Magnitude of PTSD Related to Sexual Violence in Conflict Settings and Effectiveness of Psychological Interventions in Armed Conflict Contexts: A Systematic Review and Meta-Analysis — Oak Academic Publishing
Research ArticleOpen AccessGoogle Scholar indexed
Magnitude of PTSD Related to Sexual Violence in Conflict Settings and Effectiveness of Psychological Interventions in Armed Conflict Contexts: A Systematic Review and Meta-Analysis
Faculty of Education Sciences and Clinical Psychology, Anglican University of Bukavu, Bukavu, DRC
,
Faculty of Medicine, University of Goma, Goma, DRC
,
Faculty of Medicine, University of Goma, Goma, DRC
,
Faculty of Medicine, University of Kisangani, Kisangani, DRC
1 Faculty of Education Sciences and Clinical Psychology, Anglican University of Bukavu, Bukavu, DRC
2 Faculty of Medicine, University of Goma, Goma, DRC
3 Faculty of Medicine, University of Goma, Goma, DRC
4 Faculty of Medicine, University of Kisangani, Kisangani, DRC
Background: Sexual violence in conflict settings is a major determinant of psychological morbidity, particularly post-traumatic stress disorder (PTSD). While several reviews have addressed trauma in displaced populations, few have provided consolidated estimates specific to survivors in sub-Saharan Africa. Methods: We conducted a systematic review and meta-analysis of observational and quasi-experimental studies published between 2002 and 2024. Methodological quality was assessed using the Joanna Briggs Institute tool; only studies scoring ≥50% were included. Data were extracted into Excel and analyzed in Stata 16 using random-effects models. Subgroup analyses were performed by age, setting, measurement tool, and time since assault. Heterogeneity was assessed with I 2 and Cochran’s Q, and publication bias with funnel plots and Egger’s test. Results: Fifty-eight studies (≈32,000 survivors) were included, of which 42 contributed quantitative data. The pooled prevalence of PTSD was 48% (95% CI: 42% - 54%), with higher rates among adolescents (55%, 95% CI: 47% - 62%) compared to adults (44%, 95% CI: 38% - 50%). Community-based studies reported greater prevalence (52%) than clinical settings (46%). Key associated factors included social stigma (OR = 2.1, 95% CI: 1.6 - 2.7), lack of social support (OR = 1.9, 95% CI: 1.4 - 2.5), delayed access to care >72 h (OR = 1.8, 95% CI: 1.3 - 2.4), multiple exposures to violence (OR = 2.6, 95% CI: 2.0 - 3.4), and forced displacement (OR = 1.7, 95% CI: 1.2 - 2.3). Overall heterogeneity was moderate to high (I 2 = 68%), with evidence of slight publication bias (Egger’s p = 0.04). Conclusions: Nearly one in two survivors of sexual violence in conflict settings develops PTSD, with adolescents and community-based populations particularly vulnerable. Effectiveness of psychotherapeutic interventions varies: gold-standard therapies (CBT, EMDR, NET) achieve 60% - 80% improvement, while community approaches show more modest but socially acceptable effects. These findings underscore the urgent need for systematic screening, culturally adapted interventions, and sustained follow-up strategies to reduce the psychological burden and foster resilience in conflict-affected communities.
World Health Organization (2021) Violence against Women Prevalence Estimates, 2018: Global, Regional and National Prevalence Estimates for Intimate Partner Violence against Women and Global and Regional Prevalence Estimates for Non-Partner Sexual Violence against Women. WHO. https://www.who.int/publications/i/item/9789240022256
Hossain, M., Zimmerman, C., Kiss, L., Kone, D., Bakayoko-Topolska, M., Manan K A, D., et al . (2014) Men’s and Women’s Experiences of Violence and Traumatic Events in Rural Côte d’Ivoire Before, during and after a Period of Armed Conflict. BMJ Open , 4, e003644. https://doi.org/10.1136/bmjopen-2013-003644
Betancourt, T.S., McBain, R., Newnham, E.A. and Brennan, R.T. (2013) Trauma History and Psychopathology in War-Affected Refugee Children Referred for Trauma-Related Mental Health Services in the United States. Journal of Traumatic Stress , 26, 568-577.
Verelst, A., Bal, S., De Schryver, M., Say Kana, N., Broekaert, E. and Derluyn, I. (2020) The Impact of Avoidant/Disengagement Coping and Social Support on the Mental Health of Adolescent Victims of Sexual Violence in Eastern Congo. Frontiers in Psychiatry , 11. https://doi.org/10.3389/fpsyt.2020.00382
Verelst, A., De Haene, L., Broekaert, E. and Derluyn, I. (2014) Mental Health of Victims of Sexual Violence in Eastern Congo: The Mediating Role of Stigma. Journal of Interpersonal Violence , 29, 3407-3429.
