Post-traumatic stress disorder symptoms among youths in war-affected areas of Northeast Ethiopia

Abstract

Background

Globally, youth in violent conflict and war-affected areas are experiencing an increase in the rates of post-traumatic stress disorder (PTSD). War leads to severe social crises worldwide, with youths being the most vulnerable group. They often endure severe traumatic events and are at high risk of falling victim to violent crime, which further increases their susceptibility to developing symptoms of PTSD. PTSD is a prevalent in Ethiopian regions affected by war, although empirical data on its prevalence and associated factors among youth in these areas are scarce.

Objective

To assess the prevalence and associated factors of post-traumatic stress disorder symptoms among youth in Kobo Town, Northeast Ethiopia.

Methods

A community-based cross-sectional study was conducted with 595 participants. Outcome variables were assessed using the Post-traumatic Stress Disorder Checklist (PCL-5). Data were analysed using SPSS version 25. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with PTSD symptoms. The presence of an association was indicated by an adjusted odds ratio with a 95% confidence interval, and a p-value less than 0.05 was considered statistically significant.

Results

The prevalence of post-traumatic stress disorder symptoms among youths was 62.2% with 95% CI: 58.2, 66.1). Being female [AOR = 2.62 (95% CI = 1.27, 3.66)], experiencing childhood trauma [AOR = 1.71(95% CI = 1.033, 2.76)], having depression symptoms [AOR = 1.69 (95% CI = 1.12, 2.95)], having anxiety symptoms [AOR = 1.68 (95% CI = 1.09, 2.59)], having physical injury [AOR = 3.38(95% CI: 2.17, 5.28] and having poor social support [AOR = 3.52(95% CI = 2.08, 5.99)] were factors associated with PTSD symptoms.

Conclusion

PTSD symptoms is highly prevalent among youth in the war-affected areas of Northeast Ethiopia. Being female, depressive and anxiety symptoms, childhood abuse and neglect, physical injury during war, and poor social support were factors associated with PTSD symptoms among youth. To combat this, early screening and treatment should be provided for youth with PTSD symptoms.

Introduction

Post-traumatic stress disorder (PTSD) is a mental disorder that is related to exposure to a traumatic or stressful event. Symptoms of PTSD including intrusion, avoidance, alteration of mood and cognition, and hyper arousal that persisted for one month after the stressful event [1]. PTSD can result from experiencing or witnessing traumatic events, including murder, threats, kidnapping, the death of loved ones or friends, the loss of a home [2].

The global occurrence of potentially traumatic events among youth is increasing at an alarming rate. These events include maltreatment, neglect, abuse, war, displacement, and armed conflict [3]. A survey of 24 nations conducted by the World Federation of Mental Health (WFOMH) revealed that 70% of respondents reported experiencing traumatic event, with youth experiencing such events at higher rates than other age groups [4]. Childhood and young adult traumatic events are linked to higher rates of PTSD [5, 6].

Studies from various countries highlight the severe dangers civilians face in conflict-affected region, with the prevalence of PTSD among youth reflecting direct exposure to violence, pervasive insecurity, and humanitarian crises. In Lebanese the rate of PTSD was up to 94% [7], in Nepal was 36% [8], in Syria was 36% [9], in Iraq was 35.5% [10], in Nigeria was 63% [11].

PTSD among youth is linked to a range of interconnected problems, such as anxiety, depression, substance abuse, antisocial behaviors, delayed brain development, and poor academic performance [12]. In addition, war impacts youths’ well-being in various contexts, including family, school, peer networks, the environment, and economic hardship, thereby affecting their overall well-being [13].

Previous studies have reported several factors associated with PTSD among youth including female [14, 15], children [15–17], exposure to traumatic events [15–17], experiencing death or violence [18], witnessing violence or death, and social withdrawal [17], having a previous history of mental illness, having a family history of mental illness, having a low level of education, and having a low income are associated factors for PTSD [19, 20].

Youth are significantly affected by the consequences of war, both physically and psychologically. Traumatic events and PTSD can severely hinder the developmental process of young individuals and have long-lasting implications. Recent studies have indicated a high prevalence of PTSD in Ethiopia [21]. Although studies assessed the prevalence of PTSD among youth globally, there is limited evidence on the factors associated with its development, particularly in low income countries such as Ethiopia. Previous studies in conflict-affected and post-traumatic populations have identified potential factors of PTSD such as socioeconomic adversity, lack of social support, and comorbidity mental health conditions. However, PTSD among youth remains understudied, and how these factors interact within Ethiopian’s unique sociocultural context is poorly understood. The aim of this study to assess the prevalence and associated factors of PTSD among youths residing in war-affected area of Northeast, Ethiopia.

