Prevalence of Mental Disorders and Program Accessibility

persons placed in the school programs have been displaced at least once in their life. At least one in three have been abducted by the LRA to serve as child soldiers.

Approximately half of former child soldiers have been forced to commit violence themselves, for example abducting other children or injuring people. The first research article presented within this thesis (Chapter 2) describes the various often-overlapping psychological symptoms war-affected learners, including former abductees, face after their return home. Post-traumatic stress disorder (PTSD), depression and suicidality were very common among war-affected learners, indicating an urgent need for targeted MHPSS in schools.

There are, however, limitations in our data. First, our study’s population bias remains crucial. We dealt only with survivors of LRA-violence placed in rehabilitation programs and have no information on a possible bias concerning the selection process on who survives and who is killed during LRA encounters. Some research points to the strategic nature of LRA abductions and killings; for example, variations in exposure to warfare were found to be associated with age at abduction, duration of captivity, location of captivity, being militarily trained, and being a rebel’s “wife”

(Vindevogel et al., 2011). The question of what characteristics, features and behaviors might have been adaptive for child soldiers’ survival during rebel abductions is an important one when dealing with former abductees. In addition, we do not know how many youths do not survive the aftermath of abductions after release due to, for example, poor health, lack of support or psychological ill-health and impaired functioning. These estimates would be important to understand better the societal impact of LRA-violence and respective support programs (Pham et al., 2007).

Second, there is no data available on estimates of LRA-affected youths actively seeking help and support within reintegration or other rehabilitation programs. While those abductees who went through repatriation programs would

General Discussion

have formally been offered to go through support programs, there are countless others who survived in other ways or were affected differently by the LRA violence not fitting in the beneficiary profiles of aid programs. Many may have remained without direct support. While the inclusion criteria in the educational support programs we drew our study samples from were outlined in the previous chapters (Chapters 2, 3, 4), we have little information on how support-seekers compare to those not reaching out for support in the LRA-affected areas. While the found prevalence rates of mental ill-health in our study were comparable to those found in the overall population of Northern Uganda (Ertl et al., 2014), it is noteworthy that program thresholds concerning entry and accessibility of rehabilitation support are determining factors with regard to the programs’ quality for LRA-affected communities. This consideration draws attention also to the extent to which LRA-affected populations have to actively contact programs to be able to benefit from them. Programs reaching out to affected individuals appear much more promising, even more so if community involvement is high (Kelly et al., 2016; Schiltz et al., 2015). It must be noted that mental ill-health is always paralleled by functional impairment. In our survey, we demonstrated that MHPSS can be offered in mobile teams operating in different locations and reaching out to learners, while teachers from the respective communities had a high level of involvement in designing teacher counseling intervention and implementation (Chapter 4). MHPSS programs embedded in other support activities have the potential to foster accessibility and feasibility and to make use of the natural nexus between education and psychosocial programming. The role of the receiving communities, including parents and peers, also remains important in such programs (Betancourt et al., 2013).

During trauma and reconciliation education (Chapter 4), it became evident that many former child soldiers had not ever shared their experiences of LRA-abduction stories, due to shame, guilt, or stigma they (feared to) face in the communities. Despite the ongoing Amnesty Act and warranted impunity, we noted youths’ sincere worries to be prosecuted by the International Criminal Court (ICC) or national authorities after being forced to perpetrate violence. It became clear that enhanced public information on issues related to national and international justice including both the Amnesty Act and the mandate of the ICC would have contributed to breaking their silence (Allen, 2006). In line with this finding, it is our recommendation that the school context should be used better to address these

General Discussion

topics, which may enhance the learner’s readiness to seek social or other forms of support, increasing their functioning and openness to reconciliation.

Especially for returning females, community stigmatization was common, with manifold consequences on their social life and functioning. Sexual enslavement, forced marriage and forced pregnancies were experiences of female LRA returnees.

We must assume that actual traumatic experiences of sexual nature are much higher than reported and are under-represented in the presented survey (Chapter 2), due to stigmatization and shame (Porter, 2015). While often returning fighting male youths are regarded as potential spoilers for peace due to an increased risk of violence in the future, it is crucial not to neglect the specific needs of survivors of sexual and gender-based violence in reintegration and educational programs. For females these needs include adequate psychosocial support to recover from experiences of sexual violence, access and information concerning women’s protection issues and ongoing domestic violence, access to health care including reproductive health and the provision of childcare support. Addressing these aspects adequately will enhance the accessibility and effectiveness of programs for females.

One of our studies’ most crucial findings (from Chapter 2) is that all efforts need to be undertaken to reintegrate not only abductees returning from the LRA, but all war-affected youths. The prevalence rates of mental ill-health we found in the classrooms were comparable with those found in Ugandan IDP camps and indicate the shift of psychosocial problems into the education sector and recovery programs.

Both groups of abducted and non-abducted participants in our surveys had reported significant numbers of trauma events and high prevalence rates of mental ill-health, including PTSD, depression and suicidality. Every fifth non-abducted girl in our study (Chapter 2) reported suicidal ideations, indicating the urgent need for building psychosocial case management systems. As put forward by other authors (Ager et al., 2011; Annan et al., 2006; Inter-Agency Standing Committee - IASC, 2007), our research agrees that there are no grounds to assume that sub-groups of war-affected youths can be excluded from support; on the contrary, our results demonstrate the urgent need for MHPSS referral pathways for all war-affected youths. The education centers can serve as feasible entry points to a functional MHPSS referral system.

General Discussion

5.2 Predictors of Mental Disorders and Breaking the Cycle of