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Journal of Traumatic Stress

October 2014, 27, 593601

Quality of Life in Ethiopias Street Youth at a Rehabilitation Center


and the Association With Trauma
Kerstin Mannert,1 Sandra Dehning,1,2 Daniela Krause,1 Bianka Leitner,1 Georg Rieder,3
Matthias Siebeck,2,4 Markos Tesfaye,2,5 Mubarek Abera,5 Hailemariam Hailesilassie,5 Kenfe Tesfay,5
and Andrea Jobst1,2
1
Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany
2
Center for International Health, Ludwig Maximilian University, Munich, Germany
3
kinder unserer welt e.V. and Department of Neurology, Traunstein District Hospital, Germany
4
Department of Surgery, Ludwig Maximilian University, Munich, Germany
5
Department of Psychiatry, Jimma University, Ethiopia

Quality of life (QOL) tends to be lower among the homeless than the general population, and traumatic events experienced on the streets
have a negative impact on QOL. Low-income countries face a high number of street youth, yet little research has been performed so far
on QOL, trauma, and posttraumatic stress disorder (PTSD) among this group. This study aimed at examining the QOL of a sample of
Ethiopian street youth within a rehabilitation program and at exploring whether the street youth have experienced traumatic events and
show posttraumatic stress symptoms. We interviewed 84 street youths with the World Health Organization Quality of Life Questionnaire
(WHOQOL-BREF) and the Diagnostic Interview for Children and Adolescents (DICA). Mean QOL scores differed significantly between
the groups assessed at the beginning and at the end of the program (Cohens d = 0.48). Eighty-three percent of the Ethiopian street youths
had experienced traumatic events, and 25.0% met criteria for PTSD according to the fourth edition of the Diagnostic and Statistical Manual
of Mental Disorders. QOL did not differ between those with and without PTSD symptoms. These findings show the high rate of traumatic
events among Ethiopian street youth and the importance for rehabilitation programs that focus on improving QOL. The results of the study
may have cultural limitations.

The homeless tend to have lower quality of life (QOL; Information Networks [IRIN], 2004). Knowledge about QOL
Hubley, Russell, Palepu, & Hwang, 2014) than people in gen- is necessary to address street youths needs and experiences
eral. The World Health Organization (WHO) defines QOL as and examine the effectiveness of interventions (Hubley et al.,
individuals perceptions of their position in life in the con- 2014) to improve QOL in this group (Altena, Brilleslijper-
text of the culture and value systems in which they live, and Kater, & Wolf, 2010). Interventions such as stable hous-
in relation to their goals, expectations, standards and con- ing, providing food, and training to minimize the victimiza-
cerns (WHOQOL Group, 1995, p. 1403). In low-income coun- tion risk are most likely to improve QOL in mentally ill
tries like Ethiopia, young people especially are endangered homeless persons (Sullivan, Burnam, Koegel, & Hollenberg,
by living on the streets. Official Ethiopian government num- 2000). Therefore, programs to reintegrate street youth into
bers estimate that 150,000 children live on the streets; non- their families or communities are urgently needed (Kudrati,
governmental organizations (NGOs) estimate that the prob- Plummer, & Yousif, 2008).
lem is far worse, at nearly 600,000 (Integrated Regional Traumatic events might have an additional negative im-
pact on street youths QOL. Some studies suggest that post-
The authors Kerstin Mannert and Sandra Dehning contributed equally to this traumatic stress disorder (PTSD) is associated with lower
article. Parts of Kerstin Mannerts doctoral thesis conducted at the Faculty QOL (dArdenne, Capuzzo, Fakhoury, Jankovic-Gavrilovic,
of Medicine, Ludwig Maximilian University, Munich (in preparation) are in- & Priebe, 2005; Rapaport, Clary, Fayyad, & Endicott, 2005)
cluded in this article. This study was supported by the Center of International
Health, Ludwig Maximilian University, Munich. The authors thank Jacquie and causes broad functional impairment, especially in adoles-
Klesing, board-certified editor in the life sciences, for editing assistance with cents (Zatzick et al., 2008). A prospective epidemiologic study
the manuscript. in injured adolescents found a significant association between
Correspondence concerning this article should be addressed to Andrea Jobst, long-term PTSD and QOL deficits over 24 months (Holbrook
Department of Psychiatry and Psychotherapy, Ludwig Maximilian Univer- et al., 2005). In low-income countries like those in sub-Saharan
sity, Nussbaumstrasse 7, 80336 Munich, Germany. E-mail: A.Jobst@med.uni-
muenchen.de Africa, childhood trauma usually is associated with warlike vi-
olence (Ertl, Pfeiffer, Schauer, Elbert, & Neuner, 2011; Harder,
Copyright  C 2014 International Society for Traumatic Stress Studies. View

