The pattern and burden of non-communicable diseases in armed conflict-exposed populations in Northeastern Nigeria

Introduction

Northeastern Nigeria is recovering from the impacts of the decade-long insurgency and perennial armed conflict (Brottem, 2021; Garba, 2018; Ojiego-Okoro, Umeh & Nwodom, 2024). During the conflict, healthcare facilities and public infrastructures were destroyed, and private enterprises were decimated (Tafida et al., 2023). Between 2008 and 2023, Nigeria has recorded about 8.7 million internally displaced people, forced to live in refugee camps or as internally displaced persons (IDPs) mostly in the northeastern states of Adamawa, Borno and Yobe (Ekoh et al., 2023; Internal Displacement Monitoring Centre, 2024). The prolonged exposure to these humanitarian crises has inflicted severe psychological distress, economic hardship, and social instability on the affected populations (Garba, 2018; Ojiego-Okoro, Umeh & Nwodom, 2024). The insurgency has led to the deaths of an estimated 350,000 lives since 2009 (Internal Displacement Monitoring Centre, 2024), and the survivors have endured extreme trauma, including the loss of loved ones, forced displacement, lack of food and water, near-death experiences, kidnapping, severe bodily injury, and lack of medicines and social services (Garba, 2018; Ojiego-Okoro, Umeh & Nwodom, 2024).

NCDs, which include conditions such as diabetes, hypertension, depression, obesity, and cancer, are not primarily caused by an acute infection but have long-term health consequences that require long-term treatment and care (Allen et al., 2017; Avan et al., 2019; Carrette, D & Hasumi, 2018; Greene-Cramer et al., 2020; Hosseinpoor et al., 2012; Jawad et al., 2019; Narayan, Ali & Koplan, 2010). Conflict and post-conflict settings, such as those experienced in northeastern Nigeria, increase the risk of developing NCDs (Carrette, D & Hasumi, 2018; Greene-Cramer et al., 2020; Jawad et al., 2019). The stress and trauma of such settings often lead individuals to adopt unhealthy coping mechanisms such as drug abuse, alcohol abuse, smoking, and sedentary behaviors—major risk factors for NCDs (Ojiego-Okoro, Umeh & Nwodom, 2024; Tafida et al., 2023). The vicious cycle of unhealthy lifestyle habits and socioeconomic disadvantages exacerbates the burden of NCDs in conflict-exposed populations (Tafida et al., 2023). Additionally, fragile and violent situations disrupt the continuity of care for NCDs, weaken health systems and drastically reduce access to social services (Carrette, D & Hasumi, 2018).

In Nigeria, the national prevalence of hypertension was estimated at 30.6% (95% confidence interval (CI) [27.3%–34.0%]) (Adeloye et al., 2021), with complications such as stroke, chronic kidney disease, heart failure and myocardial infarction affecting about 75% of those diagnosed (Kassy et al., 2022). About a quarter of emergency room presentations in urban Nigeria stem from hypertension-related complications (Adeloye et al., 2021). Diabetes mellitus (DM) also presents a significant public health challenge, with a pooled national prevalence of 5.77% (95% CI [4.3–7.1]) (Adeloye et al., 2021). DM is a chronic metabolic disease associated with factors such as sedentary lifestyle, unhealthy diet, advancing age, low socioeconomic status and depression (Hill-Briggs et al., 2021; Mezuk et al., 2008; Ramalan et al., 2023) and accounts for an overall mortality rate of 30.2 per 100,000 population in Nigeria (Adeloye et al., 2021). Other conditions, such as central obesity, affect 39% of the Nigerian population (Bashir et al., 2022). Depression, a common mood disorder with a lifetime prevalence of 3.9% in Nigeria (Gbadamosi et al., 2022), is particularly debilitating among conflict-exposed populations (Akinrolie et al., 2022)

NCDs have a multifactorial origin, with risk factors ranging from psychosocial stress, environmental insults, and genetic predisposition to behavioral and unhealthy cultural practices (Roberts et al., 2009; Sharma et al., 2020). In Juba, South Sudan, approximately 50% of conflict-exposed individuals met the criteria for depression (Roberts et al., 2009). Similar findings have been reported in other conflict-affected areas, such as Ukraine, where there is an increase in blood pressure, consumption of alcohol and cigarettes, and increased incidence of coronary heart disease and endocrine diseases, including DM (Greene-Cramer et al., 2020).

