Results
Sample demographics are shown in Table
1. Of the 48 eligible participants identified, 30 youth completed the interview, 53 % were female (
n = 16) and (47 %) were male (
n = 14). Youth ranged in age from 10–15 years old (mean age = 13.07) and represented 4 villages.
Table 1
Sample Demographics: Trauma Exposure, Gender and Age
Trauma Exposure | Ages 10–12 | Ages 13–15 | Ages 10–12 | Ages 13–15 | Total |
Low (0–1 events) | 1 | 2 | 1 | 1 | 5 |
Medium (2–3 events) | 2 | 3 | 2 | 4 | 11 |
High (4+ events) | 4 | 4 | 3 | 3 | 14 |
Total | 7 | 9 | 6 | 8 | 30 |
Exposures to violence and stress
Almost half (46.7 %) of the 30 youth participants experienced 4 or more traumatic events, 36.7 % reported 2–3 and 16.7 % reported 1 or no traumatic events in their lifetime. Exposures to different forms of violence included witnessing the death of a friend or family member, being in a combat situation and forced separation from family and lack of basic needs, such as lack of medical care, lack of shelter, and lack of food were reported among youth participants. The qualitative analysis revealed that exposures to traumatic stressors occur at the individual, family and community level.
Individual exposure to violence
The majority of young adolescents interviewed had a personal story of loss and suffering. Participants described experiences of militia groups coming through their village. For example, a fifteen year old girl recollects her experiences with conflict-related violence,
“In the past (2004), we were not sleeping in our houses. Our village was all the time attacked by FDRL (armed combatants) These soldiers terrorized, killed, and raped people, and plundered houses, if I had power, I would kick them out of my country. These crooks came very often, during the day or at night, and inflicted to people horrendous things. They came to our house, when I was 7, and grabbed our property, goats, clothes and other things”.
Youth participants describe armed groups intentions as primarily to plunder or steal items of value from homes. The memory of armed conflict is long lasting and difficult for many youth to forget. These events cause continued anxiety and fear that can be detrimental to mental health. For example, a fourteen year old male recounts.
“What has already frightened me is the thought that the people who come here to kill others can also kill me as I am alone in the house. I am unable to help myself and stop this fear, and so I wish we had people to protect our village. Bandits have already killed a neighbor; I’ve been afraid since then”.
The effects of armed conflict continue to influence youth lives. A ten year old female explains.
“I’m afraid, when I hear gunshots and when people fight in the village, even though I may not know those people. I’m also afraid when I see blood, especially when mothers are nursing people who got wounded in fights. Usually such events upset me, and I usually hide in order not to see what’s going on. One doesn’t forget easily after they saw blood. Sometimes I even vomit”.
Experiencing violence at the individual level may directly affect mental health and well-being outcomes or may be mediated by coping strategies.
Violence in the family
A common theme from nearly half of youth interviews was the experience of domestic violence, both witnessing violence between parents and experiences of being beaten by a family member. This is an important finding because attachment relationships with parents/caregivers are critical for helping youth to cope with trauma and stress [
14]. Family members can act as a protective factor or parents can limit youth coping if they themselves are unable to cope with their trauma [
39]. A 12 year old female speaks about witnessing violence between her parents.
“When my parents are angry, they quarrel, and dad dismisses mum from the house. Sometimes they fight up to the point of wounding each other. When mum is angry, she barks at everybody in the house. Their reactions are not good: when they fight and wound each other, they have to be taken to hospital for treatment, and pay the money they’d spend on our school fees and food”.
Youth are aware of the significant negative impact domestic violence has on the entire family’s health and economic stability. As explained above, the money used to cover medical costs related to the violence could have been spent on school fees for children or other family needs.
Other youth described triggers of violent episodes in the house. Many youth, pointed to alcohol and it’s role in provoking violent episodes. A fifteen year old male explains.
“When my dad is angry or sad, he beats children, refuses to eat and goes to drink. When he comes back drunk and finds food on the table, he spills it on the ground, and then goes to sleep....Dad’s reaction is not good, because he can wound one of us, and then he’ll need money to rush the victim to hospital”.
A twelve year old girl explained that violence in her family has become more frequent and effects family relationships.