Methods and materials

Study design, setting and periods

A community-based cross-sectional study was conducted among youth residents of Wollo zone, North Ethiopia from May to June 2023. Wollo zone is one of the 10 zones found in the Amhara regional State, with the administrative center of Raya Kobo located 570 km from Addis Ababa, the capital of Ethiopia. The total population of Kobo town was 24,867, comprising of 12,482 males and 12,382 females. Among them, 12,885 are classified as youth, and a total of 9,398 households were counted in this town. This area was repeatedly affected by war between the federal government of Ethiopia and the Tigray regional forces from 2012/2019 to 2013/2023.The study included individuals exposed post-war.

Study participants and procedures

All youths who were residents of selected Keble individuals and were present during the data collection period were study participants. Youths had to have resided in Kobo town for a minimum of 6 months were included in the study. Youths with severe illnesses and communication difficulties were excluded.

The sample size was determined using the single population proportion formula with the following assumptions by Epi Info software: 95% confidence interval, a margin of error (d) of 0.05, and a percentage (p) of 50%.

After adding a design effect of 1.5 and accounting for a non-response rate of 5%, the final sample size was 595. The study used a multistage sampling technique, where initially, out of 4 kebeles, 2 kebeles were randomly selected using the lottery method, followed by the random selection of 2 kebeles. Proportional allocation was done based on the number of participants in each kebele, and household lists were obtained from the Kobo town administrative office. Samples were selected proportionally from each kebele after determining the sampling interval (K) value. The starting point of the interval was determined through lottery method. If more than one eligible youth were present in a household, only one was selected using the lottery method. For eligible participants not found at home, interviewers made re-visited the home in other times (Fig. 1).

Fig. 1.

Showing sampling technique and procedure for Prevalence and associated factors of post-traumatic stress disorder symptoms among youths in Kobo town, Northeast Ethiopia

Recruitment procedures

The target participants were youth residing in Kobo Town for at least 6 months and above who may have experienced or are at risk of experiencing trauma and stress related disorder. we meet participants in person by collaborate with local community youth organizations in Kobo Town to help spread the word about the study and gain their support in recruiting participants, and schools to identify potential participants. Instruments were translated in to local Amharic language. The survey was conducted for 1 month; data was collected by 6 psychiatry professionals (BSc, holder in psychiatry) for each data collection site). Two days of training were given for data collectors and supervisions for the study objectives, sampling procedures, tool usage, and protocols for addressing ethical issues and ensuring confidentiality and way of the team prepared for the potential post traumatic reactions during the survey. All team members received comprehensive training on trauma-informed care, including Pre-Survey Preparation, informed consent, Self-Care, Team Debriefing, Post-Survey Debriefing, practicing empathy during and after the survey.

To control data quality initially, the questionnaires were prepared in English and then translated back into the local language Amharic to ensure consistency. A pre-test was conducted on 5% of the total sample size before the actual data collection period, with a Cronbach’s alpha of 0.85 for the (PCL-5) scale. Data collectors and supervisors received two days of training before the data collection, which covered the study objectives, sampling procedures, tool usage, and protocols for addressing ethical issues and ensuring confidentiality. Prior to data entry, the collected data were checked for completeness and consistency.

NiY = Total youth of each Kebele.

ni = sample size from each Kebele household.

n = total sample size.

Data collection instrument

The study questionnaire had socio-demographic factors, clinical factors (Includes depression symptoms, anxiety symptoms and family history of mental illness), Traumatic events and psycho social factors, substances use factors.

Depression symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), a nine-item self-report questionnaire that measures depression severity over the past two weeks. Each item is rated on a 4-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day). The Cut-off point of depression was 10 or above [22]. PHQ-9 items showed good internal consistency (Cronbach’s alpha = 0.85) [23].

Anxiety symptoms were assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale, a self-report instrument designed to evaluate the severity of generalized anxiety disorder. The GAD-7 consists of seven items, each rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). A total score of 8 or higher on the GAD-7 is indicative of clinically significant anxiety [24]. GAD-7 validated in Ethiopia and has good internal consistency (Cronbach’s alpha = 0.77) [25].

