chipata, Bauleni, Chawama, Kanyama, Makeni, Garden, Zingalume, Garden House, Chelston, George, Chilenje, and Kabanana townships. The sample included those refugees who had fled Rwanda and had experienced the genocide (the direct trauma exposure group—DE), and those who were children of those who had fled Rwanda and experienced the indirect consequences of the genocide and living as refugees (the indirect trauma exposure group—IE).

An estimated number of 900 refugees reside in the townships of Lusaka (Commissioner for Refugees in Zambia, personal communication, February 6, 2018). Based on our statistical sampling determination, using a 5% significant level (α = .05) and 80% statistical power (β = .20), a minimum sample size of 270 was determined to be sufficient. In this study, 267 participants were recruited. To obtain the sample, and given the nature of refugee research, purposive sampling was used to access participants, followed by snowball sampling. To avoid selection bias, the Commissioner for Refugees in Zambia was contacted several times to provide demographic data, thus increasing the possibility of representativeness. The focus for this study was on adult refugees whose primary residence was within the townships of Lusaka.

Instruments

A battery of questionnaires comprising a demographic questionnaire, the Impact of Event Scale–Revised (IES-R) and the General Health Questionnaire-28 (GHQ-28) was administered to each participant. The demographic section elicited personal information such as age, gender and area of residence, education, employment, religious affiliation, number of children, income, and marital status.

IES-R

The IES-R is a 22-item self-report measure that assesses subjective distress arising from traumatic events and experiences. The IES-R (Weiss & Marmar, 1997) was developed to parallel the Diagnostic and Statistical Manual of Mental Disorders (4th Edition; DSM-IV) criteria for PTSD. The 22 items are rated on a 5-point scale, ranging from 0 to 4. A higher score implies more and more severe problems. The 22 items are clustered into three subscales: intrusion, avoidance, and hyper-arousal. A cut-off score of ⩾33 was used to identify PTSD (Creamer et al., 2003; Hussain et al., 2013; Morina et al., 2013). This scale has been shown to possess adequate psychometric properties as an assessment of exposure to trauma (Acarturk et al., 2018). The Cronbach alpha of the instrument in this study was .96.

GHQ-28

The GHQ-28 is a psychological scale used to measure general functional psychiatric morbidity (Goldberg & Hillier, 1979) and recent psychological distress. The GHQ-28 version categorizes psychological symptoms into four domains: somatization; anxiety and insomnia; social dysfunction; and severe depression. Each of the four subscales consists of seven items. The items are endorsed on a 4-point Likert-type scale. The GHQ-28 is scored by assigning 0 for response choices 1 and 2, and 1 for response choices 3 and 4, for each item. A cut-off point of ⩾5 is used to detect psychological distress. Higher scores on the GHQ-28 subscales reflect poorer functioning (Goldberg & Williams, 1988). Cronbach’s alpha for the complete scale in the current study was .95. In addition, the Cronbach alphas for the GHQ-28 subscales were somatic (0.87), anxiety and insomnia (0.89), social dysfunction (0.88), and severe depression (0.89).

Procedure

Comprehensive training sessions were held for 2 weeks with the research team, covering the research procedures, administration of the questionnaires, and conducting of interviews. To ensure fairness, four trained research assistants, who were fluent in English, Nyanja, Kinyarwanda, and French, administered the questionnaire to each participant. Participation in this study was voluntary and refugees from Rwanda or their family, aged 18–65 years, living in the townships of Lusaka, were invited to participate. Those who agreed to participate were asked to complete consent forms before participating in the study. The response rate was 98.9%. The average time taken to complete the battery was 45–60 min.

Ethical considerations

Ethical clearance was obtained from the Human Sciences Research Ethics Committee, University of KwaZulu-Natal (HSS/0119/018D). Permission was also sought from the Commissioner of Refugees to conduct research in Zambia among the Rwandan people. The consent form was available in English and translated into Kinyarwanda by an expert, to ensure that the participants understood the study and what they were consenting to.