this article online at wileyonlinelibrary.com Mutiso, Khasakhala, Burke, & Ndetei, 2012; Klasen, Oettingen,
DOI: 10.1002/jts.21953 Daniels, & Adam, 2010). Little consideration has been given
593
594 Mannert et al.

to the consequences of traumatic events among street youth, skills. Interviews were conducted in accordance with the ethical
who are exposed to prolonged and repeated traumatic events standards in the 1975 Declaration of Helsinki. Confidentiality
like violence and rape (Tyler, Hoyt, Whitbeck, & Cauce, 2001). was strictly maintained during interviews. Two Ethiopian psy-
In a study in Latin American and Ethiopian street children, chologists from Jimma University were trained by the research
half the boys reported regular physical attacks; girls were es- organizers and performed the interviews. The interviewer read
pecially prone to rape or sexual abuse (Lalor, 1999). Moreover, each question aloud and gave the interviewee sufficient time to
street life affects health status; several studies, predominantly answer. Interviews took about 1 hour, and all assessments were
from the United States, reported high rates of trauma and PTSD completed in a single session. Inclusion criteria were willing-
among homeless youth (Bender, Ferguson, Thompson, Komlo, ness to accept the projects contents and rules and a general
& Pollio, 2010; Gwadz, Nish, Leonard, & Strauss, 2007; interest in being reunited with family. Exclusion criteria were
Stewart et al., 2004; Whitbeck, Hoyt, Johnson, & Chen, 2007) addiction to alcohol or khat and having spent more than a year
and, for example, child laborers in Addis Ababa, Ethiopia, on the streets.
were found to have internalizing and mood disorders signif- Participants were 89 youths, aged 6 to 20 years, who were
icantly more often than nonlaborers (Fekadu, Alem, & Hag- recruited and then completed evaluation forms; however, five
glof, 2006). PTSD is characterized by reexperiencing the event, completed them incorrectly, therefore the sample contained 84
numbness of feelings/emotions, avoidance of stimuli associated youths (25, 29.8% female; 59, 70.2% male). There were 35
with the event, and increased arousal (American Psychiatric As- children (41.7%) just starting the 3-month psychosocial reha-
sociation [APA], 1994). Traumatic events and PTSD in child- bilitation program and there were 49 at the final stage (58.3%).
hood can have significant effects on adolescent development The mean age of the whole sample was 13.79 years (SD = 2.81,
(Gerson & Rappaport, 2013) and lead to chronic mental disor- range = 620). The mean age of the children at the beginning
ders (Sack, Clarke, & Seeley, 1995). Even when full PTSD di- of the project was 13.43 years (SD = 2.40, range = 618),
agnostic criteria are not met, partial symptomatology may cause and the mean age of those at the end of the project was 14.33
serious functional impairment (Stein, Walker, Hazen, & Forde, years (SD = 2.40, range = 1020). The average time spent on
1997) and have possible severe long-term consequences, espe- the street was 4.46 months (SD = 3.34, range = 112) in the
cially because general and particularly mental health resources whole sample, 3.67 months (SD = 2.12) for the children at the
in most Sub-Saharan African countries are rather limited beginning of the project and 4.93 months (SD = 3.88) for the
(Sathiyasusuman, 2011). children at the end of the project. The mean former family size
Although rehabilitation programs are suggested to have pos- was 5.05 people (SD = 1.93) in the whole sample, 5.17 (SD =
itive effects on QOL, to our knowledge no study has focused on 1.90) for the children at the beginning of the project and 4.96
the relation between QOL, trauma, and PTSD in street youth (SD = 1.96) for the children at the end of the project. Sociode-
and the impact of a rehabilitation program on QOL. Therefore, mographic characteristics did not differ significantly between
the current study investigated two samples of street youth at the group at the beginning and the group at the end of the project
the beginning and end of a 3-month, community-based reha- (see Table 1).
bilitation program in Jimma, Ethiopia. The main aim was to We used the United Nations Childrens Fund (UNICEF;
examine QOL; the second was to explore earlier experiences 1986) definition to divide the youth into two groups according to
of traumatic events and current PTSD symptoms. Additional their status before entering the program: (a) On-the-streetlive
aims were to evaluate whether characteristics such as sex, age, and work on the street at day and sleep at home with families
education, family conditions, number of traumatic events, and or relatives (69.5%, n = 57); (b) of-the-streetlive, work, and
rehabilitation processes were associated with PTSD and to test sleep on the streets without any family support (30.5%, n =
for differences in QOL scores on the basis of trauma, PTSD, 25). All of the of-the-street youths were male, whereas 57.9%
and rehabilitation. of the on-the-street youths were male and 42.1% female.
The rehabilitation program, Facilitator for Change, is highly
structured, consisting of school, basic vocational training (as
Method a hairdresser, tailor, or carpenter), and recreational activities
(e.g., sports) and aims to reintegrate street youth into their
Participants
families and community and improve living conditions and
Participants were recruited from a community-based rehabilita- QOL. When possible, street youth return to their families at
tion project for street youth implemented by the Ethiopian NGO night. Otherwise, they live independentlysupervised by so-
Facilitator for Change in Jimma and funded by kinder unserer cial workersor in foster families, if aged below 14 years and
welt e.V. (Germany). Jimma is a rural town with over 120,000 without family support. Therefore, the program addresses QOL
inhabitants, 352 km (219 miles) southwest of the capital, Addis aspects, especially social relationships and environment. It does
Ababa (Central Statistical Agency of Ethiopia, 2007). not provide any specific treatment for physical and psycholog-
The Jimma University Ethical Review Board approved the ical issues, apart from access to general medical support. The
study. All participants gave oral rather than written informed living circumstances associated with the project, however, espe-
assent because some of them had limited reading and writing cially being away from the streets, might improve physical and

