Cherewick et al. Conflict and Health (2015) 9:35 DOI 10.1186/s13031-015-0062-5

RESEARCH Open Access

Coping among trauma-affected youth:a qualitative study

Megan Cherewick1*, Anjalee Kohli2, Mitima Mpanano Remy3, Clovis Mitima Murhula4,Arsene Kajabika Bin Kurhorhwa4, Alfred Bacikenge Mirindi4, Nadine Mwinja Bufole4, Jean Heri Banywesize4,Gisele Mushengezi Ntakwinja4, Gracia Mitima Kindja4 and Nancy Glass1,2

Abstract

Background: Eastern Democratic Republic of Congo has endured decades of conflict resulting in widespreadexperiences of conflict related trauma and destruction to health and social infrastructure. The aim of this qualitativestudy was to provide a context specific understanding of youth exposure to violence (ages 10–15 years) and use ofcognitive and behavioral coping strategies.

Methods: A purposive sampling strategy based on age, gender and exposure to traumatic events was used toidentify eligible youth in an ongoing parent study from four villages in the Walungu Territory, Eastern DemocraticRepublic of Congo. These four villages were selected from a total of 10 participating in the parent study becauseof the reported high exposure to conflict-related trauma. The interview guide consisted of broad open-endedquestions related to the following topics, 1) identification of traumatic experiences, 2) methods for coping andchanges in coping behavior 3) gender and age differences in coping, 4) sources of psychosocial support. Agrounded theory approach was used to identify emergent themes.

Results: 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 (mean age = 13.07). Exposures to different formsof violence and stress were reported among youth participants. Exposures to traumatic stressors occur at theindividual, family and community level. In response to traumatic stress, youth reported both cognitive andbehavioral coping strategies. Cognitive coping strategies included trying to forget and praying. Behavioral copingstrategies included social support seeking and risk-taking behavior. These strategies may be used in mutuallyreinforcing ways, with youth employing more than one coping strategy.

Conclusion: This qualitative research provides important, culturally grounded information on coping strategiesused by youth in rural post-conflict settings where limited psychosocial support services are available. Understandinguse of cognitive and behaviors coping strategies may inform local community and international developmentprograms to support youth mental health along adaptive trajectories resulting in promotion of well-being andreduced risk taking behaviors.

Keywords: Coping, Conflict-affected, Youth, War, Trauma, Adolescent, Resilience

* Correspondence: Mnarasi2@jhu.edu1Department of International Health, Johns Hopkins Bloomberg School ofPublic Health, 615 N. Wolfe Street, 21204 Baltimore, MD, USAFull list of author information is available at the end of the article

© 2015 Cherewick et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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BackgroundDemocratic Republic of Congo: rebuilding afterprolonged conflictThe Democratic Republic of Congo (DRC) has endureddecades of destruction to health and social infrastructure. Ahistory of colonialism, theft of the DRC’s enormous mineralwealth and strategic ‘pitting’ of ethnic groups against oneanother set the stage for prolonged conflict including twoconflicts with neighboring countries. Within this context,families are striving to rebuild their households and com-munities and improve the life and livelihoods of futuregenerations.A cross-sectional study in the Ituri province in the

eastern DRC investigated conflict-related traumatic eventsand found that among 477 girls and 569 boys ages 13–21,95 % of the respondents reported at least one traumaticevent; on average, adolescents were exposed to 4.7 trau-matic events over their lifetime, and 52 % of adolescentsmet the criteria for PTSD [1]. Violence, population dis-placement and the destruction of health and educationalinstitutions have weakened the local systems requiredto respond to children’s mental health and promotewell-being.

Armed conflict and mental health of childrenWorldwide, UNICEF estimates that over one billion chil-dren under the age of eighteen are affected by conflict(UNICEF, 2009). Globally, an estimated two million chil-dren have lost their lives over the past decade to armedconflict, six-million have been left severely injured ordisabled, twelve million have been left destitute and300,000 children have served as child soldiers [2]. Thestress and trauma of armed conflict is devastating topsychological well-being and healthy development ofchildren. The developmental period between childhoodand adolescence is a particularly vulnerable period oftime characterized by, “complex and multiple changesacross biological, psychological and interpersonal do-mains” [3]. The psychological impact of armed conflict onchildren includes increased prevalence of PTSD, anxiety,depression [4], psychophysiological disturbances such asnightmares and trouble sleeping, fear, grief, behavioralproblems [5], and changes in educational attainment andperformance, lack of hope and personality changes [6]. Re-searchers report that children are aware of stress and theircoping strategies due to psychological trauma and are ableto identify stressors, describe coping strategies and evalu-ate the effectiveness of those strategies at ages as young assix years old [7].To date, most research on conflict affected children

has focused on PTSD [8] with less research focused ondepression and behavioral problems. Pooled prevalenceestimates from 17 armed conflict affected countriesfound that the impact of armed conflict resulted in 47 %

of children with moderate to severe diagnosis of PTSD,43 % with depression and 27 % with anxiety [2]. Armedconflict can result in psychological distress in the shortterm, but can also lead to long-term psychopathology.Research with former child soldiers in Mozambique found50 % of participants reported traumatic stress reactionssixteen years after return to civilian life [9]. Furthermore,protracted conflict involving non-state actors such as rebelgroups can directly harm child development when chil-dren witness or experience conflict-related violence andcan also indirectly harm children’s well being by weaken-ing health care delivery systems, disrupting schools anddestroying infrastructure [10].However research has also shown that youth exposed

