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Conflict-Affected Women’s Perceptions of
Psychosocial Well-being in the Acholi Sub-Region of
Northern Uganda
Principal Investigators Martha Bragin, PhD Taaka Jennipher, MA. April, 2013
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 1
Imprint:
To cite this study: Bragin, M., Taaka, J. & Eibs, T. (2013). Conflict-Affected Women’s Perceptions of Psychosocial Well-being in the Acholi Sub-Region of Northern Uganda. Vienna and Kampala: CARE Österreich For further information refer to [email protected]
Online download under: http://care.at/expert/coe-resources/psychosocial and http://careuganda.org/
April 2013
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 2
Preface
The suffering of the conflict-affected women in the Acholi Sub-Region of Northern Uganda is well known and well documented. Ugandan researchers have taken leadership in understanding their needs and struggles in cultural context. This suffering has made it difficult for them to claim their rights, exercise their agency. Therefore CARE Österreich integrates psychosocial support in its holistic model for women’s empowerment. But what is psychosocial well-being? How do conflict affected women define it in their own language and in their own terms? What does it mean in local cultural context? No one has asked this critical question of the conflict affected women in the Acholi –Sub- Region of Northern Uganda. It is of vital importance that research conducted with poor, marginalized and conflict affected women not continues to marginalize them by only asking them what is wrong. It is critical to study these women’s vision for a fulfilling life going forward and precisely how they wish to make their dream a reality. Measuring program success against women’s own vision in cultural context sets a new standard for the study of well-being overall. In this spirit CARE Österreich included in its three country program “Claiming Rights – Promoting Peace: Women’s empowerment in conflict affected areas” (Nepal, Burundi, Uganda), financed the Austrian Development Cooperation and CARE Österreich private donors, the partnership with the Silberman School of Social Work at Hunter College to support CARE to find out in a participatory research what psychosocial wellbeing means in the local contexts of the program and to develop culture-sensitive indicators which would support CARE, its implementers and participants to monitor the changes in the psychosocial wellbeing of women in the intervention area. We hope this study will contribute to the refinement of CARE Österreich’s holistic model for women’s empowerment and convince other development actors to integrate a psychosocial dimension in their development actions.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 3
Acknowledgements:
The Principal Investigators (PI) wish to acknowledge the 652 study participants who knew that they would not benefit from the study in any direct way, and yet they took the time to teach us about their experience. Our heartfelt gratitude goes to CARE International in Uganda, and to the Deputy Program Manager, Rose Amulen who made this study possible. The PI’s also express tremendous gratitude to the Gulu Field Office of CARE International in Uganda, under the direction of Mr Godfrey Orach Otobi, Programme Manager, NUWEP, without whose support and generosity the work would not have been possible. We especially thank Sandra Achom for project oversight, under extremely challenging circumstance and Justin Komakech, driver, who worked with us as a full team member, sacrificing his time to travel with the project, providing logistics, and translation as well as transport. In addition, gratitude is owed to the entire office staff for their collaborative spirit, especially, Mike, Logistics Manager, and Janani Luwum, M and E Officer. The PIs express their gratitude to the partner organizations and community-based facilitators for their efforts to insure that the study continued. We are grateful to the Uganda National Council on Research and Technology for guidance in allowing this research to go forward.
Study Support Team Tonka Eibs International CO PI & Psychosocial Advisor CARE Austria Rose Amulen Deputy Program Director, CARE International in Uganda Orach Godfrey Otobi Programme Manager, Northern Uganda, CARE International in Uganda Sandra Achom Gender Based Violence and Psychosocial Support Advisor, NUWEP Janani Luwum Monitoring and Evaluation Officer, NUWEP Research Team Martha Bragin International PI Silberman School of Social Work, CUNY Taaka, Jennipher PI, Uganda, Psychosocial Consultant CARE International in Uganda Tonka Eibs International CO PI & Psychosocial Advisor CARE Austria Rose Nyakata Komakech Social Protection Specialist, SGBV &PSS CARE International in Uganda Maxwell Oola Okello Translator, Research Assistant Justin Komakech Translator, Logistician and Driver Hannah Gray Research Assistant Data Analysis Team Kelsey Adolphs Research Assistant Veronica Mollere Research Assistant Sarnaz Lofti Research Assistant Adina Tabor Research Assistant Jessica Gershwin Data Analyst
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 4
CONTENTS
Background to The Study .............................................................................................................................. 7
Purpose of the Study ................................................................................................................................. 8
Objectives of the study ......................................................................................................................... 9
Rationale and significance .................................................................................................................... 9
Critical Review of the Literature ................................................................................................................. 11
Psychosocial work with children ............................................................................................................. 12
Evaluating psychosocial programs for children .................................................................................. 13
Evaluating Psychosocial Programs During and After Armed Conflict ..................................................... 14
Psychosocial Well-being and “Subjective Well-being:” Integrating Literature from Economics ............ 18
What about Women and Psychosocial Well-being in Areas of Armed Conflict? ................................... 21
Summarizing the Literature on Evaluating Psychosocial Interventions for Conflict-affected Women .. 22
Women and Girls in Northern Uganda ................................................................................................... 23
The Psychological and Social Situation of Formerly Abducted Girls ....................................................... 25
Solutions proposed in the literature: .................................................................................................. 28
Some studies of psychosocial interventions for adults in the region ................................................. 29
Women, Well-being and Agency in Northern Uganda ........................................................................... 29
Women’s perceptions of well-being in Northern Uganda .................................................................. 31
The Study Design ......................................................................................................................................... 32
Figure 1: The study design ...................................................................................................................... 33
Study hypothesis ................................................................................................................................. 34
Study objectives .................................................................................................................................. 34
The main study questions: .................................................................................................................. 34
Methodology ........................................................................................................................................... 35
Methodological approaches ............................................................................................................... 35
Site Selection ....................................................................................................................................... 37
Recruitment and sampling .................................................................................................................. 38
Figure 2: Total numbers: participants, focus groups and key informants Rounds One and Two ........... 39
Figure 3: Focus Group Sample: Round One ............................................................................................ 40
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 5
Figure 4: Focus Group Sample Round Two ............................................................................................. 40
Procedures and Results ............................................................................................................................... 40
Study Procedures for Round One: .......................................................................................................... 40
Study Procedures for data analysis and interpretation ...................................................................... 41
Results from Round 1 .............................................................................................................................. 42
Questions for Concept Identification .................................................................................................. 42
Language and terminology ................................................................................................................. 42
Domains of Well Being for Conflict-affected Women in the Acholi Sub-Region of Uganda............... 43
Study Procedures: Round 2 ..................................................................................................................... 45
A. Concept validation: Presentation to the Ugandan PI and teams ................................................... 45
B. Concept validation: Focus group discussions for Round 2 ............................................................. 45
C. Participatory Ranking Method (PRM) ............................................................................................. 46
D. Concept validation: Key informant interviews ............................................................................... 47
E. Nightly group meetings ................................................................................................................... 48
F. Final workshop with senior staff CARE Uganda .............................................................................. 48
Results from Round 2 .............................................................................................................................. 49
A. Results from the concept validation exercise: new item added .................................................... 49
Domains of Well Being for Conflict-affected Women in the Acholi Sub-Region of Uganda............... 50
B. Results of the Participatory Ranking Exercise ..................................................................................... 52
Table 1: Consolidated Ranking of Domains for all Districts ................................................................ 52
Table 2: Consolidated Ranking of Domains for Agago ........................................................................ 53
Table 3: Consolidated Ranking of Domains for Lamwo/Kitgum group ............................................... 54
Table 4: Consolidated Ranking of Domains for Gulu groups .............................................................. 55
Table 5: Ranking of Ex-combatant Groups .......................................................................................... 56
C. Results from the key informant interviews .................................................................................... 57
Figure 5: The traditional Acholi homestead in community context ................................................... 57
D. Results of the final workshop ......................................................................................................... 64
Figure 6: A Holistic View of the Relationships among the Domains ................................................... 64
Limitations of the Study .............................................................................................................................. 65
A. Sampling Limitations .......................................................................................................................... 65
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 6
B. Limitations of Language and Translation ............................................................................................ 66
Additional Limitations ......................................................................................................................... 66
DISCUSSION: LOOKING AT WOMEN’S WELL-BEING THROUGH AN ACHOLI LENS ..................................................... 67
A. The Psychosocial Working Group ....................................................................................................... 68
Figure 7: Illustrating the relationship to the Psychosocial Working Group ............................................ 70
B. The Capabilities Framework ............................................................................................................... 71
Figure 8: Illustrating the relationship to the Capabilities Framework .................................................... 73
C. Hobfoll and colleagues’ Five Essential Elements for Effective Psychosocial Interventions ................ 73
Figure 9: Illustrating the inter-relationship of all of the domains to the main categories of well-being 75
Establishing a Baseline for Psychosocial Well-being: Utilizing What We have Learned from this Study ... 76
A. Sample Questions for the Implementation of a Baseline Study on Psychosocial Well-being among
Conflict-affected Women in the Acholi Sub-region of Northern Uganda along Six Domains ................ 76
B. Replication of the Methodology for future use through Participatory Monitoring and Evaluation .. 80
Conclusion ................................................................................................................................................... 80
References .................................................................................................................................................. 81
Annex A: Partners Supporting the Study .................................................................................................... 91
Annex B: Geographic Distribution and Number of Participants Round One Uganda ................................. 92
Annex C: Geographic Distribution and Number of Participants Round Two Uganda ................................ 93
Annex D: Protocol for the Second Round of Well-being Research: Acholi Sub-Region Uganda ................ 94
Annex E: Key Informants ............................................................................................................................. 97
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 7
BACKGROUND TO THE STUDY
The 24-year war, waged by the Lord’s Resistance Army (LRA) in Uganda, is one of Africa’s longest
(Republic of Uganda: Peace Recovery and Development [PRDP], 2007). At the end of 2005, an estimated
1.6 million people, the entire rural population, were forced to leave their homes to live in internally
displaced persons (IDP) camps, for fear of being attacked and/or abducted by rebels (Republic of
Uganda PRDP, 2007; Annan, Blattman, Mazurana, & Carlson, 2011). Annan, Blattman, Mazurana, and
Carlson (2011) found that “twenty-six percent of female youth (aged 14–35) and 47 percent of male
youth were abducted. Abduction length ranged from a few hours to 12 years, averaging 11.4 months for
females and 9.1 months for males” (p.883). While security incidents have steadily decreased since 2006,
the prolonged period of conflict and instability has taken a tremendous toll on the population and the
economy of the region. Economic activity is now resuming and most internally displaced persons are
returning to their villages; the North remains the poorest region in the country - lagging behind on all
socioeconomic indicators (Republic of Uganda PRDP, 2007; Bukuluki & Mugisha, 2010).
Armed conflicts cause significant psychological and social suffering to affected populations, and
can undermine the long-term mental health and psychosocial well-being of the affected population
(Interagency Standing Committee [IASC], 2007). Prolonged conflict and displacement, such as that
experienced in Northern Uganda, can erode normally protective supports and increase the risk of
diverse psychosocial problems (Baingana, Bannon, & Thomas, 2005; Pederson, 2002). When families are
forced into camp life for a generation, away from their normal lives, traditions and livelihoods, the
effects on family life itself can be profound, rendering the reintegration period a challenging one.
Ugandans have engaged in extensive research on the way that violence and displacement have
affected the population, and even begun to look at war-borne sources of resilience; however by force of
circumstance and necessity these studies have almost exclusively focused on children and adolescents
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 8
(Akello, 2006, 2009; Barton & Mutiti, 1998; Betancourt, 2009; Kryger & Lindgren, 2011; Macmullen &
Loughry, 2004; Omona & Matheson, 1998). Special concerns regarding the effects of war and abduction
on girls and young women have been noted, especially the effects of violence and trauma upon mental
and physical health (Amone-P’Olak, 2005; Annan, Blattman, Carlson, & Mazurana, 2008; forthcoming;
Baines, 2008; Mazurana & McKay, 2003, 2004; McKay, 2004). Therefore, CARE International in Uganda,
as part of its strategy to enable conflict-affected women to develop and benefit from plans for peace
and post-war recovery, has included psychosocial supports in its empowerment program for women.
The program, called Northern Uganda Women’s Empowerment Program (NUWEP), provides a
comprehensive, integrated model of services leading to the final goal of well-being and participation.
However, there is as yet no study of the definition of psychosocial well-being as perceived by conflict-
affected women in the region, nor is there a study that indicates whether improved psychosocial well-
being, as part of a comprehensive package of supports, correlates to greater participation in the peace
and recovery processes desired by NUWEP.1 This study begins that process.
Purpose of the Study
The purpose of this study is to develop an understanding of psychosocial well-being among
conflict-affected women in the Acholi Sub-Region of Northern Uganda, as defined by the women
themselves, in their own language and on their own terms, in order to establish indicators by which to
measure the effectiveness of psychosocial programs developed for their benefit.
1Northern Uganda Women’s Empowerment Program is a multi-donor comprehensive program. The original
program, funded by the Austrian Development Association was called “Roco Kwo”, Acholi for “transforming lives”.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 9
Objectives of the study
To understand the precise meaning of “psychosocial well-being” for conflict-affected Acholi
women in the Acholi Sub-region of Uganda.
Based on this understanding, to develop culture-sensitive indicators for use in measuring the
concept of psychosocial well-being for conflict-affected women in the defined areas.
To contribute to the development of a replicable, rapid and practical method to develop
indicators for psychosocial well-being to be utilized in the design of monitoring and evaluation
of future programs for adult women.
The long-term goal of the study is to insure that programmatic supports for psychosocial well-
being are appropriate and effective in context, and enable the testing of the program hypothesis that
psychosocial interventions are an essential element in facilitating women’s participation in the political
and social processes that affect their future.
Rationale and significance
In recent years, new international standards have indicated that the best way to provide
psychosocial support to people affected by armed conflict is through psychosocial programs, that is,
programs that improve psychological well-being through social activities (Wurzer & Bragin, 2009). In
2007, the Interagency Standing Committee (IASC) of the United Nations Office of Humanitarian
Coordination Assistance (UNOCHA) launched official guidelines to be followed in the development of
mental health and psychosocial support in emergency settings including armed conflict. These best-
practice standards are based on the findings available from extensive consultation and field research
(IASC, 2007; van Ommeren & Wessells, 2007). However, the evidentiary base for the effectiveness of
psychosocial programs in general and the best practices recommended by international guidelines
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 10
remains thin (Wessells, 2009). This is because the conditions in the field often make it difficult to carry
on proper empirical studies, as the need to provide care to all must take precedence over learning
(Hobfoll et al., 2007).
