Post-traumatic stress disorder and associated factors among adults exposed to stress in Ethiopia: A meta-analysis and systematic review

Abstract

Objective:

Post-traumatic stress disorder is a complex psychiatric disorder that develops after exposure to traumatic events, such as violent physical assaults, accidents, rape, natural disasters, and conflicts, stranger than usual human experiences. The typical presentation of intrusive thoughts, the persistence of the trauma, the avoidance of pertinent stimuli, emotional numbness, and physiological hyperarousal are the characteristics of this anxiety symptom. Despite the presence of a study conducted on this problem, the pooled effect, particularly in Ethiopia, is not known; therefore, this study assessed the allover burden of post-traumatic stress disorder.

Method:

The available study was extracted and conducted on post-traumatic stress disorder and its associated factors in Ethiopia by three independent authors. The data were analyzed by using STATA version 11 after extraction was done on a Microsoft Excel spreadsheet. The random-effect model was used to estimate the pooled effect size of post-traumatic stress disorder and its effect in the previous studies with 95% confidence intervals. Funnel plots analysis and Egger regression tests were conducted to detect the presence of publication bias. A subgroup analysis and a sensitivity analysis were done.

Result:

Thirteen (13) studies were included with a total of 5874 study participants in this meta-analysis and systematic reviews. The pooled prevalence of post-traumatic stress disorder in Ethiopia was 39.28% with a 95% confidence interval (26.54, 52.01). Poor social support (adjusted odds ratio = 2.86; 95% confidence interval (1.81, 4.53)), being female (adjusted odds ratio = 1.89; 95% confidence interval (1.53, 2.34)), presence of previous mental illness (adjusted odds ratio = 4.72; 95% confidence interval (2.62, 8.36)), and witness (adjusted odds ratio = 2.01; 95% confidence interval (1.30, 3.11)) were associated with post-traumatic stress disorder.

Conclusion:

The burden of post-traumatic stress disorder in this meta-analysis and systematic review is high; therefore, immediate intervention is needed for those specific traumatized individuals.

Keywords

Meta-analysis post-traumatic stress disorder systematic review Ethiopia

Introduction

Post-traumatic stress disorder (PTSD) is the development of anxiety symptoms after excessive exposure to distressful life events experienced with terror, fear, and helplessness.¹ According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), PTSD is classified as a trauma-stressor-related disorder, rather than an anxiety disorder. PTSD is characterized by being exposed to a stressful event that leads to a life-threatening, subsequently, intrusive recollections event, hyperarousal symptoms, and avoidant behavior related to the traumatic event.² The four cluster symptoms listed in DSM-5 after exposure to a traumatic event are avoidance, intrusion, detrimental cognitive and emotional changes, and changes in arousal and reactivity.³ Those symptoms could be present or persist for at least one month, but in some cases, some people may experience delayed-onset PTSD which means symptoms that occur within six or more months after the traumatic event.⁴ Additionally, the diagnosis of PSTD also requires significant distress and functional impairment in social or occupational, or other important areas of functioning.^5,6 Other similar clinical manifestations due to medication, substance use, or other illness should be ruled out.⁵

According to the International Classification of Diseases 11th Revision (ICD-11), PTSD is a syndrome that occurred by exposure to extremely traumatic events or a series of events after that they re-experience such traumatic events.⁷ In ICD-11, PTSD is considered by the presence of exceedingly ominous or horrifying occurrence situations similar to DSM-5 but it contains three core symptoms; a sense of impending danger, avoiding memories of the horrific situation and encountering it again unlike in DSM-5 total symptoms grown to 20.⁸ Different events cause PTSD which usually happened accidentally such as car accidents, war, and fire. The burden of mental illness particularly PTSD is reported as a great public health issue in a conflict-affected population in which war and armed conflicts contribute to poverty, lack of employment, community violence, insecure living circumstances, and changes in the social dynamic.⁹

PTSD is a public health issue that contributes to poverty, lack of employment, insecure living circumstances, and change in the social network and is highly associated with low quality of life.¹⁰

There are many predictors which were associated with PTSD in different works of literature including being female, the presence of other mental illnesses, more than one exposure, and poor social support.^11–14