to armed conflict do not necessarily develop psychopath-ology and in contrast, many youth demonstrate remark-able resilience. Norman Garmezy is often credited withdeveloping the field of resilience research with pioneer-ing research conducted in the early 1970s focusing onpositive adaptation for children at risk for psychopath-ology [11, 12]. Researchers since have began to focus onresilience, seeking to identify factors that allowed someindividuals to cope better than others when faced withadversity [12–16]. Some of the factors that protect againstpsychological distress and promote psychological well-being at the individual level include female gender, higherintellectual capacity, political activity, problem-solving,seeking social support and demonstrating faith in a higherpower or religion [14, 17, 18]. Research has also identifiedfactors related to an individual’s external social ecologyincluding family and community level factors. Protectivefactors at the family level include family support and sta-bility and parental monitoring [19–21]. At the communitylevel, attachment to community and peers through schoolor churches, community acceptance and access to socialsupport were associated with youth resilience [19, 22–24].While research has identified the importance of investigat-ing factors related to positive adaptation, less is knownabout how youth’s individual coping strategies are imple-mented within specific cultural contexts. More research isneeded to better understand which coping strategies youthemploy in the Democratic Republic of Congo and howthese strategies have the potential to help or harm mentalhealth in conflict-affected youth.

Theoretical background on copingLazarus and Folkman (1984) originated the term “coping”to describe responses to stress [25]. Lazarus and Folkmandefined stress as a condition or feeling experienced whena person appraises an event as “exceeding his or her re-sources and as endangering well-being” [25]. This theoryposited that the best way to measure coping was throughan individual’s personal appraisal. Personal appraisal refersto the various ways individuals seek to modify adverse

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aspects of their life to minimize the internal threat ofstressors. Appraisal can be primary (perception of a stres-sor) or secondary (evaluation of potential effectiveness andconsequences of coping behaviors) [25]. Coping is effectiveif stress is accurately appraised and specific behavioral andcognitive strategies are used to manage, reduce or toleratestressful events [26].The cognitive and behavioral coping strategies used by

youth have been grouped in different ways. Lazarus andFolkman distinguish coping styles as emotion centeredcoping which seeks to regulate internal emotions andthe meaning of an event and problem-based coping whichaims to change the problem or conflict [25]. Other re-searchers have grouped coping in different ways. Beehrand McGrath distinguish more categories of coping stylesand group styles as preventive, anticipatory, dynamic, re-active and residual coping [27]. Ghimbulut categorizedcoping styles as, “emotion coping” (focusing on changingone’s own emotions), behavioral coping (directed towardthe cause of the problem) and cognitive coping (directedon one’s own beliefs) [28]. A study with war-affectedchildren in Croatia found six distinct coping strategiesincluding aggressive activities, problem oriented, avoidanceand relaxation, emotion expression and social supportseeking [6].While some research suggests that emotion oriented

coping behaviors are associated with poorer mental healthand problem based coping behaviors are associated withbetter mental health outcomes [29, 30], other researchershave questioned whether emotion focused coping shouldbe considered maladaptive. For example, in environmentssuch as humanitarian emergencies and armed conflict,engagement (problem focused) coping may be a less ap-propriate coping method than disengagement (emotionfocused) coping because youth may be powerless to ac-tively change stressors related to the conflict/disaster andinstead emotion focused coping may be a positive strategy,more easily accessible than problem focused strategies.Considering the cultural context in which coping strat-

egies are employed is essential to gain depth of meaningto motivations for employing a particular strategy andthe positive or negative benefits of using a particularstrategy. Qualitative case-study research with Cambodianrefugees found that avoidant coping was utilized withtraumatized Cambodian refugees who sought to avoidthoughts, behaviors and activities that reminded them ofthe past and linked this coping strategy to a history of“dishonorable events in Cambodian history” and collectiveshame felt by Cambodians [31]. The Cambodian beliefsystem perceives personal bad fortunes stem from dishon-orable events in a previous life and therefore led individ-uals to use avoidant coping strategies rather than moreproblem focused strategies. Qualitative narrative researchwith 14 Sudanese youth refugees found that a sense of

communal self was thematic in interviews and thatsuppression and distraction were a common copingstrategy [32]. Participants used distraction to avoid dif-ficult thoughts and feelings and believed this strategyhelped “protect themselves from feelings that they feelpowerless to handle” [32]. Research with Zimbabwean ad-olescents found that there was greater use of emotion fo-cused strategies rather than problem solving strategiesbecause cultural norms in Zimbabwe discourage problemsolving strategies that may involve confrontation or chal-lenging elders and instead youth favor distancing, keepingto themselves and other emotion focused strategies thatmay be more characteristic of a collectivistic society versusan individualistic society [33]. Whereas in Western soci-eties coping strategies are often connected to an individu-alistic approach whereby individuals seek help throughyouth counseling, in developing countries and contextswhere youth have experienced armed conflict, the copingapproach may be more collective in nature, with greateruse of community support systems to support emotionfocused coping strategies rather than problem focusedstrategies. In addition, cultural norms can shape use ofcoping strategies. For example, a mixed method studyamong Palestinian refugee youth (ages 8–17) living inGaza found that girls were less likely to use copingstrategies that would require them to be far from homeand used more strategies that involved being close tohome such as praying in the home, whereas boys weremore likely to use leisure activities and relaxation activitiesoutside of the home [34]. Cultural gender role expectationscan influence types of coping strategies utilized by youth.In the Democratic Republic of Congo, recent research

questions whether disengagement (emotion focused)coping should be construed as a maladaptive reactionto conflict affected situations, and argues a more detailed,context specific understanding is needed to understandyouth coping strategies [35]. This research in the DRC,among 952 armed conflict affected youth ages 13–21,found that in response to traumatic exposure, disengage-ment coping behaviors, such as distraction, resignationand social withdrawal were more common among ado-lescents as compared to engagement behaviors such ascognitive restructuring or problem solving [35]. Quali-tative research is needed from a youth perspective tobetter define and gain depth of knowledge as to thecognitive and behavioral coping strategies. As notedabove, research has stressed the importance of contextin understanding variations in use of coping strategies.Documenting how conflict affected children cope withadversity will improve our understanding of the typesof cognitive and behavioral strategies utilized by youthand relationships with individual, family and communityfactors, thus informing youth-based programs in conflictand post-conflict settings.

