Journal of Interpersonal

Violence
Volume 23 Number 8
August 2008 1108-1119
Posttraumatic Stress © 2008 Sage Publications
10.1177/0886260507313975
Disorder Following http://jiv.sagepub.com
hosted at

Ethnoreligious Conflict in http://online.sagepub.com

Jos, Nigeria
Rose E. Obilom
Jos University Teaching Hospital
Tom D. Thacher
Mayo Clinic

In September 2001, ethnoreligious rioting occurred in Jos, Nigeria. Using a

multistage cluster sampling technique, 290 respondents were recruited in Jos
7 to 9 months after the riots. Data were collected regarding demographics,
exposure to traumatic events, and psychological symptoms. Resting pulse
and blood pressure were recorded. A total of 145 (52.5%) witnessed or were
victims of personal attacks, 165 (59.6%) lost their possessions, 56 (20.7%)
had their homes burned, 44 (16.2%) witnessed relatives’ deaths, and 8 (2.9%)
were robbed. A total of 252 (89.7%) of the respondents met reexperiencing
criteria, 138 (49.1%) met avoidance criteria, and 236 (84.0%) met arousal
criteria for posttraumatic stress disorder (PTSD). A total of 116 (41%, 95%
confidence interval [CI] = 36% to 47%) met all three categories for PTSD.
Only personal attacks (adjusted odds ratio = 2.8, 95% CI = 1.7 to 4.7) and a
heart rate of 90 beats/min or more (adjusted odds ratio = 2.8, 95% CI = 1.4
to 5.8) were significantly related to PTSD in a multivariate model.

Keywords: posttraumatic stress disorder; ethnic; religious; violence; Africa;

heart rate

E thnic, political, and religious tension in Nigeria periodically erupts in

regional conflicts. Traumatic events associated with these conflicts
include physical assault and the loss of family members and property.
Persons who witness such violence are at risk for posttraumatic stress dis-
order (PTSD). PTSD represents a clustering of anxiety-related symptoms
following exposure to an event that provokes fear, helplessness, or terror in
response to the threat of injury or death (American Psychiatric Association,
1994). These symptoms include reexperiencing the trauma (e.g., images,
flashbacks, nightmares), avoiding reminders of the event, and increased
1108

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 Obilom, Thacher / PTSD in Nigeria 1109

arousal. Events that may precipitate PTSD include natural disasters, traffic
accidents, armed robbery, burns, rape, kidnapping, torture, spouse abuse,
terrorist attacks, and civil conflicts. Interpersonal violence is more likely to
provoke PTSD than accidents and natural disasters (Yehuda, 2002). A
meta-analysis demonstrated increased basal heart rates in persons with
PTSD, which were particularly pronounced in those with chronic PTSD
(Buckley & Kaloupek, 2001).
Although ethnic, political, and religious conflicts are frequent in Africa,
few studies have documented the nature of PTSD in African countries.
PTSD has been observed across cultures and appears to be a universal phe-
nomenon (Mezey & Robbins, 2001; Njenga, Nicholls, Nyamai, Kigamwa,
& Davidson, 2004; Silove, 2000). The prevalence of PTSD 6 to 8 years
after population massacres in Algeria was 37% (de Jong et al., 2001). Eight
years after the Rwandan genocide, 25% of those surveyed met symptom
criteria for PTSD (Pham, Weinstein, & Longman, 2004). PTSD occurred in
35% of a nonrandom sample of Kenyans 1 to 3 months after the U.S.
embassy bombing in Nairobi (Njenga et al., 2004). In contrast, after the
September 11, 2001, attack in New York, the prevalence of PTSD symp-
toms was 7.5% (Galea et al., 2002). Most deaths at the World Trade Center
were not witnessed, unlike the situation in wars and riots, in which indi-
viduals witness violent death.
From September 7 to 12, 2001, violent intertribal and religious conflict
erupted in Jos, Nigeria (1991 census population 650,839), the capital of
Plateau State. Jos is a multiethnic city located in north central Nigeria, with
12 administrative wards. The majority of residents are civil servants, farm-
ers, traders, students, and miners. English and Hausa are the main lan-
guages spoken, although substantial proportions speak multiple other
languages. The indigenous Berom ethnic group is predominantly Christian,
and the Hausa ethnic group is predominantly Muslim. Prior to this, tensions
were raised by the appointment of a nonindigent Hausa settler as coordina-
tor of the local government poverty eradication program (Asaju, 2001).
Mutual suspicion and rivalry between the predominantly Muslim Hausa
settlers and the predominantly Christian indigenes erupted into rioting
when a woman living near a downtown mosque was denied access to her
home just prior to Friday prayers. Fighting rapidly spread to other parts of
Jos and surrounding villages, and widespread community violence and
destruction of property ensued. Initial reports indicated that from
September 7 to 12, over 500 people were killed, 958 were severely injured,
and homes, shops, vehicles, mosques, and churches were destroyed in and
around Jos (Asaju, 2001). Over the ensuing 3 years (2001 to 2004), conflict

