Health of conflict-affected children in South Sudan. Children's roles, skills and competencies in identifying health threats, proposing solutions and implementing action

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Health of conflict-affected children in

South Sudan

Children’s roles, skills and competencies in

identifying health threats, proposing solutions and

implementing action

Thesis submitted in accordance with the requirements of the University

of Liverpool for the degree of Doctor in Philosophy

By

Brigitte Elisabeth Müller-Schmid

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DECLARATION

The material presented in this thesis is a result of my own work and has not

been presented, nor is it currently being presented, either in part or wholly as part of

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ABSTRACT

Background: This research was conducted in 2010, in Akobo County, Jonglei State, South Sudan, a region with a long history of inter-ethnic conflict.

Consideration of children in situations of armed conflict tends to focus on their protection and frequently portrays children as passive victims. Previous research and evaluations of child participatory programming, however, provide powerful testimonies as to the capacities and desire of children to be more involved. The aim of this research was to explore children’s health needs from a child perspective and to determine existing and potential opportunities and challenges for children to participate in health decision making.

Methodology: This research uses qualitative and quantitative methods for different but well defined purposes within the same overall research project. Qualitative methods including interviews, focus group discussions, non-participant observations and workshops were used to explore knowledge and perspectives related to children’s health needs, children’s risk exposure and available means of protection as well as children’s roles, skills and capabilities to engage in decision making. Subsequently, a cross sectional mental health survey was conducted to investigate exposure to traumatic events, Post-traumatic Stress Disorder (PTSD), anxiety and depression using the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist (HSCL-25). Positive outcomes were identified using the Post-traumatic Growth Inventory (PTGI). Multivariate linear regression analysis was used to define associations between variables.

Results: One hundred and forty-four children aged 7-18, 88 adult community members and 20 staff of service providers participated in the qualitative study. Psychological distress was identified as the main perceived health threat and as a potential challenge to children’s participation. The qualitative findings further illustrate children’s suffering, but also the resilience and adaptability of children affected by armed conflict and their capacity and motivation to contribute and take action to improve their everyday life. Adult community members showed a high level of trust and belief in children’s strength, ability and willingness to address issues, take risks and make decisions. At the same time, adults voiced great concerns about losing authority and control over their children if children were given more rights. Interviews with service providers showed that half of them had consulted with children at some point during program implementation. A higher degree of children’s participation, where children have the initial idea and decide how the project is to be carried out, with adults available but not taking charge, was found to be an issue of concern to child mandated agencies alone.

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death, abduction and injury of loved ones’ (p<0.01) and adverse mental health outcomes. The PTGI demonstrated a high prevalence of positive change (PTG) as a result of the most traumatic event in children in all five categories: ‘spiritual change’ (73%), ‘relating to others’ (67%), ‘personal strength’ (60%), ‘appreciation of life’ (54%) and ‘new possibilities’ (52%). Regression analysis showed a significant positive relationship between PTG and post-traumatic stress (p<0.001) suggesting that growth and symptom severity may be independent of each other, that is, both growth and psychological distress can co-exist.

Conclusion: The direct impact of armed violence has significantly contributed to extremely high levels of trauma exposure while the long term consequences of conflict such as poverty, the destruction of social networks and family relationships have deprived children of their support system. Our findings indicate that PTG and posttraumatic stress can go hand in hand. According to the theory that PTG results from the struggle with highly challenging life circumstances these findings indicate that the trauma categories associated with post-traumatic growth have threatened children’s pre-trauma view in a significant way, thus fostering PTG in the individuals attempt to assimilate the traumatic event into a new, modified world view.

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ACKNOWLEDGMENTS

My most sincere thanks go to the children and adult community members of

Nyandit and Bilkey Payams who interrupted their daily activities to talk to me and the

members of the research team. Their hospitality and the many hours spent together

made this research an outstanding experience which impressed me deeply.

I would also like to thank my Sudanese Key co-investigator and translator Wal

Makuach Wiu whose empathy with the children and the community was outstanding.