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Research aimThe purpose of the qualitative study is to examine youth(ages 10–15 years) exposure to violence and other trau-matic events, use of cognitive and behavioral copingstrategies and the (contingent) relationships of thesecoping strategies with family and community. The prin-cipal objectives of study are to document youth definedcoping strategies, to consider how coping may informadaptation trajectories over time and to consider op-portunities to support coping strategies that promotewell-being and better mental health outcomes. This studywill provide a context specific understanding of mentalhealth and the role of coping strategies following exposureto diverse and multiple traumatic events. This qualitativework will also be used to adapt existing coping scales foryouth for use in future quantitative phases of this research.By providing a culturally grounded basis for developing acomprehensive framework of coping, this research willprovide the basis for empirical testing of the relationshipbetween use of coping strategies and mental health andwell-being. The findings can be used to broaden the dis-course on coping strategies utilized by conflict affectedyouth and to identify factors and relationships that sup-port healthy coping strategies.

MethodsStudy design and settingThis study uses the research infrastructure of a largerNational Institute of Health (NIH)/National Institute ofChild Health and Human Development (NICHD) fundedrandomized community trial of a youth-led livestockmicrofinance program, Rabbits for Resilience (RFR). RFRis a collaborative project between Programme d’Appui auxInititatives Economiques (PAIDEK), an established Congo-lese microfinance institute, and Johns Hopkins UniversitySchool of Nursing (JHUSON). RFR is designed to increaseyouth and family resilience to ultimately improve healthand emotional adjustment after exposure to adversity andtrauma. RFR includes male and female youth ages 10–15years living in 10 rural villages in the Walungu territory inEastern Democratic Republic of Congo. The ten villagesincluded in the impact evaluation of RFR were selected forseveral reasons including; (1) feasibility of delivering anintervention over a wide geographical area; (2) commit-ment to the intervention and study by traditional chiefsand administrators; and (3) findings from village-levelassessments that showed few health and developmentprograms exist in the area, including microfinance. Thepeople living in these rural villages have experiencedsignificant violence, displacement and trauma over the past20 years with limited health care, schools or governmentalor non-governmental organizations to provide support andresources.

Theoretical perspectiveIn order to understand youth participant exposure toviolence and other traumatic events and their cognitiveand behavioral coping strategies, a grounded theory ap-proach was used in the initial coding of the data anddeductive reasoning used to explore how emergent themesrelate to existing theory [36]. The grounded theorymethodological approach is grounded in the constructivistepistemology, that meaning is co-created in the discoursebetween people. The grounded theory approach supportsthe role of subjectivity in creation of meaning. Moreover,gaining knowledge through discourse is necessarilygrounded in a particular social and historical context.For this study a grounded theory perspective is valuablebecause of the implicit focus on taking Congolese youthcomments as true representations of their perspectiveon trauma and coping. Second, a deductive processwas used whereby emergent themes were categorizedbased on existing theory suggesting two coping do-mains, cognitive and behavioral coping strategies. Thisstudy utilizes in depth interviews and relies on the dia-logue between interviewer and interviewee to con-struct an improved understanding of ways youth copewith stress.

SampleA purposive sampling strategy was used to identify eligibleyouth enrolled in the parent study. Investigating typesof exposure to violence and other traumatic events thatyouth experienced was important to understand con-textual variables that can affect coping and resultingmental health outcomes. At baseline, youth completeda survey including the Harvard Trauma Questionnaire.Youth were selected from four of the 10-study villages.These four villages were selected because of the re-ported high exposure to conflict-related trauma. Withinthese villages, baseline data from the parent study wasused for purposive sampling based on age, gender andexposure to traumatic events to identify 48 youth (12from each village). Traumatic exposures were representedby a wide range of experiences including murder offamily/friends, having ill health without care, lackingfood and water, being seriously injured, being close todeath, separation from family, experiences in combatand brainwashing. Specifically, youth were selected forvariation on experience of trauma: low exposure totrauma (0–1 events), medium exposure (2–3 events)and high exposure (4 or more events). Within eachtrauma exposure level purposive sampling involvedachieving a balanced distribution of participants byage [11–16] and gender. Of the 48 eligible participantsidentified, 30 youth completed the interview (16 werenot available on the days of fieldwork).