“In past, my parents didn’t quarrel. It’s only these days that they’re quarreling, and my father is more and more absent. When dad comes back drunk, he disturbs the family and fights with mum. I don’t like to see him drunk. In such moments, mum is sad, but after some time she cools down, and things get back to normal. But dad will go away with his friends, and come back late and angry. I hate seeing people barking at each other in the family. It’s good neither for parents nor for children”.
These exemplars indicate that youth witness and experience diverse types of violence in their home, and that they have linked alcohol use and loss of financial resources to the violence in their home.
Community violence and threats of instability
Instability in the community and communication between people about the threat of violence can impact youth mental health. Youth participants repeatedly described two threats of violence in the community; La Kabanga and sorcerers (witches) indicating persistent fear and worry by youth. La Kabanga, an in vivo term used by youth and refers to a weapon (a rope used to strangle people) and is also used to refer to people who kill others with this weapon (‘Kabanga people’). Many children described deep fear of Kabanga people. This fear is strengthened by discussion about La Kabanga between peers and families in the community. A ten year old female responded,
“I’m afraid of the ‘Kabanga’ people (they strangle people with cords). When I heard a child was killed by them in Walungu, I was afraid. I’m afraid of walking alone at night”. An eleven year old male distinguishes between armed combatants from armed conflict and Kabanga people, suggesting that Kabanga people are bandits that kill for no reason rather than being motivated to fight for a particular militia group exclaiming, “I’m also afraid of these bandits who pitilessly kill people at night. I’ve never met them, but people are strangled by ‘Kabanga’ men”. While these threats of Kabanga men may or may not be fictional, belief in the concept of stranglers in the night may cause increased fear and isolation of youth. For example, a fourteen year old male described isolating himself from the community to remain safe.
“When I heard stranglers were killing people in other villages, I was so scared that I couldn’t take a walk in my village, because I thought I could bump into them. In order not to be caught by them, I stayed home, and that’s what helped me survive. But up to now I’m still afraid of them”.
Another threat of violence in youth interviews was violence via “poisoning” from sorcerers, or witches. Traditional beliefs in these settings include belief in sorcerers who may be hidden in the community and who use witchcraft to seek advantage, revenge or to destabilize relationships in families and communities. One 12 year old female recounts, “One day, girls in our village called me a thief and a sorcerer, and said my mother was a sorcerer and a poisoner”. Such accusations have the potential to destabilize community relationships and perpetuate revenge related violence. For example, a fourteen year old male recounts, “I’ve already been angry, especially the day my mother was killed. She had a friend who poisoned her, and then fled to Bukavu. When I consider that I’m motherless, I always say that if anyone shows me my mother’s killer, I can also kill her”. The existence of belief systems around sorcerers and stranglers can perpetuate fear and feelings of community instability. For example, a 14 year old female remarks, “There’s no security in our village because of sorcerers and Kabanga”. These beliefs can be further perpetuated in the community and among youth when there is an unexplained death in the family or community that is attributed to sorcery. For example, a fourteen year old girl recounts, “When my friend died, I was afraid, because she was not sick. She was taken to the prayer-room, and then she passed on suddenly. I felt very bad, because I heard my friend was killed by a witch”.
Emergent themes: cognitive and behavioral coping strategies
Youth described a wide range of coping strategies in response to experiences of trauma and violence and these strategies were grouped into two domains, cognitive and behavioral coping strategies. The most common cognitive strategies included trying to forget the traumatic event and use of prayer and behavioral strategies included risk taking behaviors and seeking social support. While trying to forget and praying were grouped as cognitive strategies and risk taking behaviors and social support seeking were grouped as behavioral strategies, there existed considerable overlap between these two domains. For example, engaging in play or spending time with friends was reported as a way to help youth “forget”, but it also implies use of social support, particularly if the play is with friends or distraction activity involves spending time with others. The authors grouped distraction activities such as playing with friends under the “trying to forget” theme if the youth stated that the goal of the activity was to help in trying to forget. Therefore, the authors caution that while these domains were best supported by youth reports of coping, there exists potential for these domains to be correlated with one another and in some cases would not exist in isolation from another coping strategy. Furthermore, while these strategies have been included in existing coping scales their meaning within the Congolese context may be different. In particular, trying to forget and prayer may be particularly helpful coping strategies, especially in the short term, as youth navigate adaptation trajectories over time.