The global disease burden of mental illness estimated by the World Health Organization including stress-related disorders was the second leading cause of disability by the year 2020. A study conducted by Mexican individuals from a sample of various regions found that the prevalence of PTSD was 19%.¹⁵ The study done on European prisoners found the highest prevalence of PTSD among those in Finland (27.8%) followed by Croatian (20.6%), England (20.2%), and Germany (18.4%).¹⁶ In East Africa, like Uganda, the prevalence of PTSD ranges from 11.8 to 54%.^17–19 The prevalence of PTSD among internally displeased people ranges from 3.6% to 88% in different studies from different countries.^10,20,21 Ethiopia experienced the most internal displacement during the first half of 2018. According to the Internal Displacement Monitoring Center report, 1.4 million people experienced internal displacement.²² In the Ethiopian context, PTSD can be found in different life events such as conflict or war, car accidents, and internal or external displacement. The prevalence of PTSD had great variation from 15.4% to 85% which needs the pooled effect of this problem in Ethiopia.^{11–13,23,24} This study contributed to a better understanding of the epidemiological burden of PTSD in low-income countries.

Currently, the burden of PTSD becomes raising due to different incidents in Ethiopia like internal displacement due to the existing war, natural disasters, and human medical events such as car accidents.^24,25 This meta-analysis and systematic review contributes a lot to the policymakers and to the stakeholders who give different forms of support and interventions. Knowing the pooled prevalence of PTSD and its determinant factors can clear the ambiguity of the inconsistent results. Even though there are studies conducted on PTSD in different traumatic events, there is no study that shows the overall or pooled effect of this problem in Ethiopia. In Ethiopia, the different studies indicated different or inconsistent results of PTSD among different settings. This study revealed a consistent and conclusive pooled prevalence of PTSD among studies conducted in Ethiopia. Therefore, the main objective of this meta-analysis and systematic review study was to determine the associated factors and pooled prevalence of PTSD in Ethiopia.

Method

This study was conducted to estimate the pooled prevalence of PTSD and its associated factors among survivors of trauma in Ethiopia. The search for published articles was found by using Medline, PubMed, Scopus, Cochrane, EMBASE, African journal online, HINARI, ScienceDirect, and other gray literature were not found by searching Google, Google Scholar, and other internet search engines to search any additional articles until March 30, 2022. The extra publications were also discovered by screening the references of existing peer-reviewed journals for potentially pertinent studies using the references of published studies related to PTSD. The searching terms by the prevalence of PTSD and associated factors OR other Medical Subject Heading (Mesh), keywords, and free text search terms were used. To identify the available pieces of literature, we include different terms for PTSD and combined terms by using Boolean operators search terms. The querying terms used in these studies (“post-traumatic stress disorder”) AND (“associated factors” OR “determinants” AND “survive from trauma” OR “Ethiopia”). This meta-analysis and systematic review registration on the PROSPERO registration protocol is ongoing.

Inclusion and exclusion criteria

All published articles in the peer-review journal on PTSD and/or associated factors among survivors from trauma in Ethiopia reported until March 2022 were included in this meta-analysis and systematic review. PICO in the prevalence study is Condition, Context, and Populations used for inclusion and exclusion criteria for this systematic review: Conditions—studies conducted on PTSD, Context—Ethiopia, and Populations—people survivors from the events. Fortunately, all the studies included in this study were cross-sectional study designs; articles published in peer-reviewed journals; conducted in Ethiopia; on PTSD; with full text; published from 2015 to March 2022; and written in international language. A total of 5874 study participants were involved in this study with an interval of 204–830 sample size in each study. Among articles that were published in peer-reviewed journals after 2015, articles with full-text and freely accessible, written in English, studies conducted on human beings, and studies of PTSD were eligible for inclusion in this systematic review and meta-analysis. Gray literature on PTSD was not available in the dedicated search time. Studies conducted without an abstract, which have no full text, and studies that were difficult to get the required data from studies of PTSD in Ethiopia were excluded. Besides this, articles missing editorial reports, letters, reviews, and commentaries were excluded from the study.

