The Impact of Armed Conflict on Children and Their Communities

Qualitative Findings from Burundi

Tol, Wietse A. 1/2

Reis, R. 3Sururu, A. 4/5

Ndayisaba, A. 5De Jong, J.T.V.M. 1/6/7

1: HealthNet TPO, 2: Vrije Universiteit Amsterdam, 3:University of Amsterdam 4: University of Burundi, 5: TPO Burundi, 6: GGZ Amsterdam, 7: Boston University School

of Medicine

Thanks to:

• PLAN Netherlands

• Research team: Séraphine Hakizimana and assessors Espérance Niyongere, Jérémie Niyonkuru, Melchicedec Nduwayezu, Philippe Cishahayo

Overview of Presentation

• Introduction– Critique on biomedical domination– Qualitative literature contribution– Burundian civil war background

• Methodology– Setting– Participants & Instrumentation– Data Analysis

• Results– Impact of armed conflict– Resources available to deal with impact– Interaction between ecological levels

• Conclusions

Introduction (1)

• Most of the literature on the impact of armed conflict has been done from a biomedical perspective– Use of psychiatric classification (DSM III-R, IV)– Focus on individual impact– With child refugees in high-income settings

• Current literature reviews stress:– Shift of focus away from Posttraumatic Stress Disorder, to

include other co-morbid disorders– Role of resilience– Paradigm shift proposed: examine effects of chronic stress,

protective/ risk factors, role of cultural context, gender/ age and type of conflict situation

Introduction (3)

• Burundi:– 8 million population, 90% subsistence agriculture– Landlocked, foreign earnings coffee and tea– 68% below poverty line– HIV-AIDS and displacement

• Civil war:– Ethnic tensions (Tutsi & Hutu) since independence (1962)

from colonization– Larger clashes in 1962, 1965, 1972, 1988– 1972 first genocide– 1993 assassination of president Ndadaye sparking large-

scale killings– 250,000 to 300,000 killed; 880,000 displaced– Peace process from 2000 (Arusha accords), with later

addition of two rebel groups (2003, 2006)

Introduction (4)

• Objectives of this study1. Description of the impact of armed conflict on children

and their communities from an emic (insider’s) perspective

2. Assessment of resources and initiatives available to deal with this impact

• Part of Randomized Controlled Trial– Preparation of instrumentation (selection, adaptation,

construction)– Examination of public mental health context– Ability to see “fit” of intervention and context

Methodology: setting

• Areas for overall project and Randomized Controlled Trial were chosen based on Public Mental Health Principles (e.g. community concern, feasibility, etc. [see

De Jong, 2002])• Areas for qualitative study chosen to be similar in:

– Livelihood (subsistence agriculture)– Ethnicity (mixed, but majority Hutu)– Conflict history– Avoidance of areas with heavy presence of humanitarian

organizations

• North-Western provinces of Burundi were chosen (Bubanza, Cibitoke, and Bujumbura Mairie)

Methodology: Participants and Instrumentation

• Participants identified through initial community meetings and subsequent snowball sampling

• Focus Group Discussions:– Impact of conflict– Exploration and relevance of

psychosocial problems– Coping with problems

• Illness Narratives:– Causes– Help-seeking– Role of different stakeholders– Current state

• Key Informant Interviews:– Impact of conflict– Problems seen– Treatment

Burundi

FGDChildren: 4 (N=46)Parents: 6 (N=57)Teachers: 4 (N=42)

Illness NarrativesN=40: family members, guardians and orphanages

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

Methodology: Procedures

• 4 local assessors (male/ female, mixed ethnicity) with a BA in psychology

• One-month training program, with a focus on interviewing skills and field-practice

• Ethical approval from Vrije Universiteit Amsterdam and agreement from community leaders

Methodology: Data Analysis

• Interviews were tape-recorded, transcribed and translated to English

• Content analysis with grounded theory approach (Strauss & Corbin, 1998)

1. Listing and grouping text relevant to research questions

2. Development and testing of code-filter based on groups

3. Code-filter application to all data

• ATLAS.ti 5 qualitative data analysis software used

Data Analysis: Ecological Approach

Child Family School/ Friends Community&

the Supernatural

Results: Impact of Civil War

• Individual– Psychological problems: problems are often explained in terms of

“madness” [Umusazi]: throwing stones, talking abnormally / rudely, wandering places. Linked with evil spirits/ poisoning/ sorcery

– Other psychological problems: grief, sadness, anger, sensitivity, withdrawal, trouble with reminders

– Moral problems: disobedience, early sexual behaviors, gang-like behaviors, substance abuse

• Family-level– Killings/ HIV-AIDS/ poverty cause enormous gap in possibility of

(extended) families to provide for children in basic needs– Loss of land and roots– Internal conflicts related to inheritance/ possessions of orphans– Increased polygamy, relaxes in morality– Exploitations in guardian families

Results: Impact of Civil War

• Peer-level/ School-level:– Sensitivity in play– Stigma of orphans/ mental problems– Increased aggressiveness/ war games– Increased distance between teachers and caregivers

(child problems and family difficulties)– Issues related to punishment– High drop-out rates (poverty)– Distrust/ hate between ethnic groups

• Community-level:– Complaints about loss in traditions– Complaints of “broken morality”– Complaints of loss of connectedness and mutual care

between neighbors– Traditional communities scattered through displacement

Interaction between ecological levels: Impact

• Large-scale killings of parents and loss of land erodes values of family and community interaction and care. Children in guardian families are exploited or less cared for (family accusations of sorcery). These children take to the streets (girls: prostitution, boys: theft/ rape) and show behavior which is deemed immoral and causes a sense of cultural decline.

• Evil spirits as a way to express community disarray.

Results: Some resources available to deal with impact

Resource Problems seen Process of healing

Treatment mechanisms

Traditional healers Mental problems, general childhood illnesses, former fighters

Medication, incisions, inhalations, rituals and advice

Magic: the power of God and medication

Church: praying healing

Mental problems, physical illnesses

Religious instruction, advice and exorcist rites

The power of God through people (Holy Spirit)

Wise men [abashingantahe]

Family conflicts/ inheritance conflicts

Discussion and advice

Wisdom and communication

NGO’s Orphans, former child soldiers

Developing relationship of trust, caring & sharing

Basic needs assistance, play, and communication

Results: Resources available to deal with impact

Traditional Healing:

- Pure herbalists- Mixed practitioners

Church:- Exorcist approaches- Pastoral approaches

Non-Governmental

initiatives (orphans/ child

soldiers)

Formal health care

Interaction between ecological levels: Resources

• Some traditional healers can work with the evil spirits that child soldiers bring back from fighting in the civil war, addressing disrupted community/ supernatural relations

• Income generation ( e.g. church) for orphaned groups keeps groups of youth with little opportunities and no support from inducing sense of community decline

Discussion

• Limitations: – Not ethnographic study; shorter time, more data,

and little time to do purposive sampling to fill gaps.– Working with assessors from own context: missing

opportunities for curiosity on aspects that are deemed normal

• Strengths:– Much data– Opportunities for triangulization– Different techniques (FGD, KII, IN) combine well for

an ecological perspective

Conclusions

• Importance of social and moral context in understanding individual expressions of psychological complaints

• Necessity to address damaged family and community social and moral fabric, in a comprehensive way

• Necessity to work with poverty-related initiatives

• Necessity to address supernatural problems, that seem expressions of social fabric damage