Cognitive strategies: trying to forget
The
most common coping behavior described was “trying to forget”. Although youth engaged multiple coping strategies to deal with stress and trauma, trying to forget was often described as the ultimate goal in dealing with stress and trauma. Many different activities were described as helping children to “forget it all”. For example, a 12 year old female responded.
“To forget it all, I play with my friends. A little time after I’ve played, sadness goes down. I also share with my friends. We chat about good things that make us laugh, and I feel okay. I also pray or sing in order to feel better. When I’m sad, I do my best to get bad thoughts off my mind”.
Another 12 year old female describes failed attempts to forget despite trying to distract herself.
“One day, I was extremely sad, and I went to a wedding ceremony to see if it’d help me forget, but anger went on burning inside me. Sometimes, I keep myself working (fetching water, for instance), but it doesn’t help”.
Youth described additional ways to forget as coping including prayer, playing with friends, and working. A fifteen year old female suggests that forgetting an event is associated with “moving on”. She describes forgetting an event or feeling as turning the page, “When I’ve taken some sleep or rest, I’m able to turn the page and move on”. Other youth described how seeing ability of others to cope positively might help youth to “forget”. A fourteen year old boy explains, “When I’m sad or angry, I isolate myself. But when I see that other people are fine, I also forget that I was sad or angry. I manage to forget it”. Powerless to change past events, focusing on activities that might lead towards “forgetting” a traumatic event may allow youth to use cognitive distancing to overcome harmful memories.
Cognitive strategies: prayer
A second cognitive strategy thematic in the youth interviews was the use of prayer. Religion is an important component of Congolese cultural identity. As a support system, religion extends not only to individuals through prayer but also to families and communities by bringing people together in and outside the church.
For youth, prayer was described as powerful for reconciling past events and asking forgiveness, giving strength in the present and providing hope for the future. A fifteen year old girl explains how prayer helps her to cope with past events and forgive and also continues to provide strength in the present.
“I’ve been ill at ease, ever since my parents died. I’ve never seen my dad: it seems he passed on, when I was in my mum’s womb. And my mum passed away, when I was 8. My mum told me that dad was killed (poisoned) by someone living in this village. This is no longer a problem to me, because I’ve already forgiven my dad’s killer. When I see this person, I don’t feel any grudge in my heart. When I remember my parents, I only pray – it’s the only thing I can do. Prayer fortifies me, and keeps these sad thoughts off my mind, although it’s difficult sometimes”.
Youth described turning to prayer to overcome maladaptive urges such as seeking revenge. A fourteen year old boy explains that in reaction to his mother’s death he turns to his faith and prays to get rid of urges to seek revenge.
“I can get rid of this kind of thoughts only by praying to God. But sometimes these thoughts persist in my heart even after I have prayed. My father told me that I must pray when I begin to have these thoughts, and that prayer will help me forget them”.
Prayer is a powerful coping behavior because it draws upon a community resource (religious institutions) and connects that resource through individual action (prayer). In this way, prayer is accessible at all times as a coping strategy but is also rooted in and connected to larger family and community support systems.
Behavioral strategies: risk taking behavior
Youth also described a range of
risk taking behaviors that pose physical and psychological risks to healthy development. Youth reported risk taking behaviors including drinking, prostitution, stealing, fighting, seeking revenge, violence and other criminal activity. Girls also reported experiencing pressures to marry early or engage in risk taking behaviors including prostitution. A twelve year old girl described, “Raped girls tend to get married too early because of trauma”. Another important risk taking behavior reported by both boys and girls is use of alcohol. Drinking alcohol is a coping strategy that most youth are exposed to when they see adults drinking. Drinking was viewed as more common among older children than younger children. One twelve year old girl responded about age differences in coping strategies.
“They react differently, because younger children and older children think differently: when younger children are angry, they cry and insult others. But older children can go to sleep, to play, to take alcohol, to smoke, to sing, etc”.
Whether in the family or in the community, alcohol consumption may be a behavior that youth learn to be a “mature” type of coping behavior without fully understanding risks to their physical and psychological development. Youth participants described risk taking youth as “vagabonds” or “street kids”. This description may imply that youth may be driven towards risk taking behaviors as a coping mechanism when family and social support systems are absent.