The time has come to strengthen the evidence for effective psychosocial interventions in order
to insure that they are replicated, that ineffective practices are discarded, and that program participants
receive the highest possible quality of service (Wessells, 2009; Ager, Stark, Akesson & Boothby, 2011;
Stummer, 2009).
Researchers have recommended that in order to evaluate the effectiveness of psychosocial
programs, we need to evaluate on three domains: 1) skills and knowledge 2) emotional well-being and
3) psychological well-being as perceived by program participants and their communities (Ager, Stark,
Akesson, & Boothby, 2010). UNICEF has completed a full set of guidelines for understanding these
domains when establishing psychosocial programs for children and adolescents (A. Ager, W. Ager,
Stavrou, & Boothby, 2011). However, there is almost no research that defines women’s psychological
and social well-being in their own voice and on their own terms (Stark, Ager, Wessells, & Boothby, 2009;
A. Ager, W. Ager, & Boothby, 2010).
CARE has taken leadership in this area by measuring the effectiveness of its programs for
economic well-being (CARE, 2005) and its programs for women’s empowerment (CARE Norway, 2009).
The next step is to help women to sort and define what psychological and social well-being
means to them, what mechanisms they could use to maintain it, and what is needed, materially
psychologically, and socially to make it possible. The results of this study will be used to foster a
participatory process wherein women will define well-being and help to design, monitor and evaluate
the effectiveness of psychosocial programs created for their benefit, as they do the other components
of the program.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 11
CRITICAL REVIEW OF THE LITERATURE
There is a small but significant literature that defines psychosocial programs. The Cape Town
Principles and Best Practices on the Prevention of Recruitment of Children into Armed Forces and on the
Demobilization and Social Reintegration of Child Soldiers in Africa, provided a widely used definition,
reiterated and emphasized ten years later in the Paris Principle (The Paris Principles, 2007; UNICEF
1997). The prefix “psycho” refers to the psychological dimension of the individual, and has to do with
the inner world of thoughts, feelings desires, beliefs, values, cognition and ways in which people
perceive themselves and others. The suffix “social” refers to the relationships and environment of the
individual. It includes the material world as well as the social and cultural context in which people live,
ranging from the network of their relationships to cultural manifestations, to the community and the
state. It is also used to refer to the socio-economic resources and material conditions of life. The term
‘psychosocial’ is used to explain the way these aspects of the person are inseparable, with each
continuously influencing the other so that it is impossible to tease them apart (The Paris Principles,
2007; UNICEF, 1997).
The Psychosocial Working Group (PWG), a consortium comprising international humanitarian
agencies and university partners who specialized in community-based psychosocial work with children,
defined psychosocial as the interplay between human capacity, social ecology and culture/values (A.
Ager, W. Ager & Boothby, 2010). The Psychosocial Working Group has developed a conceptual
framework that identifies three domains representative of a person’s resilience and ability to adjust
after having experienced a traumatic life event. This framework includes: human capacity (i.e. mental
health and well-being), social ecology (one’s interpersonal relationships and interdependency
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 12
within social structures), culture and values. The availability of physical, material, and cultural
resources further promote one’s sense of adjustment (Psychosocial Working Group, 2003).
Loughry and Eyber (2003) reviewed the extant literature on psychosocial work with children in
humanitarian settings (Loughry & Eyber, 2003). They define psychosocial interventions as those that
enhance and influence human development by addressing the negative impact of social factors on
people’s thoughts and behaviors (Loughry & Eyber, 2003). According to the consensus, found in the
authors’ review, they do this by instituting social programs that support the positive interaction of
behaviors within the social context (Loughry & Eyber, 2003).Thus, psychosocial supports are social
interventions intended to affect the psychological well-being as well as the social situation of the
participants (Loughry & Eyber, 2003; Wurzer & Bragin, 2009).
Psychosocial work with children
All of these definitions had their origins in psychosocial work with children, since it was the
recognition of the psychological and social consequences of armed conflict on children’s dynamic
development that first caused humanitarian actors to recognize the importance of intervening in both
psychological and social realms (Bragin, 2005; Loughry & Eyber, 2003).
Studies regarding psychosocial work with children have identified lessons learned working with
children affected by war (Boothby, Crawford, & Halperin, 2006; Stark, Ager, Wessells & Boothby, 2009).
The studies indicate that many former child soldiers were able to reintegrate into society because of the
support and acceptance of the community. Similar outcomes were also indicated in various research
studies with former child soldiers and children affected by armed conflict throughout the world (Stark et
al., 2009; Karki, Kohrt & Jordans, 2009; Amone-P’Olak, 2005; MacMullin & Loughry, 2004). However,
none of these studies directly defined or addressed what well-being meant to the children or how they
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 13
found it within their families, community or society, until the 2011 study on the impact of the school-
based Psychosocial Structured Activities (PSSA) program on conflict-affected children in Northern
Uganda (Ager, Akesson et al., 2011). This program with conflict-affected children involves a community
service component, and encourages teacher and parental involvement through intermittent meetings to
discuss the children’s well-being. According to Ager and Akesson, et al. (2011), this method was tested
in various regions of the world and found to fit well with the post-conflict area of Northern Uganda in
the Gulu and Amuru Districts (Ager, Akesson et al., 2011, p. 3).
The above cited study explores the correlation between youth affected by the violence
committed and experienced as well as other emotional stressors brought on by the conflict in Northern
Uganda. It reflects on and begins the process of defining psychosocial well-being of youth as indicated
by teachers, parents and the youth themselves (Ager, Akesson et al., 2011). This is an important
predecessor to the present study.
Evaluating psychosocial programs for children
Researchers in humanitarian work have conducted a number of studies examining extant
programs that address the needs of children in crisis-affected areas (Ager, Stark, Akesson, & Boothby,
2010). The studies found that the empirical evidence thus far appears thin as to which interventions
work best, and which do not work at all. Participants in these studies identified that interested agencies
need to establish a “culture of learning,” which allows for consistent and culturally competent research
and evaluation. In addition, the studies conclude that further research is essential to understanding
how to insure that psychosocial interventions, in conflict settings, are integrated into overall
programming and evaluated for effectiveness (Jordans, Tol, Komproe, & de Jong, 2009; Ager, Stark, et
al., 2010).
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 14
UNICEF developed a country implementation guide to monitoring and evaluation psychosocial
programs. The guide stresses the need to define, operationalize and measure emotional and social well-
being before beginning any psychosocial intervention with children (A. Ager, W. Ager, & Boothby, 2010).
While there is a difference between women’s and children’s needs and rights in understanding well-
being, UNFPA and UNICEF (2011) have begun to address this issue together.
A positive approach to defining well-being in cultural context is through various forms of case
studies, including qualitative and quantitative data collection. The methodology of the school-based
Psychosocial Structured Activities (PSSA) program was developed as a collaborative effort between Save
the Children Uganda and Ugandan authorities. This study successfully engaged conflict –affected
students in evaluating the effects of a structured curriculum on their own perceived psychosocial well-
being (Ager, Akesson, et al., 2011).
Evaluating Psychosocial Programs During and After Armed Conflict
However, the work with children is not the only psychosocial work that suffers from a limited
evidence base for effectiveness. The very nature of the emergencies that create the need to develop
psychosocial programs, has made it difficult to develop clinical trials that would yield satisfactory
information regarding whether, how and to what degree they are effective (Hobfoll et al., 2007; Bragin,
2010). Among the difficulties in doing this is to insure that measurement is relevant to the program
participants. Bracken (1998), points out that measurement of effectiveness must take into account the
constructs that are meaningful to the society in which they are being measured in order to evaluate
effectiveness (Bracken, 1998). He warns against mistaking the reliability of measures for validity.
Culture, environment, gender, age, and socio-economic factors all impact how individuals and societies
understand well-being, and cannot be understood through lenses that do not take local culture and
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 15
values into account (Bracken, 1998; Honwana, 1999; Summerfield, 1999, 2001; Wessells, 1998). Current
inter-agency guidelines on mental health and psychosocial support in humanitarian emergencies
specifically preclude the use of measures validated in western terms to be utilized in other contexts,
much as non-western measures would not be used to evaluate the psychological and social state of
those in the west (IASC, 2007).
One attempt to develop some sort of cross-cultural model was that of Hobfoll and his colleagues
(2007). They include war as one of many situations they discuss in their study of interventions to effect
well-being in the face of “mass trauma.” The study’s authors explain that in emergency situations
controlled trials are not possible, so they utilize a panel of international experts (from Europe, the
United States and Israel) to develop a consensus on essential elements of programming. While they do
not specifically mention “psychosocial” programs by name, nor do they speak specifically about well-
being, this first attempt at an empirical standard for intervention with an adult population is an
important one. The study isolates five essential elements required for successful psychosocial
intervention following what the authors call “mass trauma.” The five elements are 1) a sense of safety,
2) calming, 3) a sense of self– and community efficacy, 4) connectedness, and 5) hope (Hobfoll et al.,
2007, p. 284).
Organizations engaged in psychosocial work have noted the importance of developing tools to
study its effectiveness in numerous reports (Duncan & Arntson, 2004; Ager, 2008; Williams, Mikus Kos,
Ajdukovic, van der Veer & Feldman, 2008; Ajdukovic, 2008; A. Ager, W. Ager & Boothby, 2010).
Inconsistencies in programming and differing viewpoints on how to realize such evaluations of
psychosocial programs led to the North Atlantic Treaty Organization (NATO) sponsoring a workshop on
the subject; evaluating community-based psychosocial programs in areas affected by war and terrorism
(Williams et al., 2008). Workshop participants developed specific recommendations for evaluation, and
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 16
note they are also necessary in the design and implementation of psychosocial interventions. Most
important, they noted that such definitions must be meaningful to the people who are involved, and
that such definitions and the ways in which they are operationalized must be consistent with the
understanding of program participants - if such programs are to be evaluated for meaningful definitions
of success (Bragin, 2005; Ager, Boothby, Wessells, 2007; van der Veer, 2008; Williams et al., 2008;
Jordans, Tol, Komproe & de Jong, 2009; Ager, Stark, Akesson, & Boothby, 2010).
Participatory methods in measuring children’s well-being during and after armed conflict
To support such a role for program participants the conference recommended using consensus
methodologies to understand concepts relevant to psychosocial interventions. They cited many other
authors who advocated this method as a way to begin to understand psychosocial well-being in cultural
context (Bragin, 2005; Ager, Boothby, Wessells, 2007; van der Veer, 2008; Williams et al., 2008; Ager,
Stark, et al., 2010; Jordans et al., 2009).
One attempt to do that with programs for children and youth was the Community Participatory
Evaluation Tool (CPET) (Bragin, 2005), which engages community members including elders, parents,
children and youth to define children’s successful development, detail the effects of war on both
development and coping, and provide a template for design, monitoring and evaluating psychosocial
programs against it. The underlying concept of well-being in this model was successful achievement of
developmental milestones appropriate to being a respected member of the community.
Another example of consensus methodology is the Participatory Ranking Method (PRM) used in
Sierra Leone to assist girls associated with armed groups define and explain how they could successfully
reintegrate into society (Stark, Ager, Wessells & Boothby, 2009). The approach places the girls as
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 17
experts in their own lives and allows for participants to address issues in a culturally relevant and
meaningful way. The issue of well-being is defined through the aggregation of the girls’ priorities.
In the 2011 Northern Uganda PSSA study, the intervention program included all children who
were raised in the stress-ridden conflict-zone, not solely children who had formerly been abducted. This
allowed for a more comprehensive perspective on well-being. In addition, the classroom component of
the program was implemented by the children’s regular school teachers, so as not to affect the outcome
of the research by introducing new educators with this change in curriculum. Throughout this study,
depicted by Ager and Akesson et al. (2011), activities focused on issues of “safety and control, self-
esteem, thoughts and reactions during danger, resource identification, and coping skills” (p. 3) through
instructive presentations, reflective exercises, drama and games. Parental engagement was made
possible through meetings with the teachers and the Save the Children organization. This approach gave
the parents insight into their children’s personal experiences with the new program activities. A
combination of teacher, parental and self-evaluations allowed the youth to have a say in their own
experience, interest, perception of change, and idea of well-being (Ager, Akesson et al., 2011).
The Inter-Agency Guide to the Evaluation of Psychosocial Programming in Humanitarian Settings
(A. Ager, W. Ager, et al., 2011) significantly advances this process by standardizing the domains by which
the impact of the programs, that is their actual success in creating change, could be measured. The
domains are skills and knowledge, emotional well-being, and social well-being. They have de-coupled
the elements of psychosocial well-being, after the efforts a decade earlier to link them. The document,
sponsored by UNICEF, focuses almost exclusively on evaluating programs for children, leaving space to
follow up with similar efforts focused on programs for adults.
In summary, literature related to increasing the effectiveness of psychosocial programs through
empirical evaluation consistently calls for studies to define and operationalize psychosocial well-being as
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 18
the critical next step (Bragin, 2005; Ager, Boothby & Wessells, 2007; van der Veer, 2008; Williams et al.,
2008; Ager, Stark, et al., 2010; Jordans et al., 2009). Some significant strides have been made in regard
to children and adolescents. In the area of women’s well-being it appears that such definitions and
measures are yet to appear in the literature on humanitarian intervention, leaving these as needed next
steps moving forward.
Psychosocial Well-being and “Subjective Well-being:” Integrating Literature from Economics
Well-being has been studied extensively in economics, although citations of these studies are
often absent from the psychosocial literature. Sen (1980) defines well-being and agency within the
context of one’s perceived sense of freedom. An individual’s autonomy and personal liberty are
inextricably linked to his or her agency. Agency is then correlated to the inherent ability to consciously
choose happiness and fulfillment through actions and interactions. Sen postulates that the main feature
of a person’s well-being is the individual’s functioning vector, which exemplifies the urgent pursuit of a
specific outcome, such as escaping morbidity or undernourishment (Sen, 1985). With regards to the
empowerment of women as promoting economic growth and viability within families and communities,
Sen articulates the importance of women’s agency, in correlation with educational attainment, as
securing positive economic and social outcomes for both her and her children (Sen, 1999). This
aforementioned development then positively impacts the progression of the community in which
women live (Sen, 1999). On the other hand, Sen is careful to differentiate women’s agency and
empowerment from subjective well-being as two distinct concepts (Sen, 1985, p. 169).