Data analysis

The data were collected and captured using the Statistical Product and Service Solutions, version 25 (IBM SPSS 25). The data were checked for skewness and collinearity and found to be within the accepted range. Normality tests were used to assess potential skewness. Absence of collinearity was confirmed by assessing the pairwise correlations of the explanatory variables. Descriptive statistics were used to report on the demographic variables. The items in each of the scales and subscales were averaged and utilized as composite scores. To determine associations between demographic characteristics and PTSD (using the IES-R scale), as well as psychological distress (using the GHQ-28 subscales), we utilized the Pearson Chi-square test for association. Binary logistic regression was used to assess PTSD as well as the different components of psychological distress, which includes somatic symptoms, anxiety/insomnia, social dysfunction, and severe depression. Assumptions of binary logistic regression were evaluated, and there was no evidence of violation. The statistics were tested at the 5% significance level.

Results

The age of participants (N = 267) ranged from 18 to 65 years (M = 33.99; Table 1). Over half of the participants (52.1%) were female. Almost half of the participants (49.8%) were single. Just over half of the study participants (51.7%) had children and a majority (61.7%) had undergone some formal education. Over half (51.7%) were unemployed, and around 69.7% reported that they had no financial support. Just under half of the participants earned less than K300 (49.4%) for their monthly income (Table 1).

Table 1.

Sociodemographics of the study sample (N = 267).

	n	%
Gender
Male	128	47.9
Female	139	52.1
Trauma exposure
Indirect	107	40.1
Direct	160	59.9
Marital status
Married	109	40.8
Living together	1	0.4
Separated/divorced	8	3.0
Single	133	49.8
Widow/widower	16	6.0
Children
No children	129	48.3
1–2 children	47	17.6
3–5 children	71	26.6
⩾6 children	20	7.5
Education
Primary	58	21.7
Secondary	107	40.1
College	50	18.7
University	52	19.5
Financial support (other than salary)
Yes	81	30.3
No	186	69.7
Nature of financial support
None	186	69.7
Family	41	15.4
Church	31	11.6
NGO	6	2.2
Employment status
Employed	129	48.3
Unemployed	138	51.7
Monthly income (all income including support or earned)
⩽K300	132	49.4
K301–K600	45	16.9
K601–K2000	54	20.2
⩾K2001	36	13.5

IE: indirect exposure; DE: direct exposure; NGO: non-governmental organization; K: Kwacha (1USD = ±K20 as of June 2020). Note: values for financial support do not correspond because of missing values.

As shown in Table 2, high levels of PTSD (76.8%; cut-off score of ⩾33) were reported by the participants on the IES-R. These were significantly associated with trauma exposure (p < .001), marital status (p < .001), number of children (p < .001), education (p = .005), and employment status (p < .004). There were no significant differences for gender.

Table 2.

Participants’ responses on the IES-R and GHQ-28.

	IES-R		GHQ-28
	PTSD, n (%)	p	Somatic symptoms, n (%)	p	Anxiety/insomnia, n (%)	p	Social dysfunction, n (%)	p	Severe depression, n (%)	p
Total symptoms	205 (76.8)		85 (31.8)		98 (36.7)		73 (27.3)		61 (22.8)
Gender
Male	101 (78.9)	.424	42 (32.8)	.742	49 (38.3)	.608	35 (27.3)	.999	24 (18.8)	.126
Female	104 (74.8)	.424	43 (30.9)	.742	49 (35.3)	.608	38 (27.3)	.999	37 (26.6)	.126
Trauma exposure
Indirect	66 (61.7)	< .001***	15 (14.0)	< .001***	22 (20.6)	< .001***	9 (8.4)	< .001***	6 (5.6)	< .001***
Direct	139 (86.9)	< .001***	70 (43.8)	< .001***	76 (47.5)	< .001***	64 (40.0)	< .001***	55 (34.4)	< .001***
Marital status
Married/living together	95 (87.1)	< .001***	50 (45.5)	< .001***	52 (47.3)	.003**	48 (43.6)	< .001***	35 (31.8)	.011*
Separated/widowed	1 (100)		13 (54.2)		13 (54.2)		10 (41.7)		13 (54.2)
Single	7 (87.5)		22 (16.5)		33 (24.8)		15 (11.3)		13 (9.8)
Number of children
No children	84 (65.1)	< .001***	20 (15.5)	< .001***	30 (23.3)	< .001***	15 (11.6)	< .001***	12 (9.3)	< .001***
1–2 children	35 (74.5)		12 (25.5)		13 (27.7)		10 (21.3)		14 (29.8)
3–5 children	68 (95.8)		42 (59.2)		43 (60.6)		38 (53.5)		28 (39.4)
⩾6 children	18 (90.0)		11 (55.0)		12 (60.0)		10 (50.0)		7 (35.0)
Education
Primary	53 (91.4)	.005**	27 (46.6)	.030*	28 (48.3)	.213	23 (39.7)	.004**	18 (31.0)	.052
Secondary	86 (80.4)		31 (29.0)		37 (34.6)		29 (27.1)		22 (20.6)
College	33 (66.0)		16 (32.0)		17 (34.0)		16 (32.0)		15 (30)
University	33 (63.4)		11 (21.2)		16 (30.8)		5 (9.6)		6 (11.5)
Financial support
Yes	55 (67.9)	.071	18 (22.2)	.026*	24 (29.6)	.113	17 (21.0)	.124	17 (21.0)	.633
No	150 (80.7)	.071	67 (36.0)	.026*	74 (39.8)	.113	56 (30.1)	.124	44 (23.7)	.633
Employment status
Employed	110 (85.2)	.004**	54 (41.9)	.001**	59 (45.7)	.003**	51 (39.5)	< .001***	42 (32.6)	< .001***
Unemployed	95 (68.9)	.004**	31 (22.5)	.001**	39 (28.3)	.003**	22 (15.9)	< .001***	19 (13.8)	< .001***

