Trauma and Mental Health in South Africa: Overview

The World Health Organization estimates that about 5 million deaths per years are caused by trauma and intentional and unintentional injuries. Almost 9 out of 10 (90%) of these injury-related deaths occur in low and middle-income countries (LMICs), one of which is South Africa (Fogarty Global Injury and Trauma Research Training Program, n.d.).

In the context of a country in the midst of change, violence in South Africa, and the physical and psychological injuries that can result, is one of the three growing public health crises (along with HIV and tuberculosis and maternal, neonatal, and child health) that have made health care and prevention so challenging (Mayosi, Lawn, and Niekerk, 2012). While these epidemics are receiving attention and creating synergy for change, and there is progress – more in some areas than others – there is consensus that there is a need for increased budgets for health research, as well as emerging new leadership to conduct the work that is required for sustainable changes to be maintained.

Ten years ago, the Phodiso program, an international collaboration between universities in South Africa and UCLA, was launched with the aim of focusing on minimizing the negative health and mental health effects of trauma exposure, specifically depression and post-traumatic stress disorder (PTSD). Phodiso means, “healing” in the Northern Sotho language of South Africa. A central objective of the Phodiso program was to increase the number of research leaders or investigators who are able to conduct bio-behavioral studies of trauma and injuries and their effects on health and mental health. Phodiso is one of a few training programs that acknowledge and encourage the integration of local cultural values into research design and development that promotes coping, health promotion, resilience and social support for trauma survivors. The papers included in this special section focus on aspects of trauma and the effects of trauma in a cultural context that pertain to the way of life in South Africa.

These articles highlight the complexities of the effects of trauma and call for tailored interventions to address the lasting effects on health and mental health. (See figure 1) There are three main themes covered by the papers in this special issue: (1) The cultural context of violence, (2) Children and families, and (3) Circumstances or “Aftermath” arising after violence.

Figure 1.

Drs. Thebe Madigoe and Nolwandle Mbalo cover the cultural context of violence. In the first article, entitled, “Towards a culturally appropriate trauma assessment in a South African Zulu community“, Dr. Thebe Madigoe presents the premise that many of the culture bound beliefs about mental illness and trauma are not taken into consideration when Western developed measures are used to assess symptoms of post-traumatic stress. In response, Dr. Madigoe and team developed a culturally specific measure of PTSD (Z-CTEQ) and administered this among one hundred Zulu-speaking help-seeking adults recruited in the North-Eastern KwaZulu-Natal region. They found that the use of the Z-CTEQ, when added to the widely used Structured Clinical Interview for DSM disorders (SCID), increased the rate at which traumatic events were elicited by 28.1%. These results underscore the importance of using culturally relevant tools for the diagnosis and management of trauma in diverse cultural settings.

While culturally specific tools assist with proper diagnosis of mental health problems, it is equally important to integrate the cultural context in treatment following traumatic incidences such as rape. A lack of understanding with regard to how culture influences mental health is often a critical barrier to treatment. Dr. Mbalo and her team investigated factors associated with the development of depression and post-traumatic stress disorder among female rape survivors six months following rape. Women were recruited from Limpopo, Western Cape and KwaZulu-Natal (KZN). Striking regional differences were found that were linked to socioeconomic status. Specifically, women in KZN province were seven times more likely to experience depression compared to women in other provinces, while unmarried survivors in KZN had significantly greater rates of depression (six times) and post-traumatic stress disorder (PTSD) compared to their married/cohabiting counterparts. These findings demonstrate how regional differences in socioeconomic status and relationship dynamics increase the risk for PTSD and depression.

Children and families are a relatively understudied population, and this is an important emerging research area in South Africa. In this issue, we focus on the development of tools to address adolescent suicide as well as the relationship between maternal mental health and child development outcomes. Adolescent suicide is an emerging area of concern in South Africa. Notably, the South African National Mental Health Policy Framework Strategic Plan has identified suicide prevention among adolescents as a key area of focus (National Department of Health Annual Report, 2012). In the paper titled, “The development of a screening tool for the early identification of risk for suicidal behavior among students in a developing country,” Dr. Naseema Vawda and her team directly respond to this initiative by describing the development of a screening tool for teachers to identify at-risk South African youth for suicide. In this study, twelve factors related to suicidal behavior were identified and included. While the results are preliminary, this is a necessary starting point for teachers to refer students at high risk for suicidal behavior; and this paper contributes to research on adolescent mental health, particularly suicidal behavior, in LMICs like South Africa.