CARE international has used this concept to develop indicators of economic well-being through
strategic impact indicator studies (SIIS) in Nepal, Uganda and Burundi. This was followed by the
development of guidelines from the implementation of baseline studies for women’s empowerment
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 19
(CARE Norway, 2009). These guidelines address the issue of women’s empowerment and suggest the
means of studying agency in a meaningful way, while at the same time remaining as two distinct sets of
indicators.
An outgrowth of Sen’s work has been the division of the study of well-being into two categories,
“objective,” involving measurable economic and social assets, and “subjective,” involving thoughts,
feelings, attitudes, and social relationships (Conceicao & Bandura, 2008). This may well correlate to
psychosocial well-being and is therefore the subject of our more extended study here.
Most of the economic literature on subjective well-being uses the proxy “happiness” (Conceicao
& Bandura, 2008; McGillivray, 2007). This substitution, while popular among economists, has been
widely criticized as limiting and not an appropriate proxy (Ryff, 1989; Nagpal & Sell, 1985, 1992;
Kashdan, 2004; Conciecao & Bandura, 2008; McGillivray, 2010). Happiness, they argue, has been
defined as how one feels at a specific time, and can quickly change, while well-being is more about how
one defines their overall life, over the long term (Ryff, 1989; Nagpal & Sell, 1985, 1992; Kashdan, 2004;
Conciecao & Bandura, 2008; McGillivray, 2010). It has been suggested that happiness may be an innate
capacity, related more to biology and temperament than to experience and far removed from the Sen’s
ideas regarding agency and freedom of action (Conceicao & Bandura, 2008; McGillivray, 2010).
The capabilities approach to the study of subjective well-being.
Sen’s critique of the proxy “happiness” led to a positive definition of subjective well-being as
“living a good life” (Anand et al., 2005, p.10). He argues that these can be studied in terms of
“capabilities,” that is “what people are able to do or able to be” (Anand et al., 2005, p.11,). These are to
be differentiated from activities of daily living and represent potential and aspirational states as well as
actual experience. Sen’s approach is context dependent requiring that people define for themselves the
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 20
conditions for a good life (Robeyns, 2003). Feminist authors have debated whether there is actually a
need to create a fixed number of capabilities, representing a universal standard, or whether in fact
participatory methods are the more important factor (Nussbaum, 2003; White & Petit, 2007; Klasen,
2007).
Measures of subjective well-being
Two tools have been located that specifically attempt to measure subjective well-being as a
complex psychological phenomenon: the Ryff scale, created by the American psychologist Carol D. Ryff
(1989), and the Subjective Well-being Inventory, developed for the World Health Organization’s regional
office in India by Nagpal and Sell (1992).
Ryff (1989) draws from a combination of psychological constructs that include Maslow’s
hierarchy of needs, and Erikson’s psychosocial stage model to define, measure and understand well-
being (Ryff, 1989). Her measurement tool includes: the several components of self-acceptance, positive
relations with others, autonomy, environmental mastery, purpose in life and personal growth as
necessary to understanding well-being (Ryff, 1989). This tool was validated for use in the United States
and lacks validation for other contexts. However, preliminary discussions with key informants in Burundi
produced independent mention of Maslow’s hierarchy of needs, and the importance of psychosocial
development as important issues to study. Therefore, it will be important to keep these factors in mind
when coding the results of the current study.
The Assessment of Subjective Well-being Scale (SUBI) by Nagpal and Sell (1992) was developed
among educated populations in India and has been validated for use with non-western populations of
men and women. The authors consider the methodology that they used, rather than the inventory itself,
to be a significant breakthrough in measuring subjective well-being as it is participatory, and was
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 21
developed with the professional community as well as the community at large. Borrowing from
anthropology, they coined the phrase “stepwise ethnographic exploration” (1992) to establish the
domains of inquiry to be included in the inventory. Stepwise ethnographic exploration is an iterative
consensus methodology that brings together a wide range of key informants and ordinary people to
develop consensus regarding a list of concepts that should be utilized. The consensus led to eight areas
of concern that were elaborated into specific inventory items. These eight areas were: mental mastery
over self and environment; rootedness and belongingness; structural and cohesive aspects of family life;
density of social network; security in adversity (relating to health and economics); and harmony
between expectations and achievement. As the interviews became increasingly structured, inventory
questions were elaborated and posed to a sample population for validation.
This methodology parallels the one used in consensus methodologies developed for children
and adolescents in armed conflict, and may have significance for defining women’s well-being in areas of
armed conflict. It also runs parallel to Sen’s suggestion that subjective well-being is always context
dependent (Robeyns, 2003).
What about Women and Psychosocial Well-being in Areas of Armed Conflict?
Extensive searches on EBSCO, JSTOR, Project Muse, and relevant journals, on variations of the
key words “women” and “well-being” in areas affected by conflict yielded surprisingly few results. Some
literature exists on psychosocial well-being of women and war; however, most consist of reports or
manuals for care. Becker and Weyermann’s manual (2006) is among those that illustrate the
psychosocial effects of war on women in some detail. The 2010 UNFPA report on conflict and change
affirms the importance of UN Resolution 1325, stating that women are not only adversely affected by
conflict, but that they are also crucial to the peace-building process and the rebuilding of communities
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 22
and nations. While it also documents the progress made on UN Resolution 1325, it does not address
concepts of women and psychosocial well-being. Wurzer and Bragin (2009) discuss the importance of
integrating psychosocial interventions into women’s empowerment programs, and explore a resilience-
based approach to programming. However, a systematic study of the concept of psychosocial well-
being, as defined by women in conflict-affected areas, has not yet been accomplished.
Summarizing the Literature on Evaluating Psychosocial Interventions for Conflict-affected Women
The literature indicates that while psychosocial interventions in areas of armed conflict has been
seen as a “best practice” intervention, evidence of the precise effectiveness of such interventions
remains thin (Ager, Boothby & Wessells, 2007; van der Veer, 2008; Williams et al., 2008; Jordans et al.,
2009). In order to develop that body of evidence, researchers have recommended that it will be
necessary to define and operationalize standards of psychological and social well-being for affected
people in cultural and social context (Bragin, 2005; Ager, Boothby & Wessells, 2007; Hobfoll et al., 2007;
van der Veer, 2008; Williams et al., 2008; Ager, Stark, et al., 2010; Jordans et al., 2009).
To address this issue, a number of studies have been conducted leading to the elaboration of
methods to evaluate the effectiveness of psychosocial programs for children and adolescents in
emergency situations (Ager, et al, 2011; A. Ager, W. Ager & Boothby, 2010; A. Ager, W. Ager, Stavrou &
Boothby, 2011; Stark, Ager, Wessells & Boothby, 2009).
There have also been a beginning group of studies of adult women’s well-being in areas of
armed conflict that have focused on establishing the negative effects of the conflict on women’s overall
well-being as predecessors to further developing methods to evaluated psychosocial program
effectiveness (Horn, 2009; TPO Nepal, 2007; UNFPA, 2010; Becker & Weyermann , 2006).
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 23
In addition, studies of well-being in adults that allow for positive psychosocial outcomes to be
explored also exist in a variety of different literatures including the resilience literature and that of
economics (Conciecao & Bandura, 2008; Sen, 1999, Hobfoll et al., 2007, Reich, Zautra, & Hall, 2010;
Ungar, 2010). These approaches have yielded conceptual support but have fallen short in the area of
methodology.
However, a particularly promising approach, grounded in the economic literature is the
Subjective Well-being Index which uses a “stepwise ethnographic exploration” as a method of choice for
understanding the well-being of adult women (Nagpal & Sell, 1992).
Next steps are to explore the literature on psychosocial well-being among women in the specific
areas of armed conflict where CARE’s psychosocial programs for women’s empowerment and
participation take place: Nepal, Burundi and Uganda in order to learn about specific advances there in
the study of women’s well-being. The purpose will be to help to refine what is known about the
subjective well-being among women in the conflict zones of these three countries.
Women and Girls in Northern Uganda
Twenty-two years of war in Northern Uganda resulted in massive destruction of the rural
economy and social services as fear of child abduction and violent conflict resulted in the entire
population living in overcrowded camps for displaced persons. During this period the war-borne
violence and displacement led to intense psychological, social and economic suffering of the population
(Akello, 2006; Annan et al., 2010; Barton & Mutiti, 1998; IASC, 2007; Bukuluki & Mugisha, 2010; Kryger
& Lindgren, 2011; Machel, 2000; Omona & Matheson, 1998; Vinck et al., 2007). The deleterious effects
of war and forced conscription impacted all members of the population, and destroyed many aspects of
communal infrastructure that require concerted time and effort to rebuild (Annan et al., 2010; Baingana
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 24
et al., 2005; Barton & Mutiti, 1998; Betancourt et al., 2008; de Jong & Kleber, 2007; Jenkins et al., 2004;
Jenkins et al., 2010; Pedersen, 2002; Porter, 2007; Summerfield, 1991; Williamson, 2006). Even though
only part of the population experienced abduction, an entire generation experienced displacement and
separation from land and livelihood. Uganda, from the beginning of the conflict, has engaged national
and international specialists to develop psychosocial programs that support the capacity of the
population to survive emotionally and socially (Annan et al., 2010; Barton & Mutiti, 1998; Bukuluki &
Mugisha, 2010; Wurzer & Bragin, 2009).
The bulk of the literature on the psychosocial situation of Northern Ugandans has focused on
those who had been abducted into the fighting. It has been estimated that 24,000-38,000 children and
28,000 adults were abducted and held captive by the Lord’s Resistance Army (LRA). Approximately 24%
of those held captive were girls and women (Baines, 2008; Pham et al., 2007). The conflict has had
particularly dire ramifications on the reintegration and acceptability of abducted girls and women back
into their communities (Amnesty International, 2007; Annan et al., 2008; Annan & Aryemo, 2009;
Mazurana et al., 2002; Mazurana et al., 2003; McKay & Mazurana, 2004; McKay, 2004; UNICEF, 2005).
Girls and women who have committed atrocities, were sexually abused, forcibly “married,” and borne
children while captive and face a multitude of physical and psychological hardships (Annan et al., 2008;
Baines, 2011; Fox, 2004; McKay & Mazurana, 2004; Wood, 2009) .
There remains a paucity of literature regarding population-based perceptions of wellness and
psychosocial well-being among Ugandan girls and women in the post-conflict period. A thorough search
of EBSCO, Google Scholar, Sage Journals, and JSTOR yielded a number of scholarly articles that
addressed the unique experiences of girls and women during captivity and the reintegration process,
focusing largely on responses to trauma in contrast to well-being. Research conducted by Akello (2006),
McKay & Mazurana (2004), McKay (2004), Annan et al. (2008), and Baines (2008) in particular provide
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 25
the most comprehensive understanding of the myriad of difficulties experienced by Northern Ugandan
girls and women. It is noteworthy that the experiences of female youth and adult women are presented
interchangeably in the literature, thereby demonstrating that the experiences of girls and women are
distinct from their male counterparts with regards to gender, familial, and social roles. The considerable
differences between the sexes also apply to the reintegration processes of girls and women, made ever
the more complex because of their roles as wives, mothers and perpetrators of violence while
combatants in the bush (Amnesty International, 2007; Annan et al., 2008; Annan et al., 2009; Baines,
2008; Brett, 2002; Fox, 2004; Mazurana et al., 2002; McKay & Mazurana, 2004).
The Psychological and Social Situation of Formerly Abducted Girls
Both girls and boys held captive by the LRA experienced extreme hardship that included their
forced participation in atrocities as combatants (Akello, 2006; Betancourt, 2008; Blattman & Annan,
2007; Bolton et al., 2007; Kryger, 2011; Kryger & Lindgren, 2011; Machel, 2000; Omona & Matheson,
1998; McCarthy & Marks, 2010; Mendelsohn, 1998; Pedersen, 2002; Pham et al., 2007; Stichick, 2001;
Wessells, 2004). They equally lacked shelter, food, accessibility to medical care and education (Akello,
2006; Annan et al., 2010; Barton & Mutiti, 1998; Blattman & Annan, 2007; Machel, 2000; MacMullin &
Loughry, 2004). However, girls’ experiences were particularly calamitous due to gender-based violence
(Amnesty International, 2007; Annan et al., 2008; Fox, 2004; McKay & Mazurana, 2004; Orach, 2009).
Girls were often subjected to sexual abuse by multiple perpetrators (Mazurana & McKay, 2003; Wood,
2009). They were also forcibly “married” to captors who had many wives and pregnancy could
exacerbate violence. Girl mothers would often carry their babies on their backs during warfare. A
common practice was to drug the babies, in order to sedate them during the fighting. While many girls
died during pregnancy and childbirth due to lack of medical care and difficult circumstances under which
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 26
they were living, others self-induced abortions to spare their children the suffering into which they
would be born. (Annan et al., 2008, in press; Baines, 2008; Pham et al., 2007; McKay, 2004; McKay &
Mazurana, 2004).
Girls, who eventually escaped or were rescued from their captivity in the bush, often did not go
through the official UN protocol of disarmament, demobilization, and reintegration (DDR) (McKay, 2004;
Mazurana et al., 2002; McKay & Mazurana, 2004). This process entails demobilizing soldiers, removing
their guns, and providing psychological and material assistance to ex-combatants to help them return to
their civilian way of life (Baines, 2008; Betancourt, 2009; McKay, 2004). Although girls and boys were
equally entitled to DDR by law, many girls were not afforded the benefits of this formal process. Instead,
they simply returned to impoverished communities without any intervening support. With few
resources or support available to them, these girls often relocate to locations where family members
and friends live, or they move to urban areas where they are at a much higher risk of being forced into
prostitution, experience sexual assault, and contract sexually transmitted diseases, such as HIV
(Amnesty International, 2007; Baines, 2008; McKay, 2005).