Exposure to Traumatic Events: was assessed using 16 items from the Harvard Trauma Questionnaire (HTQ) [26]. Participants who responded ‘yes’ to experiencing at least one traumatic event in the past year were considered to have experienced a traumatic event. When the Participants who responded ‘no in the past year were considered to have no traumatic events.’ HTQ was previously adapted for use in South Sudan and found to have strong reliability, with a Cronbach’s α of 0.87 [27].

Psycho social Support was assessed using Oslo Social Support Scale(OSSS-3) measures social support strength in three categories: poor social support [3–8], moderate social support [9–11], and strong social support [12–14, 28].

Outcome variable was assessed using PCL-5 is a 20-item assessment tool used to screen PTSD. PCL-5 is a 5- point Likert scale ranging from 0 to 4 (0: Not at all, 1: A little bit, 2: Moderately, 3: Quite a bit and 4: Extremely). A cut-off point of ≥ 33 out of 80 were considered to have PTSD [29]. PCL-5 had a strong internal consistency in Ethiopia, with a Cronbach’s alpha = 0.78) [30].

Substance used was conducted using yes or no questionnaires, which were adapted from the WHO ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test). ASSIST is a reliable screening tool used to identify substance use in individuals with different levels of usage [31, 32]. Family history of Mental and clinical illness assessed using yes or no response questionnaires.

Data analysis

The collected data were entered into Epi-Data version 4.6, and analyzed using SPSS version 25. Descriptive statistics were presented as frequencies and percentages, summarized in tables and text. To determine the strength of association between the dependent and independent variables, adjusted odds ratio was conducted using logistic regression, and the significance level was determined using a 95% Confidence Interval. Bi-variate and multivariate logistic regression analyses identified independent predictors of PTSD. Variables with p-values less than 0.25 in bi-variate analysis were included in multivariate analysis. Variables with p-values less than 0.05 in multivariate analysis were considered significant predictors of PTSD. Model fit was assessed using the Hosmer-Lemeshow test was 0.781 and multicollinearity (tolerance > 0.1, VIF < 10).

Results

Sociodemographic characteristic of participants with PTSD symptoms

In this study, a total of 595 youths participated with 100% response rate. The age of the participants ranged from 15 to 24 years with a mean age of 20 ± 3.2 SD. The majority (63.4%) of the participants were female, and out of the participants 70.6% were aged between 18 and 24 years. More than half (67.0%) of the participants were single, and about 42.5% of the participants were attending secondary school.(Table 1).

Table 1.

Scio-demographic characteristics among youth with post-traumatic stress disorder in Kobo town, North, East, Ethiopia, n=595

Variable	Category	Frequency	Percentage %
Age	15-19	175	29.4
	20-24	420	70.6
Sex	Female	377	63.4
	Male	218	36.6
Marital status	Single	357	60.0
	Divorced	103	17.3
	Married	135	22.7
Educational status	Not attended formal education	38	6.4
	Primary	198	33.3
	Secondary	253	42.5
	Collage and above	106	17.8

Comorbidity of mental illness in participants with PTSD symptoms

Among the study participants, about 36.8% of the participants reported having childhood trauma. One-fourth (26.7%) of the participants had experienced physical abuse and neglect. About (29.4%) of the study participants had a family history of mental illness. The majority (72.8%) of the participants had depressive symptoms, more than half (59.3%) of the participants had anxiety symptoms. Nearly two third (62.2%) of the participants had PTSD symptoms.(Table 2).

Table 2.

Clinical characteristics and Comorbidity of mental illness among youth with post-traumatic stress disorder symptoms in Kobo town, North, East, Ethiopia, n=595

Variable	Categories	Frequency	Percentage %
Childhood trauma	Yes	219	36.8
	No	376	63.2
Physical abuse and neglect	Yes	159	26.7
	No	436	73.3
Family history of mental illness	Yes	175	29.4
	No	420	70.6
Family history of depressive symptoms	Yes	99	16.6
	No	496	83.4
Family history of anxiety symptoms	Yes	76	12.8
	No	519	87.2
Depressive symptoms of the participants	Yes	433	72.8
	No	152	25.5
Anxiety symptoms of the participants	Yes	353	59.3
	No	242	40.7
PTSD symptoms	Yes	370	62.2
	No	225	37.8
Depressive symptoms and PTSD symptoms	Yes	294	49.1
	No	76	12.8
Anxiety symptoms and PTSD symptoms	Yes	241	40.5
	No	113	19

Social support and substance use characteristics of the participants

According to the study’s participants, about 40.8% used substances in the past 3 months, and 30.1% of the participants used both alcohol and khat. Regarding social support, more than half (59.8%) of the participants reported having poor social support (Table 3).

