Mission impossible? Mental health assessments in conflict zones: A study of policy change in Rwandan coffee & its impact on community health Jutta Tobias, Ph.D.

The Society for the Psychological Study of Social Issues

October 9, 2009

Objectives

• An illustration of – How to conduct effective mental health assessments in war-torn communities – The link between economic and community mental health in post-conflict settings • And what type of policy changes may promote this

Agenda

• The broader context of community health in conflict settings • The case study behind this presentation • Some insights on mental health assessments in conflict zones • Practical tips on how to conduct mental health assessments in war-torn communities

The underlying context

• In conflict societies: Mental health inextricably linked to group relations – Especially the relations

between

groups in war-torn communities shape a nation’s potential for sustainable peace, growth and equitable governance • Community health ≈ social capital • Social capital fosters – Physical and mental health – Economic progress and development • Contact between (antagonistic) groups can promote conflict reduction

The case study: Rwandan specialty coffee

• Rwandan coffee and conflict • Post-genocide policy changes in coffee sector – Industry liberalization – Commercially induced contact between Hutu and Tutsi – Journalistic reports of informal reconciliation • Our research questions – Links between increased economic and social capital?

• Our findings – Policy changes may promote improved group relations as ancillary effect beyond targeted economic gains – Both main ethnic groups seem to benefit equally

Why is mental health difficult to assess in conflict zones?

Beyond invisibility…

• Trauma – Threat of re-living painful memories or of making ongoing conflict more salient • Social desirability (a.k.a. dishonesty) – Especially when outsiders conduct assessments • Political concerns – “Reconciliation” in Rwanda

Mental health in conflict communities

• No single definition – Depends on context (e.g. ethnic groups, child soldiers) • Can be approximated via social capital (K) variables: – “Bonding” social K: supportive relationships and mutual cooperation within communities – “Bridging” social K: degree of trust between socially heterogeneous groups •

Particularly relevant in conflict contexts

Some examples of this:

• How conflicts are handled within a community • Degree of female participation in decision-making • Trust in leadership • Expectations of the future • How much anger, how much solidarity exists More examples: The World Bank/Social Development/Social Capital website

Practical tips

1. Create a baseline for assessment 2. Define valid operational concepts 3. Levels of analysis matter 4. Assessing controversial topics 5. Sensitive questions & illiteracy

Tip #1: Assessment baseline

• Ideally: conduct assessments pre- and post-intervention – Often logistically difficult or impossible • Is there a valid control group?

• Individuals’ memory is malleable – Useful: triangulate baseline through assessing related constructs

Tip #2: Valid constructs

• Theoretical constructs need to be ‘pulled down’ to operational levels – E.g. “reconciliation”: • What are valid proxy concepts? • How does the term’s meaning change – Across contexts? – Across groups? – Across time?

Tip #3: Levels of analysis matter

• Different levels of people relationships – Individual relationships (one on one) – Individual vis-à-vis own group – Individual vis-à-vis other group(s) – Relationships between groups • Useful assessment techniques: – Observations, group evaluations – Asking 3rd person questions helps • “What do

people

think of…?” • “How would

the majority of community members

rate…?”

Tip #4: Assessing controversial topics

• Ethnic identity in Rwanda – Unacceptable to discuss group identity directly • But

essential

for impact assessment – Impossible to use traditional in/outgroup ratings – Solution: • Assess group membership indirectly • Use of socially acceptable ‘trigger’ synonyms – “Survivor” or “With family members in prison”

Tip # 5: Sensitive questions and illiteracy

• If feasible: Obtain assistance from literate helper within community • Use symbols & secret ballot for – sensitive questions (e.g. ethnic identity in Rwanda) – Manipulation checks (to validate honest responses) Important: requires extensive interviewer training

Pictorial representation

With group members in prison “Survivor” Different group “Returnee” Pressure from others Not comfortable to speak truth

Critical Success Factors

• Focus on process: – Pilot-test concepts in local context – Allocate ample time for back-translations – Prepare to replace invalid assessments • Create Plan B, C, etc. to assess complex constructs – Involve local knowledge holders & make space for regular reviews • Including local survey takers

Take-home points

Possible and feasible if well-planned: Mental health assessments in conflict zones • Linked to relations between groups • Assessing community mental health – Ideally: conduct observations, group assessments – Helpful: asking individuals indirect (3rd person) questions Promoting commercial contact between groups in post conflict societies may foster enhanced community relations, economic and social capital development.

Thank you!

Also to George Mason University’s Mercatus Center and to Ann Lion Coleman from Abt Associates

More information

• www.mercatus.org/enterpriseafrica • My email: [email protected]