Additional difficulties ensue, even when young, formerly abducted girls and women attempt to
participate in formal demobilization programs (Amnesty International, 2007; Baines, 2008; Mazurana et
al., 2002; McKay & Mazurana, 2004). DDR in many war-torn regions has targeted boys and men while
disregarding the roles girls and women have played as combatants in fighting forces. McKay and
Mazurana (2004) note that there is a gender-discriminatory framework at play, which perpetuates the
view that girls and women only served as “sex slaves,” “wives,” and “camp followers” while in the bush.
They are therefore not eligible for the skills training and schooling made available to male ex-
combatants, as part of the DDR process, despite evidence that they had in fact fought alongside men
and boys who committed the same acts (McKay & Mazurana, 2004). This parallels similar difficulties
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 27
among other girls in the region, and should not be seen as an isolated problem. Even when the rigorous
use of traditional ceremonies are designed to promote community acceptance, girls and young women
continue to be viewed suspiciously, and with contempt, by their family members and neighbors (Akello,
2006; Amnesty International, 2007; Annan et al., 2008; Baines, 2008; Mazurana & McKay, 2004; UNICEF,
2005).
The literature also indicates that girl mothers face particular challenges in providing for
themselves and their children, due to a lack of education and resources (Annan et al., 2008; McKay &
Mazurana, 2004). Again, despite participation in reintegration ceremonies, girl mothers in Northern
Uganda face rejection by former husbands, and with their children are often threatened and abused by
family and community members (Annan et al., 2008; Mazurana & McKay, 2004). In order to avoid
threats and potential re-abduction by the LRA and their captor “husbands,” girl mothers often move to
distant communities and avoid living or associating themselves with other girl mothers to avoid negative
attention. Yet by living in isolation, these mothers are prone to depression and feelings of hopelessness
(Annan et al., 2009; Betancourt & Khan, 2008).
Other studies indicate that formerly abducted girls and women exhibit difficulty in abiding by
the cultural norms and gender-specific roles of their communities after having lived as combatants in
the bush for extended periods of time. Some may then be prone to violent outbursts. These
psychological symptoms are also cited as a source of difficulty in achieving acceptance as members
within their communities (Annan et al., 2008; Baines, 2008; Kryger, 2011; Mazurana et al., 2002; McKay,
2004; McKay & Mazurana, 2004; Vinck et al., 2007).
A recently published study focusing exclusively on women and girls returning from LRA captivity
however challenged these notions in the years following the amnesty and return of the population from
the IDP camps (Annan et al., 2011). The study noted the tendency toward psychosocial resilience among
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 28
these women and girls, especially amongst those who returned as mothers, specifically contradicting
earlier findings. The study points out that one factor not studied or considered, is that those who were
unable to find correlates to resilience, may have died or been killed in captivity and that the capacity for
survival itself should be understood. Still that does not explain the relatively positive coping shown by
the populations in the intervening years between 2008 and the present study.
Participants of the study were asked to define economic well-being as well as psychological and
social difficulties. The study did not look at the effectiveness of the various psychosocial programs in
which the formerly abducted may have participated and therefore stopped short of developing specific
indicators for psychosocial well-being, leaving them for future studies such as this one.
These may be significant as they may help to account for the relatively positive findings only
four years after the more negative ones.
Solutions proposed in the literature:
The literature suggests that female ex-combatants be an integral part of the reintegration
process in order to ensure a more fluid transition for themselves, their families and communities
(Akello, 2006; Annan et al., 2008; Lith, 2007; MacMullin & Loughry, 2004; McKay & Mazurana, 2004;
McKay, 2004; Wessells, 2004; Williamson, 2006). It is therefore important that ex-combatant subjective
perceptions and views of the past, along with their desires during the reintegration process, be honored
and incorporated (Betancourt, 2009). McKay & Mazurana’s (2004) research demonstrates that girls are
resilient, and can clearly articulate what empowers them. Girls have stated that empowerment entails
multiple components, including their communities’ acceptance of them, their families and friends’ love
and support, and the performance of rituals and ceremonies affirming their inclusion into the
community while cleansing them of their past. These ceremonies also signify that those in attendance
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 29
forgive ex-combatants for their participation in atrocities committed in the bush. Opiro (2006) found
that self-efficacy and confidence may also be realized through the promotion of education and skills
training, through including formerly abducted girls in specially designed programs at school.
Some studies of psychosocial interventions for adults in the region
Despite the severe conditions that prevailed in Northern Uganda, psychosocial programs were
also developed for Sudanese refugees sheltering in camps in the region.
A review of literature related to mental health and psychosocial well-being among Sudanese
refugees in Uganda unearthed caveats against using western mental health measures in non-western
environments. However, when the author began to look specifically at the refugees, her work refocused
to a discussion of mental illness and symptomatic responses (Tempany, 2009).
Another study, again of Sudanese refugees in Uganda, did find ways to elicit refugees’ ideas
regarding well-being. Wiebke Hoeing (2004), a graduate student studying in the Rhino Camp of Northern
Uganda, raises the question as to why the well-being of refugees is always studied in the negative, and
pathologizing their experiences without allowing refugees to explain or define their own lives. Hoeing
does not attempt to catalogue the factors that he finds into a measure, but he does fulfill the initial
ethnographic task of allowing the refugees to speak for themselves.
Women, Well-being and Agency in Northern Uganda
These study findings coincide with our aims of seeking how girls and women define psychosocial
well-being. However, there is no definitive literature in which girls and women in Northern Uganda
define psychosocial well-being and agency. Like the overall psychosocial literature, the studies that do
exist have focused on girls rather than women.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 30
The following represents a review of extant literature on psychosocial well-being and
subsequent intervention programs for this population. Various studies, most notably McKay and
Mazurana (2004), Brett (2002), and Machel (2000) recognize that the resilience and agency of girls and
women should be fully acknowledged when designing and implementing reintegration programs,
without analysis of the way in which psychosocial well-being is defined by participants themselves
(Annan et al., 2008; Brett, 2002; Machel, 2000).
McKay and Mazurana (2004) note that girls’ and women’s resilience and agency is evident in
their ability to maintain a strong sense of self despite the dire straits they experienced in captivity, as
exemplified by their ability to escape their captors (McKay & Mazurana, 2004; Annan et al., 2010).
Psychosocial support may then enhance this resilience in the form of schooling and skills training (McKay
& Mazurana, 2004; Opiro, 2006).
Kryger and Lindgren’s (2011) qualitative exploration sought to determine which factors
promoted post-traumatic growth (PTG) among a small sample of former child combatants by expanding
upon their perceptions and definitions. However, it is important to note that the sex of individual
participants in the study was not revealed, raising questions of its viability among female ex-combatants
whose gender-specific experiences and views warrant exploration and sensitivity relating to the design
and implementation of beneficial psychosocial interventions.
Twelve youth were interviewed in the study, resulting in the emergence of four key themes,
which the authors recommend be incorporated within the PTG intervention model: social support
gleaned from family and community members; participation in the form of acquired knowledge and
skills training so that positive contributions are made to the community; positive self-perception on
behalf of the youth and those in their immediate network of family and community peers; and a strong
faith in god which promotes youths’ participation in activities conducive to personal growth and
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 31
development (Kryger & Lindgren, 2011). The authors acknowledge that future research is needed to
assess whether the four themes may be applied to interventions within the Ugandan cultural context, as
the precise location of the participants was not disclosed to protect them from negative consequences
(Kryger & Lindgren, 2011). Therefore, the proposed PTG model may pose potential problems in
communities that may harbor distrust and contempt for the past actions of their youth (Kryger &
Lindgren, 2011).
Women’s perceptions of well-being in Northern Uganda
Extensive search of the literature including EBSCO, JSTOR and the “grey literature” found no
studies that focus exclusively on women’s subjective beliefs regarding psychosocial well-being.
Researchers had found it critically important to define and operationalize psychological and social well-
being of affected populations in their own voice and terms in order to evaluate the effectiveness of
psychosocial programs (Ager, Stark, et al., 2010). This appears to be an important next step in evaluating
psychosocial programs for women in conflict-affected communities in Northern Uganda as well.
Therefore, CARE International in Uganda initiated this process in its recent research (Bukuluki &
Mugisha, 2010; Just, 2010; Kemirembe, 2011). Bukuluki and Mugisha utilized self-esteem, self-efficacy
and social inclusion as proxies for well-being in their comprehensive baseline study, as these correlate to
resilience (Bukuluki & Mugisha, 2010; Wurzer and Bragin 2009). The next step would be to follow
through with a population-based qualitative exploratory study to enable the definition of well-being
based on the perceptions of conflict-affected women, for the purpose of enhancing the effectiveness of
the evaluation of psychosocial programs for conflict-affected women in post conflict Northern Uganda,
most notably those of NUWEP.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 32
Women’s contributions to the discourse of what psychosocial well-being represents and entails
for them personally could greatly impact the effective design and implementation of interventions
meant to strengthen the infrastructure and cohesiveness of post-conflict communities. Women’s roles
as peace keepers would therefore be strengthened, as would the economic and social development of
otherwise disenfranchised familial and communal structures within the Ugandan cultural context.
The extensive nature of the research on both the effects of conflict as well as coping and
resilience, along with studies on economic well-being lead to a useful place for this small present study
in elaborating the views of conflict-affected women on the factors that comprise their own well-being
and the conditions needed to attain it for themselves and their children.
THE STUDY DESIGN
The study design, all interview guides and other documents used in this exercise, were approved
by the Uganda National Commission on Science and Technology (UNCST), which supervises research
conducted in Uganda, as well as the Ugandan Joint Clinical Research Center Aggregated Institutional
Review Board and the Institutional Review Board of Hunter College, City University of New York.
The present study is conceived as part of a larger three country-study, with the overall objective
of contributing to the capacity to measure the effectiveness of psychosocial programs for conflict-
affected women, by addressing a significant gap in the literature noted above; that is the operational
definition of “psychosocial well-being” in cultural context. The present study also intends to address the
gap in the literature on conflict-affected populations in Northern Uganda by including the voices of
conflict-affected adult women, as distinct from children and girls; and presenting for the first time their
positive views of an end state of psychosocial well-being and the means needed to arrive at that state.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 33
Figure 1: The study design
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 34
Study hypothesis
The hypothesis of this study is that conflict-affected women in the Acholi sub-region are able to
develop an operational definition of psychosocial well-being in their cultural context.
Study objectives
To place the study of conflict-affected women’s perceptions of psychosocial well-being
in the Acholi Sub-Region in the context of the literature on conflict-affected women in
Uganda.
To learn from conflict-affected women in the Acholi Sub-Region how they describe
psychosocial well-being and the factors necessary to attain it.
To contribute to the development an operational definition of psychosocial well-being
for conflict-affected women in the Acholi Sub-Region.
To establish culturally sensitive indicators of psychosocial well-being to be used in the
design, monitoring and evaluation of psychosocial programs in the sub-region.
To develop a practical, reliable and valid method for developing indicators of
psychosocial well-being to include in program design, monitoring and evaluation.
To enable future testing of the main program hypothesis that psychosocial well-being is
associated with successful empowerment and participation in the peace process and as
stipulated in UNSCR 1325.
The main study questions:
How do conflict-affected women in the Agago, Lamwo, and Gulu Districts of Acholi Sub Region
understand psychosocial well-being?
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 35
What are the conditions that these women believe are necessary to achieve psychosocial well-
being?
What questions could be added to future program assessments and evaluations that would help
evaluators know if the conflict-affected Acholi women of Agago, Lamwo, and Gulu Districts of
Acholi Sub Region experienced psychosocial programs to be effective?
Methodology
Methodological approaches
To address these questions, twin methodological approaches were employed:
Stepwise Ethnographic Exploration, to insure construct validity in cultural context.
The participatory ranking method (PRM) of Columbia University to facilitate reliability,
transparency and replicability.
“Stepwise Ethnographic Exploration” (Nagpal & Sell, 1992) is a method that has been validated
for studying psychological well-being related to health and used successfully in South Asia. The
Participatory Ranking Method, used successfully by Columbia University for learning about perceptions
of psychosocial well-being among children and adolescents has not yet been used by adults in Uganda
but has been validated in other conflict-affected countries.
Consensus methodologies, such as these have demonstrated effectiveness in developing valid
instruments in cultural context (Ager, Boothby, Wessells, 2007; van der Veer, 2008; Williams, Mikus Kos,
Ajdukovic, van der Veer & Feldman, 2008). These methodologies deliberately rely upon the
development of indicators through systematically arranged focus group discussions.
Data analysis was run concurrently with fieldwork in a reflexive and iterative process and
followed by a retrospective analysis. Following field data collection, handwritten notes including case
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 36
studies were assembled and typed in Microsoft Word. The notes were reviewed thoroughly and coded
manually to discern emerging issues, unique quotations and cross-cutting experiences across districts.
The study was conducted in two rounds. The first round elaborated the nature of the concept in
social and cultural context and determines which words and questions should be used to insure
construct validity. This is particularly important when working with adults who may see the world in a
more complex way than the children and adolescents on which the Participatory Ranking Method was
validated. Classification of responses into meaningful categories helped to bring out their essential
pattern, which closely followed the main themes of the investigation. Retrospective analysis utilized
Atlas-ti software for the second round of interviews, to develop objective indicators for the frequency
and ranking of concepts and variables.
The second round utilized semi-structured interviews supplemented by participatory ranking
methods to validate the indicators developed during the first round of interviews. These procedures
supported individual engagement of all focus group participants in local context. The questions derived
from the analysis of the original interviews were raised with participants in the original groups and some
who had not been included in the original focus groups to validate their accuracy. Questions were
grouped into domains, including those that comprise well-being and those factors that may be viewed
as necessary to achieve it.
Following participants’ agreement that the questions reflected their ideas regarding well-being,
participants were asked to rank responses in each domain as to their importance. Once again, detailed
notes were taken from each group and the process continued until there was saturation. The ranked
questions were used to develop a pattern of responses to be used as indicators in a future baseline
studies to measure the effectiveness of psychosocial programs to improve well-being amongst this
population.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 37
The diagram below illustrates the stepwise ethnographic exploration:
Site Selection
The Roco Kwo program is implemented in 23 sub-counties spread among the seven (7) districts
(Kitgum, Lamwo, Pader, Agago, Gulu, Nwoya and Amuru) of the Acholi Sub Region in Northern Uganda.