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Congolese research team and development of the youthinterview guideCongolese research team members were previously trainedby the parent study team and had successfully completedqualitative and quantitative research in the study villages.Congolese interviewers actively participated in the design,development, piloting and revision of the youth interviewguide. The research team reviewed and revised interviewquestions to ensure questions were culturally relevant andwould be appropriate for ages 10–15. The questionnairewas translated by the Congolese research team into locallanguages, Swahili and Mashi, used for interview withyouth. Probes were developed with local partners to capturegreater depth in participant responses. The interview guidewas piloted in June 2014 among 5 youth in the microfi-nance demonstration project site located in a village outsideof Bukavu, the capital city of South Kivu province. Follow-ing the pilot test, the research team revised the interviewguide and conducted a second pilot test among 5 differentyouth. Revisions included the removal of redundant ques-tions to shorten length, rewording of questions found to beconfusing or unclear and minor re-ordering of questions topromote improved flow of the instrument as a whole. Thefinal guide consisted of broad open-ended questions relatedto the following topics, 1) identification of trauma-relatedexperiences, 2) methods for coping and changes in copingbehavior 3) respondent’s perception of gender and age dif-ferences in coping, 4) sources of psychosocial support. Afterfinal revisions to the interview guide, the researcher com-menced two day team training in administration of consent(in alignment with IRB regulations), ethics, and qualitativeinterview methods.

ProceduresThe Johns Hopkins School of Medicine Institutional Re-view Board (IRB) approved this study (IRB: CIR00001977;Date: 06-23-14). The research team also received approvalto conduct the research with local partners PAIDEK byvillage traditional and administrative leaders. Parents/care-givers of eligible youth were provided with the purpose ofthe study, risks and benefits of participation in the studyand then were asked to provide verbal informed consentfor their child to participate. If a parent/caregiver con-sents, their child was then asked for verbal assent afterreceiving details on the purpose of the study and priorto beginning the interview. No participants’ names wererecorded, all interviews were conducted in private and noinformation was shared outside the research team.After parents/caregivers provided informed consent

and youth provided assent, the interviewer selected a lo-cation within the village for the interview, the locationwas away from parents/caregivers and friends that wouldallow for privacy and disclosure during the interview.The interviewers started with asking youth participants

to describe their typical day, their family, their communityand activities they participate in. Initial questions allowedthe interviewer to develop a level of rapport with theyouth where they would feel comfortable answering morepersonal questions. The interviewer utilized probes to ex-plore topics related to coping strategies, trauma and familyand community relationships in greater depth. The finalinterview guide resulted in interviews between 30 and60 min in length. All participant answers were recordedverbatim and participants were provided with compensa-tion for their time equal to 2USD, an amount consideredappropriate after consultation with village leaders and re-search team members.

AnalysisAfter completion of interviews, a Congolese translatorcompleted translation of all transcripts from French orthe local language (Swahili or Mashi) to English. Thetranslations were cross-checked by researchers based inthe US and in consultation with the Congolese researchteam. After completion of the translation and review,the analysis used a grounded theory approach, which isrooted in a participatory transformative paradigm [36, 37].First initial codes were developed through line-by-linecoding of a sub-sample of interviews (interviews of 5 girlsand 5 boys). Line-by-line coding involves providing a codeto each line of written data and allows for ideas to emergethat may have escaped attention if reading for a generalthematic analysis [36]. Line-by-line coding allows the re-searcher to identify implicit actions and meanings, identifygaps in the data and to note common relationships andsignificance between codes. Where appropriate, codeswere left in vivo, to preserve participants’ language andmeaning. In vivo codes are locally defined terms that con-dense meaning and are characteristic of societies and re-flect assumptions, actions and imperatives [36]. The nextanalysis phase was the development of focused codes thatwere applied to all interviews. Focused codes are devel-oped from using the most significant and/or frequent ini-tial codes to make analytic sense of the data. Next, axialcoding was used to represent the content of focused codesand to relate common codes, categories and concepts toeach other. Second, a deductive process was used wherebyemergent themes were categorized based on application ofexisting theory suggesting two coping domains, cognitiveand behavioral coping strategies. Final coding structurewas applied to each transcript using Atlas Ti software.During the application of focused and axial coding,

memos were written by the researchers to help identifyemergent themes related to youth coping styles. Memosallow the researcher to capture comparisons and con-nections and to construct analytic notes [36]. Iterativeinductive content analysis was used to identify emergentthemes and connections between themes [38]. Verbatim

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statements that capture emergent themes were identifiedfor use as quotes.

ResultsSample demographics are shown in Table 1. Of the 48eligible participants identified, 30 youth completed theinterview, 53 % were female (n = 16) and (47 %) weremale (n = 14). Youth ranged in age from 10–15 years old(mean age = 13.07) and represented 4 villages.

Exposures to violence and stressAlmost half (46.7 %) of the 30 youth participants experi-enced 4 or more traumatic events, 36.7 % reported 2–3and 16.7 % reported 1 or no traumatic events in theirlifetime. Exposures to different forms of violence includedwitnessing the death of a friend or family member, beingin a combat situation and forced separation from familyand lack of basic needs, such as lack of medical care, lackof shelter, and lack of food were reported among youthparticipants. The qualitative analysis revealed that expo-sures to traumatic stressors occur at the individual, familyand community level.

Individual exposure to violenceThe majority of young adolescents interviewed had apersonal story of loss and suffering. Participants describedexperiences of militia groups coming through their village.For example, a fifteen year old girl recollects her experi-ences with conflict-related violence,

“In the past (2004), we were not sleeping in ourhouses. Our village was all the time attacked by FDRL(armed combatants) These soldiers terrorized, killed,and raped people, and plundered houses, if I hadpower, I would kick them out of my country. Thesecrooks came very often, during the day or at night,and inflicted to people horrendous things. They cameto our house, when I was 7, and grabbed ourproperty, goats, clothes and other things”.

