**1. Introduction**

In order to address the health and development catastrophe brought on by the virus, low- and middle-income countries get assistance from the UN COVID-19 Response and Recovery Fund [1]. The COVID-19 conference took place in Eastern Africa while the region's governments struggled with a number of problems. Millions of people have been compelled to leave their homes due to protracted hostilities, droughts, and insecurity [2]. Millions more have fled to neighboring countries where they live in makeshift refugee camps. The majority of the countries in the region are in some type of fragile and conflict-prone state (for example, Somalia and South Sudan) and/or are undergoing political reform (for example, Sudan and Ethiopia). They have a very low capability to contain the COVID-19 pandemic and lower the ensuing unemployment, poverty, and hunger [2].

Some of the most significant political, security, and conflict developments related to COVID-19 and its effects on neighboring nations include the postponement of Ethiopia's August 2020 elections and the declaration of a state of emergency by the government. Given that many of Ethiopia's most potent opposition groups and one of its most potent regional governments (Tigray) have voiced their opposition to these changes, this might be a significant source of conflict. If COVID-19 spreads widely across the nation, the mounting costs of the disease could cause significant sociopolitical instability. COVID-19's rising economic expenses could become sources of serious socio-political instabilities if it spreads broadly across the country. Since November 4, 2020 war has been started following Ethiopian Northern Command attack by Tigray People Libration Front (TPLF). A millions were displaced, thousands massacred, all public and private infrastructures destroyed in the conflict setting, children were raped in group, thousands killed [3, 4]. This in turn highly influences the mental well-being of conflict-affected people in Ethiopia during COVID-19 era.

"One in five persons in conflict zones lives with some type of mental disease, ranging from mild sadness or anxiety to psychosis," was according to WHO data from 2019. To contain the COVID-19 epidemic and reduce the accompanying unemployment, poverty, and starvation, it is also stated that "almost one in ten people live with a mild or severe mental disorder [5]." Despite the fact that there was limited research among students from conflict-affected areas, various research on the impact of the pandemic on individuals' mental and psychological well-being, notably at the college and university level, were undertaken during COVID-19 in Ethiopia. In the Benchi Sheko zone, for instance, the prevalence of sadness, anxiety, and stress was 21.2%, 27.7%, and 32.5%, accordingly [6], while the psychological impact of COVID-19 was 16.2% among college students [7]. According to another study, 22.2%, 39.6%, and 40.2% of graduating class members, respectively, suffered from stress, anxiety, or depression [8]. In a related study, depression was shown to be widespread in 46.3% of participants, anxiety in 52%, and stress in 28.6% [9]. The prevalence of depression, anxiety, and stress among university students in Addis Abeba was 51%, 51.6%, and 11.1%, respectively [10].

Students are subjected to both direct and indirect repercussions of violence during armed conflict, including erroneous military enlistment, murders, gender-based violence, trafficking, illegal detentions, and family separation [11]. Schoolchildren who have experienced conflict are more likely than those who have not to experience post-traumatic stress disorder, sadness, or anxiety [12]. Direct and indirect exposure to traumatic events, as well as increased levels of daily stressors, are suggested to be the causes of these effects [13]. There are not many mental health therapies available for conflict-affected students, and treatment disparities between adults and primary school students in low-resource settings are even worse [14].

People who have had to move frequently have gone through various traumas, acts of violence, wounds, and economic crises, making them more vulnerable to psychiatric issues [15–17]. The following issue is likely to get worse as a result of the COVID-19 epidemic's ongoing spread. Despite this, there are no reports on the influence of the pandemic and the conflict environment on the mental health of those affected by the conflict in Ethiopia. For people affected by armed conflict, mental anguish has been identified as a key public health concern and has been connected to social network alterations, poverty, unemployment, community violence, and unsecured living situations. Therefore, even when the hostility has subsided and the crisis has passed, emotional distress is substantially associated with a lower quality of life [18, 19]. Additionally, mental trauma can affect anyone and have a detrimental effect on everyday activities, sleep quality, productivity, and job performance [9]. Their longterm academic, social, and mental health results may be significantly impacted by their capacity to manage the epidemic and to effectively and correctly regulate their emotions and behavior during the pandemic [20].