Table 3.

Social support and substance use characteristics among youth with post-traumatic stress disorder symptoms in Kobo town, North East, Ethiopia, n=595

Variable	Category	Frequency	Percentage (%)
Any substance use in the last 3 months?	Yes	243	40.8
	No	352	59.2
Alcohol, khat and cigarettes	Yes	48	8.1
	No	547	91.9
Alcohol and Khat	Yes	197	30.1
	No	416	69.9
Alcohol and cigarettes	Yes	86	14.5
	No	509	85.5
Alcohol	Yes	22	3.7
	No	573	96.3
Khat	Yes	46	7.7
	No	549	92.3
Cigarette smoking	Yes	43	7.2
	No	552	92.8
Social support	Poor social support	356	59.8%
	Moderate social support	139	23.4%
	Strong social support	100	16.8%

Traumatic events (types and exposure) factors

Out of the study participants, more than half (60.2%) of the participants reported experiencing trauma events during the war, while two third (66.4%) of participant having physical injuries (Table 4).

Table 4.

Traumatic events associated with post-traumatic stress disorder symptoms among youth in Kobo town, Northeast, Ethiopia, n=595

Variable	Categories	Frequency	Percentage (%)
Traumatic events exposure during the war	Yes	450	75.6
	No	145	24.4
Physical injury, property destruction and imprisonment	Yes	48	8.1
	No	547	91.9
Physical injury and imprisonment	Yes	34	25.7
	No	561	94.3
Imprisonment and property destruction	Yes	31	5.2
	No	564	94.8
Physical injury	Yes	395	66.4
	No	200	33.6
Imprisonment	Yes	18	3.0
	No	577	97
Property destruction	Yes	39	6.6
	No	556	93.4
Sexual abuse/rape	Yes	19	13.2
	No	576	96.8
Trauma exposure experienced by your parents/friends	Yes	338	60.2
	No	237	39.8

Prevalence and associated factors of post-traumatic stress disorder symptoms among youth

The overall prevalence of post-traumatic stress disorder symptoms among youth was 370 (62.2%) with (95% CI: 58.2–66.1).

Being female, childhood trauma, depressive symptoms, anxiety symptoms, physical injury, and poor social support were factors significantly associated with PTSD symptoms.

Being females had 2.62 times higher odds of developing PTSD symptoms compared to males [AOR = 2.62 (95% CI = 1.27, 3.66)]. Youths who experienced childhood abuse and neglect had 1.71 times higher odds of developing PTSD symptoms compared to those without such experiences [AOR = 1.71(95% CI = 1.033, 2.76)]. Youths who experienced depressive symptoms had 1.69 times higher odds of developing PTSD symptoms compared to youth without depressive symptoms [AOR = 1.69 (95% CI = 1.12, 2.95)]. Youths who had anxiety symptoms had 1.67 times higher odds of developing PTSD symptoms compared to those without anxiety symptoms [AOR = 1.68 (95% CI = 1.09, 2.59)]. Youths who experienced physical injury had 3.38 times higher odds of developing PTSD symptoms compared to those who did not have any physical injuries [AOR = 3.38(95% CI: 2.17, 5.28]. Youths who had poor social support had 3.5 times higher odds of developing PTSD symptoms compared to those who had strong social support [AOR = 3.52(95% CI = 2.08, 5.99)]. (Table 5).

Table 5.