Youth participants describe armed groups intentionsas primarily to plunder or steal items of value from homes.The memory of armed conflict is long lasting and difficultfor many youth to forget. These events cause continued

Table 1 Sample Demographics: Trauma Exposure, Gender and Age

Girls

Trauma Exposure Ages 10–12 Ages 13–15

Low (0–1 events) 1 2

Medium (2–3 events) 2 3

High (4+ events) 4 4

Total 7 9

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 thatthe people who come here to kill others can also killme as I am alone in the house. I am unable to helpmyself and stop this fear, and so I wish we had peopleto protect our village. Bandits have already killed aneighbor; I’ve been afraid since then”.

The effects of armed conflict continue to influenceyouth lives. A ten year old female explains.

“I’m afraid, when I hear gunshots and when peoplefight in the village, even though I may not know thosepeople. I’m also afraid when I see blood, especiallywhen mothers are nursing people who got woundedin fights. Usually such events upset me, and I usuallyhide in order not to see what’s going on. One doesn’tforget easily after they saw blood. Sometimes I evenvomit”.

Experiencing violence at the individual level may directlyaffect mental health and well-being outcomes or may bemediated by coping strategies.

Violence in the familyA common theme from nearly half of youth interviewswas the experience of domestic violence, both witnessingviolence between parents and experiences of being beatenby a family member. This is an important finding becauseattachment relationships with parents/caregivers arecritical for helping youth to cope with trauma andstress [14]. Family members can act as a protective fac-tor or parents can limit youth coping if they themselvesare unable to cope with their trauma [39]. A 12 yearold female speaks about witnessing violence betweenher parents.

“When my parents are angry, they quarrel, and daddismisses mum from the house. Sometimes they fightup to the point of wounding each other. When mumis angry, she barks at everybody in the house. Theirreactions are not good: when they fight and woundeach other, they have to be taken to hospital for

Boys

Ages 10–12 Ages 13–15 Total

1 1 5

2 4 11

3 3 14

6 8 30

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treatment, and pay the money they’d spend on ourschool fees and food”.

Youth are aware of the significant negative impact do-mestic violence has on the entire family’s health and eco-nomic stability. As explained above, the money used tocover medical costs related to the violence could have beenspent 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 rolein provoking violent episodes. A fifteen year old maleexplains.

“When my dad is angry or sad, he beats children,refuses to eat and goes to drink. When he comes backdrunk and finds food on the table, he spills it on theground, and then goes to sleep....Dad’s reaction is notgood, because he can wound one of us, and then he’llneed money to rush the victim to hospital”.

A twelve year old girl explained that violence in herfamily has become more frequent and effects familyrelationships.

“In past, my parents didn’t quarrel. It’s only these daysthat they’re quarreling, and my father is more andmore absent. When dad comes back drunk, hedisturbs the family and fights with mum. I don’t liketo see him drunk. In such moments, mum is sad, butafter some time she cools down, and things get backto normal. But dad will go away with his friends, andcome back late and angry. I hate seeing peoplebarking at each other in the family. It’s good neitherfor parents nor for children”.

These exemplars indicate that youth witness and ex-perience diverse types of violence in their home, andthat they have linked alcohol use and loss of financial re-sources to the violence in their home.

Community violence and threats of instabilityInstability in the community and communication be-tween people about the threat of violence can impactyouth mental health. Youth participants repeatedly de-scribed two threats of violence in the community; LaKabanga and sorcerers (witches) indicating persistentfear and worry by youth. La Kabanga, an in vivo termused by youth and refers to a weapon (a rope used tostrangle people) and is also used to refer to people whokill others with this weapon (‘Kabanga people’). Manychildren described deep fear of Kabanga people. Thisfear is strengthened by discussion about La Kabanga be-tween peers and families in the community. A ten yearold female responded, “I’m afraid of the ‘Kabanga’ people

(they strangle people with cords). When I heard a childwas killed by them in Walungu, I was afraid. I’m afraidof walking alone at night”. An eleven year old male distin-guishes between armed combatants from armed conflictand Kabanga people, suggesting that Kabanga people arebandits that kill for no reason rather than being motivatedto fight for a particular militia group exclaiming, “I’m alsoafraid 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 maynot be fictional, belief in the concept of stranglers in thenight may cause increased fear and isolation of youth. Forexample, a fourteen year old male described isolating him-self from the community to remain safe.

“When I heard stranglers were killing people in othervillages, I was so scared that I couldn’t take a walk inmy village, because I thought I could bump into them.In order not to be caught by them, I stayed home, andthat’s what helped me survive. But up to now I’m stillafraid of them”.

Another threat of violence in youth interviews was vio-lence via “poisoning” from sorcerers, or witches. Traditionalbeliefs in these settings include belief in sorcerers who maybe hidden in the community and who use witchcraft toseek advantage, revenge or to destabilize relationships infamilies and communities. One 12 year old female re-counts, “One day, girls in our village called me a thief and asorcerer, and said my mother was a sorcerer and a poi-soner”. Such accusations have the potential to destabilizecommunity relationships and perpetuate revenge relatedviolence. For example, a fourteen year old male recounts,“I’ve already been angry, especially the day my mother waskilled. She had a friend who poisoned her, and then fled toBukavu. When I consider that I’m motherless, I always saythat if anyone shows me my mother’s killer, I can also killher”. The existence of belief systems around sorcerers andstranglers can perpetuate fear and feelings of communityinstability. For example, a 14 year old female remarks,“There’s no security in our village because of sorcerers andKabanga”. These beliefs can be further perpetuated in thecommunity and among youth when there is an unexplaineddeath in the family or community that is attributed tosorcery. For example, a fourteen year old girl recounts,“When my friend died, I was afraid, because she wasnot sick. She was taken to the prayer-room, and thenshe passed on suddenly. I felt very bad, because I heardmy friend was killed by a witch”.