IE: indirect exposure group; DE: direct exposure group. PTSD cut-off score = ⩾33. GHQ-28 cut-off score = ⩾ 5.

p < .05; **p < .01; ***p < .001.

Participants reported high levels (cut-off score of ⩾ 5) of somatic symptoms (31.8%), anxiety and insomnia (48.3%), social dysfunction (27.3%), and severe depression symptoms (22.8%) (Table 2). Somatic symptoms were significantly associated with exposure to trauma, especially in the DE group (p < .001), marital status (p < .001), number of children (p < .001), education (p = .030), financial support (p = .026), and employment status (p = .001). Anxiety and insomnia were significantly associated with age (p < .001), marital status (p < .003), number of children (p < .001), and employment status (p < .003). Social dysfunction was significantly associated with age (p < .001), marital status (p < .001), number of children (p < .001), education (p = .004), and employment status (p < .001). Severe depression was significantly associated with respondents’ generation (p < .001), marital status (p < .001), number of children (p < .001), education (p < .030), and employment status (p < .001) (Table 2).

Table 3 shows the factors significantly associated with psychological distress (as measured by the four GHQ subscales). Those in the IE group were significantly less likely (odds ratio [OR] = 0.268; 95% confidence interval [CI] = [0.088, 0.817]) to have social dysfunction than were the DE group. Educational attainment was significantly associated with social dysfunction. Compared to those with a university education, those who had primary school (OR = 3.845; 95% CI = [1.186, 12.459]), secondary school (OR = 4.643; 95% CI = [1.519, 14.190]), or college education (OR = 6.189; 95% CI = [1.841, 20.810]) were more likely to have social dysfunction. IE group and college qualification were significantly associated with severe depression. Those in the IE group were significantly less likely (OR = 0.158; 95% CI = [0.049, 0.517]) to have severe depression than those in the DE group. Those with a college qualification, rather than a university qualification, were more likely to have severe depression (OR = 4.107; 95% CI = [1.278, 13.204]).

Table 3.

Binary logistic regression of somatic symptoms, anxiety, social dysfunction, and severe depression.