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Quality of Life in Ethiopias Street Youth 595

Table 1
Sociodemographic Characteristics of Sample Pooled and by FC Project Status
Total Start of FC project End of FC project
(N = 84) (n = 35) (n = 49)
Variable n % n % n %
Sex
Male 59 70.2 26 74.3 33 67.3
Female 25 29.8 9 25.7 16 32.7
Street status
On-the-streeta 57 69.5 24 70.6 33 68.8
Of-the-streeta 25 30.5 10 29.4 15 31.3
Education
Grades 14 32 38.1 12 34.3 20 40.8
Grades 58 32 38.1 18 51.4 14 28.6
Grades 913 19 22.7 4 11.4 15 30.6
Basic reading 1 1.2 1 2.9 0 0.0
Ethnicity
Oromo 40 48.2 15 42.9 25 52.1
Dawro 15 18.1 4 11.4 11 22.9
Amhara 7 8.4 5 14.3 2 4.2
Keffa 7 8.4 4 11.4 3 6.3
Gurage 3 3.6 0 0.0 3 6.3
Others 11 13.3 7 20.0 4 8.3
Origin
Jimma 75 90.4 33 97.1 42 85.7
Outside Jimma 8 9.6 1 2.9 7 14.3
Family status
Mother dead 10 12.0 3 8.6 7 14.6
Father dead 27 32.5 13 37.1 14 29.2
Both parents dead 15 18.1 4 11.4 11 22.9
Both parents alive 31 37.3 15 42.9 16 33.3
Living with
Mother 59 71.1 28 80.0 31 64.6
Father 37 44.6 14 40.0 23 47.9
Grandparents 11 13.1 4 11.4 7 14.3