Bi-variate and multivariate analysis of post-traumatic stress disorder symptoms among youth in Kobo town, North, East, Ethiopia, n=595

Variable	Category	PTSD		COR	AOR 95%CI	p-value
		Yes	No
Sex	Female	260	117	2.18(1.55, 3.08)	2.62(1.69,4.08)	.002
	Male	110	108	a	a
Physical abuse and neglect	Yes	119	40	2.19(1.46, 3.29)	1.71(1.03, 2.76)	.047
	No	251	185	a	a
Depressive symptoms	Yes	294	149	1.97(1.36, 2.87)	1.69(1.12, 2.95)	.000
	No	76	76	a	a
Anxiety symptoms	Yes	241	112	1.68(1.09, 2.59)	1.68(1.09, 2.59)	.024
	No	129	113	a	a
Social support	Poor social support	287	69	3.27(2.03, 5.25)	3.52 (2.08, 5.99)	.017
	Moderate social support	27	112	.19(.11, 1.34)	.20 (.11, 1.37)	.062
	Strong social support	56	44	a	a
Trauma exposure	Yes	131	118	2.80(1.93,4.06)	1.75(.08, 2.83)	.054
	No	71	179	a	a
Alcohol and cigarettes	Yes	119	113	1.69(1.18,2.24)	.70(.44,1.13)	.142
	No	101	162	a	a
War-related Physical injury	Yes	285	110	3.51(2.45, 5.01)	3.38(2.17, 5.28)	.025
	No	85	115	a	a
Physical injury and property destruction by your parents/Friends	Yes	85	115	1.50(1.01,2.25)	1.51(.90, 2.54)	.046
	No	99	44	a	a

NB: COR crude odd ratio, AOR adjusted odd ratio, CI  confidence interval,a = reference, PTSD post-traumatic stress disorder

Hosmer and Lemeshow Test = 0.781, no multicolinearity (Tolerance > 0.1 andVIF < 10).

Discussion

In the present study revealed a high prevalence of PTSD symptoms among young people in Kobo Town was 62.2% (95% CI: 58.2, 66.1%). This study is consistent with previous studies conducted in Kenya 64% [33], Nigeria 63%, South Ethiopia and Northwest Ethiopia among the general population was 58.4% and 59.8%, respectively [34, 35].

However, the present finding was lower than study conducted in Palestinian 76.5% [36]. This variation may be attributable to several factors: such as study setting: Previous studies were conducted in institutional settings, which may have heightened stress levels compared to the community-based approach of the current study. Another difference could be due to variation in Assessment Tool Sensitivity: The tool used in previous studies may have been more sensitive in detecting symptoms than the one used in the current study. The possible variation might be the unique characteristics of the war: War-related trauma may influence PTSD symptoms development compared to other types of trauma. War exposes individuals to prolonged, repeated, and often extreme stressors (e.g., combat, displacement, loss of loved ones), which may lead to more severe and chronic PTSD symptoms compared to single-event traumas [37, 38]. Unpredictability and lack of control in war settings exacerbate feelings of helplessness, a core symptoms of PTSD [39]. Another possible variation might be timing of data collection: Previous studies were conducted immediately after the war, while the current study conducted four months post-war, may report a lower the prevalence of certain symptoms as immediate responses to trauma often subside over time, potentially shifting from acute stress reactions to more chronic conditions like PTSD for some, while others participants may be recovered. The timing of data collection could impacts the prevalence of PTSD symptoms, particularly in the context of war related conflict. This captured more acute stress reactions.

In contrast, the finding of this study was higher than in studies conducted in Morocco 25.8% [40], Rwanda 16.5% [41],Ethiopia among children and adolescents 36.45% [42], Western Ethiopia 33% [43], Northern Uganda 57% [44], Syria 31% [14], 28.2% [45], India 49.81% [46], Iraq 35.5% [10]. Several factors could explain this discrepancy. The possible variation could be different age of participants, the present study focused on a varied age range of participants, included youth with age range of 15–24 years, a highly vulnerable group, while the previous studies included on individuals aged 50 and older. Another variation might be use of different assessment tools, the CPSS-SR and the PCL-C, with distinct cutoff points, may have influenced the results. In Uganda, the study included enrolled school students aged 12–19 who demonstrated good psycho-social supports, indicative of potentially lower levels of post-traumatic stress disorder symptoms. The Impact of Event Scale Revised (IES-R), a tool Aligned with DSM-IV criteria for PTSD, was employed with a cut-off score of 22 out of 60. Differences in findings may be attributable to the specific assessment tool and its designated threshold. In Rwanda, the study was conducted 15–25 years post-trauma, possibly reflecting the impact of various interventions on prevalence reduction. In contrast, the current study was conducted shortly after the war. While India used the PC-L-5 with a cut-off of 50 and Iraq employed the PTSD Scale for DSM-IV with a cut-off point 31, Morocco’s study, conducted in a high-stress institutional setting, focused on adolescents aged 14–17 and used the DSM-IV with a cut-off of 40. These methodological differences may account for the higher prevalence observed compared to previous studies.