*Conflict Settings and COVID-19's Effects on Psychological Health DOI: http://dx.doi.org/10.5772/intechopen.107466*

The prevalence of mental disorders appears to be significantly higher than the general population in post-conflict and conflict-ridden cultures, including student populations [21]. Statistical estimates from a number of general population studies indicated that the prevalence of mental distress ranges from 1% to 5% [22, 23], and for high-risk populations such as displaced people [24, 25], it ranges from 3% to 58%. When COVID-19 was in effect, it was anticipated that mental anguish would increase in a conflicting environment [26]. To the best of the investigators' knowledge, Ethiopia has not had any particular published studies. As a result, this study aimed to close that gap by generating new knowledge regarding the mental health of conflictaffected people in Ethiopia during the COVID-19 era.

### **2. Methods**

From April 1 to April 30, 2021, a community-based cross-sectional survey was undertaken. During the mid-COVID-19 outbreak in south Ethiopia, the survey was done in conflict-affected areas. In which more than a million were displaced in year 2018 due to inter-communal violence and conflict between Gedeo and Guji zone in south Ethiopia [27]. The respondents were chosen using a systematic random selection procedure. Because the conflict-affected people resided in different sites, proportional allocation to the number of household in each site was used to ensure that the sample was representative. The study covered all houses in the conflict-affected area of south Ethiopia that are situated on the border between the Gedeo and West Guji zones, as well as those that were accessible during the data collection period. Seriously ill people were not allowed to participate in the study.

According to a study conducted in Adama, Ethiopia, the sample size was calculated using the single population proportion technique, with a 3% margin of error (d), a 95% confidence interval of certainty (alpha = 0.05), and a 10% non-response rate, assuming p = 21.6% [28]. A total of 795 people were chosen as a representative sample size. Mental distress was the study's dependent variable. Conflicted- and trauma-related factors, clinical-related factors (history of mental illness, family history of mental illness, pre-existing medical illness), COVID-related factors (suspected/confirmed for COVID-19, knowledge about COVID-19), and social support were all independent variables. Using pretested questionnaires, data was collected by six Bsc nurses and routinely monitored by three psychiatry professionals. The questionnaire was translated into Amharic and then back to English to verify uniformity. Data collectors were taught how to conduct interviews with respondents and how to clarify any ambiguous questions as well as the study's goal. They were also taught about ethical principles and how to gain informed consent from respondents.

Mental distress was measured using the Kessler Psychological Distress Scale (K-10, [29]). The K10 scale, which consists of 10 questions on emotional states and a fivepoint rating scale for each response, is an easy way to gauge psychological distress. The K10 scale is a 10-item survey that asks respondents to score their recent 30-day anxiety and depressive symptoms on a five-point Likert scale. Participants in this study were classified as normal if they received a score of 20 or less, whereas those who had a score of 20 or more were identified as experiencing emotional distress [30]. It was validated with a consistency of 0.93, sensitivity of 84.2%, and specificity of 77.8% at a cut-off point of 6/7. It was reasonable as a result [31].

The Oslo-3 social support scale, which goes from 3 to 14, is used to assess social support. According to this scale, those who score between 3 and 8 are considered to have insufficient social support, those who score between 9 and 11 have moderate social support, and those who score between 12 and 14 have high social support [32]. According to this study's findings, pupils who scored below the minimum requirements during the study's conduct had lower law achievement. Data on sociodemographics, drug use history, clinical variables, COVID-19-related characteristics, and conflict and trauma-related events were gathered using yes/no response questionnaires and operationalized in accordance with a number of academic works.

Epidata version 4.2 was used to clean, code, and enter data, which was subsequently exported to SPSS Data was cleaned, coded, and entered using Epidata version 4.2 before being exported to SPSS version 24 for descriptive methods analysis and data summarizing. Logistic regression analysis was used to establish links between mental anguish and related factors. In bivariable logistic regression, variables with a P value of less than two were included in the multivariable logistic regression model. An adjusted odds ratio (AOR) with a 95% confidence interval was used to assess the strength of associations, and a P value of less than 0.05 was considered statistically significant (CI).
