IV World Congress on Traumatic Stress

Qualitative research on the psychosocial impact of war on children in Burundi and

Indonesia

Wietse A. Tol - HealthNet TPO/ Vrije University Amsterdam

Ria Reis - University of Amsterdam

Dessy Susanty - CWS Indonesia

Adolphe Sururu - HealthNet TPO Burundi

Aline Ndayisaba - HealthNet TPO Burundi

Joop T.V.M. de Jong - HealthNet TPO/ Vrije University Amsterdam

“It never rains… it pours”

Presentation contents• Introduction• Research Objectives• Methodology

– Setting & Procedures• Results

– Summary of informants– Most relevant problems – Damage to the social fabric– Morality problems

• Discussion/ Suggestions for psychosocial interventions

Introduction: HealthNet TPO• HealthNet TPO: a merger of HealthNet

International (medical care in post-conflict settings) and the Transcultural Psychosocial Organization (psychosocial care in post-conflict settings)

• HealthNet TPO is an international organization that works to develop research-informed (mental) health and psychosocial care systems in (post-) conflict and (post-) disaster areas, with the aim of increasing structural public (mental) health care

Introduction: Child Thematic Project

• Psychosocial project for children affected by armed conflict in Burundi, Indonesia, Nepal, Sri Lanka, and Sudan– Public mental health approach; different types of interventions

for differently affected children

– Components: school-based group intervention, youth groups, awareness raising, psychosocial counseling

– Integrated research component to come to evidence-based practices

• Randomized Controlled Trial (RCT) on school-based group intervention

• N = 1 study on psychosocial counseling

Research Objectives

• Preparation for RCT on school-based group intervention [ISRCTN25172408, ISRCTN66249480,

ISRCTN42284825] – “Cultural fit” of school-based intervention– Choice & adaptation of outcome instrumentation/

translation

• Research questions– How do community members perceive the

(psychosocial) impact of conflict?– What resources are available in the community to deal

with this impact?

Methodology: setting• Burundi:

– Repeated cycles of killings and violence along ethnic lines since independence, between Hutu’s and Tutsi’s (250,000 to 300,000 killed, 880,000 displaced [Amnesty

International, 2004])– Data collection in rural areas in two Northwestern

provinces, heavily affected by violence

• Central Sulawesi, Indonesia:– Periodic religious communal violence, since 1998 in Poso

region. In 2002: 1,000 killed and 100,000 displaced [Human Rights Watch, 2002]

– Data collected in mixed Muslim/ Christian areas in rural areas around Poso

Methodology: procedures• Key Informant Interviews with child experts in

the community

• Focus Group Discussions with children, teachers, parents

• Semi-structured Interviews with children and parents/ caretakers of affected children

• Informants identified through community meetings and subsequent snowball sampling

Methodology: procedures [cont.]

• 4 local assessors with at least BA in social science• One-month training program, with a focus on

interviewing skills and field-practice• Interviews were tape-recorded, transcribed and

translated to English• Content analysis with grounded theory approach

(Strauss & Corbin, 1996)• ATLAS.ti 5 qualitative data analysis software used

Results: Summary of informantsBurundi Indonesia

FGDChildren: 4

Parents: 6

Teachers: 4

FGDChildren: 9

Parents: 11

Teachers: 8

Illness NarrativesN=40: family members, guardians and orphanages

Illness NarrativesN=43: mainly mothers, and other family members

Key InformantsN=32: trad. healers (animist & Christian exorcists), teachers, medical officers, priests/ nuns, NGO-personnel

Key InformantsN=44: trad healers (massage, herbalism), midwives, teachers, medical officers, Koran/ Sunday school teachers, priests

Results: Most important categories

Burundi Indonesia

• Poverty

• Damaged social fabric, especially at family & community level

• Family looses protective function (poverty , deaths)

• Complaints of loss in moral structure

• Emotional problems, esp. sadness/ increased sensitivity

• Poverty

• Damaged social fabric, especially at peer & community level• Family looses protective function (plantations destroyed)

• Complaints of loss in moral structure

• Emotional problems, esp. fear/ rebellion

Results: Damaged social fabric Burundi Indonesia

Family

• Loss of parents

• Abuse by guardian families (no food, affection, verbal/ physical abuse, hard work)

• Increased conflicts within family (e.g. inheritance, increased aggression)

• Loss of access to traditional land

• Re-marriage/ polygamy and unequal treatment between children

Family

• Parents working hard to re-build cacao gardens, no attention for children

• Increased conflicts due to increased rebellion of children

Results: Damaged social fabric Burundi Indonesia

Friends/ peer level

• Distrust/ hate between ethnic groups

Friends/ peer level

• Tensions between religious groups:

* separation in schools

* sensitivity in teasing

* increased fighting

* increased consciousness of which group one belongs to

* fear

Results: Damaged social fabric Burundi Indonesia

Community

• Loss of social solidarity

• Increased witchcraft/ poisoning accusations

• Continued displacement

• Feelings of revenge

• Ethnic distrust/ hate

Community

• Increased solidarity within religious groups

• Bad (modernizing) influence of military, TV programs

• Distrust/ lack of interaction between religious groups

• Feelings of revenge

• Fear of rumors

• Poverty causing inequality between groups

Results: complaints of damaged morality

Burundi Indonesia- Prostitution, promiscuity, sexual violence

- Drugs, alcohol

- Opposition to authority/ lack of respect

- Fearless children

- General “hardening”, e.g. in fighting

- Groups of orphans living on the street showing criminal behavior

• Early sexual behaviors

• Use of rude words

• Drugs, alcohol, smoking

• Opposition to parents, authority/ lack of respect

• Difficult to discipline

• General “hardening”, e.g. in fighting

• Bad influence of TV, movies

• School drop-outs stealing

Discussion: the psychosocial

• Importance of looking at more than individual emotional complaints (cf. use of symptom checklists)

• Importance of damage to morality

• Differences in damaged social fabric in different armed conflicts, settings, need for different types of interventions

Suggestions for intervention• A Systems-approach rather then isolated

psychosocial interventions:– Difficult to separate the effects of poverty and war– Illness experiences often include spiritual (Burundi:

bewitchment, Indonesia: fate as decided by God), physical, social and psychological explanations

• For example:– Community-based development approaches; income

generation/ occupational training projects that build social connections between orphans and their communities in Burundi

– Working on access to school of children, involving all religious groups

Suggestions for intervention• Working with the damaged social fabric• Burundi:

– Joining community efforts aimed at decreasing ethnic tensions; e.g. scouting, school-based efforts by teachers

• Indonesia:– Reconciliation efforts at peer and community levels

between ethnically different groups– Utilizing available initiatives; inter-religious meetings,

school-based efforts, community sports games