Emergent themes: cognitive and behavioral copingstrategiesYouth described a wide range of coping strategies in re-sponse to experiences of trauma and violence and these

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strategies were grouped into two domains, cognitive andbehavioral coping strategies. The most common cognitivestrategies included trying to forget the traumatic eventand use of prayer and behavioral strategies included risktaking behaviors and seeking social support. While tryingto forget and praying were grouped as cognitive strategiesand risk taking behaviors and social support seeking weregrouped as behavioral strategies, there existed consider-able overlap between these two domains. For example, en-gaging in play or spending time with friends was reportedas a way to help youth “forget”, but it also implies use ofsocial support, particularly if the play is with friends ordistraction activity involves spending time with others.The authors grouped distraction activities such as playingwith friends under the “trying to forget” theme if the youthstated that the goal of the activity was to help in trying toforget. Therefore, the authors caution that while these do-mains were best supported by youth reports of coping,there exists potential for these domains to be correlatedwith one another and in some cases would not exist in iso-lation from another coping strategy. Furthermore, whilethese strategies have been included in existing copingscales their meaning within the Congolese context maybe different. In particular, trying to forget and prayermay be particularly helpful coping strategies, especially inthe short term, as youth navigate adaptation trajectoriesover time.

Cognitive strategies: trying to forgetThe most common coping behavior described was “tryingto forget”. Although youth engaged multiple coping strat-egies to deal with stress and trauma, trying to forget wasoften described as the ultimate goal in dealing with stressand trauma. Many different activities were described ashelping children to “forget it all”. For example, a 12 yearold female responded.

“To forget it all, I play with my friends. A little timeafter I’ve played, sadness goes down. I also share withmy friends. We chat about good things that make uslaugh, and I feel okay. I also pray or sing in order tofeel better. When I’m sad, I do my best to get badthoughts off my mind”.

Another 12 year old female describes failed attemptsto forget despite trying to distract herself.

“One day, I was extremely sad, and I went to a weddingceremony to see if it’d help me forget, but anger went onburning inside me. Sometimes, I keep myself working(fetching water, for instance), but it doesn’t help”.

Youth described additional ways to forget as copingincluding prayer, playing with friends, and working. A

fifteen year old female suggests that forgetting an eventis associated with “moving on”. She describes forgettingan event or feeling as turning the page, “When I’ve takensome sleep or rest, I’m able to turn the page and moveon”. Other youth described how seeing ability of othersto cope positively might help youth to “forget”. A four-teen year old boy explains, “When I’m sad or angry, Iisolate myself. But when I see that other people are fine,I also forget that I was sad or angry. I manage to forgetit”. Powerless to change past events, focusing on activitiesthat might lead towards “forgetting” a traumatic eventmay allow youth to use cognitive distancing to overcomeharmful memories.

Cognitive strategies: prayerA second cognitive strategy thematic in the youth inter-views was the use of prayer. Religion is an importantcomponent of Congolese cultural identity. As a supportsystem, religion extends not only to individuals throughprayer but also to families and communities by bringingpeople together in and outside the church.For youth, prayer was described as powerful for recon-

ciling past events and asking forgiveness, giving strengthin the present and providing hope for the future. A fifteenyear old girl explains how prayer helps her to cope withpast events and forgive and also continues to providestrength in the present.

“I’ve been ill at ease, ever since my parents died. I’venever seen my dad: it seems he passed on, when I wasin 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 nolonger a problem to me, because I’ve already forgivenmy dad’s killer. When I see this person, I don’t feelany grudge in my heart. When I remember myparents, I only pray – it’s the only thing I can do.Prayer fortifies me, and keeps these sad thoughts offmy mind, although it’s difficult sometimes”.

Youth described turning to prayer to overcome mal-adaptive urges such as seeking revenge. A fourteen yearold boy explains that in reaction to his mother’s deathhe turns to his faith and prays to get rid of urges to seekrevenge.

“I can get rid of this kind of thoughts only by prayingto God. But sometimes these thoughts persist in myheart even after I have prayed. My father told me thatI must pray when I begin to have these thoughts, andthat prayer will help me forget them”.

Prayer is a powerful coping behavior because it drawsupon a community resource (religious institutions) and

Cherewick et al. Conflict and Health (2015) 9:35 Page 9 of 12

connects that resource through individual action (prayer).In this way, prayer is accessible at all times as a copingstrategy but is also rooted in and connected to larger familyand community support systems.

Behavioral strategies: risk taking behaviorYouth also described a range of risk taking behaviors thatpose physical and psychological risks to healthy develop-ment. Youth reported risk taking behaviors includingdrinking, prostitution, stealing, fighting, seeking revenge,violence and other criminal activity. Girls also reportedexperiencing pressures to marry early or engage in risktaking behaviors including prostitution. A twelve yearold girl described, “Raped girls tend to get married tooearly because of trauma”. Another important risk takingbehavior reported by both boys and girls is use of alcohol.Drinking alcohol is a coping strategy that most youth areexposed to when they see adults drinking. Drinking wasviewed as more common among older children thanyounger children. One twelve year old girl respondedabout age differences in coping strategies.

“They react differently, because younger children andolder children think differently: when youngerchildren are angry, they cry and insult others. Butolder children can go to sleep, to play, to take alcohol,to smoke, to sing, etc”.