Note. 2 values are not shown, because none were significant. FC = Facilitator for change.
a According to dArdenne UNICEF (1986) definition.

psychological health and well-being (e.g., enough to eat, dry oped by the WHO and validated in several studies (Skevington
bedroom), as might attention from social workers. The 3-month et al., 2004; Trompenaars, Masthoff, Van Heck, Hodiamont,
program is followed by 1 year of postrehabilitation support. & De, 2005), to explore QOL. The WHOQOL-BREF was
developed in diverse cultures to identify universal QOL
components (Saxena, Carlson, & Billington, 2001), although
Measures
only one study was performed in Africa (Harare, Zimbabwe;
In addition to age, time spent on the street and former family Saxena et al., 2001). It has been applied to assess trauma
size, additional basic sociodemographic characteristics were effects on QOL among postconflict displaced Ethiopians
recorded, including status (on- or of-the-street), sex, ethnicity, (Araya, Chotai, Komproe, & de Jong, 2007) and in adolescents
place of origin, education, and family conditions before living (Al-Fayez & Ohaeri, 2011; Awasthi, Agnihotri, Chandra,
on the street (see Table 1). Singh, & Thakur, 2012; Teixeira et al., 2011), but its cultural
We used the World Health Organization Quality of Life ques- limitations should be considered when interpreting findings.
tionnaire (WHOQOL-BREF; Skevington, Lotfy, & OConnell, The WHOQOL-BREF comprises 26 questions related to the
2004), a short version of the WHOQOL-100 assessment devel- previous 2 weeks; responses are rated on a 5-point Likert-like

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
596 Mannert et al.

