Democratic Republic of Congo: rebuilding after prolonged conflict
The Democratic Republic of Congo (DRC) has endured decades of destruction to health and social infrastructure. A history of colonialism, theft of the DRC’s enormous mineral wealth and strategic ‘pitting’ of ethnic groups against one another set the stage for prolonged conflict including two conflicts with neighboring countries. Within this context, families are striving to rebuild their households and communities and improve the life and livelihoods of future generations.
A cross-sectional study in the Ituri province in the eastern DRC investigated conflict-related traumatic events and found that among 477 girls and 569 boys ages 13–21, 95 % of the respondents reported at least one traumatic event; on average, adolescents were exposed to 4.7 traumatic events over their lifetime, and 52 % of adolescents met the criteria for PTSD . Violence, population displacement and the destruction of health and educational institutions have weakened the local systems required to respond to children’s mental health and promote well-being.
Armed conflict and mental health of children
Worldwide, UNICEF estimates that over one billion children under the age of eighteen are affected by conflict (UNICEF, 2009). Globally, an estimated two million children have lost their lives over the past decade to armed conflict, six-million have been left severely injured or disabled, twelve million have been left destitute and 300,000 children have served as child soldiers . The stress and trauma of armed conflict is devastating to psychological well-being and healthy development of children. The developmental period between childhood and adolescence is a particularly vulnerable period of time characterized by, “complex and multiple changes across biological, psychological and interpersonal domains” . The psychological impact of armed conflict on children includes increased prevalence of PTSD, anxiety, depression , psychophysiological disturbances such as nightmares and trouble sleeping, fear, grief, behavioral problems , and changes in educational attainment and performance, lack of hope and personality changes . Researchers report that children are aware of stress and their coping strategies due to psychological trauma and are able to identify stressors, describe coping strategies and evaluate the effectiveness of those strategies at ages as young as six years old .
To date, most research on conflict affected children has focused on PTSD  with less research focused on depression and behavioral problems. Pooled prevalence estimates from 17 armed conflict affected countries found that the impact of armed conflict resulted in 47 % of children with moderate to severe diagnosis of PTSD, 43 % with depression and 27 % with anxiety . Armed conflict can result in psychological distress in the short term, but can also lead to long-term psychopathology. Research with former child soldiers in Mozambique found 50 % of participants reported traumatic stress reactions sixteen years after return to civilian life . Furthermore, protracted conflict involving non-state actors such as rebel groups can directly harm child development when children witness or experience conflict-related violence and can also indirectly harm children’s well being by weakening health care delivery systems, disrupting schools and destroying infrastructure .
However research has also shown that youth exposed to armed conflict do not necessarily develop psychopathology and in contrast, many youth demonstrate remarkable resilience. Norman Garmezy is often credited with developing the field of resilience research with pioneering research conducted in the early 1970s focusing on positive adaptation for children at risk for psychopathology [11, 12]. Researchers since have began to focus on resilience, seeking to identify factors that allowed some individuals to cope better than others when faced with adversity [12–16]. Some of the factors that protect against psychological distress and promote psychological well-being at the individual level include female gender, higher intellectual capacity, political activity, problem-solving, seeking social support and demonstrating faith in a higher power or religion [14, 17, 18]. Research has also identified factors related to an individual’s external social ecology including family and community level factors. Protective factors at the family level include family support and stability and parental monitoring [19–21]. At the community level, attachment to community and peers through school or churches, community acceptance and access to social support were associated with youth resilience [19, 22–24]. While research has identified the importance of investigating factors related to positive adaptation, less is known about how youth’s individual coping strategies are implemented within specific cultural contexts. More research is needed to better understand which coping strategies youth employ in the Democratic Republic of Congo and how these strategies have the potential to help or harm mental health in conflict-affected youth.
Theoretical background on coping
Lazarus and Folkman (1984) originated the term “coping” to describe responses to stress . Lazarus and Folkman defined stress as a condition or feeling experienced when a person appraises an event as “exceeding his or her resources and as endangering well-being” . This theory posited that the best way to measure coping was through an individual’s personal appraisal. Personal appraisal refers to the various ways individuals seek to modify adverse aspects of their life to minimize the internal threat of stressors. Appraisal can be primary (perception of a stressor) or secondary (evaluation of potential effectiveness and consequences of coping behaviors) . Coping is effective if stress is accurately appraised and specific behavioral and cognitive strategies are used to manage, reduce or tolerate stressful events .