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1110 Journal of Interpersonal Violence

spread to other parts of Plateau State, where ethnic groups are also divided
along religious lines. A government census committee confirmed that
53,789 people (18,931 men, 17,397 women, and 17,459 children) died from
violent conflict, and over 200,000 people were displaced (Obateru, 2004).
We conducted a community-based prevalence survey of PTSD 7 to 9
months after the crisis in Jos to assess the prevalence of and risk factors for
PTSD in survivors of the conflict. We also sought to determine if increased
sympathetic activity, manifest by increased pulse rate and blood pressure,
was associated with PTSD symptoms. Our aim was to identify factors that
predict greater risk for PTSD in a Nigerian setting, which may be amenable
to potential intervention.

Methods

Data were collected 7 to 9 months after the Jos riots. The ethics com-
mittee of the Jos University Teaching Hospital approved the study. Written
informed consent was obtained from ward heads and individual study par-
ticipants. For those who were illiterate, data were collected with a struc-
tured questionnaire developed by one of the authors (R. E. O.), a family
physician fluent in English, Hausa, and Igbo languages. Those who were
literate filled out the questionnaire in the author’s presence. Persons aged
12 years and older, resident in Jos prior to and during the crisis, and who
experienced or witnessed traumatic events during the crisis were eligible
for inclusion. We included persons as young as 12 years because they were
capable of participating in the study and of reporting PTSD symptoms.
Their inclusion would allow us to more adequately explore the effect of age
on the occurrence of PTSD. Persons with depressive, anxiety, or mental
symptoms severe enough to interfere with normal activities or require
hospitalization prior to the crisis and those with chronic illnesses were
excluded, because of the potential confounding association of these conditions
with depression, anxiety, and heart rate.
Respondents were selected by means of a multistage cluster-sampling
technique (“Multistage Sampling,” 2000). The sampling frame consisted of
the eight wards where rioting was most intense. Assuming a prevalence of
PTSD similar to that found after the Rwandan genocide of 25% (Pham
et al., 2004), a sample size of 290 was estimated to provide a precision of
±5% with 95% confidence. From each ward, a proportionate, random sam-
ple of streets were selected, totaling 45 streets. From the approximate
center of a selected street, the direction (right or left) was determined by

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 Obilom, Thacher / PTSD in Nigeria 1111

coin flip, and consecutive residences were approached. Not more than 2
eligible persons per household were selected, and 6 or 7 participants were
recruited per street to attain the total required sample. A household was
defined as people sharing common sleeping quarters and eating from the
same pot. Muslim households generally required permission from the
household head before participation was allowed.
Respondents were asked if they had experienced or witnessed any trau-
matic events, including the violent deaths of relatives or friends, physical
abuse, injuries, personal attacks, robberies, the loss of property, or the burn-
ing of their homes, during the riots. PTSD was assessed using questions
from a structured PTSD diagnostic interview guide (Zimmerman, 1992). A
diagnosis of PTSD required that a respondent must have witnessed or expe-
rienced a traumatic event, have at least one symptom of reexperiencing the
event, have three avoidance symptoms, and have two arousal symptoms. All
symptoms must have been present during the preceding 1 month to qualify
as current PTSD. Resting pulse rates and blood pressures of respondents
were also measured.
Data were entered in Epi Info 3.3.2 (Centers for Disease Control and
Prevention, Atlanta, Georgia) for analysis. The χ2 test was used to test asso-
ciations between covariates and PTSD. Logistic regression was used to
identify significant risk factors for PTSD while controlling for important
confounders (p < .2).