Measurement of PTSD

The dependent variable of this meta-analysis and systematic review was to estimate PTSD in Ethiopia. PTSD is usually measured by a post-traumatic stress disorder checklist (PCL) with different types; these are (PLC-5), PCL-Military (PCL-M), PCL-Specific (PCL-S), PCL-Civilian (PCL-C), and PLC-5 of DSM-5.²⁶ The included studies were measured by using one of the above-listed versions of the PTSD checklist. For instance, the PLC-5 measurement tool used a cutoff point ranging from 0 to 80 and a score of ⩾33 was considered positive for PTSD.²⁷

Reporting

This meta-analysis and systematic review followed the epidemiology checklist of meta-analysis of observational study and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.²⁸

Data extraction

Two authors identify the articles by their title and abstract by using the selection criteria independently. The screening of all the articles that had the necessary data and extraction was done by using Microsoft Excel Spreadsheet. All studies approved by both reviewers were included and the disagreements were solved by the third author to get a common consensus. After the agreement, the identified articles, the principal investigator’s name, years of publications, study period, study population, and sample size were extracted. The combined estimated effects of the related covariates and PTSD, together with their 95% confidence intervals (CIs) and odd ratios, were also extracted. The first authors communicated to solve the difficulties related to the paper they conducted to get additional information.

Quality appraisal of the selected literature

Three reviewers (GN, FA, and TT) were involved in the screening and measuring of each paper by using standard tools to check the quality of articles included in this meta-analysis and systematic review. The Joanna Briggs Institute was utilized to evaluate the quality of each study.²⁹ Quality measurement instruments were developed to measure the quality of articles conducted with observational research. The final rating scale of greater than or equal to five out of nine was included in this meta-analysis and systematic review. The different scores between the two authors at the time of quality assessment evaluation were discussed with the presence of a third investigator to reach an agreement.

Statistical analysis

The data extracted in Microsoft Excel were used to further analysis by using STATA version 11 statistical software. A random-effect model of the meta-analysis was used to estimate the pooled effect size of all articles with their 95% CI . The forest plots were utilized to determine the pooled effect size and weight of each recruited study with 95% CI in order to display the graphic summary of data. The degree of heterogeneity among the included articles was done by the index of heterogeneity (I² statistics).³⁰ Subgroup analysis was done by using study area, study design, and study population, and sensitivity analysis was assessed to check the presence of a source of heterogeneity. Publication bias was checked by using Funnel plots analysis and Egger weighted regression tests. A p-value of <0.05 in Egger’s test was considered to have statistically significant publication bias.^31,32

Results

Identify studies

There were 8430 studies identified in the search engine and five additional studies were also identified through other sources; 967 were removed after the duplications and 463 studies were excluded. Another, five papers were excluded after the assessment full-text; finally, 13 studies were included in this systematic review and meta-analysis (Figure 1).

Figure 1.

Flow chart describing the selection of studies conducted on PTSD in Ethiopia.

Characteristics of included studies

A total of 13 studies conducted on PTSD and its associated factors among adults exposed to a stressor in Ethiopia were included in this meta-analysis and systematic review (Table 1).

Table 1.

Characteristics of studies included in this meta-analysis and systematic review conducted on PTSD among adults in Ethiopia.

Authors	Region	Publication year	Study design	Study population	Sample size	Prevalence
Asnakew et al.²⁵	Addis Abeba	2019	Community-based	Community	830	37.3
Yohannes et al.¹²	Addis Abeba	2018	Institutional-based	Patient	492	22.8
Ali et al.²⁴	Amhara	2021	Community-based	Community	610	59.8
Alenko et al.³³	Oromia	2019	Institutional-based	Drivers	402	16.1
Bezabh et al.³⁴	Addis Abeba	2018	Community-based	Community	603	19.9
Duko et al.¹⁴	SNNPR	2020	Institutional-based	Patient	205	46.3
Golja et al.³⁵	Oromia	2020	Institutional-based	Patient	204	17.1
Madoro et al.⁹	SNNPR	2020	community-based	Community	636	58.4
Wolde et al.²³	Gambella	2021	Institutional-based	Prisoners	411	85
Girma et al.³⁶	Oromia	2018	Institutional-based	prisoners	336	31
Asnakew et al.¹¹	Amhara	2021	Institutional-based	Healthcare provider	423	55.1
Fikadu et al.³⁷	Amhara	2019	Institutional-based	Patient	299	46.5
Bedaso et al.¹³	SNNPR	2020	Institutional-based	Patient	423	15.4

PTSD: post-traumatic stress disorder; SNNPR: Southern Nations Nationalities and Peoples’ Region.