Purposive sampling was undertaken for the districts, sub-counties and parishes, where the study shall be
done, considering the following:
The program operates in both rural and peri-urban settings, with the biggest area of coverage
being rural. The districts of Agago and Lamwo represent a rural population, while Gulu district and Bobi
sub county, represent a peri-urban setting.
The districts selected were among those hardest hit by the armed conflict by the Republic of Uganda
PRDP (2007), including abduction rates of 47%, rural displacement rates of 100% as well as ancillary
effects including an HIV/AIDS prevalence rate of 9 percent, and a life expectancy rate below 48 years.
The districts were also those where CARE’s integrated psychosocial programs were operating as part of
•Unstructured Interviews with Interviewers
•concept identification
•Unstructured Interviews with Key Informants
•concept Identification
•Semi Structured Focus Group Discussions
•concept clarification
next
step •Semi Structured Interviews with Key Informants in the field
next
step
•Interviewers meetings
•Consensus on concepts/ development of domains of inquiry
•Focus Group discussion: structured
•Qualitative concept validation
•Semi Structured Interviews with Key Informant
•Qualitative concept validation
•Development of interview guide for psychosocial well-being of women in cultural context
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 38
NUWEP in order to insure protection and care for all participants, preventing harm, and finally for
possibility of access by land vehicle within the study time frame. The districts also contrasted rural and
peri-urban areas.
The particular characteristics of each district were noted in the record and are included as part
of the final report.
Recruitment and sampling
Subjects were recruited from among program participants who are between 18 and 65 years of
age and have been ongoing participants in a local women’s support program for at least two years. An
equal number of women were recruited from the NUWEP programs and those who were part of other
groups designed for economic support alone. No woman without access to ongoing support was
recruited in order to ensure protection of the subjects. In any situation where service needs were
uncovered, they were offered from within and outside of the program and provided with follow-up. The
solidarity group members recruited for participation in the focus group discussions (FGDs) were selected
purposively based on the following criteria:
The partner organizations have capacity to support any woman reporting distress through ongoing psychosocial activity and referral to a designated expert service for the treatment of psychological and mental health distress.
Women with the following characteristics: o Women who spent a long time in camps o Women who were attacked, injured or harmed by the conflict o Women disabled by war (landmines, battle, other violence) o Women who were abducted o Women who are ex-combatants for any reason o Women who had children “in the bush” o Widows o Women who lost children, parents and other close family members to the
conflict
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 39
These limiting characteristics also reduced the number of eligible participants. To further reduce the
numbers, every 5th qualifying group was given the recruitment letter.
The study was conducted and repeated in focus groups until saturation was reached in the first
round. A total of 652 persons participated in the study, including 623 participants in focus group
discussions and 26 participants in key informant interviews. 323 persons participated in the first round
of whom 317 were women and six were men, three of whom were key informants. In the second round,
329 persons participated of whom 325 were women and three were male key informants. The
participants themselves decided who would participate in one round only and who would volunteer for
both. The criteria were willingness to spare the time during the rainy season in the first round, and the
harvest during the second round.
Figure 2: Total numbers: participants, focus groups and key informants Rounds One and Two
Districts Total # Focus Groups
Total #FG Participants See X2
Total FG Participants Seen X 1
Total # FG Participants
# Key Informants
Total # study participants
Agago 9 79 78 157 10F 1M 168
Lamwo 13 137 117 (3M) 254 4F 1M 259
Kitgum 2 0 26 26 2F 28
Gulu 12 100 86 186 8F 1M 195
Kampala 0 0 0 0 2F 2
Totals 36 316 307 623 26F 3M 652
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 40
Figure 3: Focus Group Sample: Round One
Districts # FGDs
# FGD Participants
Key Informant Interviews
Total
Agago 5 17, 9, 15, 20, 17 7 F 85
Lamwo 6 4, 18, 20, 34, 24, 17 (3M)
2 F 119
Gulu 6 19, 24, 12, 7, 12, 12 5 F 91
Kitgum 2 18, 8 2 F 28
Total 19 307 3 (M) 16 323
Figure 4: Focus Group Sample Round Two
Districts # FGDs # Participants KIIS Total
Agago 4 26, 15, 17, 21 4 (3F) 1 M 83
Lamwo 7 15, 25, 25, 25, 21, 14, 12
3 (2F) 140
Gulu 4 19, 21, 12, 18, 4 (3F) 1 M 104
Kitgum 2 15, 15 1 1 M
Kampala 0 0 2 (2F) 2
Total 17 316 13(10F) 3 M 329
PROCEDURES AND RESULTS
Study Procedures for Round One:
The first round addressed steps 1 – 5 of the Stepwise methodology. Two research teams were
established, one led by the Ugandan PI accompanied by an international team member and translator;
the other led by the international PI, a local team member and a translator.2
The first round followed steps 1 - 5 of the Stepwise Ethnographic Inquiry and proceeded as follows:
2 The translators were competitively selected by open advertisement. All were native Acholi speakers with a
university degree and experience working in psychosocial programs.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 41
Senior program management and program advisors met with the research team to begin the
process of concept identification. After an explanation of the study and the stepwise
methodology were reviewed, the participants were asked to gather in small groups to discuss
the meaning of psychosocial well-being, as distinct from economic well-being, amongst Acholi
women. The research team identified key informants and held open discussions for concept
identification.
Open ended discussions were held with selected focus groups, which included discussion about
the concept and free listing to establish which questions were most useful to help women to
discuss the issue of psychosocial well-being. This is a process of concept clarification.
Key informants were selected by the community for further concept clarification.
After each day of discussions the research teams reviewed the notes and again clarified
concepts in an iterative process that continued each day. This was part of the process of concept
clarification.
The days’ notes were then transcribed and reviewed for agreement.
Study Procedures for data analysis and interpretation
Interviewers meeting, in which the interviewers from the two teams shared their perceptions of
the accumulated results of the meetings.
The typed notes from the interviews were coded by one research assistant using Atlas-ti
software.
The typed notes from the interviews were hand coded by a second research assistant who
counted the instances of different themes occurring.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 42
The results of the methods were combined and synthesized in a meeting with the International
Principal Investigator and the research assistants.
Results from Round 1
These results address the first two study questions, namely:
How do conflict-affected women in the Agago, Lamwo, and Gulu Districts of Acholi Sub-Region
understand psychosocial well-being?
What are the conditions that these women believe are necessary to achieve psychosocial well-
being?
Questions for Concept Identification
The following questions were asked in the initial workshop and the key informant interviews to facilitate
the identification of the concept of psychosocial well-being in the Acholi context.
o How do you define psychosocial well-being for yourself?
o How do you define psychosocial well-being for program participants?
o What questions do you think are important to ask?
How would you ask those questions?
What words would you use and why?
o Who are (other) key community members and opinion leaders we should invite to
inform the discussion?
Language and terminology
The concept of psychosocial well-being was imported by the international community and
mostly associated with responses to adversity. The studies done in Northern Uganda focused on that
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 43
adversity. Defining what it really meant to be well, both psychologically and socially, was quite new for
the participants and they struggled to find ways to speak about this idea.
Language is indelibly connected to culture. The way of thinking about an idea is reflected in the
words that one uses, and the way that one uses them. Acholi words can be short, with amplification
made by facial expression and accompanying stories.
The specific terminology:
The following terms were repeated across the focus groups in different districts. They were confirmed
with other groups and discussed with the research team as part of concept clarification.
In Acholi there is a word for all being well, “tye maber.” Referring to physical, economic, social and
emotional wellbeing, it is often used as a polite response to a greeting. Therefore, as more detailed
language was needed to accompany it, we used the phrases together.
“Ber-bedo” is the generic term for “to be in a state of wellness.”
“kwo tye maber “refers to a good life, used for psychosocial well-being beyond tye maber.
“kuc tye” means peace at heart and refers to the ways in which a person is free of anxiety and
worry.
“yom cwiny“ refers to joy, something that can be both momentary and transcendent: one can
have spiritual joy as well as emotional joy.
The domains below illustrate how these were operationalized.
Domains of Well Being for Conflict-affected Women in the Acholi Sub-Region of Uganda
Peace/ absence of war is the precondition for all other indicators (all 19 focus groups)
Once that is established, the following domains comprise the total concept as expressed in ber-bedo,
kwo tye maber, kuc tye, yom cwiny.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 44
Good home and marriage a. Solve problems through discussion b. Mutual love c. Mutual understanding and trust d. Good sex e. Working together at home and in the garden f. Officially recognized marriage g. Freedom from alcoholism h. Husband teaches children at the fireplace at night
Raising Children Well a. When all of the children are well fed b. When all of the school fees are paid and the children are in school c. Spending time with children laughing and talking d. Children to support me when they grow e. Children’s good behavior throughout life reflects well upon me
Being part of women’s associations, VSLA, clan, church, etc. a. The opportunity to work together b. Provides emotional support c. Provides answers to difficult questions d. Not to be alone/ support from outside
Access to resources: knowing we can meet our basic needs a. VSLA provides financial security (access to emergency cash/ investment funds) b. Seeds and tools/ drought and flood resistant crops c. Access to health care including safe motherhood d. Access to nutritious food e. Support from the clan (emergency cash, emergency support)
Being able to help others a. Being known as one who helps b. Knowing that I can help c. Being the best at helping d. Representing others at meetings
Education a. Acquisition of knowledge, skills b. Access to information c. Knowledge about agriculture for the soil and climate
Participation and Advocacy a. To be seen and heard b. To represent self and others c. To advocate for one’s own ideas
Religion and Spirituality a. Connection to God b. Connection to the land and the Acholi traditions
The Garden a. To work in the garden b. To see a good harvest
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 45
c. Enough and good quality nutritious food
Dressing well, smartly, looking good and having a clean home a. To have a clean house b. To have clean children c. To bathe and to clean d. To look good
Time to rest and relax
Study Procedures: Round 2
In round two we completed the last sections of the Stepwise Ethnographic Inquiry including a)
validation of the domains above with the Ugandan PI and team; b) validation of the domains with focus
group discussions and c) key informant Interviews. We then added the Participatory Ranking Method
(PRM)
These procedures were designed to further address the first two study questions namely:
How do conflict-affected women in the Agago, Lamwo, and Gulu Districts of Acholi Sub Region understand psychosocial well-being?
What are the conditions that these women believe are necessary to achieve psychosocial well-being?
A. Concept validation: Presentation to the Ugandan PI and teams
The coded findings were presented in a meeting to the Ugandan PI and the rest of the research
team for their comments and revisions. The team members were not surprised by the findings there
were a large number, but they felt that this decision should be made by the women who saw and
remembered the issues as distinct.
B. Concept validation: Focus group discussions for Round 2
The domains and sub-categories were presented to focus groups consisting of the same women
who had participated in Round 1 and women who had not participated (see Annex C for location of the
focus groups and the number of participants in each group). The focus groups took 1.5 hours each (see
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 46
Annex D for the protocol for the focus groups). Each domain and sub-category was read and each
participant was asked whether to subtract the category, subtract any item, or add any item to the
domains.
C. Participatory Ranking Method (PRM)
Once the participants had validated each domain and its subcategories, we followed with the
participatory ranking exercise. When we returned from the field the research team analyzed the ranking
using SPSS, and developed means for each focus group. We consolidated the ranking by region and then
all the regions together. For convenience, we illustrated the ranking with bar graphs.
Rationale for the including the method
The Participatory Ranking Method supported the validation process beyond the use of coding
and focus group consensus and insured that each woman would participate in some way. When the
group members were asked to formally rank the domains, each woman was seen taking time, asking
questions and being engaged in the inclusion or exclusion of categories and in the elements each
contained. This led to a review of whether low-ranking domains should be included, and if so, why. This
also gave the opportunity to decide to rank separately or include within the domains any items that
were added.
Implementation of the method
After each focus group reviewed the individual domains and sub-categories, the research team
held up an illustrative poster for each domain, and again repeated the sub-categories under the domain.
The participants were asked which they would choose if only one element was possible. They were
asked to line up behind the poster that represented their first choice. The one capturing the most votes
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 47
for number one was given the rank of 1. Then that poster was removed. The participants were asked to
choose the one that they would want if they had one additional domain. The same procedure was
followed until all were ranked. The participants were told that they could add or subtract any domain if
they wished to do so.
The women consistently started by noting that the domains were actually interdependent, like
most aspects of life. We agreed that the women would not be forced to prioritize; they were free to
work on developing all of the aspects of well-being within their activities.
D. Concept validation: Key informant interviews
Who was interviewed
The key informant interviews in this round came in two categories: local persons specifically
recommended by community members as experts on the psychosocial well-being of women; and
notable persons who were leaders in the peace and well-being of the conflict-affected communities. In
the local communities the Rwot Okoro, or women’s cultural leaders, either were interviewed
themselves, or designated others they considered effective, including traditional healers and a Rwot
Moo, male cultural leader who traditionally performs ceremonies designed to maintain or improve
community, clan and personal well-being. (For more information please see Annexes B, C and E).
The senior informants included: the professional social worker, assigned for the support of the
community based Rwot Okoro, designated by the Rwot Acan, the senior cultural leader; the Bishop and
Retired Bishop of the Anglican Church, two representatives of an organization of women formerly
abducted; and two women members of parliament from the sub-region, one of whom was formerly
abducted herself and the other who was the leader of the peace initiative. The list of key informants
can be found in Annex E.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 48
The interview process and structure
The purpose of the interviews was to provide an additional layer of validation for the domains
established by the focus group, correlating them to cultural ideas of psychosocial well-being. This was
also intended as a further protection against the ideas being those of CARE or the NGO partners. The
key informants were not presented with the domains that the women had developed, but rather were
asked the open ended question, “what does it mean for a woman to be well, psychologically and
socially?”
The responses were coded for frequency and emphasis. First, those responses that
corresponded to the domains already coded were listed. Then the additional categories were coded,
analyzed separately and included as additions to the results framework.
E. Nightly group meetings
Each evening, following the completion of the focus group discussions and local key informant
interviews, the teams met together to discuss the day’s results and to consider issues that might have
arisen. Again they raised the question of consolidating the domains and honoring the reluctance of the
women in the focus groups to do so, the teams decided not to further the issue of consolidation.
