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

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
to the consequences of traumatic events among street youth,
who are exposed to prolonged and repeated traumatic events
like violence and rape (Tyler, Hoyt, Whitbeck, & Cauce, 2001).
In a study in Latin American and Ethiopian street children,
half the boys reported regular physical attacks; girls were es-
pecially prone to rape or sexual abuse (Lalor, 1999). Moreover,
street life affects health status; several studies, predominantly
from the United States, reported high rates of trauma and PTSD
among homeless youth (Bender, Ferguson, Thompson, Komlo,
& Pollio, 2010; Gwadz, Nish, Leonard, & Strauss, 2007;
Stewart et al., 2004; Whitbeck, Hoyt, Johnson, & Chen, 2007)
and, for example, child laborers in Addis Ababa, Ethiopia,
were found to have internalizing and mood disorders signif-
icantly more often than nonlaborers (Fekadu, Alem, & Hag-
glof, 2006). PTSD is characterized by reexperiencing the event,
numbness of feelings/emotions, avoidance of stimuli associated
with the event, and increased arousal (American Psychiatric As-
sociation [APA], 1994). Traumatic events and PTSD in child-
hood can have significant effects on adolescent development
(Gerson & Rappaport, 2013) and lead to chronic mental disor-
ders (Sack, Clarke, & Seeley, 1995). Even when full PTSD di-
agnostic criteria are not met, partial symptomatology may cause
serious functional impairment (Stein, Walker, Hazen, & Forde,
1997) and have possible severe long-term consequences, espe-
cially because general and particularly mental health resources
in most Sub-Saharan African countries are rather limited
(Sathiyasusuman, 2011).
Although rehabilitation programs are suggested to have pos-
itive effects on QOL, to our knowledge no study has focused on
the relation between QOL, trauma, and PTSD in street youth
and the impact of a rehabilitation program on QOL. Therefore,
the current study investigated two samples of street youth at
the beginning and end of a 3-month, community-based reha-
bilitation program in Jimma, Ethiopia. The main aim was to
examine QOL; the second was to explore earlier experiences
of traumatic events and current PTSD symptoms. Additional
aims were to evaluate whether characteristics such as sex, age,
education, family conditions, number of traumatic events, and
rehabilitation processes were associated with PTSD and to test
for differences in QOL scores on the basis of trauma, PTSD,
and rehabilitation.
Method
Participants
Participants were recruited from a community-based rehabilita-
tion project for street youth implemented by the Ethiopian NGO
Facilitator for Change in Jimma and funded by kinder unserer
welt e.V. (Germany). Jimma is a rural town with over 120,000
inhabitants, 352 km (219 miles) southwest of the capital, Addis
Ababa (Central Statistical Agency of Ethiopia, 2007).
The Jimma University Ethical Review Board approved the
study. All participants gave oral rather than written informed
assent because some of them had limited reading and writing
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Mannert et al.
skills. Interviews were conducted in accordance with the ethical
standards in the 1975 Declaration of Helsinki. Confidentiality
was strictly maintained during interviews. Two Ethiopian psy-
chologists from Jimma University were trained by the research
organizers and performed the interviews. The interviewer read
each question aloud and gave the interviewee sufficient time to
answer. Interviews took about 1 hour, and all assessments were
completed in a single session. Inclusion criteria were willing-
ness to accept the projects contents and rules and a general
interest in being reunited with family. Exclusion criteria were
addiction to alcohol or khat and having spent more than a year
on the streets.
Participants were 89 youths, aged 6 to 20 years, who were
recruited and then completed evaluation forms; however, five
completed them incorrectly, therefore the sample contained 84
youths (25, 29.8% female; 59, 70.2% male). There were 35
children (41.7%) just starting the 3-month psychosocial reha-
bilitation program and there were 49 at the final stage (58.3%).
The mean age of the whole sample was 13.79 years (SD = 2.81,
range = 620). The mean age of the children at the beginning
of the project was 13.43 years (SD = 2.40, range = 618),
and the mean age of those at the end of the project was 14.33
years (SD = 2.40, range = 1020). The average time spent on
the street was 4.46 months (SD = 3.34, range = 112) in the
whole sample, 3.67 months (SD = 2.12) for the children at the
beginning of the project and 4.93 months (SD = 3.88) for the
children at the end of the project. The mean former family size
was 5.05 people (SD = 1.93) in the whole sample, 5.17 (SD =
1.90) for the children at the beginning of the project and 4.96
(SD = 1.96) for the children at the end of the project. Sociode-
mographic characteristics did not differ significantly between
the group at the beginning and the group at the end of the project
(see Table 1).