scale. The first two items refer to general perception of Table 2


QOL, and overall satisfaction with health, and the remaining Descriptive Statistics for WHOQOL-BREF for Total Sample
items are in four domains: physical (Domain 1; 7 items) and
Variable n Minimum Maximum M SD
psychological health (Domain 2; 6 items), social relationships
(Domain 3; 3 items), and environment (Domain 4; 8 items). We General health 83 12.50 100.00 50.30 18.52
deleted the question about satisfaction with sexual relationships Physical health 82 21.43 100.00 64.48 19.12
from Domain 3 to adapt the scale for our study population. To Psychological 81 16.67 95.83 59.47 17.12
improve comparability of the results with domains composed Social relationships 83 25.00 100.00 56.93 23.45
of unequal numbers of items, the Likert scale was transformed Environment 81 15.63 87.50 50.77 19.65
into a 0100 scale according to WHOQOL group guidelines
(Angermeyer, Kilian, & Matschinger, 2000). We used the Note. WHOQOL-BREF = World Health Organization Quality of Life question-
naire.
Amharic version of the Diagnostic Interview for Children and
Adolescents (DICA; Reich, 2000)a reliable, acceptable,
and feasible instrument in Ethiopia (Kebede, 2000)to assess more traumatic events and those who had not. We checked for
self-reported PTSD symptoms. The DICA was designed on the normal distribution with the Kolmogorov-Smirnov test. The
basis of DSM-IV PTSD criteria. The Amharic version of the predetermined level was .05. Corrections for multiple testing
DICA has been used in several Ethiopian studies (Ashenafi, were not used.
Kebede, Desta, & Alem, 2000; Fekadu, Alem, & Hagglof,
2006). Nevertheless, the DICA might have cultural limitations
Results
because it was developed in the United States.
During the DICA, participants were asked whether they had The highest mean domain scores in the WHOQOL-BREF were
experienced, witnessed, or been confronted with a traumatic found for physical health (M = 64.48, SD = 19.12), followed
event involving actual or threatened death or serious injury. by psychological health (M = 59.47, SD = 17.12) and social
The response to the event had to involve intense fear, helpless- relationships (M = 56.93, SD = 23.45). The lowest mean scores
ness, and horror or, in younger children, disorganized and agi- were for environment (M = 50.77, SD = 19.65) and general
tated behavior (APA, 1994). If they answered in the affirmative, QOL (M = 50.30, SD = 18.52; see Table 2). No differences
additional questions were asked to explore symptoms of reex- in QOL were found between on- and of-the-street youths or
periencing (e.g., intrusive thoughts), avoidance, hyperarousal, between those who had (Criterion A) or had not experienced a
duration, and clinically significant distress and impairment in traumatic event (independent sample t test).
social or other important areas of functioning. The DSM-IV According to the DICA, 70 of the youths (83.3%) had experi-
diagnostic criteria for PTSD were fulfilled if symptoms had enced one traumatic event (DSM-IV Criterion A): 97.1 % re-
lasted longer than 4 weeks and caused significant functional ported one intrusion (Criterion B); 90.0%, three avoidance
impairment. symptoms (Criterion C); 92.9%, two hyperarousal symptoms
(Criterion D); and 80.0%, significant distress or impairment
(Criterion F). PTSD diagnostic criteria (Criteria BD for > 1
Data Analysis
month) were met in 30.0% (n = 21) of these youths (25.0% of
The raw data were entered into an SPSS (Version 20) database. the total group; see Table 3). The mean age at the most traumatic
We performed descriptive analyses of sociodemographic and event was 10.56 years (SD = 3.31), and the mean time since that
clinical characteristics by independent sample t tests and 2 event was 3.27 years (SD = 2.62, range = 010). Psychopatho-
tests. Data for a complete scale were missing for five partici- logical symptoms had occurred on average 1.64 weeks (SD =
pants, so all data from these participants were excluded from the 1.41) after the event. The mean number of traumatic events was
analysis. Therefore, data from 84 participants were included in 7.76 (SD = 3.99, range = 112). The most common traumatic
the analyses (N = 84). If single items were missing, these items experiences were having the house destroyed by fire or flood
or subscales were excluded from the analysis. Differences in (45.7%) and witnessing a person dying (45.7%); other types
sociodemographic and clinical characteristics related to PTSD are listed in Figure 1. Noteworthy is that street youths whose
were only measured in a subgroup with 1 previous traumatic mother had not been living at home before they entered the
event (DSM-IV Criterion A fulfilled). To explore the relation street were more likely to fulfill PTSD criteria, 2 (1, N = 84)
between QOL and PTSD and compare those findings between = 4.77, p = .029; see Table 4. PTSD was not significantly asso-
youths at the beginning and end of the program (program sta- ciated with sex, place of origin, ethnicity, whether parents were
tus), we performed univariate analyses of variance within the alive, education, age (mean age in group with positive PTSD
group fulfilling Criterion A. Prediction of QOL scores based on criteria: 13.05 years, SD = 2.92; mean age in group without
program status and PTSD symptoms was tested with a linear positive PTSD criteria: 14.17 years, SD = 2.38), time spent on
regression model. Independent sample t tests were performed street (mean time in group with positive PTSD criteria: 5.00
to test for differences between QOL scores of on- and of-the- months, SD = 4.83; mean time in group without positive PTSD
street youth and between those who had experienced one or criteria: 4.54 months, SD = 3.20), number of traumatic events

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Quality of Life in Ethiopias Street Youth 597