The South African government has invested a great deal in improvement of maternal and child health. While many structural factors have been studied, mental health problems that are prevalent in South Africa (e.g., PTSD) have received less attention. In conditions of extreme poverty and instability, characteristic of much of the developing world, the pressures on parents differ markedly from those faced by parents in communities that are typically the focus of research in child development. Dr. Koen’s paper investigates the associations between maternal and infant development. Using data from the Drakenstein Child Health Study, she and her team found that PTSD was significantly associated with poorer fine motor and adaptive behaviour-motor development, suggesting that maternal PTSD may be a critical factor in infant neurodevelopment. This issue is important to address in programs that are designed to improve maternal and child health perhaps by identifying and managing maternal PTSD.

A cornerstone piece of this special issue is the focus on the circumstances and aftermath of traumatic experiences that give rise to negative mental health outcomes for individuals in South Africa. In his discussion of PTSS/PTSD and other traumas experienced by homeless refugees living in South Africa, Dr. Idemudia reviews four linked papers that address pre- and post-migration difficulties and their relationship to post-traumatic stress symptoms/disorder. These four papers report both quantitative and qualitative data from Dr. Idemudia’s study of 125 randomly selected homeless Zimbabwean refugees in Polokwane, Limpopo Province, South Africa. The key findings of this research included: That pre and post migration traumas contributed to PTSS and PTSD in this vulnerable population; From in-depth qualitative interviews, that many of the challenging socioeconomic, cultural, structural and institutional experiences resulting in PTSS/PTSD, were seen across all the migration stages; That gender differences emerged such that the path relationship between pre and post-migration stress and poor mental health/PTSD was not significant for men whereas this path was significant for women; And finally, that rape and sexual harassment were common abuses, and that perpetrators were mainly border and police officers. These papers highlight the need for establishing programs within host or receiving countries to assist in the structural challenges faced by refugees in the process of migration.

Common in South Africa is interpersonal violence that results in assault and injury. Despite knowledge of the high number of assaults in this country, few studies have investigated factors that are associated with repeat assault and injury. In a study of two 24-hour emergency clinics (EC) located in Elsies River and Khayelitsha near Cape Town, Dr. Claire van der Westhuizen and colleagues recruited a sample of 200 patients who were assessed for injury history, traumatic events and mental disorders. Recurrent assault injury was found in 31% of the sample and recurrent injury was predicted by lifetime traumatic events other than injury experiences. Women were less likely to present with assault injuries than men, and assault injury was strongly associated with high levels of witnessing community violence. Routine EC practice should include psychosocial support for assault-injured patients. At a broader level, efforts at reducing violence in the community are key to reducing the likelihood of subsequent injury and assault.

The final paper of this issue titled “The aftermath of rape among rural women in Limpopo and North West Provinces of South Africa”, led by Dr. Gail Wyatt and her team, reports on a study conducted in a sample of 77 women from Limpopo and North West Provinces of South Africa. The study examined how both the situational characteristics of rape and individually-based factors, relate to symptoms of depression, PTSD and dysfunctional/high-risk sexual behaviors at the 12-month follow-up. Specifically, increases in dysfunctional sexual behaviors and depression were associated with undermining influences within the survivor’s social support system as well as beliefs in myths about rape at the 12-month follow up. To our knowledge this is the first study in rape survivors in South Africa to demonstrate how changes in factors such as beliefs in myths about rape and social undermining that are unique to the individual and social context influence the long-term negative mental health outcomes over time. Interventions that are designed to educate women survivors and citizens of South Africa about rape may reduce pervasive effects over time and reduce risk for re-victimization.

The studies of intentional injury and trauma reported in this special issue highlight the kind of mental health outcomes that can occur within men, women, youth and children in this context - outcomes that are completely preventable. These papers keep the dialogue going about an epidemic in South Africa that deserves more attention, in an effort to find solutions for change.

The most rewarding outcome of these dialogues is that they are being upheld by a diverse and masterful group of investigators from all ethnicities, from all over South Africa. Their involvement in research as leaders is part of the new fabric of this beautiful country that was once so completely underrepresented. Now their diverse voices, research skills and lived experiences help to promote collaborations to conduct cutting edge research within a cultural context that will provide solutions to these problems. They, too, are the faces of change.