Results

A total of 290 participants were recruited, ranging in age from 12 to 85

years (M = 33.8 years, SD = 10.6 years). Forty-five Muslim household
heads refused consent. Because of missing data, records for 281 partici-
pants were included in the analysis. The prevalence of PTSD 7 to 9 months
after the crisis in Jos was 41% (95% confidence interval [CI] = 36% to
47%). Characteristics of the study participants according to their PTSD
status are shown in Table 1. The mean age of those with PTSD did not sig-
nificantly differ from that of those without PTSD (M = 32.5 years, SD = 9.9
years vs. M = 34.7 years, SD = 10.7 years, respectively; t = 1.78, df = 279,
p = .08). The risk for PTSD was unrelated to gender, educational attain-
ment, marital status, or exposure to trauma prior to the Jos riots. A total of
252 of the respondents (89.7%) met reexperiencing criteria, 138 (49.1%)
met avoidance criteria, and 236 (84.0%) met arousal criteria for PTSD. A
total of 116 (41% [95% CI = 36% to 47%) met all three categories for the

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1112 Journal of Interpersonal Violence

diagnosis PTSD. Although reexperiencing and arousal symptoms were pre-

sent in the vast majority of participants surveyed, avoidance symptoms
were less common. Because the diagnosis of PTSD required the presence
of all three categories of symptoms, avoidance symptoms tended to dis-
criminate between those with and without PTSD. The only type of trauma
significantly associated with PTSD was being the victim of or witnessing a
personal attack (p < .001), with two thirds of such participants having
PTSD. Witnessing the death of a relative was not associated with PTSD,
nor was the loss of property.
Heart rates were significantly greater in those with PTSD than in those
without PTSD (p < .001 for trend). There was also a nonsignificant trend in
the association of arousal symptoms with increasing heart rate (p = .09). A
heart rate of 90 beats/min or more had sensitivity of 22% and specificity of
91% for the diagnosis of PTSD. Heart rate was not related to age or sex.
Neither systolic or diastolic blood pressure was related to the diagnosis of
PTSD. In a multivariate logistic regression model (Table 2), only personal
attack (adjusted odds ratio = 2.8, 95% CI = 1.7 to 4.7) and heart rate of 90
beats/min or more (adjusted odds ratio = 2.8, 95% CI = 1.4 to 5.8) were
independently associated with PTSD while controlling for age as the single
important confounding variable (p = .14). No significant variable interac-
tions were present.

Discussion

In this survey, conducted 7 to 9 months after the September 7 to 12,

2001, crisis in Jos, 41% of the respondents met symptom criteria for PTSD.
We used a cluster random-sampling technique to provide a relatively unbi-
ased estimate of PTSD prevalence. This high prevalence is consistent with
studies done in other populations exposed to mass violence. The prevalence
of PTSD in Algeria was 37% (de Jong et al., 2001) and 25% in Rwanda
(Pham et al., 2004) 6 to 8 years after population massacres. PTSD occurred
in 35% of Kenyans 1 to 3 months after the U.S. embassy bombing in
Nairobi (Njenga et al., 2004). Because we surveyed the areas of Jos where
rioting was most intense, this may have accounted for the relatively high
prevalence of PTSD. In addition, the high prevalence of PTSD may reflect
the survey of study participants within 1 year of the traumatic event or the
type of violence that was witnessed. The prevalence of PTSD would be
expected to decline over time. The prevalence of PTSD among Bosnian
refugees in 1996 was 26% (Mollica et al., 1999). Three years later, the

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 Obilom, Thacher / PTSD in Nigeria 1113

Table 1
Characteristics of 281 Nigerian Participants
Classified by PTSD Status
PTSD (%, SR) No PTSD (%, SR)
Characteristic n (%) (n = 116) (n = 165) p