	Somatic symptoms					Anxiety					Social dysfunction					Severe depression
	OR	Wald	95% CI		p	OR	Wald	95 % CI		p	OR	Wald	95 % CI		p	OR	Wald	95 % CI		p
			Lower	Upper				Lower	Upper				Lower	Upper				Lower	Upper
Gender
Male	0.997	0.000	0.544	1.828	.993	1.040	0.019	0.592	1.828	.891	0.889	0.122	0.461	1.716	.726	0.530	3.267	0.266	1.055	.071
Employed
Yes	0.736	0.607	0.340	1.592	.436	0.892	0.096	0.435	1.831	.756	1.078	0.033	0.478	2.432	.857	1.149	0.110	0.506	2.609	.740
Financial support
Yes	0.738	0.731	0.368	1.480	.393	0.885	0.144	0.471	1.663	.705	1.007	0.000	0.474	2.138	.986	1.154	0.133	0.535	2.489	.716
Trauma exposure
IE	0.515	1.797	0.195	1.359	.180	0.513	2.341	0.218	1.206	.126	0.268	5.355	0.088	0.817	.021*	0.158	9.318	0.049	0.517	.002**
Marital status
Married/Living together	1.299	0.220	0.435	3.875	.639	0.776	0.234	0.278	2.166	.628	2.433	2.239	0.759	7.800	.135	1.638	0.691	0.512	5.240	.406
Separated/Widowed	1.802	0.728	0.466	6.967	.393	1.024	0.001	0.280	3.745	.971	1.956	0.851	0.470	8.123	.356	3.770	3.463	0.932	15.251	.063
Number of children
No children	0.305	2.345	0.067	1.393	.126	0.277	2.978	0.065	1.190	.084	0.684	0.225	0.142	3.287	.635	0.904	0.016	0.187	4.362	.900
1–2 children	0.332	3.488	0.104	1.056	.062	0.280	4.678	0.088	0.887	.031*	0.341	3.012	0.101	1.149	.083	0.827	0.096	0.248	2.758	.757
3–5 children	1.185	0.104	0.422	3.328	.747	1.024	0.002	0.362	2.896	.964	1.091	0.026	0.377	3.157	.872	0.913	0.026	0.306	2.730	.871
Highest qualification
Primary	1.773	1.351	0.675	4.656	.245	1.269	0.271	0.518	3.112	0.602	3.845	5.039	1.186	12.459	.025*	2.100	1.606	0.667	6.614	.205
Secondary	1.505	0.827	0.624	3.629	.363	1.168	0.150	0.532	2.562	0.699	4.643	7.256	1.519	14.190	.007**	2.041	1.679	0.694	6.003	.195
College	1.781	1.301	0.660	4.804	.254	1.102	0.044	0.446	2.723	0.833	6.189	8.680	1.841	20.810	.003**	4.107	5.622	1.278	13.204	.018*
Nagelkerke		R² = 0.243				R² = 0.174					R² = 0.31					R² = 0.275

OR: odds ratio; IE: indirect exposure.

p < .05; **p < .01; CI = 95%.

The explained variation (using the Nagelkerke R²) in psychological distress based on the four models ranged from 17.4% to 31.0%. The Nagelkerke R² was used because of its familiarity of usage in the literature. R² values range from 0 to 1. For acceptable range of good model fit, R² values closer to 1 indicate a better model fit. Table 4 shows the binary logistic regression of PTSD (as measured by the IES-R scale). The model explained 24.9% (Nagelkerke R²) of the variation in PTSD. IE group, as well as primary and secondary school levels, was significantly associated with PTSD. Those in the IE group were significantly less likely (OR = 0.387; 95% CI = [0.159, 0.945]) to have PTSD than those in the DE group. Compared to having a university qualification, those with primary school education (OR = 4.842; 95% CI = [0.409, 16.632]), or secondary school education (OR = 2.976; 95% CI = [1.291, 6.861]) were more likely to have PTSD.

Table 4.

Binary logistic regression of IES-R scale.

	OR	Wald	95.0% CI		p
			Lower	Upper
Gender
Male	1.258	0.475	0.655	2.413	.491
Employed
Yes	0.718	0.534	0.295	1.746	.465
Financial support
Yes	0.788	0.476	0.401	1.549	.490
Trauma exposure
IE	0.387	4.346	0.159	0.945	.037 *
Marital status
Married/living together	1.239	0.155	0.427	3.597	.693
Separated/widowed	2.092	0.624	0.335	13.062	.430
Number of children
No children	0.740	0.093	0.107	5.132	.760
1–2 children	0.497	0.654	0.091	2.709	.419
3–5 children	3.221	1.436	0.476	21.817	.231
Highest qualification
Primary	4.842	6.275	1.409	16.632	.012 *
Secondary	2.976	6.551	1.291	6.861	.010 *
College	1.204	0.163	0.489	2.962	.686

OR: odds ratio; IE: indirect exposure; Nagelkerke R² = 0.249.

p < .05.

Discussion

This study is, most likely, the first of its kind conducted in Zambia. Although other studies have been done among refugees in Zambia, most concentrate on refugees’ integration and livelihoods (Kambela, 2016), with emphasis on refugees living in the camps (Masuwa, 2017). This study focussed on refugees living in the townships of Lusaka. It investigated PTSD and psychological distress in two groups of Rwandese refugees: those who had direct experience of the genocide and those born to refugee parents.