Whether in the family or in the community, alcoholconsumption may be a behavior that youth learn to be a“mature” type of coping behavior without fully understand-ing risks to their physical and psychological development.Youth participants described risk taking youth as “vaga-bonds” or “street kids”. This description may imply thatyouth may be driven towards risk taking behaviors as acoping mechanism when family and social support systemsare absent.

Behavioral strategies: seeking supportA key coping behavior thematic in the interviews wasactively seeking support. Support seeking was done atmultiple levels – from peers, family and community.The qualitative analysis reveals that support seekingstrategy is multifarious and contingent on the particularcircumstances in which a youth is placed in a youth’s so-cial ecology. The results of the study affirm previousstudies while adding depth and detail to this behavioralstrategy in DRC. For some youth peers were a source ofsupport. Youth use peer relationships to talk about theirfeelings but also to engage in activities such as play,sports and singing in choirs that can help get their mindoff the trauma or stressor they have experienced. For ex-ample, a fifteen year old female responded.

“The advice this friend of mine gives me influencesme positively, and helps me deal with problems. Itenables me to stop brooding over diverse sad events Ihave experienced in my life, and I can forget”.

The most frequent source of support discussed wasfrom immediate family. Youth described the importanceof family as a source of counsel or advice when experi-encing difficult situations in addition to the families rolein providing basic daily needs such as food and payingschool fees. For example, a fifteen year old femaleresponded, “When I have a problem, I talk to my parents.They’re the ones who understand me easily and who canhelp me. When I need something, they give it to me. Andthey give me advice”. Families are an important source ofstability and guidance for youth. Youth unable to accessfamily networks for support, particularly financial support,may still seek support as a coping strategy by askingfriends and other communities members for help, includ-ing work to support financial needs. A fourteen year oldfemale states:

“When I have problems, my family no longer helpsme. Nobody helps me, so I’m on my own. If I’m sick,I’ll look for medicine alone. I can ask my friends formoney or I can go to a brick-making factory to workfor money”.

When family support systems are unavailable, youthmay rely more heavily on community support systems tosupply the resources typically provided by families. Com-munity members can help support caregivers, helping toguide parenting decisions and ways to support youththrough difficult situations. By providing support tocaregivers, community members can help to addressyouth’s needs and work as a unified team to guide youthtowards positive coping behaviors. Youth also recognizethe importance of community cohesion. For example, onefourteen year old female describes community memberslooking out for one another, “When I hear gunshots orthat there are thieves in our neighbors’ houses, I amscared… Sometimes when we hear that they’re harassingour neighbors, we cry for help. They’ll (criminals) then getscared, and take to their heels”. Community support sys-tems can take a variety of forms. Communities that are co-hesive can offer protection to one another in times ofneed. Communities can offer support to youth throughcounsel and mentorship such as types of relationshipsformed at school and church.

DiscussionExposure to trauma at the individual, family and com-munity level necessitates that youth employ differentcognitive and behavioral coping strategies. Past research

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has divided coping strategies into two domains, disen-gagement or emotion focused strategies on the one hand(trying to forget, isolation, substance use) and engagementor problem focused strategies on the other (seeking socialsupport, problem solving, political participation) [25]. Thisperspective tends to assert that disengagement/emotionfocused strategies are negatively associated with mentalhealth while engagement/problem-focused strategies arepositively associated with mental health. The current studyalong with more recent research has sought to complicatethis normative perspective on coping strategy to betterunderstand and redefine coping strategies within specificcultural contexts. Furthermore, this study highlights theneed to understand potential relationships between copingstrategies and ways that cognitive and behavioral strategiescan be mutually reinforcing with the potential to help orharm youth well-being.In eastern Democratic Republic of Congo, different

types of cognitive and behavioral coping strategies maybe tied to the post-conflict and sociocultural context foryouth participants in this study, thus underscoring theimportance of context in understanding coping strategies.Where youth may have been limited in their ability to en-gage with the traumatic event directly (a kind of “problemsolving” strategy), youth may turn to alternative strategiessuch as “trying to forget” and praying. These cognitivestrategies have been described as “disengagement strat-egies”, however it is unclear whether in this context thesestrategies should be considered to negatively affect mentalhealth.For example, a qualitative study on coping in Sri Lanka

after a tsunami disaster found that many participantsfound that keeping busy and distracting oneself could be asuccessful way of dealing with stress [40]. The researchfound that, “many engaged in work and leisure activitiesand religious rituals as a way of providing relief from theirtroubles” and found that these activities fulfilled a dualpurpose of meeting practical needs (income and livelihoodgeneration) and psychological and emotional distraction[40]. The participants in this study found that these typesof distraction activities were especially important in theimmediate aftermath of the disaster and were described asan 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 “re-appraise one’s perception and experience of a traumaticsituation instead of being rigid in one’s perception” [41].Cognitive flexibility allows acceptance and assimilationof a traumatic experience into one’s life and can provideopportunities for growth and recovery. Prayer and faith,a common coping strategy utilized by participants, may bea coping strategy that works as a form of cognitive opti-mism. Optimism has been conceptualized as the mainten-ance of positive expectations or hope for the future [42].