Sex .85
Male 141 (50.2%) 59 (50.9%, 0.10) 82 (49.7%, –0.09)
Female 140 (49.8%) 57 (49.1%, –0.10) 83 (50.3%, 0.09)
Age (years) .16a
10 to 19 20 (7.1%) 13 (11.2%, 1.65) 7 (4.2%, –1.38)
20 to 29 71 (25.3%) 27 (23.3%, –0.43) 44 (26.7%, 0.36)
30 to 39 104 (37.0%) 44 (37.9%, 0.16) 60 (36.4%, –0.14)
≥40 86 (30.6%) 32 (27.6%, –0.59) 54 (32.7%, 0.49)
Education .50a
University 84 (29.9%) 35 (30.2%, 0.06) 49 (29.7%,–0.05)
Diploma 65 (23.1%) 23 (19.8%, –0.74) 42 (25.5%, 0.62)
Secondary 74 (26.3%) 39 (33.6%, 1.53) 35 (21.2%, –1.28)
Primary 43 (15.3%) 13 (11.2%, –1.13) 30 (18.2%, 0.95)
None 15 (5.3%) 6 (5.2%, –0.08) 9 (5.5%, 0.07)
Marital status .55b
Married 173 (61.8%) 69 (59.5%, –0.32) 104 (63.4%, 0.27)
Single 98 (35.0%) 42 (36.2%, 0.22) 56 (34.1%, –0.18)
Divorced 4 (1.4%) 3 (2.6%, 1.04) 1 (0.6%, –0.88)
Widowed 5 (1.8%) 2 (1.7%, –0.05) 3 (1.8%, 0.04)
Exposure to trauma
prior to riot .96
Yes 63 (22.7%) 26 (22.8%, 0.03) 37 (22.6%, –0.03)
No 215 (77.3%) 88 (77.2%, –0.02) 127 (77.4%, 0.02)
Reexperiencing
symptoms
Yes 252 (89.7%) 116 136 (82.4%)
No 29 (10.3%) 0 29 (17.6%)
Avoidance symptoms
Yes 138 (49.1%) 116 22 (13.3%)
No 143 (50.9%) 0 143 (86.7%)
Arousal symptoms
Yes 236 (84.0%) 116 120 (72.7%)
No 45 (16.0%) 0 45 (27.3%)
Loss of property .31
Yes 165 (59.6%) 65 (56.0%, –0.49) 100 (62.1%, 0.42)
No 112 (40.4%) 51 (44.0%, 0.60) 61 (37.9%, –0.51)
Witnessed death of
relative .66
Yes 44 (16.2%) 20 (17.4%, 0.31) 24 (15.4%, –0.26)
No 227 (83.8%) 95 (82.6%, –0.14) 132 (84.6%, 0.12)

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1114 Journal of Interpersonal Violence

Table 1 (continued)
PTSD (%, SR) No PTSD (%, SR)
Characteristic n (%) (n = 116) (n = 165) p

Robbery .54
Yes 8 (2.9%) 3 (2.6%, –0.74) 5 (3.2%, 0.85)
No 282(97.2%) 163(96.4%, 0.12) 119(98.3%, –0.14)
Home burned .94
Yes 56 (20.7%) 24 (20.9%, 0.05) 32 (20.5%, –0.04)
No 215 (79.3%) 91 (79.1%, –0.03) 124 (79.5%, 0.02)
Personal attack <.001
Yes 145 (52.5%) 77 (67.0%, 2.13) 68 (42.2%, –1.80)
No 131 (47.5%) 38 (33.0%, –2.24) 93 (57.8%, 1.90)
Heart rate (beats/min) <.001a
<70 4 (1.6%) 4 (3.9%, 1.80) 0 (0, –1.52)
70 to 79 93 (37.8%) 26 (25.2%, –2.07) 67 (46.9%, 1.76)
80 to 89 109 (44.3%) 48 (46.6%, 0.35) 61 (42.7%, –0.30)
90 to 99 28 (11.4%) 17 (16.5%, 1.54) 11 (7.7%, –1.31)
≥100 12 (4.9%) 8 (7.8%, 1.33) 4 (2.8%, –1.13)
Systolic blood
pressure (mm Hg) .42a
80 to 119 88 (33.2%) 40 (37.0%, 0.69) 48 (30.6%, –0.57)
120 to 139 167 (63.0%) 62 (54.7%, –0.73) 105 (66.9%, 0.61)
≥140 10 (3.8%) 6 (5.5%, 0.95) 4 (2.5%, –0.79)
Diastolic blood
pressure (mm Hg) .83a
50 to 69 16 (6.0%) 8 (7.4%, 0.58) 8 (5.1%, –0.48)
70 to 89 191 (72.1%) 77 (71.3%, –0.10) 114 (72.6%, 0.08)
90 to 109 51 (19.2%) 19 (17.6%, –0.39) 32 (20.4%, 0.32)
≥110 7 (2.7%) 4 (3.8%, 0.68) 3 (1.9%, –0.56)

