Transcript Community-level

The Impact of Armed Conflict on
Children and Their Communities
Qualitative Findings from Burundi
Tol, Wietse A. 1/2
Reis, R. 3
Sururu, A. 4/5
Ndayisaba, A. 5
De Jong, J.T.V.M. 1/6/7
1: HealthNet TPO, 2: Vrije Universiteit Amsterdam, 3:University of Amsterdam 4:
University of Burundi, 5: TPO Burundi, 6: GGZ Amsterdam, 7: Boston University
School of Medicine
Thanks to:
• PLAN Netherlands
• Research team: Séraphine Hakizimana and assessors
Espérance Niyongere, Jérémie Niyonkuru, Melchicedec
Nduwayezu, Philippe Cishahayo
Overview of Presentation
• Introduction
– Critique on biomedical domination
– Qualitative literature contribution
– Burundian civil war background
• Methodology
– Setting
– Participants & Instrumentation
– Data Analysis
• Results
– Impact of armed conflict
– Resources available to deal with impact
– Interaction between ecological levels
• Conclusions
Introduction (1)
• Most of the literature on the impact of armed conflict
has been done from a biomedical perspective
– Use of psychiatric classification (DSM III-R, IV)
– Focus on individual impact
– With child refugees in high-income settings
• Current literature reviews stress:
– Shift of focus away from Posttraumatic Stress Disorder, to
include other co-morbid disorders
– Role of resilience
– Paradigm shift proposed: examine effects of chronic
stress, protective/ risk factors, role of cultural context,
gender/ age and type of conflict situation
Introduction (3)
• Burundi:
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8 million population, 90% subsistence agriculture
Landlocked, foreign earnings coffee and tea
68% below poverty line
HIV-AIDS and displacement
• Civil war:
– Ethnic tensions (Tutsi & Hutu) since independence (1962)
from colonization
– Larger clashes in 1962, 1965, 1972, 1988
– 1972 first genocide
– 1993 assassination of president Ndadaye sparking largescale killings
– 250,000 to 300,000 killed; 880,000 displaced
– Peace process from 2000 (Arusha accords), with later
addition of two rebel groups (2003, 2006)
Introduction (4)
•
Objectives of this study
1.
2.
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Description of the impact of armed conflict on children
and their communities from an emic (insider’s)
perspective
Assessment of resources and initiatives available to deal
with this impact
Part of Randomized Controlled Trial
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Preparation of instrumentation (selection, adaptation,
construction)
Examination of public mental health context
Ability to see “fit” of intervention and context
Methodology: setting
• Areas for overall project and Randomized Controlled
Trial were chosen based on Public Mental Health
Principles (e.g. community concern, feasibility, etc. [see
De Jong, 2002])
• Areas for qualitative study chosen to be similar in:
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Livelihood (subsistence agriculture)
Ethnicity (mixed, but majority Hutu)
Conflict history
Avoidance of areas with heavy presence of humanitarian
organizations
• North-Western provinces of Burundi were chosen
(Bubanza, Cibitoke, and Bujumbura Mairie)
Methodology: Participants and Instrumentation
• Participants identified through
initial community meetings and
subsequent snowball sampling
• Focus Group Discussions:
– Impact of conflict
– Exploration and relevance of
psychosocial problems
– Coping with problems
• Illness Narratives:
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Causes
Help-seeking
Role of different stakeholders
Current state
• Key Informant Interviews:
– Impact of conflict
– Problems seen
– Treatment
Burundi
FGD
Children: 4 (N=46)
Parents: 6 (N=57)
Teachers: 4 (N=42)
Illness Narratives
N=40: family members,
guardians and orphanages
Key Informants
N=32: trad. healers (animist
& Christian exorcists),
teachers, medical officers,
priests/ nuns, NGO-personnel
Methodology: Procedures
• 4 local assessors (male/ female, mixed
ethnicity) with a BA in psychology
• One-month training program, with a focus
on interviewing skills and field-practice
• Ethical approval from Vrije Universiteit
Amsterdam and agreement from
community leaders
Methodology: Data Analysis
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Interviews were tape-recorded,
transcribed and translated to English
Content analysis with grounded theory
approach (Strauss & Corbin, 1998)