The cognitive and behavioral coping strategies used by youth have been grouped in different ways. Lazarus and Folkman distinguish coping styles as emotion centered coping which seeks to regulate internal emotions and the meaning of an event and problem-based coping which aims to change the problem or conflict . Other researchers have grouped coping in different ways. Beehr and McGrath distinguish more categories of coping styles and group styles as preventive, anticipatory, dynamic, reactive and residual coping . Ghimbulut categorized coping styles as, “emotion coping” (focusing on changing one’s own emotions), behavioral coping (directed toward the cause of the problem) and cognitive coping (directed on one’s own beliefs) . A study with war-affected children in Croatia found six distinct coping strategies including aggressive activities, problem oriented, avoidance and relaxation, emotion expression and social support seeking .
While some research suggests that emotion oriented coping behaviors are associated with poorer mental health and problem based coping behaviors are associated with better mental health outcomes [29, 30], other researchers have questioned whether emotion focused coping should be considered maladaptive. For example, in environments such as humanitarian emergencies and armed conflict, engagement (problem focused) coping may be a less appropriate coping method than disengagement (emotion focused) coping because youth may be powerless to actively change stressors related to the conflict/disaster and instead emotion focused coping may be a positive strategy, more easily accessible than problem focused strategies.
Considering the cultural context in which coping strategies are employed is essential to gain depth of meaning to motivations for employing a particular strategy and the positive or negative benefits of using a particular strategy. Qualitative case-study research with Cambodian refugees found that avoidant coping was utilized with traumatized Cambodian refugees who sought to avoid thoughts, behaviors and activities that reminded them of the past and linked this coping strategy to a history of “dishonorable events in Cambodian history” and collective shame felt by Cambodians . The Cambodian belief system perceives personal bad fortunes stem from dishonorable events in a previous life and therefore led individuals to use avoidant coping strategies rather than more problem focused strategies. Qualitative narrative research with 14 Sudanese youth refugees found that a sense of communal self was thematic in interviews and that suppression and distraction were a common coping strategy . Participants used distraction to avoid difficult thoughts and feelings and believed this strategy helped “protect themselves from feelings that they feel powerless to handle” . Research with Zimbabwean adolescents found that there was greater use of emotion focused strategies rather than problem solving strategies because cultural norms in Zimbabwe discourage problem solving strategies that may involve confrontation or challenging elders and instead youth favor distancing, keeping to themselves and other emotion focused strategies that may be more characteristic of a collectivistic society versus an individualistic society . Whereas in Western societies coping strategies are often connected to an individualistic approach whereby individuals seek help through youth counseling, in developing countries and contexts where youth have experienced armed conflict, the coping approach may be more collective in nature, with greater use of community support systems to support emotion focused coping strategies rather than problem focused strategies. In addition, cultural norms can shape use of coping strategies. For example, a mixed method study among Palestinian refugee youth (ages 8–17) living in Gaza found that girls were less likely to use coping strategies that would require them to be far from home and used more strategies that involved being close to home such as praying in the home, whereas boys were more likely to use leisure activities and relaxation activities outside of the home . Cultural gender role expectations can influence types of coping strategies utilized by youth.
In the Democratic Republic of Congo, recent research questions whether disengagement (emotion focused) coping should be construed as a maladaptive reaction to conflict affected situations, and argues a more detailed, context specific understanding is needed to understand youth coping strategies . This research in the DRC, among 952 armed conflict affected youth ages 13–21, found that in response to traumatic exposure, disengagement coping behaviors, such as distraction, resignation and social withdrawal were more common among adolescents as compared to engagement behaviors such as cognitive restructuring or problem solving . Qualitative research is needed from a youth perspective to better define and gain depth of knowledge as to the cognitive and behavioral coping strategies. As noted above, research has stressed the importance of context in understanding variations in use of coping strategies. Documenting how conflict affected children cope with adversity will improve our understanding of the types of cognitive and behavioral strategies utilized by youth and relationships with individual, family and community factors, thus informing youth-based programs in conflict and post-conflict settings.