Behavioral strategies: seeking support
A key coping behavior thematic in the interviews was actively
seeking support. Support seeking was done at multiple levels – from peers, family and community. The qualitative analysis reveals that support seeking strategy is multifarious and contingent on the particular circumstances in which a youth is placed in a youth’s social ecology. The results of the study affirm previous studies while adding depth and detail to this behavioral strategy in DRC. For some youth peers were a source of support. Youth use peer relationships to talk about their feelings but also to engage in activities such as play, sports and singing in choirs that can help get their mind off the trauma or stressor they have experienced. For example, a fifteen year old female responded.
“The advice this friend of mine gives me influences me positively, and helps me deal with problems. It enables me to stop brooding over diverse sad events I have experienced in my life, and I can forget”.
The most frequent source of support discussed was from immediate family. Youth described the importance of family as a source of counsel or advice when experiencing difficult situations in addition to the families role in providing basic daily needs such as food and paying school fees. For example, a fifteen year old female responded, “When I have a problem, I talk to my parents. They’re the ones who understand me easily and who can help me. When I need something, they give it to me. And they give me advice”. Families are an important source of stability and guidance for youth. Youth unable to access family networks for support, particularly financial support, may still seek support as a coping strategy by asking friends and other communities members for help, including work to support financial needs. A fourteen year old female states:
“When I have problems, my family no longer helps me. Nobody helps me, so I’m on my own. If I’m sick, I’ll look for medicine alone. I can ask my friends for money or I can go to a brick-making factory to work for money”.
When family support systems are unavailable, youth may rely more heavily on community support systems to supply the resources typically provided by families. Community members can help support caregivers, helping to guide parenting decisions and ways to support youth through difficult situations. By providing support to caregivers, community members can help to address youth’s needs and work as a unified team to guide youth towards positive coping behaviors. Youth also recognize the importance of community cohesion. For example, one fourteen year old female describes community members looking out for one another, “When I hear gunshots or that there are thieves in our neighbors’ houses, I am scared… Sometimes when we hear that they’re harassing our neighbors, we cry for help. They’ll (criminals) then get scared, and take to their heels”. Community support systems can take a variety of forms. Communities that are cohesive can offer protection to one another in times of need. Communities can offer support to youth through counsel and mentorship such as types of relationships formed at school and church.
Discussion
Exposure to trauma at the individual, family and community level necessitates that youth employ different cognitive and behavioral coping strategies. Past research has divided coping strategies into two domains, disengagement or emotion focused strategies on the one hand (trying to forget, isolation, substance use) and engagement or problem focused strategies on the other (seeking social support, problem solving, political participation) [
25]. This perspective tends to assert that disengagement/emotion focused strategies are negatively associated with mental health while engagement/problem-focused strategies are positively associated with mental health. The current study along with more recent research has sought to complicate this normative perspective on coping strategy to better understand and redefine coping strategies within specific cultural contexts. Furthermore, this study highlights the need to understand potential relationships between coping strategies and ways that cognitive and behavioral strategies can be mutually reinforcing with the potential to help or harm youth well-being.
In eastern Democratic Republic of Congo, different types of cognitive and behavioral coping strategies may be tied to the post-conflict and sociocultural context for youth participants in this study, thus underscoring the importance of context in understanding coping strategies. Where youth may have been limited in their ability to engage with the traumatic event directly (a kind of “problem solving” strategy), youth may turn to alternative strategies such as “trying to forget” and praying. These cognitive strategies have been described as “disengagement strategies”, however it is unclear whether in this context these strategies should be considered to negatively affect mental health.
For example, a qualitative study on coping in Sri Lanka after a tsunami disaster found that many participants found that keeping busy and distracting oneself could be a successful way of dealing with stress [
40]. The research found that, “many engaged in work and leisure activities and religious rituals as a way of providing relief from their troubles” and found that these activities fulfilled a dual purpose of meeting practical needs (income and livelihood generation) and psychological and emotional distraction [
40]. The participants in this study found that these types of distraction activities were especially important in the immediate aftermath of the disaster and were described as an engagement strategy in early stages of recovery.
Trying to forget may also be representative of a kind of cognitive flexibility, which refers to the ability to “reappraise one’s perception and experience of a traumatic situation instead of being rigid in one’s perception” [
41]. Cognitive flexibility allows acceptance and assimilation of a traumatic experience into one’s life and can provide opportunities for growth and recovery. Prayer and faith, a common coping strategy utilized by participants, may be a coping strategy that works as a form of cognitive optimism. Optimism has been conceptualized as the maintenance of positive expectations or hope for the future [
42]. Research argues that cognitive flexibility, together with optimism can allow an individual to demonstrate resilience while accepting their current reality [
41].
