الفهرس 
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Abstract
For more than four decades, the Iraqi nation has lived through extremely difficult conditions, including war, political repression, community violence, and prolonged conflict, such as traumatic events that produce a large adverse impact on physical and mental health (Alshawi, 2017). The main factor that impacts the mental well-being of Iraqi people is internal displacement (International Organization for Migration [IOM], 2019). Post-traumatic stress disorder (PTSD) is the most common disorder among displaced persons (Bapolisi et al., 2020; Close et al., 2016; Murad, 2019). It strongly impacts the Quality of Life of the people affected (Sancassiani et al., 2019).
It has been shown that some people are more mentally resistant to adversity than others because their patterns of resilience differ (Sominsky et al., 2020). On the other hand, research findings indicated that resilience factor tends to decrease with an increase in environmental adversity (Holmes, 2017). Little is known about the role of resilience in understanding the relationship between PTSD and QoL among trauma-exposed individuals.
- The present study aimed to: Identify the relationship between symptoms of Post-Traumatic Stress Disorder, resilience, and quality of life among persons returning from internal displacement in Baghdad City and propose a plan of psychotherapeutic intervention for returnees from internal displacement with Post-Traumatic Stress Disorder in Baghdad City
- The study was conducted at Al-Karkh district which is affiliated to the Ministry of Migration and Displacement in Iraq.
- After returning from displacement, the returnee typically visit the district to obtain services including assistance in providing food, cash, shelter, …etc.
- A convenience sample of 600 returnees from internal displacement was recruited. Both male and female persons returning from internal displacement within six months and those aged 18 years and above were eligible to participate.
The data for this study were obtained using the following four tools.
- Tool I: Socio-demographic data, health status, and traumatic events of persons returning from internal displacement, structured interview schedule.
- Tool II: The PTSD Checklist for DSM-5 (PCL-5), was developed by Weathers et al. (2013) to assess the presence and severity of PTSD symptoms.
- Tool III: The Connor-Davidson Resilience Scale (CD-RISC), was used to measure the level of resilience.
- Tool IV: The WHOQOL-BREF is used to assess the quality of life (WHO, 1996). The scale covers four domains: physical health, psychological health, social relationships, and environmental health. In addition, it also contains two general items that measure the overall individuals’ perception of their quality of life and general health.
- Tool I was developed by the researcher after a thorough review of the literature. The adapted Arabic version of the PTSD Checklist for DSM-5 (tool II) was used.
- Tools III & and IV were adapted to Iraqi culture and tested for face validity by a jury of five experts in the field of psychiatric nursing and community health nursing at the Faculty of Nursing, Baghdad University.
- The pilot study was carried out on 30 returnees from internal displacement (5% of the entire sample). It revealed that the tools were clear, understood, and applicable.
- Participants who visited Al-Karkh district were screened to identify those who were eligible to participate. Eligible participants, who were willing to participate in the study, were interviewed on an individual basis in a private room to apply the study tools.
The following is a list of the main results derived from the current study.
Descriptive Statistics:
- More than half of the studied sample (51.8%) were females. The mean age was 44.72±13.10 years, and approximately half of them (46.2%) were married. Forty-one percent of the total sample had college and above education with a total mean of 11.00±5.36 years.
- Concerning health status, 74.3% of the sample had physical health problems. The majority of the total sample (90.2%) did not drink alcohol, and/or use addictive substances (97.8%). Only 21.2% and 13.2% reported a previous history of suicidal ideation and/or attempt (s); respectively
- As regards internal displacement status, more than half of the studied subjects (54.7%) were living in a camp during their internal displacement, with a duration of recent internal displacement ranging from 2 to 7 years with a total mean of 4.58 ±1.35 years, and the average time lapse since returning from internal displacement was 3.62 months. More than half of the studied subjects (54.7%) had received psychological support from their relatives/friends during their internal displacement.
- The cumulative number of traumatic events experienced during internal displacement ranged from 1-9, with a total mean of 4.98±1.84 times.
- The vast majority of the sample (95.2%) had been exposed to, or had seen residential areas being shelled, burned, or destroyed. Nearly two-thirds of the sample (64.3%) had a family member(s) who died because of violence.
- Sixty-eight percent of the studied subjects have been categorized as having symptoms of post–traumatic stress disorder.
- Seventy-three percent of the studied subjects perceived their quality of life as either poor or very poor (34.2% and 38.8%; respectively).
- More than one-third of the studied subjects (39.5%) reported being satisfied with their health.
- Among dimensions of QoL, the highest mean score was related to the social relationships domain, while the lowest mean score was related to the environmental health domain (50.44±18.46, and 15.44±14.00; respectively).
- Fifty-one percent of the total sample had a low level of resilience with a median of 29.0.
Association between traumatic experiences and PTSD among returnees from internal displacement
- Participants who were living with their relatives/friends had lower mean PTSD scores than those who were living in camp or those who had no shelter (33.52±14.80, and 56.64±13.53; respectively, t = -19.45, p<0.001).
- A significant positive association was reported between PTSD and the length of the most recent internal displacement (r = 0.11, P < 0.01).
- Returnees who reported to have psychological support during their internal displacement, had a lower mean score of PTSD than those who had not (45.45±18.05, and 49.49±17.84; respectively, t = 2.75, P < 0.01).