To our knowledge, no comprehensive study has been conducted on the pattern of NCDs and their behavioral risk factors during the post-conflict and rebuilding phases of Northeastern Nigeria. Therefore, the objective of this study was to explore the prevalence of NCDs, including hypertension, diabetes, depression, and obesity, and their associated behavioral coping mechanisms in conflict-exposed populations in Northeastern Nigeria. The outcomes of this study may inform healthcare authorities of the patterns and burdens of NCDs in the northeastern region of Nigeria, which may facilitate the allocation of dwindling resources to aid holistic recovery in the face of harsh global economic indices.

Methods

Results

A total of 973 participants were included in this study. The demographic characteristics and health indicators of the participants from conflict-exposed Mubi compared with those of the participants from Jada (comparison) are presented in Table 1. The proportion of the study cohort from Mubi (conflict-exposed) (52.93%) was slightly higher than that from Jada (comparison) (47.07%). The average age of the participants was 41.04 years. The average age of the participants from Jada (comparison) was slightly older than that of those from Mubi (p = 0.020). The sex distribution of the study population was balanced overall, with no statistically significant difference between Mubi (conflict-exposed) and Jada (comparison) (p = 0.510). There were no disparities in marital status between Mubi and Jada; however, the percentage of divorced individuals in Jada (comparison) (3.06%) was higher than that in Mubi. There were significant disparities in educational attainment and occupation between participants from Mubi and those from Jada (p < 0.001). Socioeconomic status varied significantly between the two locations, with a higher proportion of upper-income individuals in Jada (comparison) and more low-income individuals in Mubi. Abdominal obesity was more prevalent in Jada (comparison) (58.95%) than in Mubi (31.07%). Although there was no significant difference in blood pressure distribution between the participants from Mubi and those from Jada, there was a significant difference in the prevalence of depression in both regions (p < 0.001), with the prevalence in Mubi (conflict-exposed) being higher than that in Jada. There was no difference in glycemic status between the two regions (p = 0.502). However, there was a significant difference in healthcare insurance coverage between the two regions (p < 0.001), the percentage of individuals without insurance in Mubi (conflict-exposed) is higher than that in Jada, suggesting potential barriers to healthcare access in conflict-exposed regions. There are more civil servants in Mubi than there are Jada (27.82% vs 9.83%) (Table 1).

Table 2 shows the prevalence of chronic conditions in the study population. The prevalence of hypertension, diabetes, abdominal obesity, and depression in the study population was 22.92%, 5.04%, 44.19%, 17.94%, respectively. The participants in conflict-exposed Mubi exhibited a lower prevalence of hypertension (20.78%) and abdominal obesity (31.07%) and a higher prevalence of depression (29.69%) than their counterparts in Jada (comparison) (25.33% and 58.95%, respectively). Females showed higher rates of hypertension (24.81%), abdominal obesity (52.71%), and depression (18.64%) than males. However, males showed a higher prevalence of diabetes (6.13%) than the females. The prevalence of various conditions was notably higher among divorced and widowed individuals than among the married participants. Lifestyle factors such as smoking, sedentary behavior, high salt intake, alcohol consumption, and non-compliance with the WHO dietary recommendations also indicate varying prevalence rates for different chronic conditions. Family history also plays a role, indicating potential genetic predispositions.

The results of the multivariable logistic regression analysis of the effects of explanatory variables on NCDs, adjusted for risk factors, are shown in Table 3. The participants from the conflict-exposed Mubi exhibited significantly lower odds of abdominal obesity than their counterparts in Jada (comparison) (adjusted odds ratio [aOR] = 0.18; 95% confidence interval CI [0.11–0.28]). However, the participants from Mubi showed a higher risk of depression than those from Jada (adjusted incidence risk ratio [IRR] = 4.78; 95% CI [2.51–9.12]). Conversely, the participants in the study showed significantly higher odds of having abdominal obesity (aOR = 1.94; 95% CI [1.51–3.08]), along with an elevated risk of depression (IRR = 1.76; 95% CI [1.08–2.88]).