We used the United Nations Childrens Fund (UNICEF;
1986) definition to divide the youth into two groups according to
their status before entering the program: (a) On-the-streetlive
and work on the street at day and sleep at home with families
or relatives (69.5%, n = 57); (b) of-the-streetlive, work, and
sleep on the streets without any family support (30.5%, n =
25). All of the of-the-street youths were male, whereas 57.9%
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
a hairdresser, tailor, or carpenter), and recreational activities
(e.g., sports) and aims to reintegrate street youth into their
families and community and improve living conditions and
QOL. When possible, street youth return to their families at
night. Otherwise, they live independentlysupervised by so-
cial workersor in foster families, if aged below 14 years and
without family support. Therefore, the program addresses QOL
aspects, especially social relationships and environment. It does
not provide any specific treatment for physical and psycholog-
ical issues, apart from access to general medical support. The
living circumstances associated with the project, however, espe-
cially being away from the streets, might improve physical and
 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
bedroom), as might attention from social workers. The 3-month
program is followed by 1 year of postrehabilitation support.
Measures
In addition to age, time spent on the street and former family
size, additional basic sociodemographic characteristics were
recorded, including status (on- or of-the-street), sex, ethnicity,
place of origin, education, and family conditions before living
on the street (see Table 1).
We used the World Health Organization Quality of Life ques-
tionnaire (WHOQOL-BREF; Skevington, Lotfy, & OConnell,
2004), a short version of the WHOQOL-100 assessment devel-
oped by the WHO and validated in several studies (Skevington
et al., 2004; Trompenaars, Masthoff, Van Heck, Hodiamont,
& De, 2005), to explore QOL. The WHOQOL-BREF was
developed in diverse cultures to identify universal QOL
components (Saxena, Carlson, & Billington, 2001), although
only one study was performed in Africa (Harare, Zimbabwe;
Saxena et al., 2001). It has been applied to assess trauma
effects on QOL among postconflict displaced Ethiopians
(Araya, Chotai, Komproe, & de Jong, 2007) and in adolescents
(Al-Fayez & Ohaeri, 2011; Awasthi, Agnihotri, Chandra,
Singh, & Thakur, 2012; Teixeira et al., 2011), but its cultural
limitations should be considered when interpreting findings.
The WHOQOL-BREF comprises 26 questions related to the
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
scale. The first two items refer to general perception of
QOL, and overall satisfaction with health, and the remaining
items are in four domains: physical (Domain 1; 7 items) and
psychological health (Domain 2; 6 items), social relationships
(Domain 3; 3 items), and environment (Domain 4; 8 items). We
deleted the question about satisfaction with sexual relationships
from Domain 3 to adapt the scale for our study population. To
improve comparability of the results with domains composed
of unequal numbers of items, the Likert scale was transformed
into a 0100 scale according to WHOQOL group guidelines
(Angermeyer, Kilian, & Matschinger, 2000). We used the
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
self-reported PTSD symptoms. The DICA was designed on the
basis of DSM-IV PTSD criteria. The Amharic version of the
DICA has been used in several Ethiopian studies (Ashenafi,
Kebede, Desta, & Alem, 2000; Fekadu, Alem, & Hagglof,
2006). Nevertheless, the DICA might have cultural limitations
because it was developed in the United States.
During the DICA, participants were asked whether they had
experienced, witnessed, or been confronted with a traumatic
event involving actual or threatened death or serious injury.
The response to the event had to involve intense fear, helpless-
ness, and horror or, in younger children, disorganized and agi-
tated behavior (APA, 1994). If they answered in the affirmative,
additional questions were asked to explore symptoms of reex-
periencing (e.g., intrusive thoughts), avoidance, hyperarousal,
duration, and clinically significant distress and impairment in
social or other important areas of functioning. The DSM-IV
diagnostic criteria for PTSD were fulfilled if symptoms had
lasted longer than 4 weeks and caused significant functional
impairment.
Data Analysis
The raw data were entered into an SPSS (Version 20) database.
We performed descriptive analyses of sociodemographic and
clinical characteristics by independent sample t tests and 2
tests. Data for a complete scale were missing for five partici-
pants, so all data from these participants were excluded from the
analysis. Therefore, data from 84 participants were included in
the analyses (N = 84). If single items were missing, these items
or subscales were excluded from the analysis. Differences in
sociodemographic and clinical characteristics related to PTSD
were only measured in a subgroup with 1 previous traumatic
event (DSM-IV Criterion A fulfilled). To explore the relation
between QOL and PTSD and compare those findings between
youths at the beginning and end of the program (program sta-
tus), we performed univariate analyses of variance within the
group fulfilling Criterion A. Prediction of QOL scores based on
program status and PTSD symptoms was tested with a linear
regression model. Independent sample t tests were performed
to test for differences between QOL scores of on- and of-the-
street youth and between those who had experienced one or
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Mannert et al.
