Conflict-Affected Women’s Perceptions of · Conflict-Affected Women’s Perceptions of Psychosocial Well-being in the Acholi Sub-Region of Northern Uganda Principal Investigators

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

http://care.at/expert/coe-resources/psychosocial

http://careuganda.org/


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.


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


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


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


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


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


(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”.


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


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.


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


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


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).


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


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


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


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


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


(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


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


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


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).


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


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


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


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


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


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


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.


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


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.


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.


Figure 1: The study design


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?


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


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.


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


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


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


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.


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.


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


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.


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


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


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


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.


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


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


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)


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”



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


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)


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.


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


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


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


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


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


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


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


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


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


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


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.


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.


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


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)


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


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


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


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


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


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


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


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.


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.


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


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


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.


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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


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


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


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


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


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



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


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

Conflict-Affected Women’s Perceptions of · Conflict-Affected Women’s Perceptions of Psychosocial Well-being in the Acholi Sub-Region of Northern Uganda Principal Investigators

Documents