Table 3 no significance for program status, F(1, 82) = 3.99, p = .053,


Frequencies of DICA Analysis Based on DSM-IV PTSD Criteria PTSD diagnosis, F(1, 82) = 0.00, p = .948, or the interaction
for Total and Exposed Subgroup of program status by PTSD status, F(1, 82) = 0.05, p = .819.
Therefore, PTSD frequency did not differ between youths at
All 1 traumatic
the beginning and end of the program (program status). The
(N = 84) event (n = 70)
independent sample t test for general QOL and program status,
Criterion n % n % however, was significant, t(81) = 2.13, p = .037 (d = 0.48):
General QOL was significantly higher in the group at the end of
A (Traumatic event) 70 83.3 70 100.0 the program. Program status predicted the general QOL score
B (Intrusion) 68 81.0 68 97.1 (linear regression model; B = 4.30, SE B = 2.024, = .23,
C (Avoidance/ 63 75.0 63 90.0 t = 2.13, p = .037), whereas PTSD symptoms did not (B =
Numbing) 0.39, SE B = 4.648, = .01, t = 0.08, p = .934). Univariate
D (Arousal) 65 77.4 65 92.9 analyses for the four QOL domains showed no trend towards
AD + F 56 66.7 56 80.0 significance.
(Functioning)
AD + F + E 21 25.0 21 30.0
(Duration) = PTSD
Note. DICA = Diagnostic Interview for Children and Adolescents; DSM-IV = Discussion
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; PTSD =
posttraumatic stress disorder. To our knowledge, this is the first study on QOL, trauma symp-
toms, and rehabilitation in street youth. Our main finding was
that QOL scores were relatively low, but higher in the group at
(mean number of traumatic events in group with positive PTSD the end of the program than in that at the beginning.
criteria: 6.57, SD = 3.75; mean number in group without pos- The low QOL scores indicate that the adverse life experi-
itive PTSD criteria: 6.49, SD = 4.20), or family size before ences faced by our street youth negatively affect QOL. Com-
street life (mean size in group with positive PTSD criteria: 4.71 parative QOL figures from healthy Ethiopian youths, however,
people, SD = 2.53; mean size in group without positive PTSD are lacking; so far, Ethiopian QOL studies have focused on
criteria: 5.11, SD = 1.59), and PTSD frequency did not differ patients with human immunodeficiency virus (Deribew et al.,
between on- and of-the-street youths (see Table 4). 2009). Ethiopia provides a completely different setting to
We conducted univariate analyses of variance in the sub- Western countries, and cultural concepts of QOL may differ;
group reporting one or more traumatic events (Criterion A); hence, caution is required when comparing results. Neverthe-
QOL domains (physical health, psychological domain, envi- less, our findings seem to be consistent with an Australian study
ronment, and social relationships) were set as dependent vari- (Bearsley & Cummins, 1999) that evaluated QOL in 105 ado-
ables. Having or not having a diagnosis of PTSD and program lescents (1417 years) who were homeless or at risk of home-
status (beginning or end of rehabilitation) were set as indepen- lessness: Mean QOL domain scores, measured with ComQol-
dent factors. Regarding the domain general QOL, we found ST, ranged from 54.46 (family) to 65.67 (safety); mean overall

Figure 1. Different types of trauma experienced by Ethiopian street youth.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
598 Mannert et al.

Table 4
Sociodemographic Characteristics for Those With at Least One Criterion A Event Separately by PTSD Status
PTSD positive (n = 21) PTSD negative (n = 49)
Variable n % n %
Sex
Male 16 76.2 34 72.3
Female 5 23.8 13 27.7
Street status
On-the-streeta 17 81.0 27 60.0
Of-the-streeta 4 19.0 18 40.0
Education
Grades 14 12 57.1 17 36.2
Grades 58 6 28.6 19 40.4
Grades 913 3 14.3 10 21.4
Basic reading 0 0.0 1 2.1
Ethnicity
Oromo 10 47.6 23 48.9
Dawro 5 23.8 8 17.0
Amhara 1 4.8 4 8.5
Keffa 2 9.5 4 8.5
Gurage 2 9.5 1 2.1
Others 1 4.8 7 14.9
Origin
Jimma 19 90.5 42 89.4
Outside Jimma 2 9.5 4 8.5
Family status
Mother dead 5 25.0 4 8.5
Father dead 5 25.0 17 36.2
Both parents dead 4 20.0 9 19.1
Both parents alive 6 30.0 17 36.2
Living with
Motherb 11 55.0 38 80.9
Father 6 30.0 24 51.1
Grandparents 3 14.3 5 10.6
FC project group
Beginning 6 28.6 22 46.8
End 15 71.1 25 53.2