This study found that family and community support can be protective to youth or can act as a risk factor for negative outcomes. As a protective factor, families provide basic needs, provide safety and security and are a source of material and psychological support. A study in northern Uganda among 741 former male child soldiers found the role of the family was critical to long term mental health outcomes [
43]. Family dynamics between mother and father are also important. A qualitative study among 86 Palestinian youth affected by conflict, found youth who perceived mothers as loving but not fathers had higher levels of PTSD symptoms as compared to those with parents they both considered loving [
44]. As a risk factor, domestic violence can be an ongoing stressor for youth and can result in inability to meet basic needs including food, school fees and health care. The multiple trauma and stressors likely have a cumulative effect and may also impact the types of behavioral and cognitive coping strategies used by youth. As a mediator coping strategies may be partial (account for only part of the effect from traumatic event (s) to outcome) or total (account for all of the effect from traumatic event (s) to outcome). Considering trauma exposure on the individual, family and community level adds complexity to the ways we consider trajectories of resilience.
Given the collectivist nature of Congolese identity, community relationships have a role in shaping coping strategies. In this study participants sought support among peers, siblings, family, teachers, churches and other community members. Research has found that social support and feeling connected to neighborhoods and schools is associated with better mental health outcomes in children [
45] Prayer and religious faith was a common coping strategy utilized participants and connect individuals with religious support systems. This can be a key coping resource for individuals, particularly where they feel able to ask questions and gain council about their traumatic experiences. Faith may also work to provide people with connection to religious support systems where people feel free to ask and gain answers about traumatic situations. Research indicates that positive religious coping has a moderate positive association with psychological adjustment [
46].
While community support systems are important resources for youth, these systems can also contribute to processes of fear through interpretation of illness as being caused by sorcerers or witches. Intervention approaches aimed at improving coping strategies in youth should collaborate with local leaders to develop approaches that are non-judgmental towards traditional belief systems of causes of illness but rather work in dialogue with leaders to develop interventions that minimize negative effects of these beliefs such as perpetuating fear leading to social isolation. Social support seeking also has the potential to lead to risk taking behaviors. For example, it is plausible that some peer-support seeking could potentially increase the likelihood of engaging in risk-taking behaviors such as drinking, a negative coping behavior usually employed in social settings. Supporting positive group activities for youth could extract the benefits received through socializing in peer networks and could potentially deter youth from utilizing risk-taking behavior in social groups.
Understanding the complexity of coping among conflict-affected youth in the context of the DRC helps develop a more complete theory of cognitive and behavioral coping strategies that is helpful for modeling pathways for empirical testing. For example, unlike previous research, this study reveals that disengagement strategies can be an effective coping strategy within this context. Reliance on the western constructs of coping may inappropriately prioritize certain coping strategies as beneficial, such as engagement or problem-solving strategies, when these types of strategies may be of secondary concern or simply lacking meaning in contexts where youth are impacted by conflict related traumatic stressors. In addition to recognizing use of a particular strategy, this study identifies the possibility of overlap between coping domains and mutually reinforcing relationships between particular strategies that could potentially help or harm youth well-being. Future research could benefit from a more complex understanding of the relationships between coping strategies and potential reinforcing relationships between cognitive and behavioral strategies. A context specific framework can provide a springboard for implementing effective intervention policies.
Limitations
Results from this study may not be generalizable to other contexts as coping strategies were defined within the cultural context of the Walungu Territory in Eastern Democratic Republic of Congo. The villages sampled in this study were rural villages and coping strategies in urban contexts may differ if additional resources and support systems specific to urban environments are available. The youth included in this study had a wide range of trauma exposure related to ongoing armed conflict and it is possible that coping strategies change over time post-conflict. Future research and public health programming should consider adaptive trajectories over time.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
The study was designed by MC, AK, NG, RMM, CMM, ABM, AKB, JHB, GKM, NMB GMN. Data collection was done by CMM, ABM, AKB, JHB, GKM, GMN. The data were analyzed and interpreted by MC, AK, NG, RMM, CMM, ABM, AKB, JHB, GKM, GMN. Manuscript preparation was done by MC, AK, NG. All authors contributed critically and significantly to drafting a final manuscript. All authors approved the final version.