The pooled prevalence of PTSD in Ethiopia

The pooled prevalence of PTSD among adults in Ethiopia was 39.28% with a 95% CI (26.54, 52.01) with a total of 5874 study participants (Figure 2).

Figure 2.

Pooled prevalence of PTSD among adults in Ethiopia.

Heterogeneity and publication bias

In this meta-analysis and systematic review, heterogeneity was detected with an I² of 99.2% and a p-value of ⩽0.00. A funnel plot was used to check the existence of potential publication bias in the articles included. The funnel plot falls inside the triangle that indicates the symmetric distribution tolled indicating the absence of publication bias within the included articles (Figure 3). The indicator of the absence of publication bias was also confirmed by Egger’s regression test (p = 0.085) (Table 2).

Figure 3.

Funnel plot of this systematic review in Ethiopia.

Table 2.

Egger’s test of PTSD among adults in Ethiopia.

Std_Eff	Coef.	Std. err.	T	p > t	95% CI	Interval
Slope	28.53207	32.76	0.87	0.402	−43.57221	100.6364
Bias	4.974623	16.1196	0.31	0.763	−30.50439	40.45363

CI: confidence interval; PTSD: post-traumatic stress disorder.

Subgroup analysis

The presence of heterogeneity was confirmed as discussed above, as a result, the subgroup analysis was conducted based on region, study population, and study design. The pooled level of PTSD in this study from the included studies conducted in Addis Abeba was 26.67%, in the Amhara region (54.03), in Oromia (21.33%), in SNNPs (40.40%), and in Gambella (80.00%)—the highest burden. The finding of this subgroup analysis based on the study population indicates community (43.83%), patients (29.42%), prisoners (58.03%) with high prevalence as compared to other populations, and others (35.57%). The other subgroup analysis showed that PTSD at the community level is higher than (43.83%) that at the institutional level (37.25%). Therefore, this result showed that there is a high heterogeneity in this meta-analysis but it is not found in the subgroup analysis (p ⩽ 0.001) (Table 3).

Table 3.

Subgroup analysis of PTSD and associated factors in Ethiopia.

Variables	Subgroup	Number of studies	Sample size	Prevalence (95% CI)	I² (%)	p-Value
Region	Addis Abeba	3	1925	26.67 (15.82, 37.53)	96.8	⩽0.000
	Amhara	3	1332	54.03 (46.71, 61.35)	86.2	0.001
	Oromia	3	942	21.33 (12.13, 30.35)	91.9	⩽0.000
	SNNPR	3	1264	40.40 (10.10, 69.90)	99.3	⩽0.000
	Gambella	1	411	80.00 (81.55, 88.45)
Study population	Community	4	2976	43.83 (24.99, 62.66)	99.1	⩽0.001
	Patients	5	1623	29.42 (17.42, 41.42)	97.0	⩽0.001
	Prisoners	2	747	58.03 (5.11, 11.95)	99.7	⩽0.001
	Others	2	825	35.57 (2.65, 73.79)	99.4	⩽0.001
Study design	Institutional based	9	3195	37.25 (19.49, 55.00)	99.3	⩽0.001
Study design	Community based	2	2679	43.83 (24.99, 62.66)	99.1	⩽0.001

CI: confidence interval; PTSD: post-traumatic stress disorder.

A leave-out-one sensitivity analysis

The sensitivity analysis was conducted to check that the heterogeneity of studies might be due to the sensitivity of the single study included in this meta-analysis. Sensitivity was checked by omitting one author/paper step by step to check the effect of each study on the pooled prevalence in this systematic analysis. As the result evidenced, all the values are within the estimated 95% CI, which indicates the omission of a single study had no significant overall value difference in the result of this meta-analysis (Table 4).

Table 4.

Sensitive analysis of the meta-analysis by leaving one author step by step in Ethiopia.