The purpose of the qualitative study is to examine youth (ages 10–15 years) exposure to violence and other traumatic events, use of cognitive and behavioral coping strategies and the (contingent) relationships of these coping strategies with family and community. The principal objectives of study are to document youth defined coping strategies, to consider how coping may inform adaptation trajectories over time and to consider opportunities to support coping strategies that promote well-being and better mental health outcomes. This study will provide a context specific understanding of mental health and the role of coping strategies following exposure to diverse and multiple traumatic events. This qualitative work will also be used to adapt existing coping scales for youth for use in future quantitative phases of this research. By providing a culturally grounded basis for developing a comprehensive framework of coping, this research will provide the basis for empirical testing of the relationship between use of coping strategies and mental health and well-being. The findings can be used to broaden the discourse on coping strategies utilized by conflict affected youth and to identify factors and relationships that support healthy coping strategies.
Study design and setting
This study uses the research infrastructure of a larger National Institute of Health (NIH)/National Institute of Child Health and Human Development (NICHD) funded randomized community trial of a youth-led livestock microfinance program, Rabbits for Resilience (RFR). RFR is a collaborative project between Programme d’Appui aux Inititatives Economiques (PAIDEK), an established Congolese microfinance institute, and Johns Hopkins University School of Nursing (JHUSON). RFR is designed to increase youth and family resilience to ultimately improve health and emotional adjustment after exposure to adversity and trauma. RFR includes male and female youth ages 10–15 years living in 10 rural villages in the Walungu territory in Eastern Democratic Republic of Congo. The ten villages included in the impact evaluation of RFR were selected for several reasons including; (1) feasibility of delivering an intervention over a wide geographical area; (2) commitment to the intervention and study by traditional chiefs and administrators; and (3) findings from village-level assessments that showed few health and development programs exist in the area, including microfinance. The people living in these rural villages have experienced significant violence, displacement and trauma over the past 20 years with limited health care, schools or governmental or non-governmental organizations to provide support and resources.
In order to understand youth participant exposure to violence and other traumatic events and their cognitive and behavioral coping strategies, a grounded theory approach was used in the initial coding of the data and deductive reasoning used to explore how emergent themes relate to existing theory . The grounded theory methodological approach is grounded in the constructivist epistemology, that meaning is co-created in the discourse between people. The grounded theory approach supports the role of subjectivity in creation of meaning. Moreover, gaining knowledge through discourse is necessarily grounded in a particular social and historical context. For this study a grounded theory perspective is valuable because of the implicit focus on taking Congolese youth comments as true representations of their perspective on trauma and coping. Second, a deductive process was used whereby emergent themes were categorized based on existing theory suggesting two coping domains, cognitive and behavioral coping strategies. This study utilizes in depth interviews and relies on the dialogue between interviewer and interviewee to construct an improved understanding of ways youth cope with stress.
A purposive sampling strategy was used to identify eligible youth enrolled in the parent study. Investigating types of exposure to violence and other traumatic events that youth experienced was important to understand contextual variables that can affect coping and resulting mental health outcomes. At baseline, youth completed a survey including the Harvard Trauma Questionnaire. Youth were selected from four of the 10-study villages. These four villages were selected because of the reported high exposure to conflict-related trauma. Within these villages, baseline data from the parent study was used for purposive sampling based on age, gender and exposure to traumatic events to identify 48 youth (12 from each village). Traumatic exposures were represented by a wide range of experiences including murder of family/friends, having ill health without care, lacking food and water, being seriously injured, being close to death, separation from family, experiences in combat and brainwashing. Specifically, youth were selected for variation on experience of trauma: low exposure to trauma (0–1 events), medium exposure (2–3 events) and high exposure (4 or more events). Within each trauma exposure level purposive sampling involved achieving a balanced distribution of participants by age [11–16] and gender. Of the 48 eligible participants identified, 30 youth completed the interview (16 were not available on the days of fieldwork).