Note: PTSD = posttraumatic stress disorder; SR = standardized residual.

a. p value calculated by χ2 test for linear trend.
b. p value calculated by χ2 test.

prevalence of PTSD was 18% (Mollica et al., 2001). Of those with PTSD
in the initial survey, only 23% had persistent PTSD; the others with PTSD
in the 1999 survey were new cases.
We found that only victimization and witnessing a personal attack were
significantly associated with increased risk for PTSD, with PTSD found in
two thirds of such persons. However, witnessing the death of a relative was
not associated with PTSD. Whereas the risk for PTSD in New York after
9/11 was increased among those who lost their possessions, we did not find
this to be a risk factor of PTSD in our setting. Avoidance symptoms were

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 Obilom, Thacher / PTSD in Nigeria 1115

Table 2
Predictors of Posttraumatic Stress Disorder in a
Multiple Logistic Regression Model
Odds Ratio
(95% Confidence
Term Interval) Coefficient SE p

Age (years) 0.98 (0.96 to 1.01) –0.019 0.013 .14

Heart rate ≥ 90 beats/min 2.8 (1.4 to 5.8) 1.039 0.366 .005
Personal attack 2.8 (1.7 to 4.7) 1.028 0.260 <.001
Constant –0.43 0.47 .37

relatively infrequent compared with reexperiencing and arousal symptoms.

Similar findings were reported from Algeria, where reexperiencing, avoid-
ance, and arousal symptoms were reported in 80%, 52%, and 71% of par-
ticipants, respectively (de Jong et al., 2001). Avoidance symptoms may be
particularly influenced by culture, whereas reexperiencing and arousal
symptoms have a biological basis (Marsella, Friedman, Gerrity, &
Scurfield, 1996).
Female sex was predictive of PTSD in Kosovo (Lopes Cardozo, Vergara,
Agani, & Gotway, 2000), Rwanda (Pham et al., 2004), Algeria (de Jong
et al., 2001), and Kenya (Njenga et al., 2004), but we did not confirm this
association in Jos. The greater prevalence of PTSD among women may
have resulted from the greater frequency of sexual assault in women in
some of these other settings (Yehuda, 2002). In contrast, none of the female
participants in our study reported sexual assault. As in Gaza and Ethiopia
(de Jong et al., 2001), where men had equal or more PTSD symptoms than
women, male participants were more likely to have been directly involved
in the conflict in Jos. Additionally, Nigerian women are generally taught
from childhood to endure hardship without complaining. Despite the fact
that many Nigerians are resigned to a fatalistic worldview and may accept
adverse events as being unpreventable, the prevalence of PTSD was high.
Fatalism has also been reported as a possible contributor to PTSD in
Hispanics (Pole, Best, Metzler, & Marmar, 2005). The relationship between
a fatalistic worldview and PTSD deserves further exploration.
We found that African participants with PTSD had higher resting heart
rates than those without PTSD, consistent with increased sympathetic ner-
vous system activity. However, we did not find increased systolic or dias-
tolic blood pressure in those with PTSD. An increased basal heart rate has
been associated with PTSD, particularly chronic PTSD (Buckley &

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1116 Journal of Interpersonal Violence