The study investigated the prevalence of PTSD and psychological distress in Rwandans living in Lusaka, 24 years after the 1994 genocide. High rates of depression, PTSD, and psychological distress were found among the Rwandan refugees, especially among participants who had direct experience of the traumatic events. Furthermore, refugees with lower education and many children reported higher levels of GHQ-28-assessed somatic presentations, anxiety or insomnia, social dysfunction, and depression. This finding supports other research that depression and PTSD are common psychological distresses among refugee populations (Im et al., 2017; Miller & Rasmussen, 2010). In addition, other studies show that refugee trauma experiences remain salient long after resettlement (Bogic et al., 2015; Nose et al., 2017). Both past traumatic experiences and current day-to-day stressors contribute to refugees’ psychological distress (Rasmussen et al., 2010).

Most studies report that PTSD is more prevalent in female than male refugees (Ainamani et al., 2020). Mhlongo et al. (2018) state that exposure to sexual violence and trauma are factors that contribute to the higher rates of PTSD and depression among female refugees. However, in our study, no significant differences in PTSD by gender were found (Table 2). Studies by Schwitzer et al. (2011) and Steel et al. (2009) also found no association between PTSD and gender. In studies that show no association between gender and PTSD, there is no clear justification given for such a conclusion. However, Christiansen and Hansen (2015) and Farhood et al. (2018) advocate for further research to evaluate and explore the differences in PTSD between males and females.

We found that older refugees (namely, the DE group) were more likely to report social dysfunction and severe depression. The older refugees were more likely to have been exposed to a greater number of traumatic events compared to the younger participants. Hameed et al. (2018) found that acculturation stress, resulting from conflict between culture and identity among the DE group, creates high rates of depression and social isolation. Through social isolation, older refugees may lose socioeconomic opportunities such as finding employment and engagement in the host culture (Misago et al., 2015).

Our study found that refugees with more children and big families have higher levels of depression. This may result from the financial problems, emanating from the socioeconomic marginalization of refugees, that make it difficult for them to comprehensively satisfy family demands and obligations (Hynie, 2018). Our findings also show that lower education status is associated with depression and PTSD, bearing out the relationship between low education and depression shown in other studies (Hynie, 2018; Im et al., 2017). In other words, lower education is associated with a lower socioeconomic status which, in turn, is associated with many daily difficulties and psychological distress. According to Von Haumeder et al. (2019), access to essential human basic needs, such as education, is an important factor that reduces trauma symptoms as it enhances individuals’ socioeconomic status to cope with adverse challenges. Our study showed that refugees who did not have financial support and were not employed had significantly higher symptoms of PTSD.

Rwandan refugees in Zambia also face daily stressors that emanate from xenophobic attitudes by the locals (Bbaala & Mate, 2016). Refugees often face social isolation, negative criticism, and perceived discrimination (Nickerson et al., 2011). These challenges hinder the capacity of refugees to create socioeconomic integration and secure access to public services that offer financial and social support (Misago et al., 2015). Furthermore, uncertainties that surround refugees’ legal residency status create insecurities. Often, without credible documents, refugees cannot find employment.

Although the IE group of refugees had lower scores on trauma symptomology and depression compared to the DE group, they, nonetheless, had high levels of trauma symptoms and experienced psychological distress. Hameed et al. (2018) also found that older refugees score higher on trauma symptoms than the young. It is clear that past traumatic experiences account for more distress in the DE group. However, the IE group is also affected. Bryant et al. (2018) state that parental psychological distress and challenges arising from past traumatic experiences and socioeconomic challenges exacerbate high levels of PTSD symptoms in their children. Sangalang and Vang (2017), in their systematic review on intergenerational trauma in refugee families, found that parents’ trauma was associated with psychopathology in their children. Parental distress and intergenerational trauma affect contribute to stress in these parents’ children. Psychological distress and depression are associated with the socioeconomic and environmental context that people live in and will affect both the young and old.