Congolese research team and development of the youth interview guide
Congolese research team members were previously trained by the parent study team and had successfully completed qualitative and quantitative research in the study villages. Congolese interviewers actively participated in the design, development, piloting and revision of the youth interview guide. The research team reviewed and revised interview questions to ensure questions were culturally relevant and would be appropriate for ages 10–15. The questionnaire was translated by the Congolese research team into local languages, Swahili and Mashi, used for interview with youth. Probes were developed with local partners to capture greater depth in participant responses. The interview guide was piloted in June 2014 among 5 youth in the microfinance demonstration project site located in a village outside of Bukavu, the capital city of South Kivu province. Following the pilot test, the research team revised the interview guide and conducted a second pilot test among 5 different youth. Revisions included the removal of redundant questions to shorten length, rewording of questions found to be confusing or unclear and minor re-ordering of questions to promote improved flow of the instrument as a whole. The final guide consisted of broad open-ended questions related to the following topics, 1) identification of trauma-related experiences, 2) methods for coping and changes in coping behavior 3) respondent’s perception of gender and age differences in coping, 4) sources of psychosocial support. After final revisions to the interview guide, the researcher commenced two day team training in administration of consent (in alignment with IRB regulations), ethics, and qualitative interview methods.
The Johns Hopkins School of Medicine Institutional Review Board (IRB) approved this study (IRB: CIR00001977; Date: 06-23-14). The research team also received approval to conduct the research with local partners PAIDEK by village traditional and administrative leaders. Parents/caregivers of eligible youth were provided with the purpose of the study, risks and benefits of participation in the study and then were asked to provide verbal informed consent for their child to participate. If a parent/caregiver consents, their child was then asked for verbal assent after receiving details on the purpose of the study and prior to beginning the interview. No participants’ names were recorded, all interviews were conducted in private and no information was shared outside the research team.
After parents/caregivers provided informed consent and youth provided assent, the interviewer selected a location within the village for the interview, the location was away from parents/caregivers and friends that would allow for privacy and disclosure during the interview. The interviewers started with asking youth participants to describe their typical day, their family, their community and activities they participate in. Initial questions allowed the interviewer to develop a level of rapport with the youth where they would feel comfortable answering more personal questions. The interviewer utilized probes to explore topics related to coping strategies, trauma and family and community relationships in greater depth. The final interview guide resulted in interviews between 30 and 60 min in length. All participant answers were recorded verbatim and participants were provided with compensation for their time equal to 2USD, an amount considered appropriate after consultation with village leaders and research team members.
After completion of interviews, a Congolese translator completed translation of all transcripts from French or the local language (Swahili or Mashi) to English. The translations were cross-checked by researchers based in the US and in consultation with the Congolese research team. After completion of the translation and review, the analysis used a grounded theory approach, which is rooted in a participatory transformative paradigm [36, 37]. First initial codes were developed through line-by-line coding of a sub-sample of interviews (interviews of 5 girls and 5 boys). Line-by-line coding involves providing a code to each line of written data and allows for ideas to emerge that may have escaped attention if reading for a general thematic analysis . Line-by-line coding allows the researcher to identify implicit actions and meanings, identify gaps in the data and to note common relationships and significance between codes. Where appropriate, codes were left in vivo, to preserve participants’ language and meaning. In vivo codes are locally defined terms that condense meaning and are characteristic of societies and reflect assumptions, actions and imperatives . The next analysis phase was the development of focused codes that were applied to all interviews. Focused codes are developed from using the most significant and/or frequent initial codes to make analytic sense of the data. Next, axial coding was used to represent the content of focused codes and to relate common codes, categories and concepts to each other. Second, a deductive process was used whereby emergent themes were categorized based on application of existing theory suggesting two coping domains, cognitive and behavioral coping strategies. Final coding structure was applied to each transcript using Atlas Ti software.
During the application of focused and axial coding, memos were written by the researchers to help identify emergent themes related to youth coping styles. Memos allow the researcher to capture comparisons and connections and to construct analytic notes . Iterative inductive content analysis was used to identify emergent themes and connections between themes . Verbatim statements that capture emergent themes were identified for use as quotes.