Age was found to be a significant predictor across all the four non-communicable diseases (NCDs) studied. Participants aged 38–57 had more than twice the odds of having abdominal obesity (aOR = 2.08, 95% CI [1.46–2.96]), nearly double the odds of developing hypertension (aOR = 1.85, 95% CI [1.21–2.83]), and more than twice the risk of developing depression (IRR = 2.46, 95% CI [1.60–3.79]) compared to those aged 18–37. The oldest age group (78–100 years) exhibited significantly higher odds of hypertension (aOR = 4.39, 95% CI [1.64–11.77]) and an increased risk of diabetes (IRR = 4.43, 95% CI [0.43–48.25]). Additionally, sex-specific differences were observed, with males having lower odds of abdominal obesity than females (aOR = 0.41, 95% CI [0.29–0.59]). Educational level was a significant predictor of hypertension, where participants with tertiary education had lower odds of hypertension (aOR = 0.43, 95% CI [0.23–0.78]) compared to those with no formal education. Socioeconomic status also played a role in hypertension, with participants in the upper income level having more than four times the odds of developing hypertension compared to those in lower income levels (aOR = 4.36, 95% CI [1.13–16.80]). Family histories of hypertension and diabetes were significant predictors of diabetes and hypertension, respectively. Family history was associated with higher odds of developing hypertension (aOR = 3.12, 95% CI [1.82–4.88]) and an increased risk of diabetes (IRR = 2.96, 95% CI [1.39–6.31]). Additionally, participants with a family history of diabetes had a higher risk of developing diabetes (IRR = 4.31, 95% CI [1.92–9.67]).

In general, the model diagnostics indicate that the four regression models significantly improve prediction compared to an empty model, with all p-values <0.001. The goodness-of-fit test shows that the abdominal obesity model fits the data well (p = 0.229), while the Hypertension model reveals some issues with the fit (p = 0.042), suggesting that the predicted probabilities do not perfectly match the observed outcomes. The area under the ROC curve (AUC) for abdominal obesity (0.739) and hypertension (0.752) suggests that both models have acceptable discriminatory power, effectively distinguishing between individuals with and without the outcomes. Overall, while the models generally perform well, the hypertension fit could be improved.

Discussion

This research conducted in the conflict-exposed Northeastern Nigeria outlines the distinct differences in several key indicators between two locales in the region: Mubi, a conflict-affected area, and Jada, a territory that was largely shielded from the insurgency that plagued the region. One of the most prominent differences in the health indicators for NCDs was the five-fold higher risk of depression among the residents of the conflict-exposed Mubi than among those in Jada.

About five years post-conflict exposure in Plateau State, northcentral Nigeria, the prevalence of depression amongst affected persons was found to be 56.3% (Davou et al., 2018). This is in consonant with the findings of this study. While the conflict-exposed population of Mubi recorded a 30% prevalence of depression in the post-conflict phase, the national prevalence of depression in Nigeria is 3.8% (Gbadamosi et al., 2022). Post-conflict depression represents the most consistent mental health complication of conflict (Anbesaw et al., 2024). The prevalence of depression in the post-conflict population of the Syrian refugees, Nepalese, Mogadishu-Somalia, Ethiopian and Uganda were 59.4%, 27.4%, 59%, 38.3% and 67%, respectively (Anbesaw et al., 2024). While a pre-established diagnosis of clinical depression increases the risk of consequent type 2 DM by 60%, a pre-existing diagnosis of Type 2 DM poses a 15% risk of depression in the long run (De Groot, 2023). This implicates the potential impact of conflicts in the etiology of depression in the aftermath of conflict.