Note. PTSD = posttraumatic stress disorder; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.
a According to Unicef definition (Unicef, 1986). b 2 = 4.77, p < .05.

QOL was 60.34. In our study, mean overall QOL (M = 50.30) with our results, Bender et al. (2010) found that 57.0% of home-
was even lower. less youth in U.S. cities had experienced one traumatic event,
Interestingly, our trauma rates were similar to those in U.S. and 24.0% met PTSD criteria. Conceptual limitations have to
studies of homeless youth (Bender et al., 2010; Gwadz et al., be considered when comparing PTSD results across cultures.
2007; Stewart et al., 2004; Whitbeck et al., 2007): The majority Consequently, the term probable PTSD is more appropriate
(83.3%) of the 84 youths had experienced one or more traumatic in our sample.
events, and most reported multiple traumatic events. Of those A notable percentage of our participants reported high rates
who had witnessed one or more traumatic events, 30.0% ful- of trauma symptoms that did not fulfill PTSD diagnostic crite-
filled DSM-IV PTSD criteria; 25.0% of the entire sample, how- ria (because they subsided in < 4 weeks), but may have caused
ever, met the same PTSD criteria. Rates were similar among significant distress. A minority reported no trauma symptoms
homeless youth in New York City (Gwadz et al., 2007): 85.9% at all despite having experienced traumatic events. Further re-
had experienced one or more traumatic events. Again, in line search needs to explore these outcomes and identify possible

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Quality of Life in Ethiopias Street Youth 599