F. Final workshop with senior staff CARE Uganda
Following the completion of the field visits, prior to the interviews with the Members of
Parliament in Kampala, a small workshop was organized with CARE International in Uganda with Senior
Staff to obtain input on their thinking. The meeting included, Orach Godfrey Otobi, Program Director for
Northern Uganda, John Perry, Program Director for CARE International Uganda, and Sandra Achom,
Advisor for Gender Based Violence and Psychosocial Support. Mr. Orach Otobi is a native Acholi speaker,
and published specialist on the nature of the conflict in Northern Uganda and the situation of the
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 49
formerly abducted. Following a presentation on the preliminary findings, discussion focused on how to
utilize the results to measure the effectiveness of future psychosocial programs in ways that would be
both faithful to the complexities of Acholi culture and practical for field use.
Results from Round 2
A. Results from the concept validation exercise: new item added
The women validated the domains that were listed. This included both those who had participated in
the earlier focus groups and those who had not agreed to the inclusion of the specific domains, had
insisted that none could be removed, and that domains could they be consolidated. Many groups noted
that we had used their words or they remembered specific items that they had emphasized. However,
15 out of the 17 focus groups raised one additional point that they insisted on, the need for men’s
participation.
New Item: The inclusion of men
In 15 out of the 17, or 88%, of the focus groups, the women added that men must be included in the
process of education, access to resources, organizational support, and work in the garden. The women
stated that they had omitted that earlier but that it was important to them. They emphasized that the
It is important to include men! In the camp we had our work at home, but men were
forced to be idle and turned to drink. When women alone can save and share it
continues the conditions of the camps. This leads to conflict in the home. The young
men don’t know how to behave. They can even beat you. If we want to be well the
men need to have education and access and be included in all things. Then we can be
well in our families and in our hearts. Women’s FGD in Lamwo
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 50
men had suffered during the years in the camps due to lack of ability to work, and that this had led them
to drinking and feeling useless. The women felt that they had benefited from participation in many
programs but that the men must also be included for a happy home life. Given the opportunity to rank
it separately, only one group did so. The others all considered that the participation of men be added to
the subcategories of four domains.
The domains of well-being as finalized by the focus group participants follow. New elements are
listed in bold letters.
Domains of Well Being for Conflict-affected Women in the Acholi Sub-Region of Uganda
Peace/ absence of war remain the precondition for all other indicators
Good home and marriage a. Solve problems through discussion b. Mutual love c. Mutual understanding and trust d. Good sex e. Working together at home and in the garden f. Officially recognized marriage g. Freedom from alcoholism h. Husband teaches children at the fireplace at night
Raising Children Well a. When all of the children are well fed b. When all of the school fees are paid and the children in school c. Spending time with children laughing and talking d. Children to support me when they grow e. Children’s good behavior throughout life reflects well upon me
Being part of women’s associations, VSLA, clan, church, etc. a. The opportunity to work together b. Provides emotional support c. Provides answers to difficult questions d. Not to be alone/ support from outside e. Men must also have associations or be included
Access to resources: knowing we can meet our basic needs a. VSLA provides financial security (access to emergency cash/ investment funds)
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 51
b. Seeds and tools/ drought and flood resistant crops c. Access to health care including safe motherhood d. Access to nutritious food e. Support from the clan (emergency cash, emergency support) f. Men also must have access
Being able to help others a. Knowing that I can help b. Being the best at helping c. Representing others at meetings d. Being known as one who helps
Education a. Acquisition of knowledge, skills b. Access to information c. Knowledge about agriculture for the soil and climate d. Men must be informed and acquire knowledge
Participation and Advocacy a. To be seen and heard b. To represent self and others c. To advocate for one’s own ideas
Religion and Spirituality a. Connection to God b. Connection to the land and the Acholi traditions
The Garden a. To work in the garden b. To see a good harvest c. Enough and good quality nutritious food d. Men should also go to the garden
Dressing well, smartly, looking good and having a clean home. a. To have a clean house b. To have clean children c. To bathe and to clean d. To look “smart”
Time to rest and relax
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 52
B. Results of the Participatory Ranking Exercise
Table 1: Consolidated Ranking of Domains for all Districts
1. Access to Resources (3.72) 2. Religion and Spirituality (4.111) 3. Raising Children Well (4.444) 4. Women’s Associations/VSLA and clans/Church, others (4.556) 5. Good Home and Marriage (4.611) 6. Education (4.833) 7. Participation and Advocacy (5.833) 8. Being Able to Help Others (6.294) 9. The Garden (6.941) 10. Dressing well, smart and looking good (7.000) 11. Time to rest and relax (9.063)
NOTE: Access to resources rises to number one overall because of the extremely strong position it had in Gulu with a large peri-urban population, in which all groups rated it number 1
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 53
Table 2: Consolidated Ranking of Domains for Agago
1. Women’s Associations/VSLA and clans/Church, others including men (2.00) 2. Access to Resources including men (3.50) 3. Education including men (4.00) 4. Participation and Advocacy (4.50) 5. Dressing well, smart and looking good (5.67) 6. Religion and Spirituality (6.00) 7. Good Home and Marriage TIED WITH Raising Children Well (6.25) 8. Being Able to Help Others (6.75) 9. The Garden including men (7.75) 10. Time to Rest and Relax (10.33)
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 54
Table 3: Consolidated Ranking of Domains for Lamwo/Kitgum group
1. Good Home and Marriage (3.00) 2. Religion and Spirituality (4.286) 3. Education including men (4.714)TIED WITH Raising Children Well (4.714) 4. Women’s Associations/VSLA and clans/Church, others including men (5.286) 5. Access to Resources including men(6.00) 6. Being Able to Help Others TIED WITH The Garden including men (6.143) 7. Participation and Advocacy (6.429) 8. Time to Rest and Relax (7.167) 9. Dressing well, smartly, looking good and having a clean home(7.714)
The Lamwo/Kitgum groups had more diversity of opinion about which aspects were most important. The good home and marriage were first, with the women insisting that men had to benefit from the same supports they had to make this possible, education and raising children well tied for third place, and helping others tied with the garden for 6th.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 55
Table 4: Consolidated Ranking of Domains for Gulu groups
1. Access to Resources (1.571) 2. Religion and Spirituality (2.857) 3. Raising Children Well (3.143) 4. Good Home and Marriage (5.286) TIED WITH Women’s Associations/VSLA and clans/Church,
others including men (5.286) 5. Education Including men(5.429) 6. Participation and Advocacy (6.000) 7. Being able to help others (6.571) 8. Dressing well, smartly, looking good and having a clean home(6.857) 9. The Garden Including men (7.333) 10. Time to Rest and Relax (10.000)
The Gulu groups showed a great deal more agreement among the women and between different groups regarding ranking: the rank number and the mean are often in close correlation
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 56
Table 5: Ranking of Ex-combatant Groups
1. Good Home and Marriage (2.0) 2. Access to resources (2.5) 3. Religion and Spirituality (3.5) 4. Education / ties with Raising Children Well ( 4.5) 5. Looking Smart/ Clean home (5.5) 6. Women’s Associations/ Clans/ Church ties
with Participation and Advocacy (6.0) 7. Time to Rest and Relax (6.5) 8. The Garden (7.0) 9. Being Able to Help Others (8.0) 10. Men’s Engagement (11.0)
Two groups made up exclusively of formerly abducted women were seen twice. Both were in Lamwo where the highest concentration of women and girls were abducted.
0
2
4
6
8
10
12
RA
NK
ING
DOMAINS
Ranking of Ex-Combatant Groups
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 57
C. Results from the key informant interviews
The key informants were part of the Stepwise Ethnographic Exploration. The purpose was to
strengthen the research team members’ understanding of the cultural views of women’s well-being and
the traditional and spiritual methods used to maintain it. The interviewers were asked about women’s
psychosocial well-being, without being told of the domains established to learn if their responses
corresponded with those of the focus groups, and to the extent that they gave additional or
contradictory information should be included in the findings.
The interviews were axially coded using Atlas-ti, to correlate them to the domains that emerged
from the focus group discussions and then to explore additional themes. The additions and explanations
are included here. (A list of interviewees is found in Annex E below).
Background: Acholi culture and well-being
Key informants stressed the importance of Acholi culture and its relationship to the family as
central, first the marital couple, then the additional children, with the homestead as the center and the
land of the community all round. The fireplace was the “courthouse” and the “university” where stories
and parables were used to teach, and where worries, problems and sources of discord were talked out
by family members. The tradition says that the husband and wife should reach an understanding before
going to sleep, so that the sun does not rise in the morning on their anger.
Figure 5: The traditional Acholi homestead in community context
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 58
The informants emphasized the interconnectedness of all aspects of well-being to each other,
stating that the Acholi culture was one of circles not of lines, and that the circularity supported the
interconnectedness of aspects of life. They saw alcoholism and family violence as a result of separation
of families from their homesteads and gardens and the accompanying way of life.
Male Involvement
The key informants also stressed the involvement of men in the programs as an essential part of
promoting Acholi family life and creating positive families. They stressed that there could be no
happiness for women if men were unhappy, especially not in Acholi society. They pointed out that
Acholi custom was for men and women to work together in the garden and to participate together at
the fireplace in the evening, when family issues would be ironed out and the
forest
hunting
grazing
gardens
homesteads
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 59
couples’ peace would be restored as children were taught their cultural traditions.
Support for the healers
Religious and cultural leaders and healers have taken on the task of attempting to heal the
society. While formal social work exists in Uganda, it seems that the Fund for Victims has not really
brought the strong presence of formal supports to the north, and in particular there is little support or
supervision organized for those tasked with healing.
Religious leaders, cultural leaders, and local religious and cultural healers all expressed the need
for ongoing formalized support for their efforts to support the well-being of the community members in
their care.
Truth and reconciliation
The helpers too are broken down. If we don’t feel well then we can’t provide
good services. We need to help the church leaders heal their own wounds. The
cultural leaders also need self-care and support. When the healers are healed
they can be effective.
Religious leader in Gulu
K
The men in the camp had nothing to do. They began to feel incapable, since they were unable to
provide for their families by digging in the fields or caring for animals. They feel that they have
lost their manhood. If you want a woman to feel well, then the whole family must feel well. If we
succeed to bring men and women together we will succeed to heal this land.
Key Informant in Kitgum and in Kampala
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 60
While all of the key informants agreed that it had been important to end the war and to
welcome the formerly abducted back to the community with their children, the issue of the violence
was not actually over.
There had been no proper accounting of all that had happened during the war. Formal
reconciliation ceremonies while many, were insufficient. That is, they took no account of magnitude of
the violence. The ceremonies soon became, in the words of some, a bit formalistic because they did not
get to the heart of the devastation that the community had experienced. In particular, the government
made no acknowledgement that it too had done wrong, and bore some responsibility for the
devastating conditions of the camps. There had been no formal truth and reconciliation process that
would lead to a reconnection to the rest of the country and integrate all who had participated in the
violence, including members of the Uganda armed forces. No complete national and regional process of
healing had taken place.
While many felt that this would be difficult to achieve, religious leaders, cultural leaders,
political leaders, and women ex-combatants alike felt it was critical to a psychosocial healing processes
for the entire community.
How can you deny what has happened to you? What you have done, big or small, to
survive? How can you recapture all that you have lost and to get what you need? One
ceremony cannot solve it… we have to bring together all of those who have suffered and
who have been part of this and tell the truth…we cannot privilege one suffering over
another…the process must be very slow and very careful...
Woman Political Leader in Kampala
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 61
Special concerns of ex-combatants
With more than 26% of Acholi women formerly abducted in the four districts of the research,
they were everywhere among the participants in the study. One of the parliamentarians had been
abducted as had the head of a partner organization. The PI’s wanted to be sure however, to include
those of the formerly abducted who remained marginalized and excluded, as the literature indicated
that these issues persisted to the present day (Annan et.al, 2011). Therefore, in addition to conducting
two focus groups with formerly abducted participants, they included two representatives from an
organization of formerly abducted young women, as well as a formerly abducted community member in
Agago, who served as a spokesperson for the others. Their views are reflected among the consolidated
views in the previous parts of this section. However the researchers also wanted to leave space for their
specific concerns and so are represented here in the following discussion:
Were there lessons from surviving their experiences in captivity that could be useful to others?
The ex-combatant women had not been asked this question nor had they thought about it.
However, they came up with some significant ideas.
o Solving conflict creatively
To survive in captivity, one had to learn to get along with everyone, people from
different families and communities and educational levels. Fighting among the
group could expose a person to risk. Therefore, the abductees began to learn how
to cooperate even with those who are different. This helps them to respond well in
the community, even to those who criticize them. They can actually be excellent
mediators.
o Learning to be humble
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 62
One survived in the bush by learning to be humble, and doing what was asked without
complaining. This is also a very important skill for good community membership,
although it has increased the difficulty for some to speak up and to demand their rights.
o Learning quickly
In order to survive, they had to learn many things very quickly. Receiving the education
and skills training to which they are entitled, they could contribute more to their
communities and be a strong example for their children.
Their greatest wish is community acceptance for themselves and their children
o Those in the countryside who had returned to their lands are happy to be back at
home and wish to live well with others in the community. Some are ill and wounded
and deeply appreciative of the community’s support. They want the community
members to know that they want to live in peace with them, to listen to others as
well as to be heard.
o Those in the city want others to know that they have only gone to the city to care
properly for their children. They have gone because they were not accepted by
family, or had not had any land to return to. They do not want the children to be
In the bush you had to live with all types. If you made an enemy that might cost your life, and
fights could also lead to beatings and killings. You had to be humble and agree to everything
and you had to be clever! If you moved slowly you would surely be punished or killed. We
learned to manage ourselves among others… we could help with that… we could teach that….
Formerly Abducted Women in a Focus Group in Lamwo
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 63
stigmatized and called “rebel,” as they cannot help the way in which they were
born! They want those children to be educated and to have a good life. They are just
struggling for that.
They need someone to search for their lost children
Many of them escaped with only the baby on their backs, and had left small children in the
encampments in Sudan. They had thought that someone would search for those children. It has
been widely assumed that all of those children are dead; however, the mothers insist that more
must be done to search for them.