The second aim of this study was to identify factors associated with PTSD symptoms. Being females had 2.62 times higher odds of developing PTSD symptoms compared to males. This finding is consistence with previous studies conducted in Nigeria [47], Rwanda [48], Syria [9], Palestinian [37], and Morocco [40]. Females might develop PTSD at higher rate than males due to different factors including societal influences, coping mechanism, hormonal influences, and physiological responses to trauma. The possible explanation is that societal pressures often reduced social support networks for females which can increase their vulnerability to the impacts of trauma [49]. Societal expectations and traditional gender roles can influence how women are expected to cope with trauma. This can create barriers when female try to seek help and disclose their traumatic experiences due to stigma, shame, or fear of judgment [50, 51]. These societal barriers can prevent females from accessing timely and effective support, prolonging their distress and increasing the likelihood of the development of PTSD symptoms. Studies indicated that females are at a higher risk of experiencing traumatic events(such as sexual assault or intimate partner violence) compared to males and females are often more prone to exhibiting heightened emotional reactions to stress and trauma [52]. This increased emotional reactivity, combined with a higher prevalence of specific traumatic exposures and societal challenges contributes the development of PTSD symptoms in females. Additionally, hormonal influences such as estrogen increase susceptibility to PTSD symptoms in females. Scientific studies suggest that hormones like estrogen can modulate the brain’s stress response, potentially increasing vulnerability to PTSD [53]. Youths who experienced childhood abuse and neglect had 1.71 times higher odds of developing PTSD symptoms compared to those without such experiences.These findings is consistent with studies conducted in northern Uganda [44], Uganda [54] and Syria [9]. Early traumatic experiences can have a profound and enduring impact on a child’s physical and psychological development [55]. Early childhood traumatic events, including physical and sexual abuse, significantly increases the likelihood of developing mental illnesses like PTSD [56]. Emotional deregulation is responsible for the association between childhood trauma exposures. Emotional deregulation reveals deficiencies in the ability to manage intense, negative, and fluctuating emotional states [57]. Youths who experienced depressive symptoms had 1.69 times higher odds of developing PTSD symptoms compared to youth without depressive symptoms. This finding is consistent with studies done in Rwanda [48], Palestinian countries [37], and Morocco [40]. War and conflict-affected civilians exhibit higher prevalence of PTSD and comorbidity such as depression, anxiety, and substance use compared to survivors of natural disasters or accidents [58]. PTSD and depression disorder frequently coexist. The complex association between trauma and depressive symptoms may reflect shared risk factors [59]. Depressive symptoms may increase the likelihood of developing PTSD symptoms [60, 61]. Youths who had anxiety symptoms had 1.67 times higher odds of developing PTSD symptoms compared to those without anxiety symptoms. This finding was supported studies conducted in Nigeria [48], Palestinian [37], and Morocco [40]. The possible reason could be PTSD and Anxiety symptoms are two disorders that can occur at the same time [62]. In individuals with PTSD symptoms, feelings are often overstimulated, and anxieties can also become prolonged and exacerbated to the point of becoming uncontrollable [63]. Following a traumatic event, the chance of developing PTSD symptoms might be raised by prior anxiety combined with a lack of family or friend support [64]. Youths who experienced physical injury had 3.38 times higher odds of developing PTSD symptoms compared to those who did not have any physical injuries. This finding was consistent with study conducted in Ethiopia [65], Morocco [40] and North Uganda [44]. Direct experiences of physical injury often result in deeper trauma and have a stronger emotional impact compared to witnessing the injury or other forms of exposure [66, 67]. The mechanism of injury can be a significant risk factor for PTSD symptoms. Youth are particularly vulnerable to developing PTSD symptoms after physical injury. Individuals who experience moderate to severe physical trauma are more likely to develop PTSD symptoms [67]. Youths who had poor social support had 3.5 times higher odds of developing PTSD symptoms compared to those who had strong social support. These findings were consistence with studies conducted in Rwanda [48], Northern Uganda [44], and Ethiopia [68–70]. Social and Environmental Disruptions: war often destroys social support systems and community structures, which are critical for resilience and recovery [71]. Poor social support is significant risk factors for the development and persistence of PTSD symptoms [72].Without adequate support, individuals may experience heightened stress levels and which can exacerbate symptoms of PTSD [73]. People with poor social support, they can feel isolated, overwhelmed, and unable to manage their symptoms, making them more vulnerable to developing PTSD symptoms.