Study omitted	Estimate 95% CI	Heterogeneity
		I² (%)	p-Value
Asnakew et al.	39.44 (25.31, 57.53)	99.3	⩽0.001
Yohannes et al.	4065 (2704, 54.27)	99.3	⩽0.001
Ali et al.	37.56 (24.24, 50.89)	99.2	⩽0.001
Alenko et al.	41.21 (27.96, 54.46)	99.2	⩽0.001
Bezabh et al.	40.90 (27.39, 54.41)	99.2	⩽0.001
Duko et al.	38.70 (25.26, 52.14)	99.3	⩽0.001
Golja et al.	41.12 (27.80, 54.44)	99.3	⩽0.001
Madoro et al.	37.68 (24.28, 51.08)	99.2	⩽0.001
Wolde et al.	35.43 (25.44, 45.43)	98.6	⩽0.001
Girma et al.	39.96 (26.35, 53.58)	99.3	⩽0.001
Asnakew et al.	37.96 (24.49, 51.43)	99.3	⩽0.001
Fikadu et al.	38.68 (25.16, 52.20)	99.3	⩽0.001
Bedaso et al.	41.27 (28.10, 54.45)	99.2	⩽0.001

CI: confidence interval.

Associated factors of PTSD

Commonly significantly associated factors with PTSD were taken for further analysis from those studies included in this meta-analysis and systematic review. Poor social support was one of the factors associated with PTSD in this systematic review. Poor social support was associated with four previous studies included in this meta-analysis. The probability of developing PTSD was 2.86 times more likely among participants with poor social support than those with high social support (adjusted odds ratio = 2.86; 95% CI: 1.81, 4.53).

The other associated factor associated with this meta-analysis was being female which was associated with four previous articles included in this review. The odds of having PTSD were 1.89 times more likely among females as compared to male participants after exposure to trauma (adjusted odds ratio = 1.89; 95% CI: 1.53, 2.34).

The presence of previous mental illness was also the other factor that was associated with the five previous studies conducted on PTSD. The occurrence of PTSD among participants with a previous mental illness was 4.72 times more likely than among participants without mental illness (adjusted odds ratio = 4.72; 95% CI: 2.62, 8.36).

Being witnessed for the occurrence of trauma was associated with the two previously conducted studies on PTSD. Participants being witnessed for the occurrence of traumatic events were 2.01 times more likely as compared to the other participants (adjusted odds ratio = 2.01; 95% CI: 1.30, 3.11, Figure 4).

Figure 4.

Associated factors with PTSD among adults in Ethiopia meta-analysis and systematic review.

Discussion

The burden of PTSD is a major mental illness that occurred because of exposure to different traumatic events, particularly repeated internal conflict in Ethiopia. To the best of my knowledge, there have not been any previous studies on PTSD in Ethiopia, but there have been studies on PTSD all around the world. The prevalence of PTSD among adults in Ethiopia’s meta-analysis and systematic review was 39.28% with a 95% CI (26.54, 52.01) with a sample size of 5874. The finding of this study was consistent with other studies conducted in worldwide meta-analysis and systematic review 27.38%³⁸ and 34.68% in low- and middle-income countries with a total sample size of 9094.³⁹

The finding of this meta-analysis and systematic review is lower than that of other studies conducted in China 55.6% from interviewing 1654 participants⁴⁰ and in Ethiopia 56.8% with 387 participants.⁴¹ This discrepancy might be due to the effect of high social interactions and the presence of more engagement in religious practices that could decrease the disorders; for example, in Ethiopia, the social interaction had a preventive effect on PTSD. In another way, the prevalence of PTSD was also high as compared to another meta-analysis and systematic review conducted in different countries 22.6% with a total sample size of 176,855 participants,⁴² and 3.3% including the sum sample size of 24,267.⁴³ The discrepancy might be due to the existence of current different traumatic events including conflict within our ethnicity that cause the participants to expose to PTSD.