If we could tell the world one thing it would be that we want acceptance from the community, not only for ourselves but for our children. They need to be loved and cared about. They did not choose their fathers! They need the love and support of the whole community so that they can grow and help to bring peace to everyone! Formerly abducted woman in Lamwo
My rescue was an accident. I was on a raid with my baby on my back. The elder child was left in the
encampment across the border. Somewhat shot the baby in the head, and I was wounded.
Screaming for my baby so that we might get ambulance, I ran without thinking toward the army.
They rescued me and took me to the barracks and then to World Vision. My baby was dead… I
dream every night that my children are crying for me and no one is there to hear.
Formerly abducted woman in Agago
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 64
D. Results of the final workshop
The workshop results emphasized the dialectical tension between the need for understanding
and measuring psychosocial well-being as a distinct concept, in a quick and practical manner and the
complexities of Acholi language and culture, including the degree to which actions and interactions are
seen as circular rather than linear, with each domain reflexively related to the other.
Thus program management was interested in seeing five or six domains that could be measured,
whereas the experts in Acholi wanted to insure that the domains not be confining or limiting in any way;
the applications of western theory to Acholi ideas could lead to distortions.
The results framework that best reflects this complexity is illustrated in Figure 6, the spider
graph below.
Figure 6: A Holistic View of the Relationships among the Domains
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 65
LIMITATIONS OF THE STUDY
The study is based on qualitative data collection through focus group discussions, key informant
interviews, free listing and participatory ranking, supported by an extensive review of the literature.
Limitations range from those inherent in the nature of qualitative research as well as others related to
circumstances particular to this study.
A. Sampling Limitations
By their very nature, qualitative, phenomenological studies such as this are limited by the
statistically small number of participants, the purposive sampling and the specificity of the responses.
Therefore, the results are not generalizable beyond the specific region and population in which the
study is conducted.
Because this is an area of great poverty and psychosocial need, it was important not to raise
expectations among women who could not be provided with protection and care should any unmet
need be revealed in the course of the study. In order to insure that all of the women recruited for the
study have access to ongoing service, the researchers only recruited members of some form of solidarity
group.
The groups were run by local organizations that were also partners of CARE. To prevent partners
from skewing the results, the translators for the study were not members of partner organizations.
However, we do not know how women who had not been reached by any program for post–conflict
support would answer the study questions.
Should this methodology be used in the future at the point of program assessment, it would be
possible to obtain this information and then to form a control group that obtained only economic
support and another that received psychosocial support as defined by the women in the group.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 66
This study was largely limited to Acholi women who were affected by the conflict, based on the
fact that the recruitment materials were distributed in English and Acholi. Further studies could
especially target non-Acholi speaking residents of the region.
B. Limitations of Language and Translation
Neither the international or Uganda PI is an Acholi speaker and therefore all content was
translated. Every effort was taken to insure fidelity and consistency of translation, through daily team
meetings, discussions and concept clarification and back-translation. In addition, translation was
supported by young Acholi college graduates who worked in the field, and were supported by older,
non-professional translators, who worked in the community. However, Acholi is a very different
language from English in its essence. In Acholi, words may change meaning and emphasis by tone, as
well as by context. The pictorial representations were also imperfect, since they were cut from local
educational materials and magazines, rather than drawn specifically for the purpose. Therefore, some
open questions remain about the meaning of specific words and constructs.
Additional Limitations
The first round of the study was carried out during the rainy season, and much of the area was
experiencing record-breaking levels of torrential rains. Limited infrastructure in the region, coupled by
these unprecedented events made access to the designated parishes difficult, cutting off areas due to
flooding. Therefore some interviews had to be cut short to allow the participants to return safely to
their homes and fields, due to impending floods.
During the second round, one of the key informants, the Archbishop of the Catholic Church in
Northern Uganda, who would have had a unique perspective, was out of the country and unavailable to
meet with the research team.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 67
DISCUSSION: LOOKING AT WOMEN’S WELL-BEING THROUGH AN ACHOLI LENS
We have been able to show that conflict-affected women in the Acholi sub-region of Northern
Uganda are able to define psychological and social well-being, and the elements required to attain it.
Both the women in the focus groups and the key informants emphasized that Acholi culture has
a way of viewing home, family, and economic and social life that connects the elements they have
defined to one another. While the women participated eagerly in the ranking process, it was not
something that made sense to them, as they insisted that having only one element would not be
enough to allow them to say that they were in ber-bedo; kwo tye maber; yom cwiny.
They viewed the domains as interconnected with each creating the potential for the other.
Therefore, if we were to add elements needed for psychosocial well-being to an assessment tool, we
would have to include all without prioritizing them. Further, elements of one domain might be grouped
in different categories.
That said that it is also useful to understand the findings as they relate to a theoretical
perspective of existing understandings of psychosocial well-being.
All of these things are connected don’t you see. I may be looking “smart” and so I am a more
effective advocate for my family because people are drawn to me. I may also be more
effective because I feel better. Because I feel well and good about myself, and because I am
effective in solving my children’s problems, I am able to be helpful to others. Because I am so
well perceived I am loved by my husband and can get support from the others. This gives me
strength to do good business and so the orphans are able to eat well and go to school. Then I
have hope for the future.
Focus Group Members in Gulu
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 68
To do this, we utilized three commonly used frameworks from the literature: one from the
Interagency Guide to the Evaluation of Psychosocial Programming in Emergencies (A. Ager, W. Ager, et
al., 2011), which has set the standard for such evaluations of programs for children; the second, is the
capabilities framework of Sen (1995) which has been most frequently used to specifically understand
women in development. The third compares the study’s domains of well-being to Hobfoll and
colleagues’ (2007) five essential components of effective programming for situations of mass trauma.
Each of these frameworks can support our understanding of how the results, that the women provided,
are specifically related to psychosocial well-being for conflict-affected women.
A. The Psychosocial Working Group
The Psychosocial Working Group (2003) elaborated three domains that they considered to be
the common core of psychosocial well-being: human capacity; social ecology; culture and values.
This is a widely cited and frequently used framework and therefore is important to discuss it here. The
limitation is that the framework applies to children and adolescents, rather than adults. We looked at
the elements listed by the Acholi women, and grouped them under the 3 domains of Psychosocial
Working Group to understand whether they were in fact resonant.
Human Capacity Education
Acquisition of knowledge, skills
Access to information
Knowledge about agriculture for the soil and climate
Men to be included
Participation and Advocacy
o To be seen and heard
o To represent self and others
o To advocate for one’s own ideas Access to resources: knowing we can meet our basic needs
VSLA provides financial security (access to emergency cash/investment funds)
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 69
Seeds and tools/ drought and flood resistant crops
Access to health care including safe motherhood
Access to nutritious food
Support from the clan (emergency cash, emergency support)
Men included in all of these (except safe motherhood)
Social Ecology Good home and marriage
solve problems through discussion
Love
Mutual understanding and trust
Good sex
Working together
Freedom from alcoholism
For this to be possible, men should benefit from group support activities, education and access to resources
Raising Children Well o When all of the children are well fed o Spending time with children when they are laughing and talking
Being part of women’s associations, VSLA, clan, church, etc. o The opportunity to work together o Provides emotional support o Provides answers to difficult questions o Not to be alone/ support from outside o Men should have their own associations for support
Culture and Values Religion and Spirituality
Being connected to God and / or to the Ancestral Spirits (For some this is only God, for others both)
The Garden
To work in the garden
To see a good harvest
Enough and good quality nutritious food Being able to help others (Also Culture and Values)
Being known as one who helps
Knowing that I can help
Being the best at helping
Representing others at meetings Dressing well, smartly, looking good and having a clean home.
To have a clean house To have clean children To look dress well
Family values and traditions Sitting at night with husband and children at the fireplace
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 70
Having a culturally recognized marriage Children’s good behavior throughout life reflects well upon me Children in school
Figure 7: Illustrating the relationship to the Psychosocial Working Group
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 71
B. The Capabilities Framework
Amartya Sen’s view of what economists call “subjective well-being” is defined as “living a good
life” (Anand et al., 2005, p.10). Sen’s capabilities approach requires that well-being be described in
terms of “what human beings are able to do or be,” not only in the present but in future possibilities and
their aspirations (Anand et al., 2005, p.11). This approach is always context dependent, although Sen
himself (1985; 1999) also emphasized the importance of agency and freedom of action. This concept
resonates with what we heard from conflict-affected Acholi women. It is differentiated from the idea,
common in economic theory (Kashdan, 2004), that subjective well-being is the same as happiness. Sen
describes happiness as fleeting; unlike subjective well-being which he describes as life-defining.
Protection from threats to survival
Ecological Conditions o Peace/ no war (Stated as precondition for all well-being)
o No pestilence
o No disaster such as flood, fire and hail
o Having the knowledge to farm in ways that will protect the environment
Control over Resources
o Knowing one can provide for one’s self and one’s children
o Obtaining support when it is needed: having others to turn to
Clan support
Women’s VSLA group support
o The garden: being able to obtain a good crop
Capacity to create the present and the future
Education o Having the knowledge and information that are needed for farming o Being able to pay the children’s school fees
Community Relationships
o Sharing ideas in the women’s groups
o Helping other group members together
o Sharing troubles and joys with friends and family
o Feeling loved and respected
o Participating in community decision making
o Being able to do what others cannot
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 72
o Looking well
o Being respected by others
o Having a good harvest
Intimate Relationships
o Loving and respecting relationship with husband
o Loving relationship with children
o Providing for the children’s food, clothing and medical care
o Time at the fireplace with the family
o Time with the children when they are happy
o Feeling loved and respected at home
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 73
Figure 8: Illustrating the relationship to the Capabilities Framework
C. Hobfoll and colleagues’ Five Essential Elements for Effective Psychosocial Interventions
Hobfoll et al. (2007) list the following five essential elements that should be promoted by
psychosocial intervention programs to support survivors of “mass trauma,” that is, events that
destabilize the psychosocial well-being of survivors through disruptions to daily life and survival. The
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 74
elements that support well-being are: a) sense of safety, b) calming; c) sense of self and community
efficacy; d) connectedness; e) hope (Hobfoll et al., 2007, p.316). We looked at the elements listed by the
Acholi women, and grouped them under the five categories, to assess whether they were resonant.
Safety
o Peace/ no war
o No pestilence
o No disaster such as flood, fire and hail
Calming (relief from fear and anxiety)
Community relationships that allow for physical and emotional support in time of trouble o Obtaining support when it is needed: having others to turn to
Clan Support
Women’s VSLA group support
Group cultivation of land, or supplying emergency assistance
Good home and marriage (aspects related to mutual support)
Sense of self and community efficacy
Self-Efficacy o Having access to resources
o Control over Resources
o Knowing one can provide for one’s self and one’s children
o A good harvest
o Advocating and representing oneself and others
o VSLA savings for investment
o Being able to help others
Community Relationships
o Obtaining support when it is needed: having others to turn to
Clan Support
Group cultivation of land
Emergency assistance from VSLA
Connectedness
Community Relationships o Sharing ideas in the women’s groups o Helping other group members together o Sharing troubles with friends and family o Getting emotional support from community group membership
Intimate Relationships o Loving and respecting relationship with husband
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 75
Sexual relationship o Loving relationship with children
o Time at the fireplace with the family
o Time with the children when they are happy
o Feeling love and trust with your husband
Hopefulness o Providing for the children’s education o Women’s VSLA group support allows planning for the future o Children who are grown return to support their mothers
o Faith in God/ Spirits
o The garden (as a place of production, but also as connected to the future of the
Acholi culture and way of life)
Figure 9: Illustrating the inter-relationship of all of the domains to the main categories of well-being
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 76
ESTABLISHING A BASELINE FOR PSYCHOSOCIAL WELL-BEING: UTILIZING WHAT WE HAVE LEARNED FROM THIS STUDY
This section addresses the third research question, namely:
What questions could be added to future program assessments and evaluations that would help
evaluators know if the conflict-affected women of Agago, Lamwo, and Gulu Districts of Acholi
sub-region experienced psychosocial programs to be effective?
It also responds to two expected outcomes of the study:
to deliver culture sensitive indicators of psychosocial well-being that can be used for other
women in the sub-region.
to deliver a short-term easily replicable process by which culture sensitive indicators of
psychosocial well-being that can be used by other groups of conflict-affected women both in
Uganda and elsewhere?
The next section addresses each of these outcomes in turn.