Table 2
Descriptive Statistics for WHOQOL-BREF for Total Sample
Variable n Minimum Maximum M SD
General health 83 12.50 100.00 50.30 18.52
Physical health 82 21.43 100.00 64.48 19.12
Psychological 81 16.67 95.83 59.47 17.12
Social relationships 83 25.00 100.00 56.93 23.45
Environment 81 15.63 87.50 50.77 19.65
Note. WHOQOL-BREF = World Health Organization Quality of Life question-
naire.
more traumatic events and those who had not. We checked for
normal distribution with the Kolmogorov-Smirnov test. The
predetermined level was .05. Corrections for multiple testing
were not used.
Results
The highest mean domain scores in the WHOQOL-BREF were
found for physical health (M = 64.48, SD = 19.12), followed
by psychological health (M = 59.47, SD = 17.12) and social
relationships (M = 56.93, SD = 23.45). The lowest mean scores
were for environment (M = 50.77, SD = 19.65) and general
QOL (M = 50.30, SD = 18.52; see Table 2). No differences
in QOL were found between on- and of-the-street youths or
between those who had (Criterion A) or had not experienced a
traumatic event (independent sample t test).
According to the DICA, 70 of the youths (83.3%) had experi-
enced one traumatic event (DSM-IV Criterion A): 97.1 % re-
ported one intrusion (Criterion B); 90.0%, three avoidance
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
month) were met in 30.0% (n = 21) of these youths (25.0% of
the total group; see Table 3). The mean age at the most traumatic
event was 10.56 years (SD = 3.31), and the mean time since that
event was 3.27 years (SD = 2.62, range = 010). Psychopatho-
logical symptoms had occurred on average 1.64 weeks (SD =
1.41) after the event. The mean number of traumatic events was
7.76 (SD = 3.99, range = 112). The most common traumatic
experiences were having the house destroyed by fire or flood
(45.7%) and witnessing a person dying (45.7%); other types
are listed in Figure 1. Noteworthy is that street youths whose
mother had not been living at home before they entered the
street were more likely to fulfill PTSD criteria, 2 (1, N = 84)
= 4.77, p = .029; see Table 4. PTSD was not significantly asso-
ciated with sex, place of origin, ethnicity, whether parents were
alive, education, age (mean age in group with positive PTSD
criteria: 13.05 years, SD = 2.92; mean age in group without
positive PTSD criteria: 14.17 years, SD = 2.38), time spent on
street (mean time in group with positive PTSD criteria: 5.00
months, SD = 4.83; mean time in group without positive PTSD
criteria: 4.54 months, SD = 3.20), number of traumatic events
 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)
was even lower.
Interestingly, our trauma rates were similar to those in U.S.
studies of homeless youth (Bender et al., 2010; Gwadz et al.,
2007; Stewart et al., 2004; Whitbeck et al., 2007): The majority
(83.3%) of the 84 youths had experienced one or more traumatic
events, and most reported multiple traumatic events. Of those
who had witnessed one or more traumatic events, 30.0% ful-
filled DSM-IV PTSD criteria; 25.0% of the entire sample, how-
ever, met the same PTSD criteria. Rates were similar among
homeless youth in New York City (Gwadz et al., 2007): 85.9%
had experienced one or more traumatic events. Again, in line
with our results, Bender et al. (2010) found that 57.0% of home-
less youth in U.S. cities had experienced one traumatic event,
and 24.0% met PTSD criteria. Conceptual limitations have to
be considered when comparing PTSD results across cultures.
Consequently, the term probable PTSD is more appropriate
in our sample.
A notable percentage of our participants reported high rates
of trauma symptoms that did not fulfill PTSD diagnostic crite-
ria (because they subsided in < 4 weeks), but may have caused
significant distress. A minority reported no trauma symptoms
at all despite having experienced traumatic events. Further re-
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
factors that increase risk for greater symptom severity or pro-
mote mental health resilience (Gerson & Rappaport, 2013). The
mean time since the most traumatic event was > 3 years; the
mean time since entering street life was 4.46 months. Thus,
many participants had experienced the most traumatic event
before entering street life, possibly in their family; the event
may have been a major reason for running away, as has been
reported in previous studies (Martijn & Sharpe, 2006). PTSD
symptoms did not differ significantly between the sexes. This
is consistent with Stewart et al. (2004), but Whitbeck et al.
(2007) reported that nearly twice as many females as males met
PTSD criteria in U.S. cities. In contrast to Gwadz et al. (2007),
we found no sex differences in the individual types of trauma.
Again, cultural differences limit conclusions. Our sample may
show no sex differences because all female street youths were
on-the-street and slept in homes or shelters, meaning they were
generally more protected.