1. Listing and grouping text relevant to research
questions
2. Development and testing of code-filter based
on groups
3. Code-filter application to all data
•
ATLAS.ti 5 qualitative data analysis
software used
Data Analysis: Ecological Approach
Child
Family
Community
&
the Supernatural
School/ Friends
Results: Impact of Civil War
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Individual
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Psychological problems: problems are often explained in terms of
“madness” [Umusazi]: throwing stones, talking abnormally /
rudely, wandering places. Linked with evil spirits/ poisoning/
sorcery
Other psychological problems: grief, sadness, anger, sensitivity,
withdrawal, trouble with reminders
Moral problems: disobedience, early sexual behaviors, gang-like
behaviors, substance abuse
Family-level
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Killings/ HIV-AIDS/ poverty cause enormous gap in possibility of
(extended) families to provide for children in basic needs
Loss of land and roots
Internal conflicts related to inheritance/ possessions of orphans
Increased polygamy, relaxes in morality
Exploitations in guardian families
Results: Impact of Civil War
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Peer-level/ School-level:
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Sensitivity in play
Stigma of orphans/ mental problems
Increased aggressiveness/ war games
Increased distance between teachers and caregivers (child
problems and family difficulties)
Issues related to punishment
High drop-out rates (poverty)
Distrust/ hate between ethnic groups
Community-level:
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Complaints about loss in traditions
Complaints of “broken morality”
Complaints of loss of connectedness and mutual care between
neighbors
Traditional communities scattered through displacement
Interaction between ecological levels: Impact
• Large-scale killings of parents and loss of land
erodes values of family and community
interaction and care. Children in guardian
families are exploited or less cared for (family
accusations of sorcery). These children take to
the streets (girls: prostitution, boys: theft/
rape) and show behavior which is deemed
immoral and causes a sense of cultural
decline.
• Evil spirits as a way to express community
disarray.
Results: Some resources available to deal with
impact
Resource
Problems seen
Process of
healing
Treatment
mechanisms
Traditional healers
Mental problems,
general childhood
illnesses, former
fighters
Medication,
incisions,
inhalations, rituals
and advice
Magic: the power
of God and
medication
Church: praying
healing
Mental problems,
physical illnesses
Religious
instruction, advice
and exorcist rites
The power of God
through people
(Holy Spirit)
Wise men
[abashingantahe]
Family conflicts/
inheritance
conflicts
Discussion and
advice
Wisdom and
communication
NGO’s
Orphans, former
child soldiers
Developing
relationship of
trust, caring &
sharing
Basic needs
assistance, play,
and
communication
Results: Resources available to deal with impact
Church:
- Exorcist approaches
- Pastoral approaches
Traditional
Healing:
- Pure herbalists
- Mixed practitioners
NonGovernmental
initiatives
(orphans/ child
soldiers)
Formal health
care
Interaction between ecological levels: Resources
• Some traditional healers can work with the evil spirits
that child soldiers bring back from fighting in the civil
war, addressing disrupted community/ supernatural
relations
• Income generation ( e.g. church) for orphaned groups
keeps groups of youth with little opportunities and no
support from inducing sense of community decline
Discussion
• Limitations:
– Not ethnographic study; shorter time, more data,
and little time to do purposive sampling to fill gaps.
– Working with assessors from own context: missing
opportunities for curiosity on aspects that are deemed
normal
• Strengths:
– Much data
– Opportunities for triangulization
– Different techniques (FGD, KII, IN) combine well for an
ecological perspective
Conclusions
• Importance of social and moral context in
understanding individual expressions of psychological
complaints
• Necessity to address damaged family and community
social and moral fabric, in a comprehensive way
• Necessity to work with poverty-related initiatives
• Necessity to address supernatural problems, that
seem expressions of social fabric damage