A. Sample Questions for the Implementation of a Baseline Study on Psychosocial Well-being among
Conflict-affected Women in the Acholi Sub-region of Northern Uganda along Six Domains
To obtain the sample questions, the Principal Investigators applied the domains identified by the
women to the most easily applicable theory of psychosocial well-being, and created questions to be
added to a baseline study. This approach is based on Stepwise Ethnographic Exploration (SEE) Nagpal
and Sell (1992). The research team used Hobfoll’s five essential elements as a baseline, adding culture
and self-esteem from the psychosocial working group’s frame work, as these categories appeared to
most accurately reflect the domains that the women had elaborated. This is illustrated by figure 9
above.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 77
The questions should be answered using a likert scale in which 1= not at all, 2 = some of the time
3=most of the time 4 =all of the time.3
1. Freedom from anxiety, worry and fear
Peace and security, in my home and in my community and my country I feel safe in my community I feel safe in my home I feel accepted by others, as part of the community
Access the resources needed to be able to provide for myself and my children I have a means to feed myself and my family that is in my control I have access to information about ways to improve my crop field I can have access to organizations that will help me to improve my livelihood I have access to information about what resources are available I have a way to get financial support in an emergency I am able to get care if I am sick I am able to get health care for my children I have access to antenatal care The men in my life also have access to resources that they need I have access to safe childbirth
2. Sustaining Human Connections
Loving home and family My husband and I solve our problems through discussion My husband loves me, and I love him My husband and I share the work in the garden When the children are asleep my husband and I enjoy each other sexually Our marriage is recognized by the community My husband understands me and when he is there I am not alone
Children growing well I am able to send the children in my care to school The children in my care show love and affection to me Me and the children laugh and talk together My children’s behavior mirrors my good parenting when they are out Others praise me for the good behavior of my children
Belonging to the VSLA, clan, church, or other formal group I belong to a group that meets regularly
3 These questions are for illustrative purposes only, as the development of a fully validated instrument requires a
systematic process beyond the scope of this study.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 78
The group members listen when I am distressed The group members help me sort out difficult questions I can work together with others in a group I am not alone, I have others who understand me I share in problem solving with others When I despair, my group members lift me up When I cannot solve a difficult problem others help me to think it through and
find a solution The men in my life belong to support groups too
3. Connections to Transcendent Belief Systems
Religion and Spirituality My faith helps me to survive When I think about my faith I feel stronger I can go to my religious or cultural leaders for help any time When all else fails me I know that God is there Now that I am back on my land, I feel that I can have hope My husband sits with me at the evening fireplace and teaches the children
4. Self and Community Efficacy
Education and Information I have the chance to learn new skills I have new skills to improve my livelihood I have access to information about anything that I want to know I have the chance to obtain new knowledge I have the chance to get information about farming and agriculture I get reliable information about any program that may benefit me I have opportunities to practice what I learn The skills that I learn are useful and beneficial I am not limited in the skills or information that I can access The men in my life have access to education and information as well
Participation and Advocacy I am seen and heard in the community meetings I am seen and heard in clan or other family meetings I can represent myself at meetings I can represent others at meetings I can advocate for my ideas I can advocate for things that I want I can defend my ideas I know my rights under the law I can advocate for the things that I am entitled to
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 79
5. Self and Community Esteem
Helpfulness I am known in the community as someone who helps others I am “the best” at helping I know that I can be helpful when others are in need I am happy when I am helping someone else
Being “smart” I feel that I am beautiful I am able to dress nicely People see that I am smart when I go out I am able to bathe and be clean
Having a clean home My children are clean My house is clean and orderly I feel good when my house is clean and orderly
6. Hopefulness Children who are able to go beyond where I am in life
My children are in school I have a way to pay school fees When my children are grown they will come to bring me sugar and other good
things When my children are grown they will care for me
The garden I enjoy working in the garden I am learning how to grow crops that resist climate change am learning different
gardening methods to address climate change The men in my life are learning different gardening methods to address climate
change My husband and sons participate in the garden activities with me and my
daughters Time to rest and relax
There are moments in my life when I can just sit down and relax After the harvest I can enjoy the fruits of may labor for a few moments Someday I will be able to rest and my clan or my children will care for me
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 80
B. Replication of the Methodology for future use through Participatory Monitoring and Evaluation
This study shows that conflict-affected women in the Acholi Sub-Region of Northern Uganda can
define their own well-being effectively, and elaborate the domains and subcategories that comprise this
concept.
To develop a baseline for future programs in other areas it would not be necessary to replicate
the entire process. Rather, one can ask the questions listed in the protocols and code the results,
returning to the women’s groups with a set of domains for their approval.
The chosen domains could then be represented by an illustration either drawn by hand or cut
from a magazine. The women could rank the degree to which that element of well-being is present in
their community, and then elaborate actions the group would take to promote or improve it. The
women could then be asked on a regular basis to report improvement. The chart could be marked off as
progress is made by the group members. A modified version of the methodology, known as the SEE_PET
for Women is available separately as an individual document, with specific instructions for replication in
future assessments.
CONCLUSION
Going forward from this study, we hope that women affected by armed conflict who are
offered psychosocial programs to support their well-being, will be able to measure the effectiveness of
those programs based on their own specific ideas of what it means to be well psychologically and
socially, both in the present and in the future. CARE and its partners can learn overtime if including
program elements designed to improve psychosocial well-being makes a difference in helping women
affected by armed conflict to come to the negotiating table to discuss the future and to participate in
the benefits of peace.
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 81
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ANNEX A: PARTNERS SUPPORTING THE STUDY
Organization Persons supporting Title Location
FOKAPAWA: Forum for Kolongo Parish Women’s Association
Agnes Aloyo Program Officer Adlinga & Lapono Sub county
Denis Odongo Sub county Coordinator
Jennifer Alanyo, John Tooliba
Community based facilitator (CBF)s
Lapono, Ogole Parish
Night Latigo Lawaka Daphine
Grace Lamwaka Daffin
CBF Adlinga sub county, Orina Parish
KIWEPI Kitgum Women’s Peace Initiative
Anna Ayoo Sub county coordinator
Lukungu Sub county, in Lamwo District,
Esther Advocacy forum member
Parapono Parish, Lukungu Sub county
CBF
Licwa Parish, Parapono sub county
Vincent Akena CBF Lelapwot Parish, Parapono sub county
Ayaa Lilly Rose Okeny Hellen Keller Akaka Joseph Oryema Robert
CBFs Kitgum district Namukora Sub county
Diocese of Northern Uganda Roco Kwo: Transforming Lives
Irene Anella Program Officer Gulu District
Denis Ojok SubCounty Coordinator
Gulu District
Galdino Lalobo Grace Angoma
CBFs Bobi
Christian Popoka Acire Alfred
CBFs Awac
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 92
ANNEX B: GEOGRAPHIC DISTRIBUTION AND NUMBER OF PARTICIPANTS ROUND ONE UGANDA
District Name Sub County/ Town Council
Parish FGDS Participant
# of Key informants per location
Characteristics of Key Informants Interviewed per location
Agago Adilang Orina 1 17 1
A woman ex combatant.
Lapono Lira Kato 2 9, 15
Ogole 2
20, 17
6 1 Traditional healer, 1 woman leader, 3 TBAs in group, I lone TBA
Lamwo Lukung Licwa 2
4, 18 2 LC1, KiWEPI leader*
Parapono 2 20, 34
Lelapwot 2 24, 17
KItgum Namakoro Pagoda E & W
2
18, 8 2 Two women herbalists
Gulu Bobi Paidwe 2 19, 24 4 Knowledgeable persons in Gulu Town**
Palenga 2 12, 7 1 Teacher female
Awach Gwendiya 1 12
Paibona 1 12
Totals 19 FGDs
307 participant
16 KII
*Knowledgeable persons in Kitgum
Ann Aloo, SubCounty Coordinator KiWEPI **Knowledgeable persons in Gulu town Rose Amulen: Deputy Program Manager NUWEP Judith Adokorac: Gender Advisor, NUWEP Jannani Luwum: Monitoring and Evaluation Coordinator, NUWEP Joyce Laker: Woman’s Peace Activist and Community Leader
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 93
ANNEX C: GEOGRAPHIC DISTRIBUTION AND NUMBER OF PARTICIPANTS ROUND TWO UGANDA
District + Partner Organization
Sub County
Parish #FGDS # of participants per group
Key Informants per location
Agago District: Forum of Kalongo Parish Women’s Associations (FOKAPOWA)
Adilang
Orina 1 26 1 woman religious leader, 1 TBA 1 Rwot Moo
Lapono Lira Kato 2 15,17 1 traditional healer
Ogole 1 21
Lamwo District: Kitgum Women’s Empowerment Initiative (KIWEPI)
Lukung Licwa 2 15,25
Parapono 1 25 1 traditional healer/ Rwot Okoro
Lelapwot 2 25,21 1 Rwot Okoro
Kitgum District (KIWEPI)
Namokora Pugoda E and W
2 14,12
Kitgum Town
Rt. Reverend Macleord Baker Ochola II, Bishop, Diocese of Kitgum, Anglican Church of Uganda, Retired
Gulu District: Diocese of Northern Uganda (DNU)
Bobi Piadwe
2 19,21
Palenga 2 12,18
Awach Gwendiya Paibona
1 15
Paibona 1 15
GULU Town
2 reps of formerly abducted women’s organization
Social Worker for the Cultural Leader, Rwot Acan
Rt. Reverend Joseph Gakumba, Bishop, Diocese of Northern Uganda, Anglican
Kampala Kampala Honorable Okello Franca Judith, MP Women’s Constituency Agago
Honorable Betty Bigombe, Minister for Water, MP Women’s Constituency, Amuru
Totals 17 316 13 key informants
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 94
ANNEX D: PROTOCOL FOR THE SECOND ROUND OF WELL-BEING RESEARCH: ACHOLI SUB-REGION UGANDA
I. Greetings:
Introduction of team members, introduction of focus group members, by name, location, group
to which they belong
II. Introduction of the study:
We work together with women in Uganda who have suffered from many things; colonialism,
inequality, discrimination, violence in the home and community, decades of war. You have told
us about that suffering and we have worked together to try to make a change, in the home, the
community, and in the nation.
Today we come to you to try to learn the answer to an important question, when our programs
have succeeded, when things are good, what does it mean for a woman to be well in her heart?
III. Procedure for the group meeting, informed consent:
The informed consent protocol is read. After each paragraph questions are elicited and assent
sought from each group member. Those who wish to leave the group and the others continue.
IV. Changes to the list of domains
We asked you: For a woman to be really well in her heart, what will she be experiencing? What are the necessary elements for a woman to be “tye maber” to experience “yom cwiny,” “ber-bedo” well-being or “kuc tye” peace of mind? We also asked this question of other women in this district and in other ones. We wrote down what you said and what the others said and we combined the information into answers. We are going to read the answers one at a time and ask if you agree. Should there be changes? Should the category stay or be removed, and we will write down what you say. We have some pictures to illustrate each category. We will show you the pictures while we discuss the category to help us to remember. The pictures are not very good, so we will have to remember that they are just here to help us to remember The domains are then read one by one and the comments from each domain and subcategory are recorded
V. Ranking Exercise
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 95
Members of the team and children of the women in the groups are asked to hold up the 11 flip chart
papers containing pictures that illustrate the domains.
The question is posed:
We know that all of the aspects of well-being that you have discussed today are necessary for a woman
to truly to be well, to have joy and to have peace of mind. But if you could only have one, which would
you choose? Please line up behind your choice
The team member recording must note which has the most adherents.
Then the question is posed:
Okay, now you have your first choice. If you could have one more, which would you choose? Please
line up behind your choice.
This process was repeated until all domains are ranked.
VI. Conclusion: Are there any questions that you would like to ask us?
The group is asked to sit down. They are asked before they go, if there are any questions that they
would like to ask or statements that they would like to make.
DOMAINS OF PSYCHOSOCIAL WELL-BEING AS CODED FROM THE FIRST ROUND
Peace/ absence of war is the precondition for all other indicators (all 19 focus groups)
Good home and marriage Solve problems through discussion Mutual love Mutual understanding and trust Good sex Working together at home and in the garden Officially recognized marriage Freedom from alcoholism Husband teaches children at the fireplace at night
Raising Children Well When all of the children are well fed When all of the school fees are paid and the children in school Spending time with children laughing and talking Children to support me when they grow Children’s good behavior throughout life reflects well upon me
Being part of women’s associations, VSLA, clan, church, etc. The opportunity to work together Provides emotional support
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 96
Provides answers to difficult questions Not to be alone/ support from outside
Access to resources: knowing we can meet our basic needs VSLA provides financial security (access to emergency cash/ investment funds) Seeds and tools/ Drought and flood resistant crops Access to health care including safe motherhood Access to nutritious food Support from the clan (emergency cash, emergency support)
Being able to help others Being known as one who helps Knowing that I can help Being the best at helping Representing others at meetings
Education Acquisition of knowledge, skills Access to information Knowledge about agriculture for the soil and climate
Participation and Advocacy To be seen and heard To represent self and others To advocate for one’s own ideas
Religion and Spirituality The Garden
To work in the garden To see a good harvest Enough and good quality nutritious food
Dressing well, smartly, looking good and having a clean home. To have a clean house To have clean children To bathe and to clean To look good
Time to rest and relax
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 97
ANNEX E: KEY INFORMANTS
National Level
Honorable Okello Franca Judith ---- Member of Parliament, Women’s Constituency, Agago District
Honorable Betty Bigombe----------- Minister of State for Water, Ministry of Water and Environment
Member of Parliament Women’s Constituency, Amuru District
Rt. Reverend MacLeord Ochola II Archbishop of the Diocese of Kitgum, Church of Uganda, Retired
Regional Level
Grace Acan ----------------------------- Leader of Women of Peace, Formerly Abducted Girls
Organization/Co-founder Women’s Advocacy Network
Florence Acayo ------------------------ Community Development Officer, Office of the Acholi Cultural
Leaders, Rwot Achan/ Social Work Support to the Rwot Okoro
Judith Elsie Adokorach --------------- Program Advisor for Gender CARE International Uganda
Ann Alloo ---------------------------- Sub-county Coordinator and Co-Founder Kitgum Women’s
Peace Initiative (KIWEPI)
Rose Amulen --------------------------- Deputy Program Manager for Northern Uganda Women’s
Empowerment Program (NUWEP)
Scovia Aol ------------------------------ Chairwoman, Women of Peace, Formerly Abducted Girls
Organization
Rt. Reverend Johnson Gakumba ---------- Archbishop of the Diocese of Northern Uganda, Anglican Church
Joyce Laker ----------------------------- Vice Board Chair for Voluntary Initiative Support Organization
(VISO)
Janani Luwum -------------------------- Monitoring & Evaluation Coordinator for NUWEP
Psychosocial Well-being Indicator Study in the Acholi Sub–Region, Northern Uganda 98
District/ Parish Level
Agago
Matilda Atoo --------------------------- Orina Parish Traditional Birth Attendant
Paula Akot ------------------------------ Orina Parish Religious Leader – Catholic Lay Apostle
Betty Akuru ---------------------------- Orina Parish Ex-Combatant, Informal Counselor
Okido Quinto --------------------------- Orina Parish Traditional Cultural Leader – Rwot Moo
Names not given ------------------------ Ogole Parish Traditional Birth Attendants
Rose Akwero --------------------------- Lira Kato Parish Traditional Healer- Adjwaka
Rebecca Amono ------------------------ Lira Kato Parish Traditional Healer – Adjwaka
Margaret Aume ------------------------- Lira Kato Parish Traditional Birth Attendant
Lamwo/Kitgum
Esther Acayo --------------------------- Parapono Parish Traditional Healer – Rwot Okoro
Anek Ancilla --------------------------- Lukung Subcounty Women’s Counselor/ Rwot Okoro Lelapwot
Doreen Achayo ------------------------- Pugoda Parish Herbal Healer
Ventoria Lakrop ------------------------ Pugoda Parish Herbal Healer
Gulu
Kathy Arena ---------------------------- Palenga Parish Primary School Teacher