Also important is that PTSD symptoms were significantly
lower among youths who lived with their mothers before enter-
ing street life. Thus, in Ethiopia, living with ones mother might
have a long-term protective and stabilizing effect that can pre-
vent trauma-related symptoms. This conclusion is supported
by research highlighting the influence of family relationships
on mental health in runaway youth (Thompson, Cochran, &
Barczyk, 2012). Further research is needed to prove such a
correlation.
In our study, QOL scores did not differ significantly between
street youths with and without PTSD. This is surprising be-
cause PTSD was associated with lower QOL in psychiatric
patients in Western countries (dArdenne et al., 2005; Rapaport
et al., 2005). First, a possible reason for this finding is that the
Ethiopian street youth with PTSD symptoms have developed
strategies to counteract their trauma symptoms, and coping
strategies are associated with QOL (Nachar, Guay, Beaulieu-
Prevost, & Marchand, 2013). Second, all Ethiopian street youth
presumably have relatively low QOL, so that PTSD symptoms
perhaps do not negatively affect it; this consideration is linked
with the finding that a high percentage of participants reported
trauma symptoms, but did not meet PTSD diagnostic criteria.
Third, street youth without PTSD symptoms may fulfill diag-
nostic criteria for other anxiety or depressive disorders that may
decrease QOL. All of these points would be interesting topics
for future research.
General QOL scores differed significantly in the independent
sample t test and linear regression model between the groups
assessed at the beginning and end of the program, even though
they had similar PTSD symptoms. In contrast, in the univariate
analysis the direct relation between QOL, PTSD symptoms,
and program status did not reach significance, and the relation
between general QOL and program status showed only a trend
towards significance. The lack of change in PTSD symptoms is
understandable because the program did not offer any specific
interventions for PTSD symptoms. The higher QOL scores in
the group at the end of the program may indicate that reha-
bilitation stabilizes QOL independent from PTSD symptoms.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
599
Future research should investigate whether improving QOL
positively affects PTSD; possible additional factors that may
affect QOL during rehabilitation should be included, such as
improved housing (Sullivan et al., 2000), because satisfaction
with housing is a strong predictor of general life satisfaction
(Biswas-Diener & Diener, 2006). Regarding specific QOL do-
mains, improved living conditions, access to medical treatment,
healthy food, and dry and safe sleeping facilities may be im-
portant predicting factors and should be investigated in future
research.
The study has several limitations. The questionnaires were
not developed specifically for sub-Saharan Africa and therefore
might have cultural limitations. We did not consider psychi-
atric disorders other than PTSD, but studies indicate a high
psychiatric comorbidity in street youth with PTSD (Gwadz
et al., 2007; Whitbeck et al., 2007). Moreover, the Jimma reha-
bilitation project has specific admission criteria, so participants
may have fewer PTSD symptoms than youth actually living on
the street. For example, one admission criterion is no addiction
to alcohol; such addiction, however, is a strong correlate of
trauma and PTSD (Bender et al., 2010). Furthermore, the
results are not representative for street youth who receive no
support from services or NGOs. In addition, the nonrandom
allocation to each condition limits a direct comparison between
the street youth at the beginning and end of the program.
Culture-specific aspects of PTSD may have been neglected
(Hinton & Lewis-Fernandez, 2011). Also, DSM-IV criteria may
not reliably assess PTSD in an African country and may not
be applicable in street youth whose symptoms are influenced
by their culture, community, and complex living conditions
(Gadpaille, 2003). Future research should include the develop-
ment of measures that consider the specific cultural context. The
WHOQOL-BREF may have conceptual problems: Although
it was developed in diverse cultural settings, only one was in
Africa (Harare, Zimbabwe; Saxena et al., 2001), and some of
the questions might have been difficult for the younger children
(< 12 years old) in our sample. These limitations should be
considered when assessing the external validity of our study.
Nevertheless, our study has several manifest implications. For
example, it underscores the necessity and opportunities to
improve QOL among street youth. Service providers and other
professionals have to meet homeless youths specific needs to
increase QOL and create good working relationships (Altena
et al., 2010). Rehabilitation projects like the project in Jimma
can doubtless play an important role in assessing mental health
problems, including PTSD, but specific interventions are
needed to reduce symptoms in youth with PTSD (McManus &
Thompson, 2008).
Our study indicates that Ethiopian street youth experience
a high rate of traumatic events and consequently show PTSD
symptoms. Improvements in QOL were not associated with
changes in PTSD symptoms but with the rehabilitation project,
such as improved living circumstances. Further research is
needed to deepen our understanding of the role of specific
factors in improving QOL within rehabilitation facilities and
600 Mannert et al.
to investigate whether and in which circumstances improving
QOL positive affects PTSD symptoms.
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