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Conflict-related violence and mental health among self-settled Democratic Republic of Congo female refugees in Kampala, Uganda – a respondent driven sampling survey

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Itziar Familiar, Pamela Nasirumbi Muniina, Chris Dolan, Moses Ogwal, David Serwadda, Herbert Kiyingi, Chantal Siya Bahinduka, Enos Sande and Wolfgang Hladik

Background

Since the first and second Congo Wars in 1996–1997 and 1998–2003, respectively, political instability and armed conflict has forced an estimated 4.5 million people to flee from the Democratic Republic of Congo (DRC). The UN High Commissioner for Refugees estimated that as of February 2019, over 826,000 DRC refugees were being hosted in African countries, with as many as 60% of them currently living in Uganda.

The multiple armed conflicts affecting DRC’s vast territory make this one of the most challenging humanitarian emergencies of our time. A tragic feature of the armed conflict in the DRC has been the use of widespread sexual violence against women, including rape, as a tactic of war and destabilization.

The events leading to forced migration, as well as flight itself and life in the country of asylum, are frequently accompanied by exposure to an array of traumatic events such as severe physical and sexual violence, death threats, witnessing family and others being killed, kidnapped, or abused. These events can be emotionally shocking, and rates of stress and mental health disorders, such as anxiety disorders, post-traumatic stress disorder (PTSD), and depression are higher among refugees than in the general population.

Women are more frequently victims of sexual violence and the prevalence of PTSD and poor mental health after rape is particularly high. A systematic review and meta-analysis estimated the prevalence of sexual violence and rape among female refugees and those internally displaced at 21% (CI 95% 14.9–28.7), with authors warning about the potential underestimation due to barriers in reporting. In the DRC, population-based studies show that more than 40% of women have experienced sexual violence including rape and upwards of 50% among female refugees. Studies of DR Congolese civilians and refugees have found higher prevalence of PTSD, depression, suicidal ideation, and suicidal attempts among women who have experienced sexual violence.

Most studies describing mental health issues of refugees are based on reports from individuals assessed within organized temporary settlements. Less is known about the considerable large number of refugees who have chosen to ‘self-settle’ within a host population. Self-settled and urban refugees may be more vulnerable to exploitation, persecution and arrest, given that although they are recognized as refugees, there is little in the way of practical assistance or protection to those living outside gazetted refugee settlements. Ensuring support and access to basic services for individuals concealed in the anonymity of a city can be challenging, increasing the likelihood of risk-taking behaviors, and negative health outcomes. Self-settled refugees may experience higher levels of violence and rape with even less support available than what refugees in camps may have access to from medical non-governmental organizations (NGOs). Determining the type and magnitude of mental health problems urban refugees experience is crucial to plan and deliver adequate services, and requires methods that can be used to generate valid estimates for hidden populations that do not have a sampling frame.

The purpose of this study was to investigate rates of PTSD and depression symptoms in a population of female DR Congolese refugees living in Kampala, Uganda and their association with traumatic experiences including rape, to inform policy and service provision in host countries.