factors that increase risk for greater symptom severity or pro- Future research should investigate whether improving QOL
mote mental health resilience (Gerson & Rappaport, 2013). The positively affects PTSD; possible additional factors that may
mean time since the most traumatic event was > 3 years; the affect QOL during rehabilitation should be included, such as
mean time since entering street life was 4.46 months. Thus, improved housing (Sullivan et al., 2000), because satisfaction
many participants had experienced the most traumatic event with housing is a strong predictor of general life satisfaction
before entering street life, possibly in their family; the event (Biswas-Diener & Diener, 2006). Regarding specific QOL do-
may have been a major reason for running away, as has been mains, improved living conditions, access to medical treatment,
reported in previous studies (Martijn & Sharpe, 2006). PTSD healthy food, and dry and safe sleeping facilities may be im-
symptoms did not differ significantly between the sexes. This portant predicting factors and should be investigated in future
is consistent with Stewart et al. (2004), but Whitbeck et al. research.
(2007) reported that nearly twice as many females as males met The study has several limitations. The questionnaires were
PTSD criteria in U.S. cities. In contrast to Gwadz et al. (2007), not developed specifically for sub-Saharan Africa and therefore
we found no sex differences in the individual types of trauma. might have cultural limitations. We did not consider psychi-
Again, cultural differences limit conclusions. Our sample may atric disorders other than PTSD, but studies indicate a high
show no sex differences because all female street youths were psychiatric comorbidity in street youth with PTSD (Gwadz
on-the-street and slept in homes or shelters, meaning they were et al., 2007; Whitbeck et al., 2007). Moreover, the Jimma reha-
generally more protected. bilitation project has specific admission criteria, so participants
Also important is that PTSD symptoms were significantly may have fewer PTSD symptoms than youth actually living on
lower among youths who lived with their mothers before enter- the street. For example, one admission criterion is no addiction
ing street life. Thus, in Ethiopia, living with ones mother might to alcohol; such addiction, however, is a strong correlate of
have a long-term protective and stabilizing effect that can pre- trauma and PTSD (Bender et al., 2010). Furthermore, the
vent trauma-related symptoms. This conclusion is supported results are not representative for street youth who receive no
by research highlighting the influence of family relationships support from services or NGOs. In addition, the nonrandom
on mental health in runaway youth (Thompson, Cochran, & allocation to each condition limits a direct comparison between
Barczyk, 2012). Further research is needed to prove such a the street youth at the beginning and end of the program.
correlation. Culture-specific aspects of PTSD may have been neglected
In our study, QOL scores did not differ significantly between (Hinton & Lewis-Fernandez, 2011). Also, DSM-IV criteria may
street youths with and without PTSD. This is surprising be- not reliably assess PTSD in an African country and may not
cause PTSD was associated with lower QOL in psychiatric be applicable in street youth whose symptoms are influenced
patients in Western countries (dArdenne et al., 2005; Rapaport by their culture, community, and complex living conditions
et al., 2005). First, a possible reason for this finding is that the (Gadpaille, 2003). Future research should include the develop-
Ethiopian street youth with PTSD symptoms have developed ment of measures that consider the specific cultural context. The
strategies to counteract their trauma symptoms, and coping WHOQOL-BREF may have conceptual problems: Although
strategies are associated with QOL (Nachar, Guay, Beaulieu- it was developed in diverse cultural settings, only one was in
Prevost, & Marchand, 2013). Second, all Ethiopian street youth Africa (Harare, Zimbabwe; Saxena et al., 2001), and some of
presumably have relatively low QOL, so that PTSD symptoms the questions might have been difficult for the younger children
perhaps do not negatively affect it; this consideration is linked (< 12 years old) in our sample. These limitations should be
with the finding that a high percentage of participants reported considered when assessing the external validity of our study.
trauma symptoms, but did not meet PTSD diagnostic criteria. Nevertheless, our study has several manifest implications. For
Third, street youth without PTSD symptoms may fulfill diag- example, it underscores the necessity and opportunities to
nostic criteria for other anxiety or depressive disorders that may improve QOL among street youth. Service providers and other
decrease QOL. All of these points would be interesting topics professionals have to meet homeless youths specific needs to
for future research. increase QOL and create good working relationships (Altena
General QOL scores differed significantly in the independent et al., 2010). Rehabilitation projects like the project in Jimma
sample t test and linear regression model between the groups can doubtless play an important role in assessing mental health
assessed at the beginning and end of the program, even though problems, including PTSD, but specific interventions are
they had similar PTSD symptoms. In contrast, in the univariate needed to reduce symptoms in youth with PTSD (McManus &
analysis the direct relation between QOL, PTSD symptoms, Thompson, 2008).
and program status did not reach significance, and the relation Our study indicates that Ethiopian street youth experience
between general QOL and program status showed only a trend a high rate of traumatic events and consequently show PTSD
towards significance. The lack of change in PTSD symptoms is symptoms. Improvements in QOL were not associated with
understandable because the program did not offer any specific changes in PTSD symptoms but with the rehabilitation project,
interventions for PTSD symptoms. The higher QOL scores in such as improved living circumstances. Further research is
the group at the end of the program may indicate that reha- needed to deepen our understanding of the role of specific
bilitation stabilizes QOL independent from PTSD symptoms. factors in improving QOL within rehabilitation facilities and

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
600 Mannert et al.

to investigate whether and in which circumstances improving Fekadu, D., Alem, A., & Hagglof, B. (2006). The prevalence of mental
QOL positive affects PTSD symptoms. health problems in Ethiopian child laborers. Journal of Child Psychology
and Psychiatry and Allied Disciplines, 47, 954959. doi:10.1111/j.1469-
7610.2006.01617.x

Gadpaille W. J. (2003). Cross-cultural and gender considerations of trauma.


Adolescent Psychiatry, 27, 225258. doi:10.1016/j.jadohealth.2012.06.018
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