Ultimately, a bidirectional relationship exists between diabetes and depression (Berge & Riise, 2015). For instance, the prevalence of depression among individuals with diabetes mellitus is two to three times higher than that among people without diabetes (Bădescu et al., 2016). Chronic stress is a common denominator for both of them (Bădescu et al., 2016). Similarly, depression increases the risk of diabetes by 37% (Knol et al., 2006). However, this study did not find a statistically significant difference in the prevalences of DM in the two studied communities despite a markedly elevated prevalence of depression of 30% in Mubi as against 5% in Jada. In addition, the prevalences of DM in both communities were about the same (Mubi 5.44% vs Jada 5%). This is consistent with a recent study that reported a prevalence of diabetes ranging from 1.6% to 4.6% in the same region (Stephen et al., 2024). By implication, an effective mental health support program in this recovery will in the long run reduce the burden of DM and its attendant complications, which include diabetic kidney disease, heart attack and stroke, which are all NCDs. Furthermore, this study has also shown that DM is also associated with advancing age as reflected in the middle and elderly age brackets in Mubi. This aligns with the findings in a Chinese study (Bai et al., 2021) which revealed that the prevalence of type 2 DM increases with age, underscoring the multifactorial origin of NCDs (Syed et al., 2019).

In this study, hypertension is associated with increasing age, family history of hypertension, tertiary education, high socioeconomic status, being widowed and diabetes, which further portrays the multifactorial origin of NCDs (Alsaadon et al., 2022). Exposure to conflict bears no statistically significant relationship with hypertension in this study. This is contrary to the findings in South Sudan, which showed that the risk of hypertension increased by 50% in its conflict-exposed population (Narayan, Ali & Koplan, 2010). This could be due to differences in population characteristics, conflict duration, healthcare access, coping mechanisms, and other study-related differences.

Epidemiologically, hypertension tends to coexist with DM (Alsaadon et al., 2022). This coexistence is known to be mediated by several pathophysiologic mechanisms. Chronic inflammation, insulin resistance, oxidative stress, and vascular dysfunction have been implicated as some of the fundamental pathogenesis common to both (Sharma et al., 2020). Background family history of diabetes and hypertension is also associated with the eventual diagnosis of these diseases in their first-degree relatives, as reflected in this study (Moke et al., 2023). IDPs have increased physical inactivity (Akinrolie et al., 2022), and physical inactivity increases the burden of depression.

In this study, a comparatively higher prevalence of abdominal obesity is seen in Jada (59%) when compared to Mubi (31%). Population-based studies have shown that obesity leads to depression and vice-versa (Steptoe & Frank, 2023). Conversely, findings from this study did not reflect a corresponding increase in the burden of DM in Jada, which has a higher prevalence of obesity. However, the prevalence of abdominal obesity in both communities surpasses the national obesity prevalence of 15% in Nigeria (Ramalan et al., 2023). Obesity is increasingly being implicated as a risk factor for so many diseases, including diabetes (Ramalan et al., 2023), hypertension, breast cancer, myocardial infarction and stroke (Kinlen, Cody & O’Shea, 2017). Hence, the local primary health centres in Jada should intensify public health interventions such as health education on the need to adopt lifestyle behavioral modifications such as maintaining a healthy weight and exercising.

In this study, there are more people of low socioeconomic status in Mubi than in Jada. Generally, prolonged violent conflicts impoverish communities and reduce both personal income and commonwealth. A study showed that northeastern Nigeria has been severely impacted economically by the insurgency that plagued the region alongside the perennial farmers-herders clashes, which saw many businesses destroyed (Odozi & Uwaifo Oyelere, 2019). Low socioeconomic status is a risk factor for both T2DM and hypertension (Blok et al., 2022; Hill-Briggs et al., 2021). Consequently, economic devastation occasioned by armed conflict increases the burden of NCDs in the population, hence the need for social safety nets to stem the tide of rising NCDs, by economically empowering the locals through the provision of capital, facilities and skill acquisition support.

Conclusion

This study sheds light on the significant disparities in key health indicators between Mubi, a conflict-affected area, and Jada, a more stable environment. The prevalence of depression in Mubi is notably higher than that in Jada, emphasizing the urgent need for mental health support in conflict-affected regions. Limited access to psychosocial support for those with diabetes in Adamawa State further underscores the challenges faced by individuals with NCDs in the region. Lifestyle factors, such as nutrition and exercise, are crucial modifiable risk factors for T2D. This highlights the need for awareness campaigns on healthier dietary practices. Governmental agencies and the private sector are imperative for addressing the rising burden of NCDs in Nigeria and worldwide. This research underscores the urgent need for targeted interventions, policy changes, and increased resources to combat the growing challenge of NCDs, especially depression, in conflict-affected regions.

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