Conclusion

Our study shows that past traumatic experiences and current stressors contribute to refugees’ psychological distress. Furthermore, these challenges contribute to socioeconomic deficiencies which also contribute to high levels of distress. Considering this, our study has a number of implications for intervention and practice. First, humanitarian providers should create deliberate policies that will advance and enhance the provision of mental-health care for refugees and asylum-seekers at the time of the crises, long after the traumatic experiences and indeed on an ongoing basis. Second, trauma and psychological distress are chronic and complex conditions. To break this vicious cycle, there is a need to provide regular mental-health care that is well structured and formalized. Third, in order to facilitate a clear and sustainable refugee repatriation and transition, there is a need for stakeholders to provide refugee mental-health programs that will prepare and support refugees. Furthermore, research is needed to develop well-designed interventions and outcome measures.

One of the limitations of this study is the sample size and the restriction of the sample selection to the city of Lusaka. A bigger sample, including other refugee camps in Zambia, will provide more information and clarity on refugees’ psychological distress. Another limitation is related to the fear that refugees have of divulging information and, as a result, personal information such as the participant’s monthly income or employment may not have been accurately obtained. Other sources to estimate income or other personal information should be considered in future research.

The study contributes to the literature gap by underscoring the fact that, apart from past trauma experiences, refugees still undergo day-to-day psychological distress. Furthermore, the study makes a valuable contribution by also highlighting that, among the Rwandese migrant population in Zambia, there exists a group that has had no direct experience of the genocide but is affected by its past imprints. In addition, our study demonstrated that there are long-term consequences of violence and trauma experiences (Rieder & Elbert, 2013).

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Victor Mwanamwambwa

References

Acarturk

Cetinkaya

Senay

Gulen

Aker

Hinton

(2018). Prevalence and predicators of posttraumatic stress and depression symptoms among Syrian refugees in a refugee camp. The Journal of Nervous and Mental Disease, 206(1), 40–45. https://doi:10.1097/NMD.0000000000000693

Ainamani

H. E.

Elbert

Olema

D. K.

Hecker

(2020). Gender differences in response to war-related trauma and posttraumatic stress disorder: A study among the Congolese refugees in Uganda. BMC Psychiatry, 20(1), 17. https://doi:10.1186/s12888-019-2420-0

Bbaala

Mate

(2016). Nowhere to run: A review of the political economy of migration, identity and xenophobic violence in Zambia. African Human Mobility Review, 2(3), 617–644. https://sihma.org.za/journals/AHMR-vol-2-no-3-sep-Dec-2016, pdf#page=83

Bogic

Njoku

Priebe

(2015). Long-term mental health of war-refugees: A systematic literature review. BMC International Health and Human Rights, 15(29), 1–41. https://doi.org/10.1186/s12914-015-0064-9

Bronfenbrenner

(1977). Toward an experimental ecology of human development. American Psychologist, 32(7), 513–531. https://doi.org/10.1037/0003-066X.32.7.513

Bryant

R. A.

Edwards

Creamer

O’Donnell

Forbes

Felmingham

K. L.

Silove

Steel

Nickerson

MacFarlane

A. C.

Van Hooff

Hadzi-Pavlovic

(2018). The effect of post-traumatic stress disorder on refugees’ parenting and their children’s mental health: A cohort study. The Lancet Public Health, 3(5), 249–258. https://doi.org/10:1016/S2468-2667(18)30051-3

Christiansen

D. M.

Hansen

(2015). Accounting for sex differences in PTSD: A multi-variable mediation model. European Journal of Psychotraumatology, 6, 26068. https://doi:10.3402/ejpt.v6.26068

Creamer

Bell

Falilla

(2003). Psychometric properties of the Impact of Event Scale–Revised. Behaviour Research and Therapy, 41(12), 1489–1496. https://doi.org/10.1016/j.brat.2003.07.010

Darwin

(2005). Report on the situation of refugees in Zambia for Africa and Middle East Refugee Assistance. http://www.amera-uk.org/files/Zambia

10.

Farhood

Fares

Hamady

(2018). Correction to: PTSD and gender: Could gender differences in war trauma types, symptom clusters and risk factors predict gender differences in PTSD prevalence? Archives of Women’s Mental Health, 21, 735–743. https://doi.org/10.1007/s00737-018-0874-6

11.

Goldberg

D. P.

Hillier

V. F.

(1979). A scaled version of the General Health Questionnaire. Psychological Medicine, 9(1), 139–145. https://doi.org/10.1017/S0033291700021644

12.

Goldberg

D. P.

Williams

(1988). A user’s guide to the General Health Questionnaire. NFER-Nelson.

13.