Limitations

This study has the following limitations. The first, limitation the symptoms of PTSD were assessed based on using youth self reports of experiences in the month preceding the survey, which may have led to under- or over reporting of PTSD symptoms due to recall bias. The second limitation, some of the data were collected face-to-face interviews, which could introduce social desirability bias, particularly for sensitive topics such as sexual behavior and substance use. The third limitation, the sample was drawn from a specific community so it may not be fully generalizable to the broader youth population. The last limitation, we used the cross-sectional design which did not show causal inferences, as it only captures associations at a single point in time.

Conclusion and recommendation

This study found a higher prevalence of PTSD symptoms among youth in war-affected areas of Kobo town. Being female, depression, anxiety, childhood abuse and neglect, physical injury during war, and poor social support were factors associated with PTSD symptoms. Given this results, targeted post-conflict interventions such as mental health support, trauma-informed care, and strengthening social networks could help mitigate war-related stress reactions and reduce PTSD symptoms among affected youth. Clinical implication: recommended to emphasize the need for trauma-focused interventions tailored to war survivors, such as Cognitive Behavioral Therapy (CBT) and community-based rehabilitation programs, provide early screening and intervention services to address symptoms before they escalate, improving patient outcomes and interdisciplinary collaboration to address symptoms, co-morbid conditions, and social stressors. For policymakers; integrate mental health screening, brief interventions, and referral systems directly into existing youth-friendly services such as schools, primary healthcare centers, and community youth programs. Provide national public awareness campaigns to destigmatize mental health issues and encourage help-seeking behavior among youth and their families. For parents and teachers: develop educational initiatives for parents and teachers to increase their understanding of PTSD symptoms and their manifestations in youth. Encouraging attentive observation of changes in a youth’s behavior, mood, or academic performance, and provide supportive communication. Establish and clearly communicate accessible referral pathways to mental health professionals. For researchers; conduct longitudinal designs to establish causality of PTSD symptoms and to assess the long-term effectiveness of such interventions and also incorporate mixed-methods approaches, combining quantitative screening with qualitative in-depth interviews or clinical assessments conducted by mental health professionals to provide a more understanding and confirm diagnoses.

NY-total number of youth.

NiY-total youth of each Keble.

NHH-total number of households.

NiHH-total household of each Keble.

N-total number of youth.

k = N/n = the interval size.

ni = sample size from each Keble household.

Abbreviations

AOR

Adjusted Odds Ratio

CI

Confidence Interval

COR

Crude Odds Ratio

DSM

Diagnostic Statistical and Manual of Mental Disorders

GAD

Generalized Anxiety Disorder

OSSS

Oslo Social Support Scale

PCL-5

Post-traumatic Stress Disorder Checklist-5

PHQ-9

Patient Health Question

PTEs

Post-traumatic Events

PTSD

Post-traumatic Stress Disorder

Authors’ contributions

DS: conceived the idea, developed the proposal, participated in the data collection and analysis, and wrote the final paper. BY, DA, MW, FG, and TA participated in the data analysis and methodology, revised the subsequent drafts of the paper, and were involved in the writing and final review of the manuscript. All the authors read and approved the final manuscript.

Funding

Not applicable.

Data availability

The data included in the manuscript can be obtained from the corresponding author through the email address “biazinyenealem21@gmail.com” upon reasonable request.

Declarations

Ethics approval and consent to participate

All procedures carried out during data collection were in accordance with ethical clearance criteria obtained from the institutional review board (IRB) of the University of Gondar CMHS and from the School of Medicine Review Committee with Ref.No: uogchms/irb/4097/2024. Additional supportive letters were acquired from the Department of Psychiatry and were taken to the Kobo Town Office. The data were collected after written informed consent and assent were obtained. The privacy and confidentiality of the information provided by each respondent were properly maintained. Participants were informed that they could withdraw at any stage without any restrictions. Participants identified as having PTSD, depression, or anxiety was referred to the hospital.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.