1. IV World Congress on Traumatic Stress Qualitative research on the psychosocial impact of war on children in Burundi and Indonesia Wietse A. Tol-HealthNet TPO/ Vrije University Amsterdam Ria Reis-University of Amsterdam Dessy Susanty-CWS Indonesia Adolphe Sururu-HealthNet TPO Burundi Aline Ndayisaba-HealthNet TPO Burundi Joop T.V.M. de Jong-HealthNet TPO/ Vrije University Amsterdam It never rains… it pours

2. Presentation contents Introduction Research Objectives Methodology –Setting & Procedures Results –Summary of informants –Most relevant problems –Damage to the social fabric –Morality problems Discussion/ Suggestions for psychosocial interventions

3. Introduction: HealthNet TPO HealthNet TPO: a merger of HealthNet International (medical care in post-conflict settings) and the Transcultural Psychosocial Organization (psychosocial care in post-conflict settings) HealthNet TPO is an international organization that works to develop research-informed (mental) health and psychosocial care systems in (post-) conflict and (post-) disaster areas, with the aim of increasing structural public (mental) health care

4. Introduction: Child Thematic Project Psychosocial project for children affected by armed conflict in Burundi, Indonesia, Nepal, Sri Lanka, and Sudan –Public mental health approach; different types of interventions for differently affected children –Components: school-based group intervention, youth groups, awareness raising, psychosocial counseling –Integrated research component to come to evidence-based practices Randomized Controlled Trial (RCT) on school-based group intervention N = 1 study on psychosocial counseling

5. Research Objectives Preparation for RCT on school-based group intervention [ISRCTN25172408, ISRCTN66249480, ISRCTN42284825] –Cultural fit of school-based intervention –Choice & adaptation of outcome instrumentation/ translation Research questions –How do community members perceive the (psychosocial) impact of conflict? –What resources are available in the community to deal with this impact?

6. Methodology: setting Burundi: –Repeated cycles of killings and violence along ethnic lines since independence, between Hutus and Tutsis (250,000 to 300,000 killed, 880,000 displaced [Amnesty International, 2004] ) –Data collection in rural areas in two Northwestern provinces, heavily affected by violence Central Sulawesi, Indonesia: –Periodic religious communal violence, since 1998 in Poso region. In 2002: 1,000 killed and 100,000 displaced [Human Rights Watch, 2002] –Data collected in mixed Muslim/ Christian areas in rural areas around Poso

7. Methodology: procedures Key Informant Interviews with child experts in the community Focus Group Discussions with children, teachers, parents Semi-structured Interviews with children and parents/ caretakers of affected children Informants identified through community meetings and subsequent snowball sampling

8. Methodology: procedures [cont.] 4 local assessors with at least BA in social science One-month training program, with a focus on interviewing skills and field-practice Interviews were tape-recorded, transcribed and translated to English Content analysis with grounded theory approach (Strauss & Corbin, 1996) ATLAS.ti 5 qualitative data analysis software used

9. Results: Summary of informants BurundiIndonesia FGD Children: 4 Parents: 6 Teachers: 4 FGD Children: 9 Parents: 11 Teachers: 8 Illness Narratives N=40: family members, guardians and orphanages Illness Narratives N=43: mainly mothers, and other family members Key Informants N=32: trad. healers (animist & Christian exorcists), teachers, medical officers, priests/ nuns, NGO-personnel Key Informants N=44: trad healers (massage, herbalism), midwives, teachers, medical officers, Koran/ Sunday school teachers, priests

10. Results: Most important categories BurundiIndonesia Poverty Damaged social fabric, especially at family & community level Family looses protective function (poverty, deaths) Complaints of loss in moral structure Emotional problems, esp. sadness/ increased sensitivity Poverty Damaged social fabric, especially at peer & community level Family looses protective function (plantations destroyed) Complaints of loss in moral structure Emotional problems, esp. fear/ rebellion

11. Results: Damaged social fabric BurundiIndonesia Family Loss of parents Abuse by guardian families (no food, affection, verbal/ physical abuse, hard work) Increased conflicts within family (e.g. inheritance, increased aggression) Loss of access to traditional land Re-marriage/ polygamy and unequal treatment between children Family Parents working hard to re-build cacao gardens, no attention for children Increased conflicts due to increased rebellion of children

12. Results: Damaged social fabric BurundiIndonesia Friends/ peer level Distrust/ hate between ethnic groups Friends/ peer level Tensions between religious groups: * separation in schools * sensitivity in teasing * increased fighting * increased consciousness of which group one belongs to * fear

13. Results: Damaged social fabric BurundiIndonesia Community Loss of social solidarity Increased witchcraft/ poisoning accusations Continued displacement Feelings of revenge Ethnic distrust/ hate Community Increased solidarity within religious groups Bad (modernizing) influence of military, TV programs Distrust/ lack of interaction between religious groups Feelings of revenge Fear of rumors Poverty causing inequality between groups

14. Results: complaints of damaged morality BurundiIndonesia - Prostitution, promiscuity, sexual violence - Drugs, alcohol - Opposition to authority/ lack of respect - Fearless children - General hardening, e.g. in fighting - Groups of orphans living on the street showing criminal behavior Early sexual behaviors Use of rude words Drugs, alcohol, smoking Opposition to parents, authority/ lack of respect Difficult to discipline General hardening, e.g. in fighting Bad influence of TV, movies School drop-outs stealing

15. Discussion: the psychosocial Importance of looking at more than individual emotional complaints (cf. use of symptom checklists) Importance of damage to morality Differences in damaged social fabric in different armed conflicts, settings, need for different types of interventions

16. Suggestions for intervention A Systems-approach rather then isolated psychosocial interventions: –Difficult to separate the effects of poverty and war –Illness experiences often include spiritual (Burundi: bewitchment, Indonesia: fate as decided by God), physical, social and psychological explanations For example: –Community-based development approaches; income generation/ occupational training projects that build social connections between orphans and their communities in Burundi –Working on access to school of children, involving all religious groups

17. Suggestions for intervention Working with the damaged social fabric Burundi: –Joining community efforts aimed at decreasing ethnic tensions; e.g. scouting, school-based efforts by teachers Indonesia: –Reconciliation efforts at peer and community levels between ethnically different groups –Utilizing available initiatives; inter-religious meetings, school-based efforts, community sports games