- Having a family member (s) being killed as a result of violence was the strongest predictor of PTSD (β = 0.50, t = 18.18, P<0.001),
Correlation Matrix among key variables of the studied sample
- Pearson correlation coefficient test (r) proved strong negative correlations between PTSD and resilience, physical health domain, psychological health domain, social relationships domain, environmental health domain, and total score of QoL domains
(r = -0.72 to -0.90, p<0.001). A positive strong correlation was found between PTSD and a cumulative number of traumatic events (r= 0.73, p<0.001).
- Resilience was strongly and positively correlated with the physical and psychological health domain, social relationships domain, environmental health domain, and total score of QoL domains (r = 0.77-0.90, p<0.001). However, a negative strong correlation was reported between resilience and cumulative number of traumatic events (r = -0.63, p<0.001).
- Resilience was strongly and negatively correlated with all clusters of PTSD (r = -0.50 to -0.90, p ˂ 0.001). Also, all PTSD clusters were strongly and negatively correlated with all QoL domains and overall score of QoL.
Relationship between total score of quality of life and sociodemographic characteristics, health, and Internal Displacement status
- Male returnees had a significantly higher mean score of QoL (40.12 ± 15.73) than female returnees (33.70 ± 14.72), t = -5.16, p<0.001.
- Married returnees scored significantly higher on the QoL scale than those who were unmarried (41.53 ± 16.13, and 33.17± 13.99; respectively, t = 6.72, p<0.001).
- An increased number of years of education was positively associated with higher QOL (r = 0.35, p<0.001).
- Returnees who reported to have a previous history of suicidal thoughts and/or made a suicidal attempt (s) had significantly less quality of life than those who had not (t = -5.59, p < 0.001, and t = -2.99, P<0.01, respectively).
- Participants who were living with their relatives/friends had a better quality of life than those who were living in a camp or those who had no shelter (50.71±11.25, and 27.72±10.36; respectively, t = -25.36, p<0.001).
- Returnees who reported to have psychological support during their internal displacement had a higher mean score of QoL than those who had not (39.89 ± 14.90, and 33.58 ± 15.69; respectively, t = 5.05, P < 0.001).
Examining the moderating effect of resilience on the relationship between PTSD and the total score of QoL
- The effect of PTSD on quality of life was moderated by resilience and argued to examine the effect of PTSD on QOL among returnees with high versus low levels of resilience.
- The results revealed that the detrimental effect of PTSD on QoL was stronger for returnees with a high level of resilience (B = -0.52, β = -0.70, t = -22.02, P<0.001) than for returnees with a low level of resilience (B = -0.33, β = -0.32, t = -5.79, P<0.001).
Relationship between each domain of the QoL and socio-demographic characteristics, health, and internal displacement status of returnees
- Male participants had a significantly higher score on all domains of QoL than females.
- A significant positive but weak association was reported between age and psychological health domain (r = 0.08, P<0.05), and social relationships domain (r = 0.13, P<0.01).
- Married returnees scored significantly higher on all domains of QoL than those who were unmarried.
- The correlations between years of education and four domains of QoL were positive and moderate (r = 0.27- 0.40, P<0.001).
- Among health-related variables, returnees who drank alcohol scored significantly lower on the social relationships domain than those who did not (44.76 ± 15.96, and 51.06 ± 18.62; respectively, t = 2.83, P<0.001).
- Returnees who used addictive substances perceived their physical health better than those who did not with a statistically significant difference (52.31 ± 4.61, and 48.07 ± 18.42; respectively, t = -2.85, P˂0.01).
- Returnees who reported to have a previous history of suicidal ideation and /or attempts, had significantly lower scores on psychological health, social relationships, and environmental health domains, than those who had not.
- In relation to internal displacement status, participants who were living with their relatives/friends had significantly higher scores on all QoL domains than those who were living in a camp or had no shelter.
- A significant inverse relation was reported between the length of last internal displacement and psychological health, social relationships, and environmental health domains (r = -0.08, P<0.05; r = -0.17, P<0.001; and r = -0.12, P<0.01; respectively).
- Returnees who had received psychological support during their internal displacement had a significantly higher score on all QoL domains than those who had not.
- Conclusively, variables that are significantly associated with each domain of QoL were included in further regression analyses as covariates.
Examining the moderating effect of resilience on the relationship between PTSD and each domain of QoL.
- Resilience moderated the effect of PTSD on the environmental health domain of QoL.
- The negative effect of PTSD on the environmental health domain of QoL was significantly stronger for returnees with high resilience than those with low resilience (B = -0.50, β = -0.65, t = -14.02, P<0.001; and B = -0.13, β = -0.15, t = -2.28, P<0.001; respectively).
The following are the most important recommendations
- Collaborate with policymakers and other sectors in Iraq to establish a trauma clinic to routinely screen returnees for PTSD and provide early psychosocial intervention of post-trauma sequelae.
- Strengthen community support services to help returnees adopt essential coping strategies to promote mental health, enhance resilience, provide psychological support, treat symptoms related to stress, and facilitate recovery.
Proposed plan of psychotherapeutic interventions for returnees from internal displacement with PTSD in Baghdad City
The following is a list of proposed psychotherapeutic interventions:
- Psychological First Aid.
- Psychological debriefing
- Cognitive restructuring techniques
- Coping skills therapy
- Trauma-Focused Exposure Therapy
- Resilience-based interventions.