1. The Impact of Armed Conflict on Children and Their Communities Qualitative Findings from Burundi Tol, Wietse A. 1/2 Reis, R. 3 Sururu, A. 4/5 Ndayisaba, A. 5 De Jong, J.T.V.M. 1/6/7 1: HealthNet TPO, 2: Vrije Universiteit Amsterdam, 3:University of Amsterdam 4: University of Burundi, 5: TPO Burundi, 6: GGZ Amsterdam, 7: Boston University School of Medicine

2. Thanks to: PLAN Netherlands Research team: Séraphine Hakizimana and assessors Espérance Niyongere, Jérémie Niyonkuru, Melchicedec Nduwayezu, Philippe Cishahayo

3. 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

4. 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

5. 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)

6. Introduction (4) Objectives of this study 1.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

7. 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)

8. 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 FGD Children: 4 (N=46) Parents: 6 (N=57) Teachers: 4 (N=42) Illness Narratives N=40: family members, guardians and orphanages Key Informants N=32: trad. healers (animist & Christian exorcists), teachers, medical officers, priests/ nuns, NGO-personnel

9. 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

10. 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

11. Data Analysis: Ecological Approach Child Family School/ Friends Community & the Supernatural

12. 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

13. 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

14. 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.

15. Results: Some resources available to deal with impact ResourceProblems seenProcess of healing Treatment mechanisms Traditional healersMental 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’sOrphans, former child soldiers Developing relationship of trust, caring & sharing Basic needs assistance, play, and communication

16. 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

17. 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

18. 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

19. 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