Hameed

Sadiq

Din

A. U.

(2018). The increased vulnerability of refugee population to mental health disorders. Kansas Journal of Medicine, 11(1), 20–23. https://doi.org/10.1761/kjm.v11i1.8680

14.

Hatzfeld

(2006). Machete season: The killers in Rwanda speak. Picador.

15.

Hussain

Weisæth

Heir

(2013). Posttraumatic stress and symptom improvement in Norwegian tourists exposed to the 2004 tsunami: A longitudinal study. BMC Psychiatry, 13, 322. https://doi.org/10.1186/1471-244x-13-232

16.

Hynie

(2018). The social determinants of refugee mental health in the post-migration context: A critical review. Canadian Journal of Psychiatry, 63(5), 297–303. https://doi.org/10.1177/0706743717746666

17.

Ferguson

Hunter

(2017). Cultural translation of refugee trauma: Cultural idioms of distress among Somali refugees in displacement. Transcultural Psychiatry, 54(5–6), 626–652. https://doi.org/10.1177/1363461517744989

18.

Jacobsen

Fratzke

(2016). Building livelihood opportunities for refugee populations: Lessons from past practice. Migration Policy Institute. http://wwww.migrationpolicy.org/research/building-livelihood-opportunities-refugee-populations-lessons-past-practice

19.

Kagire

(2018, February 22). Zambia is not a permanent home for Rwandan refugees, President Lungu says. The East African. https://www.theeastafrican.co.ke/news/Zambia-not-a-permanent-home-for-Rwandan-refugees/2558-4316286-13ynx96/index.html

20.

Kambela

(2016). Angolan refugees in Zambia: Reflecting on local integration as a sustainable solution. ACCORD. https://www.accord.org.za/publication/angolan-refugees-zambia

21.

Kiernan

(2008). Genocide and resistance in Southeast Asia: Documentation, denial, and justice in Cambodia and East Timor. Transaction Publishers.

22.

Masuwa

K. C.

(2017). Prior camp experiences and stress related to post traumatic stress disorder (PTSD) among refugees at Maheba refugee settlement in Zambia [Master’s thesis, University of Zambia]. http://dspace.unza.zm/handle/123456789/5232

23.

Mhlongo

Tomita

Thela

Maharaj

Burns

(2018). Sexual trauma and post-traumatic stress among African female refugees and migrants in South Africa. South African Journal of Psychiatry, 24, 12084. https://doi.org/10.4102/sajpsychiatry.v24i0.1208

24.

Miller

K. E.

Rasmussen

(2010). War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks. Social Science & Medicine, 70, 7–16. https://doi.org/10.1016/j.socscimed.2009.09.029

25.

Miller

K. E.

Rasmussen

(2016). The mental health of civilians displaced by armed conflict: An ecological model of refugee distress. Epidemiology and Psychiatric Sciences, 26, 129–138. https://doi:10.1017/s2045796016000172

26.

Misago

J. P.

Freemantle

Landau

L. B.

(2015). Protection from xenophobia: An evaluation of UNHCR’s Regional Office for Southern Africa’s xenophobia related programmes. United Nations High Commissioner for Refugees. https://www.unhcr.org/55cb153f9.pdf

27.

Molsa

Kuittinen

Tiilikainene

Honkasalo

Punamaki

(2017). Mental health among older refugees: The role of trauma, discrimination, and religiousness. Aging and Mental Health, 21(8), 829–837. https://10.1080/13607863.2016.1165183

28.

Morina

Ehring

Priebe

(2013). Diagnostic utility of the Impact of Event Scale-Revised in two samples of survivors of war. PLOS ONE, 8(12), Article e83916. https://doi.org/10.1371/journal.pone.0083916

29.

Motti-Stefanidi

Salmela-Aro

(2018). Challenges and resources for immigration youth positive adaptation: What does scientific evidence show us? European Psychologist, 23(1), 1–5. https://dx-doi-org.web.bisu.edu.cn/10.1027/1016-9040/a000315

30.

Nickerson

Bryant

R. A.

SiloveD Steel

(2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review, 31(3), 399–417. https://doi.org/10.1016/j.cpr.2010.10.004

31.

Nose

Ballette

Bighelli

Turrini

Purgato

Tol

Priebe

Barbui

(2017). Psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in high-income countries: Systematic review and meta-analysis. Plos One, 12(2), e0171030. https://doi.org/10.1371/journal.pone.0171030

32.