He managed to organise simply anything in the field and was without a doubt my

greatest supporter during the entire period of data collection. Many thanks are also

expressed to my permanent research assistants and data collectors who worked

with great enthusiasm in extremely difficult conditions to collect high quality data. I

would also like to thank the children who became a part of the research team for

their great support in creating child friendly research instruments and for keeping our

focus on what was really important for children affected by conflict.

Very special thanks are addressed to my supervisor Dr. Timothy O’Dempsey

who was always available for all his input and encouragement throughout the

development, data collection and writing up of my thesis. I also wish to thank Prof.

Barry Munslow for his feedback and valuable comments and Dr. Brian Faragher for

his support with the statistical analysis of my survey data.

Many special thanks go to Chris Lewis, emergency medical advisor of Save the

Children UK who supported this research from the very beginning and suggested to

collect the data in Akobo County. I am equally grateful to Save the Children in South

Sudan (SCiSS) for their great support in all possible ways and their hospitality and

stimulating discussions that made this study a truly memorable experience.

I would also like to thank Dr. Olivia Lomoro, Undersecretary, Ministry of Health,

Government of South Sudan for authorising this research as well as the Akobo

County authorities and the County Health Department for welcoming and assisting

us and ensuring our safety for the duration of this study.

Last, but far from least, my most heartfelt thanks are directed to my husband

Peter who was without a doubt my greatest supporter, in all possible ways, during

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been drawn from an indigenous society allegedly devoid of institutionalized rulers into a bewildering spiral of local government authorities, district councils, party bureaucracy, regional assemblies and national parliaments – all of which were constantly being reshuffled, reorganised and disbanded” (Hutchinson, 1996:26).

In the 1980s the daily lives of the vast majority of the Nuer still revolved around

their cherished cattle, however, trading activities had started and small market

centres had been set up by Nuer merchants throughout the region. Fifty years

earlier Evans-Pritchard did not give the Nuer much credit for their trading

capabilities, mainly because of their great interest in their herds: “Nuer have nothing

to trade except their cattle and have no inclination to dispose of these: all they greatly desire is more cattle, and, apart from the difficulty that they have nothing to

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offer in exchange for them, herds are more easily increased by raiding the Dinka”

(Evans-Pritchard, 1940:42).

By the time Hutchinson had arrived, young Nuer, in the search for independence

and a shortcut to marriage, travelled to bigger cities in the North looking for

employment. Money was introduced as a new medium into Nuer culture through

trade and employment and many of these young people invested their money into

bridewealth cattle. Out of this new money/cattle equation a new type of cattle was

created, the ‘cattle of money’ and it was not unusual for the father of a bride to

accept money in place of a bridewealth cow.

Hutchinson further noted that as a result of the seventeen years civil war

(1955-1972) the men and women she encountered had become highly politicised people

deeply conscious about the vast, untapped oil wealth on their lands. She also found

that the topics of conversation had shifted and Nuer men and women did not only

discuss cattle but also political issues, regional troop movements, the Jonglei Canal

scheme and people’s urgent needs for more schools, health centres, roads,

veterinary services and the like. Hutchinson described an important shift from the

ancient key media of interpersonal bonding such as ‘blood’, ‘cattle’ and ‘food’ to

other more powerful media coming from outside their social world, namely ‘money’, ‘guns’ and ‘education’ (Hutchinson, 1996:25).

While some of the sociocultural patterns from ‘the old times’ have faded or

changed, others remained seemingly unaffected. Despite an almost total loss of

people’s livestock in many places, including Akobo County, men’s and also boy’s

work remained connected with cattle keeping activities even if there were no cattle

to be kept. The Nuer culture and social organisation is built around the herds. In the

absence of alternative sources to earn money, wealth and prestige continue to be

Health of conflict-affected children in South Sudan. Children's roles, skills and competencies in identifying health threats, proposing solutions and implementing action