Research argues that cognitive flexibility, together with op-timism can allow an individual to demonstrate resiliencewhile 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 fornegative outcomes. As a protective factor, families pro-vide basic needs, provide safety and security and are asource of material and psychological support. A study innorthern Uganda among 741 former male child soldiersfound the role of the family was critical to long termmental health outcomes [43]. Family dynamics betweenmother and father are also important. A qualitative studyamong 86 Palestinian youth affected by conflict, foundyouth who perceived mothers as loving but not fathershad higher levels of PTSD symptoms as compared tothose with parents they both considered loving [44]. As arisk factor, domestic violence can be an ongoing stressorfor youth and can result in inability to meet basic needsincluding food, school fees and health care. The multipletrauma and stressors likely have a cumulative effect andmay also impact the types of behavioral and cognitive cop-ing strategies used by youth. As a mediator coping strat-egies may be partial (account for only part of the effectfrom traumatic event (s) to outcome) or total (account forall of the effect from traumatic event (s) to outcome).Considering trauma exposure on the individual, familyand community level adds complexity to the ways we con-sider trajectories of resilience.Given the collectivist nature of Congolese identity,

community relationships have a role in shaping copingstrategies. In this study participants sought supportamong peers, siblings, family, teachers, churches andother community members. Research has found that so-cial support and feeling connected to neighborhoods andschools is associated with better mental health outcomesin children [45] Prayer and religious faith was a commoncoping strategy utilized participants and connect individ-uals with religious support systems. This can be a keycoping resource for individuals, particularly where theyfeel able to ask questions and gain council about theirtraumatic experiences. Faith may also work to providepeople with connection to religious support systems wherepeople feel free to ask and gain answers about traumaticsituations. Research indicates that positive religious copinghas a moderate positive association with psychologicaladjustment [46].While community support systems are important re-

sources for youth, these systems can also contribute toprocesses of fear through interpretation of illness as beingcaused by sorcerers or witches. Intervention approachesaimed at improving coping strategies in youth shouldcollaborate with local leaders to develop approachesthat are non-judgmental towards traditional belief sys-tems of causes of illness but rather work in dialogue

Cherewick et al. Conflict and Health (2015) 9:35 Page 11 of 12

with leaders to develop interventions that minimizenegative effects of these beliefs such as perpetuatingfear leading to social isolation. Social support seeking alsohas the potential to lead to risk taking behaviors. For ex-ample, it is plausible that some peer-support seeking couldpotentially increase the likelihood of engaging in risk-taking behaviors such as drinking, a negative copingbehavior usually employed in social settings. Supportingpositive group activities for youth could extract thebenefits received through socializing in peer networksand could potentially deter youth from utilizing risk-takingbehavior in social groups.Understanding the complexity of coping among conflict-

affected youth in the context of the DRC helps develop amore complete theory of cognitive and behavioral copingstrategies that is helpful for modeling pathways for empir-ical testing. For example, unlike previous research, thisstudy reveals that disengagement strategies can be an ef-fective coping strategy within this context. Reliance on thewestern constructs of coping may inappropriately prioritizecertain coping strategies as beneficial, such as engagementor problem-solving strategies, when these types of strategiesmay be of secondary concern or simply lacking meaningin contexts where youth are impacted by conflict relatedtraumatic stressors. In addition to recognizing use of aparticular strategy, this study identifies the possibility ofoverlap between coping domains and mutually reinforcingrelationships between particular strategies that could po-tentially help or harm youth well-being. Future researchcould benefit from a more complex understanding ofthe relationships between coping strategies and potentialreinforcing relationships between cognitive and behavioralstrategies. A context specific framework can provide aspringboard for implementing effective interventionpolicies.

LimitationsResults from this study may not be generalizable to othercontexts as coping strategies were defined within the cul-tural context of the Walungu Territory in Eastern Demo-cratic Republic of Congo. The villages sampled in thisstudy were rural villages and coping strategies in urbancontexts may differ if additional resources and supportsystems specific to urban environments are available. Theyouth included in this study had a wide range of traumaexposure related to ongoing armed conflict and it is pos-sible that coping strategies change over time post-conflict.Future research and public health programming shouldconsider adaptive trajectories over time.

ConclusionThis qualitative research provides a culturally specificportrait of coping in the Walungu Territory, EasternDemocratic Republic of Congo. While traditionally coping

strategies grouped under the “disengagement” domainhave been construed as negative coping strategies, in East-ern Democratic Republic of Congo types of disengage-ment coping such as trying to forget and praying, may helpto support youth mental health along adaptive trajectories.Coping strategies are related to risk and protective factorsat the individual, family and community level. Having at-tachment relationships with peers, family and communityprovide stability and structure as well as an opportunityfor emotion expression. Greater cohesion and integrationof family and community in intervention efforts can bettersupport strength based interventions for youth.

AbbreviationsDRC: Democratic Republic of Congo; PAIDEK: programme d’Appui auxinitiatives economiques; PFP: pigs for peace; RFR: rabbits for resilience.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsThe 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. Allauthors contributed critically and significantly to drafting a final manuscript.All authors approved the final version.

AcknowledgmentsThe authors are grateful to the youth participants in the PFP programme forproviding in depth information on their life experiences.

FundingThis work was supported by the Robert D. and Helen S. Wright Fellowship inInternational Health from the Department of International Health at theJohns Hopkins Bloomberg School of Public Health.

Author details1Department of International Health, Johns Hopkins Bloomberg School ofPublic Health, 615 N. Wolfe Street, 21204 Baltimore, MD, USA. 2Johns HopkinsSchool of Nursing, Baltimore, MD, USA. 3Programme d’Appui aux InitiativesEconomiques (PAIDEK) Pigs for Peace, Bukavu, Democratic Republic ofCongo. 4Pigs for Peace, Bukavu, Democratic Republic of Congo.

Received: 6 July 2015 Accepted: 20 October 2015

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