Priebe

Giacco

El-Nagib

(2016). Health evidence network synthesis report 47. Public health aspects of mental health among migrants and refugees: A review of the evidence on mental health care for refugees, asylum seekers and irregular migrants in the WHO European Region. World Health Organization. http://www.euro.who.int/__data/assets/pdf_file/0003/317622/HEN-synthesis-report-47.pdf

33.

Rasmussen

Nguyen

Wilkinson

Vundla

Raghavan

Miller

K. E.

Keller

A. S.

(2010). Rates and impact of trauma and current stressors among Darfuri refugees in Eastern Chad. American Journal of Orthopsychiatry, 80(2), 227–236. https://dx-doi-org.web.bisu.edu.cn/10.1111/j.1939-0025.2010.01026.x

34.

Rieder

Elbert

(2013). Rwanda—Lasting imprints of a genocide: Trauma, mental health and psychosocial conditions in survivors, former prisoners and their children. Conflict and Health, 7, 6. https://doi.org/10.1186/1752-1505-7-6

35.

Roth

Neuner

Elbert

(2014). Transgenerational consequences of PTSD: Risk factors for the mental health of children whose mothers have been exposed to the Rwandan genocide. International Journal of Mental Health Systems, 8(1), 12. https://doi.org/10.1186/1752-4458-8-12

36.

Rubanzana

Hedt-Gauthier

B. L.

Ntaganira

(2015). Exposure to genocide and risk of suicide in Rwanda: A population-based case-control study. Journal of Epidemiology and Community Health, 69, 117–122. https://doi:10.1136/jech-2014-204307

37.

Rutagengwa

(2012). Rwandan refugees in the Democratic Republic of the Congo and the application of International Humanitarian Law during the Congo wars [LLM dissertation, University of Pretoria]. http://repository.up.ac.za/handle.net/2263/27995

38.

Sangalang

C. C.

Vang

(2017). Intergenerational trauma in refugee families: A systematic review. Journal of Immigrant and Minority Health, 19(3), 745–754. https://doi.org/10.1007/s10903-016-0499-7

39.

Schwitzer

Brough

Vromans

L. P.

Asic-Kobe

(2011). Mental health of newly arrived Burmese refugees in Australia: Contributions of pre-migration and post migration experience. Australian and New Zealand Journal of Psychiatry, 45, 299–307. https://doi.org/10.3109/00048674.2010.543412

40.

Simuchoba

(2014, June 17). How did Zambia become the continent leader in refuge integration? African Arguments. https://africanarguments.org/2014/06/17/zambia-continent-leader-refugee-integration-by-arthur-simuchoba/

41.

Steel

Chey

Silove

Marnane

Bryant

R. A.

Van Ommeren

(2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association, 30(5), 537–549. https://doi.10.1001/jama.2009.1132

42.

Turrini

Purgato

Ballette

Nose

Ostuzzi

Barbui

(2017). Common mental disorders in asylum seekers and refugees: Umbrella review of prevalence and intervention studies. Internal Journal of Mental Health, 11(51), 1–14. https://doi:10.1186/s13033-017-0156-0

43.

Ullmann

Barthel

Tache

Bornstein

Licinio

Bornstein

S. R.

(2015). Emotional and psychological trauma in refugees arriving in Germany in 2015. Molecular Psychiatry, 20, 1483–1484. https://doi.org/10.1038/mp.2015.164

44.

United Nations High Commissioner for Refugees. (2013). Global trends in 2013. http://www.unhcr.org/5399a14f9.html

45.

United Nations High Commissioner for Refugees. (2017). Global trends: Forced displacement in 2016. https://www.refworld.org/docid/594aa38e0.html

46.

Von Haumeder

Ghafoori

Retailleau

. (2019). Psychological adaptation and posttraumatic stress disorder among Syrian refugees in Germany: A mixed-methods study investigating environmental factors. European Journal of Psychotraumatology, 10(1), 1686801. https://doi.org/10.1080/20008198.2019.1686801

47.

Weiss

D. S.

Marmar

C. R.

(1997). The Impact of Event Scale–Revised. In Wilson

J. P.

Keane

T. M.

(Eds.), Assessing psychological trauma and PTSD (pp. 399–411). The Guilford Press.

48.

Zahar

Sluiter

(2008). International criminal law: A critical introduction. Oxford University Press.