Kaloupek, 2001). Increased heart rate acutely after trauma may be associated
with the later development of PTSD (Bryant, Harvey, Guthrie, & Moulds,
2003). The association of PTSD with higher resting heart rates in our par-
ticipants persisted when we controlled for the confounding effect of age on
heart rate in the analysis.
There is some debate whether Diagnostic and Statistical Manual of
Mental Disorders, fourth edition (DSM-IV), criteria are valid across cul-
tures (de Jong, Komproe, & Van Ommeren, 2003). The overapplication of
the diagnosis of PTSD to conditions of suffering brought about by conflict
may be an inappropriate labeling of a natural response (Summerfield, 1999,
2002). We found positive responses to the symptom categories of PTSD
used in DSM-IV. However, we cannot prove that these are valid indicators
of psychological distress among Nigerians, because we did not demonstrate
that such symptoms are pathological in this population.
One possible limitation of our study was basing our survey on an inter-
view guide using Diagnostic and Statistical Manual of Mental Disorders,
third edition, revised (DSM-III-R), criteria for PTSD rather than DSM-IV
criteria. However, the differences between DSM-III-R and DSM-IV criteria
are relatively minor. DSM-IV adds Criterion A.2 (the person’s response to
the event involved intense fear, helplessness, or horror) and Criterion F
(clinically significant distress or impairment in social, occupational, or
other important areas of functioning). These additional criteria were likely
to have been met by nearly all the participants who met the other criteria for
PTSD in our study. Physiological reactivity was recategorized from an
arousal symptom in DSM-III-R to a reexperiencing symptom in DSM-IV.
However, this change would have little effect on the diagnosis of PTSD in
our participants, because avoidance symptoms were most critical for dis-
criminating between those with and without PTSD.
Another limitation of our study was that we assumed that PTSD was
related to the Jos trauma rather than other past traumatic exposures. Nearly
one quarter of our respondents indicated that they had experienced trau-
matic events prior to the Jos crisis. Cumulative trauma experiences can
increase the risk for PTSD, and a dose-response effect has been described
(Mollica, McInnes, Poole, & Tor, 1998), although not consistently (Mollica
et al., 1999). However, we did not observe a greater risk for PTSD among
those with past trauma exposure.
One limitation of our study could affect the estimated prevalence of
PTSD. We allowed for up to two members per household to participate in
the study. In instances in which two members from the same household
were enrolled, one participant’s PTSD symptoms could have affected the

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 Obilom, Thacher / PTSD in Nigeria 1117

PTSD symptoms reported by the other family member. The effect of a cor-
relation of symptoms between members of the same households would be
to widen the CI around the prevalence estimate.
In Jos, no organized psychological or mental health assistance was pro-
vided for victims after the riot. Professional social support is limited or
unavailable for victims of traumatic events in developing countries such as
Nigeria. This relative neglect of victims may have contributed to the high
PTSD prevalence. Those with somatic complaints will typically seek help
from primary care providers, but the psychological sources of their symp-
toms will frequently go unrecognized. Persons with PTSD are more likely
to visit primary care physicians than mental health professionals (Yehuda,
2002), and few mental health professionals practice in Africa. Primary care
physicians in low-income countries need to be trained to recognize PTSD
and to provide early intervention to reduce its associated morbidity
(Davidson, 2001). Given that effective treatment for PTSD requires multi-
ple and frequent visits, training primary care physicians to meet this need
is appropriate.
Awareness of ongoing violence in other parts of Plateau State during our
survey may have contributed to the high prevalence of PTSD that we
observed. Many of the respondents anticipated further riots or community
violence. This concern for future conflict can heighten anxiety. Efforts to
tackle the root causes of violent conflict are urgently needed (Stewart,
2002). The frequency of violent conflicts in Africa and the large burden of
PTSD persisting after such conflicts warrant greater efforts in facilitating
conflict resolution before it escalates into widespread bloodshed.
In conclusion, we found that Nigerian persons who witnessed or were the
victims of personal violence during an ethnoreligious conflict had a sub-
stantial risk for having PTSD 6 to 8 months later. PTSD was associated with
an increased pulse rate, likely reflecting sympathetic activation. Recognition
of PTSD by health care providers in Africa and training to provide early
intervention may help reduce the burden of PTSD following conflict.

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Rose E. Obilom completed her postgraduate fellowship in family medicine at the Jos
University Teaching Hospital in Jos, Nigeria. This work was submitted as a dissertation in part
fulfillment of the fellowship in family medicine of the West African College of Physicians. She
is currently an attending physician in a family medicine residency program in Lafia, Nigeria.

Tom D. Thacher was the founding head of the Department of Family Medicine at the Jos
University Teaching Hospital in Jos, Nigeria. He has supervised various resident dissertations
relevant to primary care in Nigeria. He now works in family medicine at the Mayo Clinic in
Rochester, Minnesota.

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