Related to factors associated in this meta-analysis and systematic review, the risk of PTSD is high among participants with poor social support compared to other participants. This result is in line with other studies conducted in Canada.^44,45

Poor social support may be related to this meta-analysis for a number of reasons, including the need for emotional support to offset physical trauma and family members discussing the painful occurrence.⁴⁴ This might be the effect of the difficulty of adaptation to the environment to the existing traumatic situation and they expose themselves to the occurred event that prevents involvement in the community.¹⁴ Social support is one of the most important predictors used to reduce mental distress caused by traumatic stress.⁴⁵

The other factor associated with PTSD in this meta-analysis is being female; this result is consistent with other studies conducted in Ethiopia^11,46,47 and Nigeria.⁴⁸ The probable evidence of the association could be the effect of exposure to sexual assault and being more prone to be abused and this kind of trauma strongly leads to PTSD.¹¹ The other probable reason for the association of PTSD with being female might be the effect of the high ruminative and emotional response of females to stress.⁴⁶ The other reason for the high burden of PTSD among females is the presence of differences in the neurochemical in the brain that responds to stress and harsh events.¹⁴ The other evidence could be because females have high negative self and world schema which finally leads to the development of post-stress disorders.⁴⁸ This could be because of the high intrusive thought among females than males and the sensitivity to emotional stimuli in females.⁴⁷ The natural low-stress tolerance of females could be exposed to this kind of problem and the hormonal differences had great implications for PTSD.

The presence of a previous history of mental illness was one of the factors associated with PTSD in different literature; likewise, it is associated with this meta-analysis and systematic review.^49,50 The reason for the association could be the effect of the presence of the imbalance of neurotransmitters and neuronal damage due to existing disorders than those who have no previous mental illness that finally causes PTSD.^49,50 The presence of previous mental illness might be exposure to different stressors that lead to PTSD.⁹ The existing untreated mental illness might expose the individual when they are faced with traumatic events in their life.⁵¹

Witnessing a traumatic event by close family members and other friends is an additional predictor of the occurrence of PTSD in this meta-analysis. This result is concordant with other studies assessed in South Africa⁵¹ and Nigeria.²¹ This association might be based on cultural linkage of the well-being of self being determined by the well-being of others in Africa.⁵¹ This also could be because the loss of a loved one itself is also the other cause that includes the remainder of their trauma and recurrent intrusive thought that have a great effect on the emotional state.²¹

Limitation of study

This study has its strength, albeit just as any scientific paper, it is not free from limitations. In this meta-analysis and systematic review of some subgroup analyses, a small number of articles were included which might have reduced the precision of the estimated result. Although this study is conducted among adults, the specific age group was not well determined and the prevalence of PTSD among males and females is not specified in the primary studies included in this review.

Conclusion

The pooled effect of the PTSD meta-analysis and systematic review in Ethiopia was high; therefore, immediate intervention is mandatory for those exposed to a traumatic event. As the study indicates, the presence of social support had a great implication to prevent the burden of PTSD in Ethiopia; therefore, the community needs to support its victims. Participants who had a previous history of mental illness and have a high risk of developing PTSD need special attention. Witnesses also are exposed to the development of PTSD: the respondent whose relative was exposed to trauma because of accidents is also considered for immediate intervention.

Supplemental Material

sj-docx-2-smo-10.1177_20503121231160884 – Supplemental material for Post-traumatic stress disorder and associated factors among adults exposed to stress in Ethiopia: A meta-analysis and systematic review

Supplemental material, sj-docx-2-smo-10.1177_20503121231160884 for Post-traumatic stress disorder and associated factors among adults exposed to stress in Ethiopia: A meta-analysis and systematic review by Mamaru Melkam, Techilo Tinsae, Fantahun Andualem and Girum Nakie in SAGE Open Medicine

Supplemental Material

sj-xlsx-1-smo-10.1177_20503121231160884 – Supplemental material for Post-traumatic stress disorder and associated factors among adults exposed to stress in Ethiopia: A meta-analysis and systematic review

Supplemental material, sj-xlsx-1-smo-10.1177_20503121231160884 for Post-traumatic stress disorder and associated factors among adults exposed to stress in Ethiopia: A meta-analysis and systematic review by Mamaru Melkam, Techilo Tinsae, Fantahun Andualem and Girum Nakie in SAGE Open Medicine

Footnotes

Availability of data and materials

All the data were available in the manuscript.

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

Mamaru Melkam

Supplemental material

Supplemental material for this article is available online.

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