Johnson, K., Scott, J., Rughita, B., Kisielewski, M., et al . (2010) Association of Sexual Violence and Human Rights Violations with Physical and Mental Health in Territories of the Eastern Democratic Republic of the Congo. J ournal of the A merican M edical A ssociation , 304, 553-562. https://doi.org/10.1001/jama.2010.1086
Stöckl, H. and Sorenson, S.B. (2024) Violence against Women as a Global Public Health Issue. Annual Review of Public Health , 45, 277-294. https://doi.org/10.1146/annurev-publhealth-060722-025138
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R.A. and van Ommeren, M. (2009) Association of Torture and Other Potentially Traumatic Events with Mental Health Outcomes among Populations Exposed to Mass Conflict and Displacement: A Systematic Review and Meta-Analysis. J ournal of the A merican M edical A ssociation , 302, 537-549. https://doi.org/10.1001/jama.2009.1132
Lee, E., Faber, J. and Bowles, K. (2021) A Review of Trauma Specific Treatments for Post-Traumatic Stress Disorder. Clinical Social Work Journal , 50, 147-159. https://doi.org/10.1007/s10615-021-00816-w
Stark, L., Sommer, M., Davis, K., Asghar, K., Assazenew Baysa, A., Abdela, G., et al . (2017) Disclosure Bias for Group versus Individual Reporting of Violence Amongst Conflict-Affected Adolescent Girls in DRC and Ethiopia. PLOS ONE , 12, e0174741. https://doi.org/10.1371/journal.pone.0174741
Verelst, A., De Schryver, M., Broekaert, E. and Derluyn, I. (2014) Mental Health of Victims of Sexual Violence in Eastern Congo: Associations with Daily Stressors, Stigma, and Labeling. BMC Women ’ s Health , 14, Article No. 106. https://doi.org/10.1186/1472-6874-14-106
Murray, S.M., Augustinavicius, J., Kaysen, D., Rao, D., et al . (2018) The Impact of Stigma on PTSD Symptom Severity among Survivors of Sexual Violence in the Democratic Republic of Congo. Psychiatry Res earch , 265, 224-230.
Chynoweth, S.K., Buscher, D. and Martin, S. (2020) Responding to Sexual Violence in Conflict and Emergencies. The Lancet , 395, 260-262.
Page, M.J., McKenzie, J.E., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D., et al . (2021) The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews. B ritish M edical J ournal , 372, n71. https://doi.org/10.1136/bmj.n71
Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., et al . (2013) The PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD.
Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Gusman, F.D., Charney, D.S., et al . (1995) The Development of a Clinician-Administered PTSD Scale. Journal of Traumatic S tress , 8, 75-90. https://doi.org/10.1007/bf02105408
Hossain, M., Pearson, R.J., McAlpine, A., Bacchus, L.J., et al . (2021) Addressing Violence against Women in Health Settings: A Review of Evidence and Best Practices. BMJ Glob al Health , 6, e004450.
Stark, L. and Ager, A. (2011) A Systematic Review of Prevalence Studies of Gender-Based Violence in Complex Emergencies. Trauma , Violence , & Abuse , 12, 127-134. https://doi.org/10.1177/1524838011404252
Higgins, J.P.T., Thomas, J., Chandler, J., Cumpston, M., et al . (2019) Cochrane Handbook for Systematic Reviews of Interventions. 2nd Edition, Wiley-Blackwell.
Munn, Z., Aromataris, E., Tufanaru, C., Stern, C., Porritt, K., Farrow, J., et al . (2019) The Development of Software to Support Multiple Systematic Review Types: The Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). International Journal of Evidence - Based Healthcare , 17, 36-43. https://doi.org/10.1097/xeb.0000000000000152
Hossain, M., Pearson, R.J., McAlpine, A., Bacchus, L.J., et al. (2021) Addressing Violence against Women in Health Settings: A Review of Evidence and Best Practices. BMJ Glob Health , 6, e004450.
Nyaga, V.N., Arbyn, M. and Aerts, M. (2014) Metaprop: A Stata Command to Perform Meta-Analysis of Binomial Data. Archives of Public Health , 72, Article No. 39. https://doi.org/10.1186/2049-3258-72-39
Roberts, B., Ocaka, K.F., Browne, J., Oyok, T. and Sondorp, E. (2008) Factors Associated with Post-Traumatic Stress Disorder and Depression Amongst Internally Displaced Persons in Northern Uganda. BMC Psychiatry , 8, Article No. 38. https://doi.org/10.1186/1471-244x-8-38
Vinck, P., Pham, P.N., Stover, E. and Weinstein, H.M. (2007) Exposure to War Crimes and Implications for Mental Health in the Democratic Republic of the Congo. J ournal of the A merican M edical A ssociation , 298, 543-553.
Kaysen, D., Rosen, G., Zangana, G.A.S., Mohand, A.A., et al . (2011) Survivors of Sexual Violence in Iraq: Prevalence and Correlates of PTSD and Depression. J ournal of Traumatic Stress , 24, 180-188.
Jewkes, R., Dunkle, K., Nduna, M. and Shai, N. (2010) Intimate Partner Violence, Depression and PTSD Symptoms among South African Women. BMC Public Health , 10, Article No. 123.
O’Donnell, M.L., Creamer, M. and Pattison, P. (2004) Posttraumatic Stress and Depression Following Injury. Psychol ogy Med icine , 34, 673-682.
Murray, L.K., Dorsey, S., Haroz, E., Lee, C., et al . (2014) A Common Elements Treatment Approach for Adult Survivors of Violence in Low and MiddleIncome Countries. Behaviour Research and Therapy , 63, 122-129.
Neuner, F., Schauer, M., Klaschik, C., Karunakara, U. and Elbert, T. (2004) Narrative Exposure Therapy for Survivors of Organized Violence. Journal of Traumatic Stress , 17, 295-302.
Duroch, F., McRae, M. and Grais, R.F. (2011) Description and Consequences of Sexual Violence in Conflict Settings: Médecins Sans Frontières Data. PLOS Med icine , 8, e1001107.
Glass, N., Perrin, N.A., Clough, A., et al . (20170 Violence against Women in Conflict Settings and Mental Health Outcomes: A Mixed-Methods Study. Glob al Public Health , 12, 614-628.
De Jong, J.T., Komproe, I.H. and Van Ommeren, M. (2001) Common Mental Disorders in Postconflict Settings. J ournal of the A meric an M edical A ssociation , 286, 544-552.
Bogic, M., Njoku, A. and Priebe, S. (2015) Long-Term Mental Health of Refugees Following War and Trauma: A Systematic Literature Review. BMC International Health and Human Rights , 15, Article No. 29.